COVID-19 disrupting efforts to eliminate malaria in Nigeria, says Mohammed

Dr. Audu Bala Mohammed is the National Coordinator, National Malaria Elimination Programme (NMEP). Mohammed in this interview with The Guardian ahead of the World Malaria Day (WMD) 2020, today, among other things said the novel coronavirus (COVID-19) is disrupting efforts to eliminate malaria in Nigeria. The medical doctor, however, explained how NMEP is tailoring malaria interventions in the COVID-19 response. CHUKWUMA MUANYA writes. Excerpts:

The COVID-19 pandemic has led to the neglect of other diseases especially malaria. What is the situation and level of this neglect and the implications?
The NMEP recognised the challenge faced by the Government and the tough decisions that has to be taken. To this end the NMEP oversees two major types of malaria services – preventive services inform of campaigns and routine distribution and curative services in terms of diagnosis and treatment. All health facilities are open to provide curative services of testing and treatment at all levels. However there is the challenge of having adequate Personal Protective Equipment (PPEs) or people having information that they can access the health facilities. Those that are related to prevention such as campaigns are undergoing in house review to continue components of those activities that can be handled via online platforms in preparation of actual implementations. In this regard we are in touch with state malaria programmes. I want to use this opportunity to however, make a special request to support movement of the malaria commodities across the country.

Can Nigeria still eliminate malaria?
Elimination is a goal and the country remains committed to that goal. This however requires that we must not loose any of the grounds of success we have covered.

Malaria is a major public health issue in Nigeria, with 100 per cent of the population at risk. The country has the highest proportion of malaria cases (27 per cent) and estimated malaria deaths (30 per cent) globally; nationally, the malaria burden accounts for 60 per cent of outpatient visits to health facilities and 30 per cent of child mortality. The geographic spread of the malaria burden is heterogeneous in the country, with the highest prevalence among children ages six to 59 months in the North Central, North East and North West regions, and the lowest prevalence in the South East region.

Malaria kills an estimated 95,844 Nigerians and infects 57 million yearly. This burden occurs despite efforts by the government at all levels, the private sector and the international community, to stem the tide of malaria in the country.

Nigeria accounts for 53 percent of malaria cases in West Africa and 25 percent of the global malaria burden. Nigeria contributes more that 45 percent malaria deaths in West Africa which kills about 11 people per hour.

From 2010 to 2018, there had been a steady decline in malaria-related deaths from 145,000 to the current figure of 95, 844. Due to financial incapacity the intervention had not been on any significant scale in 13 states of the federation. Government and development partners had only met about 50 per cent of the required $551,354,810.

Consequently, government had approached some lending institutions, including the World Bank, African Development Bank and the Islamic Development Bank (IsDB), to raise some financial instruments to address the gaps in some of the identified states.

Implications of unfilled gaps include risk of increased malaria morbidity and mortality, threat of a weakened work force with decreased productivity with consequences on development, loss of confidence in public health programs among others.

Our strategic plan for 2020-2022 is to accelerate the pace of malaria elimination by focusing on five critical areas which are promote and support business on workplace and community programs, policy and advocacy, partnerships, expand work in high-burden countries, communication and membership.

April 25 is World Malaria Day. What are the global and national themes and what informed the choices?
The WMD is a special day set aside for promoting global awareness on malaria and the current global efforts. The Global focus is a ‘Malaria Free World’ and the theme for the WMD is ‘Zero Malaria Starts With Me’. Countries have various adaptation to address that theme from different perspective. In the light of the COVID-19 challenge, Nigeria is emphasising the need for testing cases of fever and the use of Long-Lasting Insecticide Nets (LLINs) at this season when potentially there can be an upsurge in malaria as a result of the rains.

How far with the faking of antimalarials globally and in Nigeria? Is the situation going up or rising? If yes or no, why?
The National Agency for Food and Drug Administration and Control (NAFDAC) is better positioned to provide the current state of the quality of antimalarials. However our interactions with NAFDAC based on their monitoring of quality of drugs shows that presence of substandard Artemisinin-based Combination Therapies (ACTs) are very low in the Nigerian market. However the quality of drugs is something that requires extensive vigilance and I am happy that NAFDAC has a good system

Another big issue about malaria is treatment failure. Why does it persist?
Treatment failure is not the same thing as resistance. In simple terms, it means in a given instance the objective of a treatment has not been met. This can be due to a number of reasons such as – not taking the correct dose, treating the wrong condition, the quality of the drug at the point it is being taken, vomiting the drug, taking another drug that can counteract the effect you need from your other drug etc. It may also mean that the drug is not effective. It is this last component that is called resistance. We check for that regularly through what we call Therapeutic Efficacy Studies. As our last check in 2018 we have a sensitivity of above 95 per cent for the all the ACTs we deployed programmatically.

There are reports of rising cases of drug resistance strains of malaria as well as drug failures in the country. What is the true picture and what is NMEP doing about it?
I think I have answered that question.

