Senegal

Malaria Facts

Photo: Adolescent girl

Malaria is endemic throughout Senegal and 100 percent of the population is at risk of the disease. In 2020, 0.7% of global malaria deaths occurred in the country. [1]  The number of malaria cases declined 4.4% from 2017 to 2020 (from 52 per 1000 of the population at risk to 50) while the number of malaria deaths increased slightly by 1.8%  in the same period in (from 0.24 per 1000 population of the population at risk  to 0.245).[1] 

Despite improved access to and quality of malaria services in the public health sector, the rate of care seeking for febrile illness has remained stagnant (54% in 2014, 53% in 2018) among children under five years of age.[2] The country can be divided into two epidemiological zones: the tropical zone in the south and southeast, with year-round transmission peaking during the rainy season and lower transmission during the rest of the year; and the Sahelian zone in the north, with higher transmission toward the end of the rainy season and very low transmission during the rest of the year.[2] 

Malaria in Senegal is caused by Plasmodium falciparum, P. malariae and P. ovale. P. falciparum is responsible for almost 98% of cases. The parasites are transmitted by parasites, specifically by six species of Anopheles mosquitoes, comprising three major vectors (Anopheles gambiae sensu strictu, An. arabiensis and An. funestus s.s), and three secondary vectors of local importance (An. melas, An. nili and An. pharoensis).[3] 

The national parasite prevalence decreased from 5.9% in 2008 to less than 1% in 2017.1 There are three administrative regions in the south – Tambacounda, Kolda, and Kédougou – that have the highest malaria burden, with an estimated prevalence of 1%, 3% and 7%, respectively.[2] The Senegal National Strategic Plan (NSP) was updated and covers the years 2021–2025. The stated vision is for a Senegal without malaria to support sustainable development by ensuring universal access to the most effective and affordable malaria prevention and treatment interventions to the entire Senegalese population. The NSP objectives were set relative to 2019 levels, to reduce malaria incidence by at least 75%, reduce malaria mortality by at least 75%, and interrupt local transmission in at least 80% of eligible districts as identified in 2019.[2] 

Case management 

Injectable artesunate has been adopted as the first-line treatment for severe malaria at health centres, hospitals, and some rural health posts that are inaccessible during the high transmission season. [2] In 2020, a total of 9,179 severe cases were recorded for all ages and the programme expected to register a decrease of 100 cases every year if the implementation of interventions is accelerated. In 2020, 1,458 severe cases were recorded for children under five years of age, and the programme expected to register a decrease of 50 cases every year if the implementation of interventions was accelerated. In 2020, 7,482 severe cases were recorded for adults and the program expected to register a decrease of 50 cases every year if the implementation of interventions was accelerated. [2] 

The total needs for injectable artesunate for 2021–2023 are 95,456, 94,656, and 93,856 vials, respectively. This includes a buffer stock estimated at six months, which represents 50 percent of annual needs, and a loss rate of 10%. Rectal artesunate as pre-referral intervention has been adopted at health posts and at the community level for children aged up to five years old.[2] 

The treatment presentation used is artesunate 100 mg suppository, B/2 suppositories. The assumption used for the commodity forecast is to provide at least five boxes of two suppositories of 100 mg every year for each peripheral structure. A buffer stock estimated at six months, which represents that 50% of annual needs was taken into account and a loss rate of 10 percent was factored in. The total needs for rectal artesunate suppositories for 2021–2023 are 39,000, 40,500, and 42,000 suppositories respectively. There are no anticipated gaps for injectable artesunate or rectal artesunate for years 2021–2023.

