Malaria Control Program
Mosquito

Background study



1.1 Introduction


Malaria has remained a major public health problem in Nigeria. It accounts for over 60% outpatient visits and 30% hospital admissions in Nigeria. The disease has impacted negatively on the economy with about 132 Billion Naira lost to the disease as cost of treatment and loss in man-hours.

Malaria is an infectious disease caused by the parasite of genius Plasmodium. The four identified species of this parasite causing human malaria are Plasmodium falciparum, P. vivax, P. ovale and P.malariae. In Nigeria 98% of all cases of Malaria is due to Plasmodium falciparum. This is the species that is responsible for the severe form of the disease that leads to death. It is transmitted from bites of an infected female anopheles mosquitoes to man.

Malaria is highly endemic in Nigeria. It poses a major challenge to the country as it impedes human development. It is both a cause and consequence of underdevelopment and remains one of the leading causes of morbidity and mortality in the country (2). Malaria accounts for about 63% (1) of all visits to public health facilities (Out-patient –attendances). Thirty percent of hospital admissions are also due to malaria. It is responsible for 29% of childhood death, 25% of infant mortality and 11% of maternal mortality (3, 10).

The economic loss to Nigeria due to malaria is estimated at N132 Billion annually (RBM) due to loss of man hours resulting from sickness absence and cost of treatment. It is a major cause of absenteeism from work and school. It contributes to poverty and results in poor pregnancy outcome.

In Lagos State, malaria is responsible for 70% of outpatient attendance at the secondary healthcare facilities and over 80% of all tracer diseases reported by primary healthcare facilities (HMIS).The most vulnerable groups are under fives, pregnant women, visitors from non-endemic areas, those with sickle cell anaemia, HIV/AIDS.

The burden of the disease has been a major source of concern to Government and development partners. The expression of this challenge has been translated through many instruments: such as Abuja Declaration in year 2000, Millennium Development Goals to reduce disease burden by 2015 and Universal Access to HIV/AIDS, TB and Malaria (ATM) in 2006.

The Female anopheles mosquitoes are the vector responsible for transmitting the plasmodium parasites. The commonest species is Anopheles gambiense and Anopheles funestus. These species of mosquito breeds in clear stagnant water especially in unused discarded tyres, broken pots and other areas where water can collect.

In a Metropolitan area like Lagos State, where peoples behaviour coupled with environmental factors encourage the breeding of mosquitoes and thus increase human vector contact which promote the continuous transmission of infection, it is important to position malaria control as a top priority for Government intervention

1.2 The burden of Malaria

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The burden of malaria is quite high. It is responsible for 300 – 500 clinical cases per year. 80% of these occur in Africa. It is responsible for 1 million deaths per year all virtually due to P. falciparum; 90% of these are in Africa.

Malaria impedes human development and is both a cause and consequence of under development. Every year, Malaria is said to cost Africa an estimated $12 billion in lost productivity. Nigeria loses over N132 Billion from the cost of treatment and absenteeism from work, schools and farms to cost effective drugs and insecticides.

Other effects of malaria could be seen in the following areas:
- Technology: In Research and Development (R&D) due to increasing drug resistance to hitherto cost effective drugs and insecticides.

- Socials: The nuisance of mosquitoes with the noise and Sleep disturbance.

- International Cooperation: Malaria has negative effects on tourism and travels especially during the high transmission seasons. 1.3 Roll Back Malaria

The Roll Back Malaria (RBM) Partnership was launched in 1998 by the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF), the United Nations Development Programme (UNDP) and the World Bank (11). Through RBM, Malaria control comprises the following four primary strategies (11):
1. Case Management using Artemisinin-based combination therapies
2. Insecticide-Treated Nets (ITN) and other vector control measures.
3. Providing Malaria Treatment and Intermittent Preventative Therapy (IPT) for pregnant women.
4. Improving Malaria epidemic preparedness and response.
The goal of the RBM is to halve the malaria burden through interventions that are adapted to local needs. The African summit on Roll Back Malaria was held on the 25th of April in year 2000, Forty-four of the 50 malaria-affected countries in Africa were represented at the summit in Abuja. Nineteen heads of state were present, as well as prime ministers, vice-presidents, ministers of health, and many other partners (11).

African leaders committed themselves to halving malaria mortality in Africa by 2010 through implementation of strategies and activities agreed upon at the summit. They promised to ensure that, by 2005:
• at least 60% of those suffering from malaria have prompt access to affordable and appropriate treatment within 24 hours of the onset of symptoms

• at least 60% of those at risk of malaria – particularly pregnant women and children under five – benefit from personal protective measures such as insecticide treated bednets.

