There Is No Documented Resistance To Novel Malaria Drug In Nigeria, Says Ezeigwe

Dr. Nnenna Ezeigwe is the National Coordinator, National Malaria Elimination Programme (NMEP). Yesterday was World Malaria Day April 25, 2015. In this interview, Ezeigwe, a consultant public health physician, said contrary to reports of growing resistance of the malaria parasite to the drug of choice, Artemisinin Combination Therapy (ACT), there is no documented resistance to the nationally adopted malaria drug in the country. She said the NMEP is currently undertaking a structured study, the National Malaria Indicator Survey, with the support of the Roll Back Malaria (RBM) partners that will provide a more realistic and representative national malaria profile. The malaria expert said there is impressive national coverage of most of the available interventions, especially with the Long Lasting Insecticide treated Nets (LLINs), where over 80 per cent coverage has been recorded. Ezeigwe said the NMEP is also collaborating with the National Agency for Food Drug Administration and Control (NAFDAC) to ensure that only quality assured ACTs are used to treat malaria through the Mobile Authentication Service (MAS) code policy and similar initiatives. CHUKWUMA MUANYA writes.

There is growing global resistance to ACTs, the malaria drug of choice by the malaria parasite and even the malaria vector to insecticides and insecticide treated nets. What is the situation in Nigeria and what is the NMEP doing to address that?

From the global perspective, it is correct to state that both drug and insecticide resistance have emerged and pose serious challenges to malaria control efforts. However, at present, there is no documented resistance to the nationally adopted ACT in the country. Drug resistance is still restricted to the Greater Mekong Region around Cambodia and Vietnam. NMEP has a mechanism to track drug resistance through periodic Drug Therapeutic Efficacy studies. The assessment done in 2010 showed a clinical cure of 100 per cent for the two medicines (Artesunate-Amodiaquine and Artemether-Lumefantrine) and both showed over 98 per cent Adequate Clinical and Parasitological Response (ACPR).

Another drug therapeutic efficacy tests (DTET) are currently on-going to document the status of the medicines for 2014 and 2015.

Similarly in the last one-year, we have started to monitor the insecticides used for vector control at the Sentinel Sites across the country in order to detect any resistance as soon as it occurs. At the moment, we do not have sufficient data to make a meaningful conclusion in this regard. The NMEP is being proactive to develop a National Insecticide Resistance Management Plan for the country.

Does Nigeria have anything to celebrate in terms of meeting targets in malaria treatment?

Yes. I think we have come a long way and therefore need to celebrate along with the rest of the world. On a broader epidemiological perspective, Nigeria moved from a classification of predominantly hyper and holo-endemic to meso-endemic status between 2000 and 2010. Hyper-holo-endemicity is malaria prevalence of 50 to 75 per cent, while meso-endemicity is prevalence of 10 to 49 per cent.

In the recently conducted World Bank Malaria Control Booster Project End of Project Survey carried out in seven project states and two comparison states, the percentage of households with at least one Insecticide Treated Net (ITN)/Long Lasting Insecticide treated Nets (LLINs) was 85 per cent, above the target of 80 per cent. Also, the percentage of women with children under one year of age, who received Ante Natal Care (ANC) during last pregnancy (one or more visits), surpassed the project target of 80 per cent, at 87.2 per cent. Generally, there is impressive national coverage of most of the available interventions, especially with the LLINs, where over 80 per cent coverage has been recorded.

How about the uptake of malaria-treated nets, is there any improvement?

There is considerable improvement although a lot still needs to be done. The percentage of the population with at least one net increased from two per cent in 2003 to 55.3 per cent in 2013, according to the National Demographic Health Survey (NDHS); and from eight per cent in 2008 to 42 per cent in 2010, according to the Nigeria Malaria Indicator Survey (NMIS). The percentage of under-five that slept under a net (ITN) the night preceding the survey has increased from 5.5 per cent in 2008 to 16.6 percent in 2013 (NDHS). Our goal is to exceed 80 per cent utilisation because it is only then that we can expect to achieve a break in malaria transmission.

Are there plans to look inwards for the next novel malaria drug?

Development of medicines goes through several complex procedures and technologies, which most developing countries are still trying to perfect. The Federal Ministry of Health is encouraging the development of even traditional medicine, and if any product shows any promise, I am sure it will receive adequate support. Prevention is actually cheaper and better.
According to the Federal Ministry of Health (FMoH), malaria is responsible for 60 per cent of outpatient visits to health facilities; 30 per cent of childhood deaths; 25 per cent of deaths in children under one year; and 11 per cent of maternal deaths. What is the current situation?

Let me first note that these figures have been in existence for a long time (over 10 years) now and unfortunately, there has not been a nationally representative follow-up study to the one that generated them. My hunch is that a more recent survey may come up with a different set of figures because most of what is regarded as malaria is actually other form of febrile illnesses. NMEP is determined to establish this and is collaborating with some renowned researches to conduct another study.