Healthcare for children under five years of age is provided free of charge at formal health facilities, which are reimbursed by the government universal health insurance scheme and this has been extended to the community level.[2] 

Insecticide-treated mosquito nets  

The proportion of the population that slept under an insecticide-treated mosquito net (ITN) increased from 40% in 2014 to 63% in 2019. Similar increases were seen for children under 5 years (43% to 65%) and pregnant women (38% to 68%).[2] A mass distribution campaign in 2022 will take place in all regions of Senegal, except in the urban areas of Dakar and Thiès. This is due to the limited budget allocation amount, as well as the operational challenges to implementation experienced there during universal coverage efforts in 2019.[2] 

The successful synchronised distribution campaign with the Gambia in 2019 will be renewed and extended to other neighbouring countries to the south and southeast of the country (Guinea and the Gambia).[2] 

Malaria in Pregnancy 

The National Malaria Control Programme (NMCP) recommends that all pregnant women receive at least three doses of sulfadoxine-pyrimethamine (SP) as intermittent preventive treatment during pregnancy (IPTp), beginning as early as 13 weeks gestational age and administered one month apart until delivery. Additional doses can be given up to childbirth respecting the interval of at least one month between two doses.  

Between 2014 and 2019, the proportion of women receiving at least 2 doses of IPTp (IPTp2) increased from 40% to 63%, and those receiving at least 3 doses (IPTp3) increased from 4% to 20%. [2] 

Despite this progress, disparate levels of IPTp2 and IPTp3 coverage are still observed in some districts of Senegal as reflected in routine health data. To fill these gaps in coverage, the NMCP and the health system have been piloting a district-driven initiative of IPTp delivery at the community level. The approach consists of distribution of SP by CHWs to pregnant women starting in the second trimester of pregnancy after a census of this target population. The initial results indicate an improvement of coverage as well as an increase in completion of prenatal consultations.[2] 

Seasonal malaria chemoprevention 

The Senegal NMCP has been implementing seasonal malaria chemoprevention (SMC) since it was recommended by WHO in 2012, including children up to ten years of age. Much of the existing research on SMC was conducted in Senegal, first in children under five and subsequently in children under ten.[4] 

Sixteen districts in the five highest burden regions (Kédougou, Kolda, Tambacounda, Kaolack, and Diourbel) are being targeted for SMC campaigns. All districts in the KKT regions as well as Touba, Diourbel, and Kaolack districts will benefit from the intervention. In 2021, there were monthly sweeps for four months in Kédougou and three months in all the other target regions. However, based on the observed length of malaria transmission season in these regions, starting in 2022 an additional monthly sweep will be added to districts to cover a larger portion of the malaria transmission season. [2]

Challenges in addressing uncomplicated and severe malaria [4] 

Prompt care seeking for fever in Senegal is low. While mothers consider fever to be a sign of malaria that needs to be taken seriously, men, including fathers consider fever as a benign and temporary condition. 

Symptomatic treatment of fever by caregivers’ delays prompt care seeking and timely diagnosis and treatment of malaria 

Availability of RDTs and ACTs remained high in public structures; unexpired RDTs were available in 97% of structures and unexpired ACTs were present in 61 percent of structures (93% of public structures and 10% of private structures). The 2018 continuous Demographic and Health Survey (cDHS) found that while care had been sought for 53 percent of children under five years of age with fever in the two weeks before the survey, the vast majority in the public sector, only 14% of these febrile children had received an RDT. 

In 2018, 98% of pregnant women attended at least one ANC visit by a skilled provider. However, only 64% of pregnant women attended their first ANC during the first trimester and 59% four ANC visits or more. Regular ANC compliance remains a challenge in Senegal.