• at least 60% of all pregnant women at risk of malaria have access to chemoprophylaxis or preventive intermittent treatment.

Amongst other things, they pledged to promote community participation in rolling back malaria, make diagnosis and treatment available and accessible for the poorest groups, prevent re-emergence of malaria, provide reliable information on malaria to decision makers at all levels (from household to national level), and reduce or waive tariffs for mosquito nets, insecticides, antimalarial drugs and more.

Roll Back Malaria implementation is hinged on eight pillars:
• Emphasis on country ownership of the programme.
• Building and strengthening RBM partnership.
• Contribution to health system reform.
• Integration of Malaria control activities in Primary Health Care (PHC) and other social activities.
• Increasing cost-effectiveness interventions.
• Strengthening community participation.
• Strengthening health information systems and research.

1.4 MALARIA SITUATION ANALYSIS


A malaria situation analysis was carried out by the FMOH in year 2000 and some of the findings are as follows:
• The perception of the cause of malaria is poor and very few people link mosquito to malaria.
• 80% of malaria cases are inadequately managed at community level by the facility and home based caregivers.
• 96% of caregivers initiated actions within 24 hours but only 15% of their actions were appropriate due to inadequate dosage.
• 60% of mothers had no knowledge of the current management of convulsions. Only 5% referred such cases to hospital while most either go to traditional healers or use traditional home made concoctions.
• Improper use of parentheral antimalarials.
• Only 5% of antimalarial drugs are produced in Nigeria.
• 85% of health facilities surveyed in rural areas had stock out. None had prepackaged drugs.
• 51% of mothers obtain drugs patent medicine vendors, 89% of the drugs were found to be substandard and 43% of syrups unsatisfactory.
• Non availability of treatment guidelines in sample health facilities.

1.5 GOALS AND OBJECTIVES OF IMPLEMENTATION OF RBM IN LAGOS STATE


1.5.1 Goals

• To halve the malaria burden by 2010.
1.5.2 Objectives

• To reduce by 50% the present mortality and morbidity due to malaria in children under the age of 5 years by the end of year 2010.
• To reduce the malaria prevalence from 50% population having at least one attack to 25% population having one attack.
• To lead to a reduction in all cause child mortality by 20% by the end of year 2010.

1.5.3 Targets


- 80% coverage for effective case management.
- 80% coverage of population at risk for ITN.
- 100% coverage for Intermittent Preventive Treatment for pregnant women.

1.6 NATIONAL ANTIMALARIAL TREATMENT POLICY



The strategy for the implementation of the National antimalarial treatment Policy is that of Roll back Malaria. The RBM strategy for the Control of Malaria has four key elements:
1) Patients with malaria should have access to appropriate and adequate treatment within 24 hours of the onset of symptoms.
2) Pregnant Women particularly in their 1st and 2nd pregnancies should have access to effective antimalarial prophylaxis and treatment.
3) Insecticide treated nets and other materials should be available and accessible to persons at risk of malaria particularly pregnant women and children under five.
4) Epidemics of malaria should be recognized and steps taken for their containment within one week of their onset.

Consequent upon the result of the Drug Therapeutic Efficacy tests carried out in 2002 and 2004, there has been a change in the drug policy from Chloroquine and Sulphadoxine-Pyrimethamine to Artemisinin based combination therapies (ACTs). The policy has also adopted the use SP for Intermittent Preventive Treatment of Malaria in Pregnancy.

2.0 GOALS, OBJECTIVES & TARGETS


2.1 Goals

• To halve the malaria burden by 2010
2.2 Objectives

• To reduce by 50% the present mortality and morbidity due to malaria in children under the age of 5 years by the end of year 2010.
• To reduce the malaria prevalence from 50% population having at least one attack to 25% population having one attack.
• To lead to a reduction in all cause child mortality by 20% by the end of year 2010.

2.3 Targets


- 80% coverage for effective case management.
- 80% coverage of population at risk for ITN
- 100% coverage for Intermittent Preventive Treatment for pregnant women.

3.0 Methodology


Lagos State Malaria Control Programme has adopted the Roll Back Malaria Strategies.These strategies are:
1. Promotion of Effective case management of Malaria
2. Control of Malaria in Pregnancy
3. Promotion of the use of Insecticide Treated Nets
4. Integrated Vector Management
5. Behavioural Change and Communication
6. Monitoring and Evaluation
7. Building Partnership
8. Operational Research
The methods for implementation include:
• Training and capacity building for Health workers
• Sensitization and capacity building for caregivers at the community level.
• Public enlightenment programmes.
• Advocacy.
• Free distribution of Insecticide treated nets.
• Free Treatment of Malaria cases.
• Field epidemiological research.
• Data tracking and analysis.

