BY EWEDAIRO SODIQ AYODEJI
INTRODUCTION
Malaria is one of Africa’s (Nigeria inclusive) most daunting public health challenge, accounting for 5% of all deaths on the continent in 2019 (Statista, 2019). Although concerted antimalarial efforts have caused commendable progress in recent years, the impacts of malaria remain rife across Nigeria ranging from high mortality rates to morbidity and economic loss in terms of healthcare expenditure and viable development that is being forgone due to the inability of sick people to participate adequately in socioeconomic growth. The resilience being exhibited by malaria rightly suggests that more efforts must be expended towards securing innovative approaches that can prevent, diagnose and treat malaria. To this end, this essay proffers six innovative strategies to overcome malaria, all of which cuts across a wide range of disciplines, including public health, engineering, epidemiology, entomology, data technology and economics. Further, this essay shall submit partnership models between tiers of governments, community organizations, private sector investments and the WHO with the end goal of collaborating to eliminate malaria in Nigeria.
THE IMPACTS AND PROPELLANTS OF MALARIA IN NIGERIA
Although malaria is not peculiar to Nigeria alone, its prevalence and impacts are more ravaging here than in any other region of the world. In 2019, for example, Nigeria recorded 191,106 deaths attributed to malaria, in contrast with 0 deaths recorded in the U.S (Roster & Ritchie, 2019). Likewise, only a few African countries have been certified malaria-free by the WHO, namely: Algeria, Morocco, Tunisia, Libya, Lesotho, Seychelles and Mauritius. The situation is much worse in Sub-Saharan Africa, a region which accounts for 90% of all malaria-related deaths globally. Of this figure, children and pregnant women suffer disproportionately, with 80% of all malaria deaths in 2021 made up by children under the age of 5 (WHO, 2019). Importantly, the prevalence of malaria overwhelms the health systems in Nigeria, preventing them from being available to attend to more critical conditions like neonatal illnesses and HIV/AIDS.
In order to curb these impacts, concerted efforts have been taken by governments, NGOs and collaborative schemes aimed at preventing, diagnosing and treating malaria. Yet the problem persists in Nigeria due to a host of complex factors. Firstly, the Nigeria climate is naturally suitable for the reproduction and propagation of resilient malaria vectors and parasite species such as Anopheles gambiae, An. funestus and Plasmodium falciparum, the latter being responsible for 90% of global malaria mortality. This natural vulnerability is being exacerbated by climate change. Malaria parasites ideally thrive at temperatures between 25°C and 30°C, and most African countries(Nigeria inclusive) have entered this threshold. Between 1901 and 2021, the average temperature in Central African Republic, moved from 24.95°C to 25.78°C (Stonely, 2023) With increased temperatures and rainfall across Africa, hotter and more humid territories favourable for malaria parasites and mosquitoes to survive and transmit malaria are expanding rapidly.
Secondly, prevention and treatment efforts are being frustrated by resistance to drugs and insecticides by mosquitoes and parasites. As a result, these mosquitoes develop an immunity to measures that once tackled them. For instance, while sulfadoxine-pyrimethane was utilized effectively to treat malaria caused by Plasmodium falciparum after the efficacy of chloroquine declined, a 2009 study in Tanzania revealed that it failed to treat malaria successfully 82.2% of the time. The same experiences were encountered in Gabon, Cameroon, and the Republic of Congo. Similarly, resistance to pyrethroids, an insecticide used to treat mosquito nets, has been recorded. World Malaria Report 2020 carried out by WHO found pyrethroids resistance in 69.9% of sites where data was available. Furthermore, malaria parasites continue to develop mutations which makes them undetectable to the most common rapid diagnostic tests (RTDs) conducted in Africa. Consequently, malaria in the host’s system develops into severe stages and is transmitted widely before it is eventually detected at already critical stages. Lastly, local anti-malaria efforts suffer from poor health financing, paucity of functional health facilities and manpower and susceptibility to weak governmental institutions that lack the capacity to diligently pursue malaria control efforts. To put this narrative in perspective, the totality of North and South America has a ratio of 24.8 health workers per 1000 people. In Africa (Nigeria inclusive), however, we have an appalling ratio of 2.3 health workers per 1000 people (Stonely, 2023). All of these restrict access to adequate healthcare, making it even more difficult to treat and curb malaria.