Severe and uncomplicated malaria case management

Senegal’s NMCP adopted artemisinin-based combination therapies (ACTs) as the first-line treatment in 2006 and introduced rapid diagnostic tests (RDTs) in 2007.2 Artesunate–amodiaquine, artemether–lumefantrine, and dihydroartemisinin–piperaquine are considered as co-first line ACTs, although artesunate–amodiaquine is only used in zones in which seasonal malaria chemoprevention (SMC) is not implemented. In pre-elimination zones where incidence is <5/1,000, any confirmed case of malaria is given a single low-dose of primaquine along with the ACT treatment.2
  Injectable artesunate has been adopted as the first-line treatment for severe malaria at health centers, hospitals, and some rural health posts that are inaccessible during the high transmission season. Rectal artesunate as pre-referral intervention has been adopted at health posts and at the community level for children aged up to five years old.2
  Artesunate-amodiaquine, artemether-lumefantrine, and dihydroartemisinin-piperaquine are considered as co-first line ACTs, though artesunate-amodiaquine is only used in zones in which SMC is not implemented.2 In pre-elimination zones where incidence is <5/1,000, any confirmed case of malaria is given a single low-dose of primaquine along with the ACT treatment.2
  Universal testing for fevers became policy in 2017. RDTs are used at the health post and community level, and microscopy at higher levels. Senegal monitors antimalarial efficacy by implementing therapeutic efficacy studies in four sentinel sites each year.2
  According to the 2018 NMCP annual epidemiological bulletin report, 98 percent of confirmed cases were treated with ACT. There were 520,898 ACTs consumed and 530,944 malaria cases and 2,090,323 RDTs consumed. Ninety-eight percent of suspected malaria cases were confirmed with an RDT and/or microscope.2 Health care for children under five years of age is provided free of charge at formal health facilities, which are reimbursed by the government universal health insurance scheme; however, this has not been extended to the community level.2
 

Household ownership of insecticide-treated mosquito nets (ITNs) increased steadily from 2005–2017 (from 20–85%), but declined in 2018 to 77%.2

Malaria in Pregnancy

In 2003, Senegal adopted intermittent preventive treatment in pregnant women, with sulfadoxine/pyrimethamine (SP) given free of charge as directly observed therapy during focused antenatal care (ANC) visits in all ANC sites nationwide.2

In 2014, the NMCP updated its policy and training materials to reflect WHO recommendations. One key recommendation supported by the NMCP is that SP is given as early as possible in the second trimester with a one-month interval between two doses of SP.2
 

Seasonal malaria chemoprevention

The Senegal NMCP has been implementing seasonal malaria chemoprevention (SMC) since it was recommended by WHO in 2012, including children up to ten years of age. Much of the existing research on SMC was conducted in Senegal, first in children under five and subsequently in children under ten.2

In 2019, the SMC campaign strategy was readjusted based on the evolving malaria epidemiology in Senegal to cover a total of 15 districts, phasing out the region of Sédiou, which has seen a significant reduction in incidence, and adding the Touba and Diourbel districts in the Diourbel region.2

Monthly dosing for three months are implemented in the Diourbel, Kolda, and Tambacounda regions, and four months in Kédougou, based on the respective length of the malaria transmission season in these regions.2

Challenges in addressing uncomplicated and severe malaria2

  • Prompt care seeking for fever in Senegal is low. While mothers consider fever to be a sign of malaria that needs to be taken seriously, men, including fathers consider fever as a benign and temporary condition.
  • Symptomatic treatment of fever by caregivers’ delays prompt care seeking and timely diagnosis & treatment of malaria
  • Availability of RDTs and ACTs remained high in public structures; unexpired RDTs were available in 97 percent of structures and unexpired ACTs were present in 61 percent of structures (93% of public structures and 10% of private structures). The 2018 continuous Demographic and Health Survey (cDHS) found that while care had been sought for 53 percent of children under five years of age with fever in the two weeks before the survey, the vast majority in the public sector, only 14 percent of these febrile children had received an RDT.
  • In 2018, 98 percent of pregnant women attended at least one ANC visit by a skilled provider. However, only 64 percent of pregnant women attended their first ANC during the first trimester and 59 percent four ANC visits or more. Regular ANC compliance remains a challenge in Senegal.

Malaria epidemiological situation in Senegal

Image: Malaria epidemiological situation in Senegal

Severe malaria admissions and deaths in Senegal

Image: Severe malaria admissions and deaths in Senegal

Severe malaria policy and practice

National treatment guidelines

Recommendation

Treatment

Strong

IV artesunate

 

Recommendation

Pre-referral

Health posts

Rectal artesunate

Community level

Rectal artesunate

 

Pregnancy

Recommendation

Protection

IPTp

Sulfadoxine/pyrimethamine (3 doses)

Market information

Injectable artesunate delivery in Senegal