4.0 LAGOS STATE RBM CONTROL ACTIVITIES. (2005- date)


The Lagos State Government has always positioned Malaria control as a top priority even before the Roll Back Malaria Initiative and the Abuja call for Action. The State Government has been working on ways to improve and increase access to prompt and adequate treatment of Malaria cases in a programme termed Eko Free Malaria. Antimalaria drug is provided free for all patients who presented at the outpatient department of all the public health facilities in the State.

Also, in recognition of the fact that Malaria is responsible for more than 70% of the outpatient attendance at the secondary health facilities in the State, the Government also institutionalize a devolution programme for Malaria treatment. The Local Government Primary Health Centres now have the main responsibility of attending to cases of uncomplicated Malaria while the secondary and tertiary health facilities can now have more resources and time to attend to referred and complicated cases.

4.1 Case Management of Malaria


Prompt and effective treatment of Malaria is a critical element of Malaria control. In Lagos state, where most cases of malaria are due to Plasmodium falciparum and potentially fatal especially among the vulnerable groups, early and effective treatment could save many lives. It is vital that children under the age of 5 years, pregnant women and others have access to prompt treatment within 24 hours of the onset of symptoms, to prevent the progression-often rapid to severe malaria and death.
• Arthemeter- Lumefantrine now adopted as the first line treatment for uncomplicated malaria
• 1.240,000 Million doses of ACTs distributed through both public and private facilities (128 Public and 120 private for the Management of uncomplicated Malaria.
• 50 Copies of the National Antimalaria treatment guidelines and policy documents distributed to Heads of Medical Facilities.
• Training of 200 mothers ad caregivers(10/LGA) on Home and community management of Malaria.
• Training of over 2000 Patent Medicine Vendors on Correct Management of Malaria using the new artemisinin based combination therapy.
• Training and retraining of health workers in public and private hospitals on management and prevention of Malaria.
• Continuing Medical Education forum on Management of malaria has been organised at the State level for public health workers.

Table 1: Reported Cases of Malaria 1999- 2007


S/N Year Total Number of Malaria cases reported
1. 1999 213, 857
2. 2000 229,886
3. 2001 281,494
4. 2002 304,050
5. 2003 285,209
6. 2004 300,508
7. 2005 258,101
8. 2006 478,224
9. 2007 374,889
10 2008 428,856

Table 2: Reported Malaria deaths/Severe Malaria cases


S/N Year RSMC RMD
1. 2006 13,826 98
2. 2007 35,015 121
3. 2008 48, 603 59
Terms: RSMC = Reported Severe Malaria Cases
RMD = Reported Malaria Deaths

4.2 Control of Malaria in pregnancy/Intermittent Preventive Treatment


Malaria infection during pregnancy is a major public health problem in Lagos State. The main burden of infection results from Plasmodium falciparum like in any adult in Nigeria.
In areas of stable malaria transmission like Lagos State, most adult women have developed sufficient immunity that, even during pregnancy, P.falciparum infection does not usually result in fever or other clinical symptoms. Thus, the principal impact of malaria infection is malaria related anemia in the mother and the presence of parasites in the placenta. The resulting impairment of foetal nutrition contributes to low birth weight and is a leading cause of poorer infants’ survival and development.
The World Health Organization recommends that pregnant women in Malaria endemic areas should receive should receive two doses of Sulphadoxine -Pyrimethamine given at therapeutic doses at scheduled interval during the index pregnancy.
Studies in countries like Kenya and Malawi have shown that IPT with at least two treatment doses of SP is highly effective in reducing the proportion of women with anaemia and placenta malaria infection at delivery.

Specific activities implemented between 2005- date


• Intermittent Preventive treatment is now provided as Directly Observed under the supervision of either a trained Pharmacists or ANC service providers in Maternity outlets in the public health facilities in the State.
• However, documentation of this activity is very poor especially when it is not done at the ANC settings.
• More than 200,000 doses of Sulphadoxine -Pyrimethamine have been distributed to the maternity outlets in the Public hospitals in the State since 2005.