SOLUTION STRATEGIES TOWARDS COMBATING MALARIA IN NIGERIA
The first step towards overcoming malaria is controlling the population and spread of vectors in order to prevent the incidence of malaria altogether. Because of our natural proclivity to malaria prevalence, preventing malaria transmission would involve some degree of difficulty and new innovative approaches that might have never been deployed before in Nigeria. One of these is engaging entomologists to strategically release genetically modified and sterilized male mosquitoes to mate with females in order to reduce mosquito procreation. These mosquitoes retain the ability to mate, but are unable to produce offspring. We must make the most of our efforts by implementing this during rainy seasons when mosquitoes breed rapidly and spread disease. Also, this should be initially performed small-scale on open fields in damp communities before replicating it fully across wider territories, starting from the most disturbed communities.
Secondly, in enhancing prevention, insecticide treated-nets (ITNs) and indoor residual spraying have been a mainstay in Africa (Nigeria inclusive), and they ought to remain so. However, the use of these equipment needs to be more sensitive to insecticide resistance and the emergence of new parasites. By 2017, mosquitoes resistant to pyrethroids-treated nets had spread over 45% of East Africa (BDI, 2020). To maintain the efficacy of ITNs, Nigerian government must cooperate with WHO to disburse new ITNs that are composed of pyrethroids and chlorfenapyr together. This hybrid system works because it is unlikely that mosquitoes would be resistant to both insecticides. Health professionals must collaborate with community organizations to carry out widespread net retreatments on pyrethroids-only nets using both pyrethroids and chlorfenapyr. Furthermore, prophylactic medications must be made available in areas with high transmission intensities to ensure that those who do not have the disease maintain their status. In doing this, priority must be given to high-risk demographics such as pregnant women and younger children.
Thirdly, Nigeria needs to beef up health infrastructure and improve treatment and access to health services for malaria victims and those in endemic areas. To achieve this, we must harness the proximity of local medicine vendors to affected households. Access to malaria treatment has been stifled by a shortage of health facilities particularly in rural parts of Nigeria. In Togo, research on children under the age of 5 showed that 83% received malaria treatments from their homes with antimalarial drugs obtained from street vendors (Stonely, 2023). Another study in rural Kenya found that only 32% of its subjects lived within 2km of a formal clinic, while 87% were within 1km of a medicine vendor (Stonely, 2023). Unfortunately, these vendors are often misguided and ill-equipped, thereby compounding the malaria problem through misdiagnosis, drug overdose and other practices that can lead to severe illness and death. We can exploit their local presence to improve healthcare by offering inter-disciplinary training and orientation programs to enhance their service delivery, as well as providing basic medical equipment like microscopy which would unlock access to appropriate healthcare for remote communities detached from sophisticated clinics and hospitals.
Fourth, it is expedient to improve our surveillance systems in order to ensure that our antimalarial strategies remain effective amidst recurring incidences of drug resistance and mutations in many malaria parasites. Evidence of resistance to drugs and insecticides used on treated nets and indoor residual spraying are manifold. In some countries, the efficacy of proven drugs was found to have fallen below WHO’s acceptable success baseline. To combat this, epidemiologists can carry out molecular surveillance—by collecting and scanning a few drops of blood—that would help understand the mutations responsible for this resistance, and to make corresponding modifications in the composition of drugs and insecticides that would be utilized in these territories. Although molecular surveillance processes are cheap and easy, governments must partner with the private sector to secure heavy investments into building other surveillance systems that can detect relevant patterns if we want to make any meaningful impacts.
Fifth, the quality of malaria diagnosis needs to be ramped up. This improvement is needed because of widespread gene deletions that have rendered the dominant RTDs less effective in spotting malaria infections and parasites. For example, due to the emergence of malaria parasites that do not carry HRP2 protein, there have been numerous reports of HRP2-RDTs failing to detect such parasites. In the Horn of Africa region, a survey revealed that HRP2-RDTs failed to identify P falciparum cases more than 50% of the time (WHO, 2021). To tackle this, we can improve diagnosis by engaging engineers to integrate new diagnostic technologies like Loop-mediated isothermal amplification assay and other non-HRP2 RDTs into the present system. Engineers must work together with data analysts using geographic information systems in order to determine the most vulnerable areas that must be targeted for urgent intervention. Countries in North Africa that are currently less affected must deploy surveillance systems to detect similar gene deletions so that swift action can be taken once these mutations begin.
