Perspectives on severe malaria in Nigeria: insights from Dr Olubenga Mokuolu

Professor Olugbenga Mokuolu is a paediatrician and Malaria Technical Director at Nigeria’s National Malaria Elimination Program. He was the technical lead for the development of the country’s 4th National Guidelines on the Diagnosis and Treatment of Malaria, published in 2020.

He was interviewed by the Severe Malaria Observatory team to provide some perspective on malaria in general and few highlights on severe malaria.

Over the last 3 years, how has the overall control and treatment of malaria progressed?

“In 2015, our malaria prevalence from the Malaria Indicator Survey was 27%; in 2018, the Demographic and Health Survey showed a prevalence of 22%. This was a slower fall compared to 2010 – when we had a prevalence of 42%. But you expect a faster fall when the burden is highest, then the curve starts to flatten out and you need to take additional measures. To help you bend the curve.

“So, over the last 3 years, we have deployed long-lasting insecticide nets [LLINs] as the mainstay of control in Nigeria. New technology has improved our distribution, so that our net [LLIN] retention rate is close to 98%. We have also deployed rapid diagnostic tests, artemisinin combination therapies [ACTs] for the treatment of uncomplicated malaria and use of injection artesunate for severe malaria. .

“Seasonal Malaria Chemoprevention [SMC] is another major development for us. There are 21 states in the country that have 60% of their rainfall within a 4-month period and are considered eligible for SMC. In 2020, we had the greatest scale up of SMC in 10 of these 21 core states, with four cycles of SMC each round. This has reached about 12 million children under-5 years – a huge achievement.

“We have made good progress, but funding has been a challenge. Support from the Global Fund is sufficient to cover one-third of the needs of the country, and PMI [the President’s Malaria Initiative] funding covers approximately another one-third. For the other one-third of the country – 13 states – we have secured a World Bank loan to fund malaria interventions in 6 states and Islamic Development Bank facility for 5-states. We currently have two states without funding support. This has taken a long time to sort, but critical approvals have now been obtained, and progress is going on to ensure that the deployment of interventions in those states can begin in the first quarter of 2021.”

What is the current approach to case management of uncomplicated and severe malaria in Nigeria?

“Our fundamental approach is ‘Test, Treat and Track’.

“We encourage diagnosis before treatment, the treatment of uncomplicated malaria with an ACT, and the treatment of severe malaria starting with injectable artesunate following up with an ACT. And we do chemoprevention in pregnant women through IPTp [intermittent preventive treatment in pregnancy] using sulfadoxine–pyrimethamine.

“We have just launched the 4th edition of the National Guidelines on the Diagnosis and Treatment of Malaria. In this process [led by my team], we conducted evidence updates and therapeutic efficacy studies, monitoring ACT response. Our studies are powered so that results from a single site are representative and we can make scientific statements from that site rather than having to wait for all sites. We did three sites in 2018 – the results showed that ACTs still have efficacies above 95%. The 2020 study has been completed and currently being analysed.

“So we have a continuous stream of evidence to support recommendations. This meant that in the new treatment guidelines we were able to admit two new ACTs – pyronaridine–artesunate and dihydroartemisinin–piperaquine. These are in addition to the two we used already, artemether–lumefantrine and artesunate-amodiaquine, and we have described how these will be prioritised.”

“Regarding severe malaria, our approach to management consists of: early recognition and pre-referral treatment at lower health facilities levels; prompt diagnosis and institution of specific anti-malarial treatment with injectable artesunate; supportive care for life-threatening complications; and patient monitoring and evaluation for progress or sequelae. At discharge we try to reinforce malaria prevention. Recently there has been better targeting of the tertiary and secondary health facilities, and we have conducted a 5-year retrospective review of the status of severe malaria in the country. This is to help understand current practices and provide adapted response.”

How has the COVID-19 pandemic impacted Nigeria’s response to malaria and severe malaria in particular?

“COVID-19 came in as the unknown, and then we had the global lockdown from March to August. This had implications for our supply chain and the use of health facilities. And we had to deal with fear and stigma in relation to the  fever interface between COVID and malaria. This posed addition challenges on the demand for hospital services.

“Because people could not meet face-to-face, our planned activities were threatened. We spotted this quickly, did a risk assessment, and developed a business continuity plan. A lot of meetings, training and planning activities moved online.

“For some key activities such as the Malaria Indicator Survey, we did a risk matrix to look at activities that were necessary, what was feasible and what was not feasible. And we created scenarios based on when lockdowns might be lifted. Based on this risk matrix, we decided to postpone our next Malaria Indicator Survey until 2021.

“But for SMC, we did not have the luxury of choosing the time of implementation – it’s seasonal. So what we did was to deploy both online and minimal local (physical) meetings to plan for the SMC. We reviewed all the activities and adopted COVID-19 prevention protocols. In one instance we married the microplanning for both SMC and net-distribution activities campaign because they were happening at the same time in one of the states. Because of the size of Nigeria, we can’t distribute LLINs to the whole country in a given year; we do it in rotation, as rolling mass campaigns, going from state to state. We have recorded great successes in our SMC and LLIN mass campaigns. For SMC we reached over 12 million children in 4 cycles of the mass drug administration. This year’s experiences have been a learning point for us, and it’s probably the most successful SMC campaign we’ve had.

“We also did co-messaging between COVID and malaria. For instance, when we celebrated World Malaria Day, our slogan was ‘That fever could be malaria, get tested’ – at a time when everyone thought that a fever could only be COVID, we encouraged malaria testing.”

What are your plans for 2021?

“We expect that, from 2021 going forward, we should have an exciting programme. There have been many developments, lots of pieces coming together. The country is taking ownership of the high-burden, high-impact response initiative of the WHO.

“We have a lot of experience in our team, we have strengthened our monitoring and surveillance tools, and we have a new strategic plan, which will be active from 2021–25. This was developed as an inclusive process, informed by a stratification exercise that helped us to recalibrate our goals and objectives and scenario analysis based on coverage of the interventions.

We have special reporting platforms for data from the secondary and tertiary facilities to ensure that all facilities capture data on severe malaria in DHIS2 [District Health Information Software 2]. We will continue to engage with these institutions to optimize management of severe malaria through infrastructure for supportive care and putting in place supply chain mechanisms to minimize stock out of artesunate injection.

We still have gaps, such as being able to access information from the private sector, and the lack of interventions in the states that were not covered. So, we are engaging with the private sector, and with new funding we can cover the other states.

Malaria is consigned to a disease of the weak and vulnerable in society. It needs commitment in terms of resources and energy to make more progress. We must ensure that malaria is always a disease of concern and ensure that our governments are committed to driving the disease down.”

Strategic information and data use for malaria response in Nigeria

Image: Strategic information and data use for malaria response in Nigeria

Note the integration of different data types -incidence, prevalence, u5MR, SMC eligibility, urban areas and pyrethroid resistance. The right column shows projections in parasite prevalence based on implementation measures adopted.