Table 3: Reported Malaria in Pregnancy cases


S/N Year RMiP NoD
1. 2006 13,826 1
2. 2007 15,536 Nil
3. 2008 17, 793 0
Terms : RMip = Reported Malaria in Pregnancy
NoD = Number of deaths

4.3 Integrated Vector Management including ITN/LLINs



Vector control remains the most generally effective measure to prevent malaria transmission and therefore is one of the four basic technical elements of the Global Malaria Control Strategy.
Integrated Vector management is a process of evidence based decision making procedures aimed to plan, deliver, monitor and evaluate targeted, cost effective and sustainable combinations of regulatory and operational vector control measures with a measurable impact on transmission risk, adhering to the principles of subsidiary, intersectorality and partnership.
The concept of IVM builds on selective vector control which the WHO Expert Committee on malaria defined as the targeted use of different control methods alone or in combination, in order to prevent or reduce human vector contact most cost effectively while addressing the issues of sustainability.
Integrated Vector Management as a method of Malaria control has the attribute of being environmentally sound, intersectoral, selective, targeted, cost effective and sustainable.
Malaria Vector control activities are guided by the following principles:
- Vector control is an essential element of vector borne disease control.
- Vector control activities do not constitute individual programmes but are components of integrated disease control programmes in line with the Health sector reform.
- Vector control interventions are undertaken with a view to preventing, reducing or interrupting disease transmission.
- It is based on sound knowledge of ecological and epidemiological situations, analysis of cost effectiveness and judicious integration of available options.
- It should be sustainable, environmentally sound, economically feasible and socially acceptable.

Specific intervention components of IVM which are targeted at various vectors include:
- Environmental management
- Larviciding
- Insecticide Treated nets
- Indoor residual spraying
- Other personal protection methods

4.3.1 Long Lasting Insecticide Treated Nets


Insecticide Treated nets are a low cost and highly effective way of reducing the incidence of Malaria in people who sleep under them, and they have been conclusively shown in a series of trials to substantially reduce child mortality in malaria-endemic areas. By, preventing malaria, ITNs reduce the need for treatment and the pressure on health services, which is particularly important in view of the increase in drug resistant falciparum malaria parasites.
Since 2000 more than One Million Insecticide Treated Nets have been distributed in the State to mothers of children under the age of 5 years either during integrated programmes with immunization campaigns or during stand alone campaigns in eight(8) of the twenty(20) LGAs in the State.
It is often considered that one of the main drawbacks of ITNs is the low re-treatment rate, however, with the newly developed long lasting insecticidal nets (LLINs), the issue of net re-treatment may be resolved as long as the price is not prohibitively increased by the specific treatment.

Specific intervention programmes conducted between 2005- date

• LLINs were distributed in 10 LGAs through Integrated campaign programmes and in 2 LGAs through Stand- alone campaign programmes.
• Intensive and supervised Environmental sanitation activities carried out in Amukoko, Lawanson and Mushin LGAs through Community Partners for Health.
• Monitoring of the pilot indoor residual spraying at Araromi, Isale Agoro, Ita Opo central Mosque, Okeposu and kasali Oluwo in Epe LGA.
• Table below shows the distribution pattern of LLINs in the State
Table 1: LLIN distribution in Lagos State.(2006-2008)
S/N LGA/COMMUNITY DM ND SOURCE
1. Epe Integrated Measles campaign 14,750 GF
2. Apapa ,, 28,000 GF
3. Ibeju Lekki IPDs 8,000 GF
Free Health Mission 1,200 GF
4. Ikorodu IPDS 55,000 GF
Free Health Mision 2,000 GF
Stand alone Ongoing USAID
5. Lagos Island IPDS 35,000 GF
6. Badagry ,, 30,000 GF
7. Amuwo Odofin ,, 35,000 GF
8. Eti Osa Child Health week 22,000 GF
9. Ikeja ,, 45,000 GF
10. Ajeromi Ifelodun ,, 72,000 GF
11. Ifako Ijaiye ,, 34,000 GF
12. Ojo IPDs 60,000 GF
Free Health Mission 2,000 GF
13. Somolu Stand- alone campaign 20,000 GF
14. Alimosho Health facility 17,000 UNICEF
2,000 GF
15. Ikeja GRA Community based 150 GF
16. Olowora Community based 150 GF
17. Mosun Okunola Community based 150 GF
18. Ajegunle ,, 150 GF
19. Igbogbo ,, 150 GF
20. (Flood victims) ,, 450 GF
21. Magodo ,, 150 GF
22. Amukoko ,, JICA
23. Lawanson ,, JICA
24. Mushin ,, JICA
25. Badagry Community based 2,000 PS
26. Itoike 600 ,,
27 Mainland Free health Mission 1440 GF
28 14 LGAs Health Facility 56,000 Compass
29 14 LGAs Health Facility 60,000 Compass
30 5 LGAs( Badagry, Ikorodu) Community based 15,000 PS
31 Campaigns Community based 120,000 Netmark

