Niger

Charge du paludisme

Photo: Young girl from Niger

Malaria prevalence, cases, map, treatment, risk and deaths in Niger

Niger is one of the poorest countries in the world, with 80 percent of the population living on less than US $2 a day and with only 48 percent of the population having access to health centers within a radius of 0-5 km. The life expectancy at birth is 60.4 years. Although 84 percent of the population lives in rural areas, only 24 percent of all health care providers are found in rural areas.1

Malaria is endemic throughout Niger and is the primary cause of illness – it accounts for 28 percent of all illness in the country and 50 percent of all recorded deaths.1 However, the estimated number of cases decreased by 7.9%, between 2015 and 2019 (from 370 per 1000 population to 343 per 1000 of the population at risk) and the number of deaths decreased by 25.9% in the same period (from 0.919 per 1000 population to 0.730 per 1000 of the population at risk).2

According to the National Malaria Strategic Plan (NMSP), between 2014 and 2015, children under five years of age accounted for about three-fifths of the burden of disease (62 percent) and about three-quarters of malaria-related mortality in the country (74 percent).1

 

Prise en charge des cas de paludisme grave

Severe malaria case management

The National Malaria Control Programme’s (NMCP’s) case management objectives as outlined in the NMSP1 are:

  • At least 90 percent of suspected cases of malaria have undergone a test (RDT or microscopy)
  • At least 90 percent of confirmed malaria cases in health facilities have received adequate antimalarial treatment in accordance with national guidelines
  • At least 90 percent of confirmed severe malaria cases in health facilities have received adequate antimalarial treatment in accordance with national guidelines
  • At least 90 percent of simple malaria cases confirmed by community relays have received correct antimalarial treatment in accordance with national guidelines.
     

Diagnosis and treatment

Niger’s Malaria Diagnostic and Treatment Guidelines, updated in December 2017, state that any suspected case of malaria must be confirmed by a diagnostic test – either a rapid diagnostic test (RDT) or microscopy – followed by treatment with an artemisinin-based combination therapy (ACT).1

Microscopy is performed in district hospitals and in the private sector, while RDTs are used in health centers and at the community level. In 2019, 91 percent of the health facilities offered rapid diagnostic tests (88 percent in 2015) and 24 percent microscopy (20 percent in 2015). Sixty one percent of the facilities have a health worker trained in malaria diagnostics and treatment (52 percent in 2015).1

There is limited information available about provider behavior. According to the Service Availability and Readiness Assessment (SARA) survey, 2019), 64 percent of malaria cases were treated appropriately, and 86 percent of confirmed cases were treated according to the national directives.1
 

Community case management

In July 2016, a new community health policy was adopted to increase access to care for children under 5 years of age in villages further than five kilometers from a health facility.1

Integrated community case management (iCCM) is delivered by community health workers (CHW) known as Relais Communautaires and includes the diagnosis of malaria with RDT and treatment with ACTs, diagnosis and treatment of pneumonia and diarrhoea, and malnutrition screening with referral for all illnesses. An estimated 16,000 CHW are needed for national iCCM coverage.1 The programme is being scaled-up progressively throughout the hyper and meso endemic malaria zones.1
 

Malaria in pregnancy

Niger’s Malaria Diagnostic and Treatment Guidelines state that intermittent preventive treatment for pregnant women (IPTp) dosing should begin in the fourth month of pregnancy (after quickening) until delivery, with an interval of one month between doses. Sulfadoxine/pyrimethamine (SP) is to be administered as directly observed treatment by qualified health personnel.1

All uncomplicated malaria cases during the first trimester should receive oral quinine in three daily doses for seven days, as ACTs are contraindicated during this period. During the second and third trimesters, all uncomplicated cases are to be treated orally with ACTs (or with oral quinine for seven days if there are no ACTs available). For severe malaria, pregnant women should receive injectable artesunate or injectable quinine if artesunate is unavailable or not tolerated.1

However, pregnant women customarily wait until their last month of pregnancy before seeking care. A survey conducted in 2019 (Service Availability and Readiness Assessment, SARA) showed that while 80 percent of facilities offer IPTp services, only 47 percent have health providers trained in IPTp.1 Other than the fee for the health card (200 FCFA or U.S. 40 cents), all ANC and IPTp services are free of charge.
 

Seasonal malaria chemoprevention (SMC)

Niger initiated SMC with amodiaquine plus sulfadoxine/pyrimethamine (AQ+SP) in the southern part of the country in 2013, targeting 205,959 children between 3 months and 5 years of age during the SMC campaign.

Since 2018, approximately 4 million children, in all the 61 eligible districts, are covered during four rounds organized by NMCP with support of UNICEF, World Bank, Global Fund and PMI.1

The treatment is delivered through door-to-door campaigns as well as fixed distribution sites. Starting in 2016, malnutrition screening was added to the SMC campaign. Children identified as being severely or moderately malnourished are referred to a Centre de santé integré/Integrated health center (CSI) with a nutrition treatment center.1

 

Défis à relever pour lutter contre le paludisme simple et grave

Challenges in addressing uncomplicated and severe malaria

  • Distance and road conditions: The distance to health centers negatively impacts care seeking. Most travel is by foot and it is not unusual for people to have to walk six hours for healthcare: 61% of the population is more than an hour’s walk from a health center (76% during the wet season, May–October). In the Tahoua region, settlements that are between 4–12 hours walk from a health facility during the dry season take even longer to reach during the wet season (12–24 hours).
     
  • Lack of household finances: June to October is a time for both peak malaria transmission time and acute malnutrition. During this ‘lean season’ – right before the harvest - subsistence farmers that make up the majority of Niger’s population do not have the economic resources to visit a health facility and the population is not aware that malaria drugs are available for free at health facilities.
     
  • Limited economic empowerment of women: Women who are primary caregivers do not go to the health facility unless their husband gives them the money. In addition, women are solely responsible for the health of children and do not receive support from male households.
     
  • Negative perceptions of health posts: Caregivers think the health post is understaffed and do not feel that they will receive the help they need. Other contributing factors to unfavorable views of health posts include restricted operating times, long wait times, lack of equipment and diagnostic capabilities, and lack of medicines.

Malaria epidemiological profile for Niger

Photo: Malaria epidemiological profile for Niger

Severe malaria admissions and deaths in Niger

Image: Severe malaria admissions and deaths in Niger
National treatment guidelines

Recommendation

Treatment

Strong

IV artesunate or artemether

Alternative

Quinine

 

Recommendation

Pre-referral

Peripheral health facilities

Rectal or parenteral artesunate or IM

quinine at the facility level

Community level

Rectal artesunate

 

Pregnancy

Recommendation

Treatment

For all trimesters

IV artesunate

Recommendation

Protection

IPTp

Sulfadoxine/pyrimethamine

 

 

Seasonal Malaria Chemoprevention

Recommendation

Protection

Children aged 3 months to 5 years

sulfadoxine-pyrimethamine and Amodiaquine (SP+AQ)

 

Sources of malaria financing for Niger

Image: Sources of malaria financing for Niger