Nigeria

Malaria facts 

Malaria is transmitted throughout Nigeria, with 97% of the population at risk of malaria.  The duration of the transmission season ranges from year-round transmission in the south to three months or less in the north. Plasmodium falciparum is the predominant malaria species. The primary vector across most of the country is Anopheles (An.) gambiae s.s., accounting for 67.1% of all the An. gambiae s.s. collected, with An. funestus as a secondary vector in some areas of Nigeria [1] 

According to the 2021 World Malaria Report, Nigeria had the highest number of global malaria cases (26.6 % of global malaria cases) and the highest number of deaths (31 % of global malaria deaths) in 2021. [2] The country accounted for an estimated 54 % of malaria cases in West Africa in 2021. [2] 

Case numbers decreased 2% between 2020 and 2021,  from 312.7 to 306 per 1000 of the population at risk. Deaths increased 3.5%, from 0.94 to 0.91 per 1000 of the population at risk during that same period. [2] 

Microscopy data from the 2018 Nigeria Demographic and Health Survey (NDHS) show that the prevalence of malaria parasitaemia in children under five years of age is 23% (a decrease from 27% in 2015 and 42% in 2010), although there are significant regional, rural-urban, and socioeconomic differences: prevalence ranges from 16% in the South and South East Zones to 34% in the North West Zone.[1]  In rural populations, prevalence is 2.4 times that in urban populations (31% vs. 13%) 

Compared to the highest socioeconomic group, prevalence among children in the lowest socioeconomic group is seven times higher (38% vs. 6%) [1]  

In response to the malaria situation and to guide implementation, the National Malaria Elimination Program (NMEP) initiated the High Burden High Impact (HBHI) approach with technical support from the WHO and technical partners to address the malaria situation in Nigeria.[1] The current 2021–2025 National Malaria Strategic Plan (NMSP) is based on the vision of achieving a malaria-free Nigeria with a goal of reducing malaria morbidity to less than 10 percent parasite prevalence and mortality attributable to malaria to less than 50 deaths per 1,000 by 2025. [1]. 

The Government of Nigeria has secured credits from three multilateral banks (the World Bank, African Development Bank, and Islamic Development Bank) totalling $364 million to fund health sector interventions in 13 states of the Federation for five years (2020–2024) for malaria [1]. 

Severe malaria case management and control 

In 2012, the NMEP changed the first-line treatment for severe malaria from quinine to injectable artesunate, consistent with WHO treatment guidelines. [1] The recommended pre-referral intervention for severe malaria is intramuscular or rectal artesunate, intravenous quinine, or intravenous artemether.[1] 

Malaria in pregnancy 

Nigeria has adopted the 2016 WHO antenatal care (ANC) model which recommends a minimum of eight contacts during pregnancy. The proportion of pregnant women who received at least two doses of sulfadoxine-pyrimethamine (SP) more than doubled between 2013 and 2015 – from 17% to 41%. [1] There was a significant decrease in 2016 (31%), and then a return to 2015 levels in 2018 (i.e. 40% uptake of IPTp), A similar pattern was seen for the proportion of pregnant women who received at least three doses of SP, although coverage has not yet returned to 2015 levels (7% in 2013, 21% in 2015, 15% in 2016 and 17% in 2018). [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.[1] 

The National Guidelines specify that pregnant women with severe malaria should be treated with injectable artesunate (or intravenous quinine, if injectable artesunate is not available) from the 2nd trimester of pregnancy [1]  Recent guidelines from the World Health Organisation now recommend the use of injectbale artesunate during the 1st trimester of pregnancy. 

Insecticide-treated nets (ITNs) 

ITN ownership has plateaued and begun to slightly decrease in Nigeria – households with access to an ITN declined from 50% in 2016 to 47% in 2018. Mass ITN campaigns occur every three to four years in only 24 states, and the continuous distribution channels are not sufficient to maintain ITN coverage.[1] However, the proportion of the population that slept under an ITN the previous night increased from 41% to 43% between 2016 and 2018. In the same period, there were also increases in the proportion of children under five (from 49% to 52%) and pregnant women (40% to 58%) who slept under a net the previous night.[1] 

Seasonal Malaria Chemoprevention 

The NMEP strategy recommends seasonal malaria chemoprevention (SMC) in nine states in the Sahel region: Sokoto, Kebbi, Zamfara, Bauchi, Katsina, Kano, Jigawa, Yobe, and Borno. The recommendation is for four doses of SP + amodiaquine [SPAQ] at monthly intervals over the 4-month malaria transmission season). There are 227 local government areas (LGAs) and a population of approximately 11 million children under the age of five years in these states.[1] 

A total of 418,812,470 treatments of SPAQ will be required for SMC from 2020 - 2022 in the 9 eligible states to cover about 35 million children aged 3-59 months annually over the three-year interval. [1] 

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.[1] 

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.[1] 

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

The Government of Nigeria receives funds for malaria control from the Global Fund, USs President’s Malaria Initiative and others. It has also secured loans from the World Bank, the African Development Bank, the Islamic Development Bank.  The country has similarly been funded by DFID (now called Foreign, Commonwealth & Development Office (FCDO) as well as a number of nongovernmental players. Private sector companies in the extraction industry have also implemented malaria control programmes.[1] 

SMC programmes are being implemented in the Sokoto, Jigawa, Katsina and Zamfara States by the Malaria Consortium.[1] 

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 [4] 
• Rural communities: Some hard-to-reach rural communities (~5%) require special measures (boats or camels) to access. Routine service is difficult. [4] 
• 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. [4]