4.3 2 Indoor Residual Spraying


IRS remains the most widely used malaria vector control method. Its application has been thoroughly standardized and there are clear specifications for suitable equipment and insecticides. Field guidelines on technical and operational issues are available in almost all languages of malaria-endemic countries.
As the main effect of IRS is the killing of mosquitoes entering houses and resting on sprayed surfaces; it is not useful for the control of vectors which tend to rest outdoors, although it may be effective against outdoor biting mosquitoes which enter houses for resting after feeding.
IRS is a method for community protection and, to achieve its full effect, IRS requires a high level of coverage, in space and time, of all the surfaces where the vector is likely to rest, with an effective dose of insecticide. The selection of the insecticide has to take into account the susceptibility status of local vectors and duration of the residual effect in relation with the length of the transmission season.
IRS requires the acceptance of the population of spraying once or twice a year and a reasonable preservation of sprayed surfaces without replastering, in contrast with ITNs, which requires the continuous use of the treated nets. Thus IRS is more suitable than ITNs for the rapid protection of a population, although when IRS needs to be continued for many years, there may be an attrition of people’s acceptance of spraying. In contrast, ITNs are more suitable for progressive introduction and incorporation into sustainable population habits.
As already pointed out, long before the extensive use of ITNs, remarkable progress against malaria was achieved by IRS. It is important to arrive at rational criteria for choosing between these methods. At present it seems that the choice is made on whether or not the country has a national IRS tradition and the structures to deliver the intervention in time and with the required coverage rate.
Requirements for successful use of indoor residual spraying method:

- The mosquitoes are mostly endophilic i.e the mosquitoes rest indoors.
- Residents have a permanent abode and not migratory
- Households willingness to accept spraying.
- Ability to organize the delivery of spraying on time to all Malaria areas including information on number and location of houses to be sprayed.
IRS activities in Lagos State
• Pilot of Indoor residual spraying in 3 communities in Epe Local Government Area.
• Monitoring of the effectiveness of IRS in Araromi, Isale Agoro, Ita Opo central Mosque, Okeposu and kasali Oluwo.

4.4 Behavioural Change Communication and Advocacy


• Sensitization and advocacy seminar for heads of public health facilities on the Current antimalaria treatment guideline and policy.
• Community mobilization and awareness programmes conducted in 15 Communities in the State.
• Distribution of 20,000 copies of Information handbook on malaria.
• Distibution of posters on Malaria in Pregnancy and Malaria/vector Control.

4.5 Monitoring and Evaluation of programmes


• Supervision of the utilization of Malaria commodities at the General Hospital and LGA PHCs.
• Coordinated the 2007 ITN/IPT survey at Ikorodu and Badagry LGA. Preliminary findings showed low awareness of IPT, Low IPT1 and IPT2 coverage, Low ownership and utilization of Long lasting Insecticide treated nets.
• Six(6) meetings held with LGA Malaria Programme Managers and feedback was provided at these meetings.
• Assessment of the Knowledge, attitude and Practices on Malaria prevention and management and Community parasitemia in Oko Baba community, Makoko, Lagos Mainland LGA.
• Training of State and LGA Malaria focal person and representatives of Civil society organizations.

Malaria morbidity statistics for 2007 (Refer DSN Report)



4.6 Strengthening Effective Partnership


• Quarterly meetings of the State Roll Back malaria Partners Forum. Feedbacks are provided at these meetings and activity reports were shared.
• Training of Private service providers on current malaria management and distribution of seed stock of 100,000 doses of Arthemeter -Lumefantrine to 126 facilities.

4.7 Health System Strengthening


• Training of Health workers at LGA and Secondary Health centres on current Malaria management.
• Training of Private Health service providers on Current malaria management and Intermittent Preventive therapy.
• Continuing Medical Education for staff of Secondary Health facilities on Malaria management.
• Development of the 1st draft of the State protocol on Antimalaria treatment in order to standardize treatment.

5.0 Impact Assessment.


This has not been carried out since inception of the programme.

6.0 Financial Implication


Funding sources.
1. State Ministry of Health.
2. National Malaria Control Programme.
3. Global Fund for Malaria.
4. Development Partners: WHO, UNICEF.
5. International Partners: COMPASS, SFH