In other climes they are beginning to use sterilisation of the mosquitoes through genetic manipulation to control the spread of malaria. Is Nigeria contemplating this?
Not at this moment

Is there any relationship between malaria and COVID-19?
There is none that we know of for now. We do not have evidence to support the notion that COVID-19 is less prevalent where malaria is endemic, however you can have co-morbidity and both have fever as entry point hence, need to test all cases of fever with malaria Rapid Diagnostics or microscopy.

Interestingly most malaria drugs such as chloroquine, hydrochloroquine and ACTs have shown promise in the treatment of the novel coronavirus. What is the true picture?
There are World Health Organisation (WHO) coordinated studies ongoing looking at all candidate drugs. When concluded we would have the best scientific evidence. For now there is insufficient evidence to establish use or non-use. However, people should be cautious in use of hydrochloroquine especially overdose of it.

The situation has led to the contemplation in some quarters for the reintroduction of chloroquine on the management of malaria in Nigeria or rather the kick-starting the local manufacture. What is your take on this?
The decision to change from chloroquine to ACTs was strongly supported by evidence. It was a decision at two levels. First level was the fact of chloroquine resistance, which had become so wide spread. Here in Nigeria in 2004 chloroquine was just 34 per cent sensitive, meaning only one out of three patients treated will get well. Imagine if you treated 10 million, six million will not be cured. Now if you treat 100m? So you can appreciate the scale of the problem. The second level of the decision is that experience demonstrated that all mono-therapies – using a single drug to treat malaria- would ultimately result in resistance. So to limit and significantly delay the emergence of resistance there was a major shift in policy to now use combination treatment, especially combination of drugs that include artemisinin and another partner drug. To go back to chloroquine because of COVID-19 is not a rational action under any guise.

What are your recommendations on how to eliminate malaria in face of COVID-19?
We have rolled out plans on how to meet the agency’s mandate of eliminating malaria.
NMEP aims to free Nigeria from the scourge of malaria through leadership and coordination in developing policies, strategies and guidelines that would ensure the delivery of high impact malaria intervention equitably with a high sense of accountability.

One of his cardinal objectives in office is to increase the drive for productivity and hard work in the National Malaria response system.We will strive for the highest level of excellence in staff performance within the National Malaria system to achieve best practice in programming and outcomes. We will also aim for the best deployment of services and resources for optimum impact on beneficiaries.

To reduce the malaria burden, the Government of Nigeria, through the NMEP and in collaboration with partners, is scaling up malaria prevention and treatment interventions in line with the goals of the National Malaria Strategic Plan (NMSP) 2014–2020. Under this strategic plan, the NMEP is striving to increase insecticide-treated net (ITN) ownership coverage and raise awareness to increase ITN use. The NMEP employs a mixed-model approach for ITN distribution that includes free mass distribution campaigns and continuous distribution of ITNs to supplement the mass campaigns. Continuous distribution relies on several routine health service delivery channels: immunization campaigns; antenatal care (ANC); the integrated maternal, newborn, and child health week; school-based distribution; community-based distribution; and, distribution through the commercial sector.

Between 2014 and 2016, more than 60 million ITNs were distributed, which helped increase household ownership of at least one ITN from 8 per cent in 2008 to 69 per cent in 2015. The majority of households (77 per cent) received their ITNs through free mass distribution campaigns.

Following the recommendation by the WHO, the ITNs distributed by the NMEP have been long-lasting, insecticide-treated nets (LLINs). LLIN brands distributed in these mass campaigns include Duranet, Iconlife, Interceptor, Netprotect, Olyset and Permanet. Household ownership of at least one LLIN also reached 69 per cent in 2015. In Nigeria, most ITNs owned by households are LLINs; this is reflected in the matching proportions of households owning an ITN (68.8 per cent) and households owning an LLIN (68.7 per cent) in 2015. This indicates that the ITNs households own are LLINs. Therefore, in this study, both LLINs and nets that have been soaked with insecticides in the past 12 months will be referred to as ITNs.

To complement the ITN distribution efforts, the NMEP has also implemented advocacy, communication and social mobilization (ACSM) campaigns to improve knowledge of malaria prevention and control practices, create demand and increase the use of ITNs. Through these efforts, ITN use among the general population, children under five, and pregnant women has increased significantly since 2008.

Despite the improvements observed in ITN ownership and use at the national level, large gaps remain to reach the goals of the NMSP 2014–2020 of universal access to ITNs and 80 per cent ITN use among targeted populations by 2020. The increase in ITN ownership and use has also been uneven, with differences seen in household ITN ownership and use by place of residence, region of the country and household wealth quintile.

A study was conducted to guide future ITN strategies and investments to maximize impact increase proportionate coverage and enhance progress toward the universal access target of all populations at risk of malaria. It examined sub-national profiles of household ownership of ITNs and ITN use in the general population to identify the best predictors of ITN ownership, use and which specific sub-groups to target.