However, a more globally accepted indicator used to assess the level of control/elimination is the Slide Positivity Rate (SPR) that is percentage of cases that are positive with parasite amongst febrile cases. The study conducted in 2010 showed SPR of 35 per cent. More evidences have shown even less SPR in most urban settings in the country. For example, average SPR in Lagos is now 15 per cent. In some areas, it could be as low as five per cent. Similarly, a recent publication that documented 10-year malaria prevalence in the country showed a gradual movement from hyper and holo-endemic to meso-endemic status. I am happy to inform that the National Malaria Elimination programme is currently undertaking a structured study, the National Malaria Indicator Survey, with the support of the Roll Back Malaria (RBM) partners that will provide a more realistic and representative national malaria profile.

Furthermore, the FMoH estimates a financial loss from malaria in the form of treatment costs, prevention, loss of man-hours, and so on, to be roughly N132 billion per year that is approximately $838,564,000. How true is this? If no, what is the true picture?

This estimate was actually made by Jefney Sachs in 2001 and took into consideration costs incurred from procurement of drugs and loss of man-hours resulting from absence from work among others. These are not exaggerations. However, this cost is gradually decreasing due to the deployment of interventions by government and partners. So, it might actually be lower now. The programme is desirous of carrying out studies that will provide us with a more realistic estimate. Patriotic Nigerians with expertise in this field are encouraged to bridge this knowledge gap as corporate social responsibility.
Malaria has been linked to poverty. It is said that the disease is directly contributing to poverty, low productivity, and reduced school attendance in Nigeria. What is your take on this?

This is actually a statement of fact. Malaria is both a cause, as well as a consequence of poverty. A victim of malaria cannot be productive. S/he not only loses income but also expends the money he has to seek respite. Both scenarios lead to poverty. A child that is sick with malaria may not be able to go to school and frequent malaria episodes lead to suboptimal intellectual development, which is a recipe for poverty.

The World Health Organisation (WHO) and other stakeholders have changed from the concept of control to elimination of malaria. Is it possible to eliminate or rather eradicate malaria?

Elimination is essentially a country-level goal, while eradication is a global matter. Eradication happens when every country in the world attains a malaria free status also known as elimination. It is possible to eliminate malaria in Nigeria, if we all work together. The aim is to break malaria transmission among the population. It is quite challenging but with determination and commitment it is achievable. Nigeria has to key into the current global agenda of elimination to avoid losing out, as was the case in the global malaria eradication programme of the 50s.
Has Nigeria met the Millennium Development Goal (MDG) targets on malaria? Or rather, how have we fared in meeting those targets?

Based on the targets provided by the MDG, malaria transmission was to be halted in 2015 and a reverse in the incidence of malaria was expected to have commenced. Though we are yet to halt the disease in Nigeria, we are making great strides towards reducing the burden of the disease to an insignificant level. Cumulatively, the successes recorded in malaria control and elimination have contributed significantly to the success recorded for other MDGs, especially maternal and under-five mortality. The MDGs provided three indicators to measure progress for malaria.

The first is incidence and death rates associated with malaria. For this, it is important to note that the percentage of under-five mortality declined from 201/1000 in 2003, 157/1000 in 2008 to 128/1000 in 2013. The progress in malaria control is largely contributory to this feat because malaria is said to contribute to 30 per cent of childhood mortality. The second is the proportion of under-five children sleeping under ITNs. In this regard, the proportion of under-five, who slept under an ITN/LLIN, has increased from one per cent in 2003, six per cent in 2008 to 16 percent in 2013 (NDHS). For the third indicator, proportion of children under-five with fever, who are treated with appropriate anti-malarial drugs, has increased from 2.4 per cent in 2008 to six per cent in 2013, while the proportion of under-five who took any ACT the same day or next also increased from 1.1 per cent in 2008 to four per cent in 2013 (NDHS).

Going forward, what new things are you doing to eliminate malaria?

Nigeria aligns with WHO recommended interventions. Accordingly, we have put in place several of these to ensure the country achieve the targets of malaria pre-elimination by 2020. We have adopted a paradigm shift from focusing on the vulnerable populations to the entire population at risk. Also, new community based strategies have been adopted, some of which include the deployment of Seasonal Malaria Chemoprevention in the Sahelian region covering a population of about 40 million under five children. This involves administration of special antimalarial formulations to children less than five years of age during the malaria transmission season of about four months to prevent them from coming down with malaria.

The programme has also adopted an integrated approach by collaborating with other relevant line programmes and agency to promote integrated Community Case Management (iCCM), which incorporates other diseases with devastating effect amongst under-five children. Also, diagnosis is now being promoted at all levels, including all sale points and outlets for antimalarial medicines. This is to ensure that every suspected case of malaria is confirmed before treatment. We are also collaborating with the National Agency for Food Drug Administration and Control (NAFDAC) to ensure that only quality assured ACTs are used to treat malaria through the Mobile Authentication Service (MAS) code policy and similar initiatives. The programme has also positioned itself to now engage partners in more productive ways to improve service delivery at point of intervention.