Lastly, there is no gainsaying the fact that the chances of defeating endemic diseases like malaria are tied to political stability and economic growth which facilitate the execution of health programs and the construction of sound health systems and climate-resilient communities. Unsurprisingly, the defeat of malaria in numerous countries like China and the U.S was achieved during prolonged periods of exponential economic growth. Nigeria must be prepared to do the same. We must engage economists to devise policies and private-public partnerships that can finance malaria control innovation and upscale defunct healthcare into modern and effective medical facilities. Likewise, governments must engage community organizations to initiate and sustain programs which enhance basic sanitation and nutrition.
THE PROSPECTIVE IMPACT OF IMPLEMENTING THESE STRATEGIES ACROSS NIGERIA
One might wonder, “how do these strategies make any difference in the grand of scheme of things?”
Firstly, by using prophylactic medications and releasing sterilized mosquitoes to mate with female anopheles, we can massively reduce the intensity of malaria transmission happening at given periods. This would result in smaller numbers of people being in need of malaria treatments at the same time. Consequently, the number of distressed people who cannot receive treatments as a result of system overhaul or shortage of drug supplies would be reduced significantly.
Second, widespread usage of ITNs have the potential to reduce both the lifespan and number of mosquitoes in communities where more than half the populace make use of ITNs. This is because mosquitoes are repelled by effective insecticides. By providing pyrethroidschlorfenapyr treated nets in place of older nets that are being resisted, we can achieve the benchmark required to activate mosquito-free communities.
Finally, by improving health infrastructure through the development of modern infrastructure and by employing the skill of medicine vendors, we can cut down the frequency of untreated malaria in the continent. Africa (Nigeria inclusive) currently has the highest rate of untreated malaria in the world. Furthermore, educating medicine vendors and empowering them with basic health equipment will reduce undocumented cases of misdiagnosis. A study in Eastern Uganda on children who were prescribed chloroquine by medicine vendors found that only 34% were prescribed an amount that followed safety guidelines (Stonely, 2023). Educating and empowering these vendors will help reduce outcomes like this that can result in death.
CONCLUSION
In conclusion, the severity and impacts of malaria in our country is immense. Notwithstanding, there is an allowance for this health concern to spiral out of control if we fail to take calculated efforts towards curbing malaria. Therefore, our response needs to be elaborate and multi-faceted, including inputs from people of all groups and fields. By pooling knowledge and resources from different disciplines together, we can build innovation to reduce the risks and impacts of malaria in Nigeria.
References
Statista (2019). Distribution of the Leading Cause of Death in Africa. [Retrieved from] https://www.statista.com/statistics/1029337/top-causes-of-death-africa/
Max Roser and Hannah Ritchie, “Malaria,” Our World in Data, November 12, 2019, Retrieved from https://ourworldindata.org/malaria#citation
BDI (2020). Insecticide Resistance Increase Across Africa [Retrieved from] https://www.bdi.ox.ac.uk/news/tracking-the-spread-of-mosquito-in
A,. Stonely (2023). Prevalence of Malaria in Sub-Saharan Africa. [Retrieved from] https://ballardbrief.byu.edu/issue-briefs/prevalence-of-malaria-in-sub-saharan-africa
Avery Stanley (2023). https://ballardbrief.byu.edu/issue-briefs/prevalence-of-malaria-in-sub-saharan-africa
WHO (2019). World Malaria Report [Retrieved from] https://www.who.int/teams/global-malaria-programme/reports/world-malaria-report-2019
WHO (2021) The Urgent need to address high Prevalence of Gene Deletion in the Horn of Africa Beyond. [Retrieved from] https://www.who.int/news/item/28-05-2021-statement-by-the-malaria-policy-advisory-group-on-theurgent-need-to-address-the-high-prevalence-of-pfhrp2-3-gene-deletions-in-the-horn-of-africa-and-beyond
