Benin

Benin is divided into three main regions: southern, central, and northern. The southern region, a sub-equatorial coastal zone, has two rainy seasons (April to July and October to November) and two dry seasons (August to September and December to March). The central plateau region is characterized by a Sudan-Guinea climate. The northern region is hilly and has a Sahelian climate with one rainy season (May to October) and one dry season (November to April). These geo-climatic variations result in three malaria transmission zones: southern (heterogeneous transmission), central (holo-endemic), and northern (seasonal peaks during the rainy season). [1]

Malaria is the leading cause of mortality among children under five years of age and of morbidity among adults. It accounts for 40% of outpatient consultations and 25% of all hospital admissions. [1] Benin is among the fifteen countries with the highest number of malaria cases and deaths: 2% of the global malaria cases and 1.7% of global malaria deaths in 2021 [2]. It accounts for 4% of malaria cases in West Africa.[2]

Between 2020 and 2021 malaria cases increased slightly by 1.4% (from 378 per 1000 population to 383 per 1000 of the population at risk). Deaths also increased by 2.5% (from 0.84 to 0.86 per 1000 of the population at risk) over the same period.[2]

Ownership of insecticide-treated nets (ITNs) improved from 25 percent in 2006 (DHS) to 92 percent in 2017 (DHS). In addition, the mortality rate for children under five years of age dropped from 125 in 2006 (DHS) to 96 in 2017 (DHS). However, the IPTp3 rate remains stubbornly low at less than 20 percent (DHS 2017); DHIS1- based routine data for IPTp3 in 2020 have shown IPTp3 uptake rates ranging from 20 percent to 40 percent throughout the country’s 12 departments. The early care-seeking rate in case of fever in children under five years of age is 53 percent (DHS 2017).[1]

The disease places a significant economic strain on Benin’s development. The World Bank estimates that households in Benin spend approximately one-quarter of their annual income on the prevention and treatment of malaria.[4]

Severe Malaria Case Management

The national malaria case management guidelines follow WHO guidelines and standards. For severe malaria, treatment guidelines recommend injectable artesunate as the first-line treatment; second-line treatment would be injectable artemether, and third-line would be quinine. These initial therapies for severe disease would be followed by a full course of artemisinin combination therapies (ACTs) to avoid artemisinin monotherapy.[1]

Artesunate rectal capsules (ARC) are the recommended intervention for the pre-referral of children with severe malaria from primary health facilities to the hospitals where severe malaria is treated.[6] Due to overall concerns for the handling of medicines by nonmedical professionals, Benin’s policy does not allow use of rectal artesunate suppositories at the community level. [1]

Malaria in pregnancy 

The National Malaria Control Program (NMCP) objectives for IPTp are that pregnant women should receive at least three doses of sulfadoxine-pyrimethamine (SP) under direct supervision of health providers for protection against malaria. However, uptake of IPTp 3 rate is still low at 13.7%. [1]  

The NMCP launched a community IPT pilot in 2018 in five health districts, using PMI funding. This intervention uses outreach strategies with local health teams visiting rural areas to provide women with check-ups and administer IPT. The results obtained indicated that in 2019 in the Savè-Ouèssè, Abomey, Djidja, Agbangnizoun and Tchaourou health districts, IPTp3 coverage increased from 21.6% to 23.2% , 27.8% to 28.5% and 14% to 17%, respectively. [6] 

Seasonal malaria chemoprevention (SMC) 

SMC has been implemented since 2019 in the top four districts out of 15 health districts initially that meet at least one of the criterion from World Health Organization (WHO). As of 2021, 15 of the total 34 eligible communes in six HZs implement SMC. No changes to the implementation approach or criteria such as age of targeted children and the number of cycles are expected. 

Perennial Malaria Chemoprevention 

Benin is one of several countries participating in a Unitaid-supported project aimed at evaluating the implementation of intermittent preventive treatment in infants known as perennial malaria chemoprevention. In the model for Benin, children will receive a minimum of eight SP treatments, coinciding with the MOH’s recommended immunization schedule for children. 

NMCP’s National Strategy for Malaria Social and Behavioral Change Communication 2021–2025 (Stratégie Nationale de Communication pour le Changement Social et Comportemental contre le Paludisme 2021–2025; SNCCSC) fully aligns with and contributes to country’s vision of “a Benin without malaria by 2030”. 

In terms of indoor residual spraying, six municipalities, out of the 30 eligible, benefit from IRS in the four departments in the North and the Hills. 

Digital tools were  for SMC and ITNs campaigns were introduced in 2020. 

Challenges in addressing uncomplicated and severe malaria [1]  

With the adoption in 2019 of injectable artesunate as the first line treatment for severe malaria, there is a pressing need to fill stocks at all levels of the distribution system.   

• Although 53% of patients or their caregivers in case of children eventually seek treatment, only 28% do so promptly.   
• Limited catchment area of community health agents. This shortage makes it difficult for caregivers in remote communities to seek prompt, proper care.  
• Health workers who are non-skilled, and not trained in malaria guidelines are the most likely to receive patients in health facilities.  
• More than 50% of pregnant women attend at least 4 antenatal care visits (ANC 4).  However, only 14% of women reported receiving at least 3 doses of IPTp.  
• Insecticide resistance, in particular resistance to pyrethroids, a crucial chemical on ITNs, continues to be a major threat to vector control.