Nigeria

Photo: Alvaris Elvis from the Swiss Malaria Group

Severe malaria facts

According to the 2019 World Malaria Report, Nigeria had the highest number of global malaria cases (25 % of global malaria cases) in 2018 and accounted for the highest number of deaths (24 % of global malaria deaths).  

Case numbers have plateaued at between 292 and 296 per 1000 of the population at risk between 2015 and 2018. Deaths however fell by 21% from 0.62 to 0.49 per 1000 of the population at risk during that same period. 

Malaria is transmitted all over Nigeria; 76 % of the population live in high transmission areas while 24 % of the population live in low transmission areas.  The transmission season can last all year round in the south and is about 3 months or less in the northern part of the country.1

The burden of malaria is three times greater among rural dwellers in comparison to urban dwellers.3 According to the 2015 Malaria Indicator Survey, malaria prevalence among children under five years of age was 27 %; however, there are significant regional, rural-urban, and socioeconomic differences.  The 2015 Malaria Indicator Survey in Nigeria indicates that malaria and severe anaemia were a double fold more prevalent in rural children than their urban counterparts.  

In addition, prevalence among children in the lowest socioeconomic group is 11 times that of those in the highest socio-economic group (43 % vs. 4 %).3

Severe malaria case management and control

Under the strategic plan, the Government of Nigeria supports the treatment of severe malaria using injectable artesunate.2 The country’s guidelines for Diagnosis and Treatment of Malaria (2015) recommend using injectable artesunate (Inj. AS) for the treatment of severe malaria, or intravenous quinine if IAS is not available. Quinine is on the essential medicines list and is readily available in country.2

For pregnant women, the National Guidelines specify that pregnant women with severe malaria should be treated with injectable artesunate (or intravenous quinine, if Inj AS is not available).2 The recommended pre-referral treatment for severe malaria is intramuscular or rectal artesunate, intravenous quinine or intravenous artemether.2

Nigeria was one of the two countries with the highest exposure of malaria infection in pregnancy.1 Only 21.4% of pregnant women received 3 doses of IPTp 3 according to the 2015 multi-indicator cluster survey.1

Worryingly only 40% of the population at risk slept under an LLIN in 2018 and under 30% of children who were brought for care were tested for malaria.1

Sulfadoxine Pyrimethamine (SP) coverage

SP coverage also improved between 2010 and 2015. The proportion of pregnant women who received at least two doses of sulfadoxine-pyrimethamine (SP) increased from 13 % in 2010 to 37% in 2015.4 Nonetheless, this figure remains significantly below that for other countries in the region and scale-up remains a challenge.2

Factors hindering SP uptake among pregnant women include low antenatal care attendance rates, restrictions that prevent non-pharmacy workers from dispensing SP, missed opportunities during visits, and non-availability and stock outs.2 

Seasonal Malaria Chemoprevention

In 2018, only about 30% of the children eligible for SMC, received the intervention. The country intends to procure an additional 2.5 million SPAQ treatments to continue SMC efforts in Sokoto and Zamfara States.2

Healthcare tiers

The public health care system makes up 67% of all healthcare facilities and is divided into three levels: federal, state and local government areas (LGA) or National Primary Health Care Development Agency.2

  • The federal health budget covers tertiary care and disease control programs (including malaria control). There are 83 tertiary healthcare facilities. 
  • The state health budget cover secondary care and there are 3,992 secondary facilities.  
  • The LGA budgets addresses primary healthcare while there are 30,098 primary healthcare facilities.

The private sector makes up about 33 % of all health facilities and includes not-for-profit and for-profit organizations.

The government of Nigeria receives funds for malaria control from the Global Fund. It is also negotiating additional loans from the World Bank, the African Development Bank, the Islamic Development Bank and USAID’s President’s Malaria Initiative, among others.  The country has similarly been funded by DFID as well as a number of nongovernmental players. Private sector companies in the extraction industry have also implemented malaria control programmes.2

SMC programmes are being implemented in the Sokoto, Jigawa, Katsina and Zamfara States by the Malaria Consortium.2

Inpatient and mortality rates

Taken from Nigeria malaria country report 2018

Distribution of malaria cases

Data taken from Nigeria malaria country report WHO 2018

 

 

Severe malaria policy and practice

National treatment guidelines
Recommendation Treatment
Strong IV artesunate
Alternative  IM artemether
Alternative IV quinine
Recommendation Pre-referral
Strong IM artesunate
Alternative Rectal artesunate (children)
Alternative IM artemether
Alternative IM quinine
Pregnancy
Recommendation Treatment
Strong Injectable artesunate

 

Populations with low access to treatment

  • North Eastern Nigeria: Due to insurgencies and attacks on health workers there are operational challenges for delivering malaria intervention services
  • Rural communities : Some hard to reach rural communities (~5%) require special measures (boats or camels) to access. Routine service is difficult. 
  • Nomadic population: Population has no fixed location, making them hard to reach. They believe that fever is a Fulani illness that needs no cure; prefer private medicine vendors and avoid health facilities