Insight

Deepening malaria elimination fight despite COVID-19

Nigeria suffers the world’s greatest malaria burden, with approximately 51 million cases and 207,000 deaths reported annually. However, the unprecedented impact of coronavirus on malaria since its outbreak in the country last year has raised serious concerns, with experts now focusing on tackling both diseases simultaneously, to ensure that progress in the fight to eliminate malaria from Nigeria and the world at large is not only sustained but not reversed, writes APPOLONIA ADEYEMI

Malaria burden

Nigeria is one of the malaria endemic countries in Africa hence, conversations on malaria issues and activities are often a familiar terrain. Most feverish attacks in many far-to-reach rural communities and even urban areas are often ascribed to malaria.

Based on this, there is a business as usual attitude that pervades homes of several families whose children or relations suffer bouts of fever. This was what played out when a 15-yearold Junior Secondary School (JSS) 3 student, Tunde Yusuf, developed fever in May 2020 in the peak of the coronavirus lockdown in Nigeria. For the first three days that he was down with feverish symptoms – general body pain, high temperature, cough, catarrh, among others – he was mostly ignored by members of his family.

Beyond purchasing anti-malaria drugs for him from a nearby pharmacy at his Isheri- Oke residence, Ojodu-Berger area, a suburb of the Lagos metropolis, not much was done to enable him to get proper medical attention. Although he used the malaria medications which were combined with some antibiotics and analgesics, he was not relived from the discomfort, yet the self-medication of the ailment continued. Rather than improve, Tunde’s condition went from bad to worse and by the 10th day, his health had deteriorated badly. He could not get up from bed unassisted; neither could he feed himself, though he had no appetite.

Similarly, he experienced general body pain and chills, fever and occasional sweating. With the assistance of some concerned neighbours, his father, a roadside petty trader who deals in groceries, took Tunde on emergency to a nearby laboratory where his blood samples were promptly taken and analysed.

He tested positive for malaria parasite. Malaria is a life-threatening disease caused by parasites transmitted to people through the bites of infected female anopheles mosquitoes. Considering Tunde’s worsening condition,the laboratory staff advised that he should be taken to the Lagos State University Teaching Hospital (LASUTH), Ikeja, which has facility to admit patients for proper care. Sadly, on arrival at LASUTH before noon, the patient, his father and the accompanying neighbours met a brick wall; there was no bed space to admit him.

Although they were subsequently directed to the Lagos University Teaching Hospital (LUTH), Idi-Araba, Lagos, a federal health facility, he couldn’t be taken in there as well on the grounds of lack of bed space in the Emergency Section. Regrettably, after more than five hours in the vehicle that took him to LUTH, without getting any medical intervention, Tunde died. His body was deposited at LUTH mortuary. Tunde’s father, in whose arms he died, wept profusely. He cried for the attention of LUTH’s medical staff to come to his son’s aid, in the hope that he could still be revived, but it was to no avail. Tunde’s death, occasioned by malaria attack, was just one of such cases in Nigeria.

The country has recorded several of such deaths, not only from malaria but from other ailments during the coronavirus pandemic. The several malaria cases recorded in the country throughout the lockdown last year and still being witnessed are understandable.

Nigeria is a malaria endemic country; hence, the high number of reported malaria cases in communities. According to the World Health Organisation (WHO), Nigeria suffers the world’s greatest malaria burden, with approximately 51 million cases and 207,000 deaths reported annually (approximately 30 per cent of the total malaria burden in Africa), while 97 per cent of the total population (approximately 173 million) is at risk of malaria infection. Perhaps, based on this background, many believe that malaria attack is common among Nigerians.

Malaria cases perceived as COVID-19

The moment someone feels feverish symptoms – cold, catarrh, shrills, body pain, among others, This played out largely when coronavirus pandemic broke out in April 2020. Many patients, who became infected with coronavirus, undergone testing which returned positive for COVID-19, and taken into isolation centres for management, were also treated with ante-malaria medicines.

Among top Nigerians who survived COVID- 19 that related their experience in isolation centres with regard to the basic medications used in their treatment included the Bauchi State Governor, Bala Mohammed, the founder of Africa Independent Television (AIT), Chief Raymond Dokpesi, and Dr. Doyin Okukpe, the former spokesperson for former President Olusegun Obasanjo. The trio confirmed that ante-malaria drugs were administered on them, subsequently fuelling speculations in the public that what was treated at the various coronavirus isolation centres across the country was malaria, not COVID-19.

This confusion, particularly among commoners who constituted the majority of the populace, was palpable. Hence, it was common to hear Nigerians dispel conversations of persons down with COVID- 19 as cases of malaria.

For such Nigerians, the hues and cries about the ‘so-called’ coronavirus pandemic are unnecessary. As far as such people with that notion are concerned, these are cases of malaria: “It’s a familiar terrain; we know it; we can handle it; it’s nothing strange.”

However, behind the negative attitudes of many hindering the fight to overcome malaria, lie agonies such as the demise of Tunde, who lost his precious life to malaria disease. It was indeed a tragedy for his family! Many similar deaths occasioned by malaria occur in the country, yet, the perception that the disease is common and its infection expected regularly has persisted.

With an estimated 215 million malaria cases and 384,000 malaria deaths in 2019 globally, the WHO African Region accounted for about 94 per cent of cases and deaths globally. Although there were fewer malaria cases in 2000 (204 million) than 2019, malaria case incidence reduced from 363 to 225 cases per 1,000 population at risk within the period.

Malaria-COVID-19 link

Considering the issue of persons that tested positive for COVID-19 getting malaria treatment in isolation centres in Nigeria, a Public Health Physician, Dr. Aliyu Sokomba, explained that being infected with coronavirus doesn’t preclude that same person from malaria infection. He said: “Malaria treatment will be given to a COVID-19 patient to treat malaria if he/she manifests malaria symptoms.”

Sokomba, who is the chairman, Nigeria Medical Association (NMA) in Kaduna State, reminded Nigerians that irrespective of the coronavirus outbreak, they still live in a malaria-endemic region where most of the population are exposed to the bites of the female anopheles mosquitoes that transmit the plasmodium parasite, which causes malaria infection.

The mosquitoes pick up the parasites from infected people when they bite to obtain blood needed to nurture their eggs. Furthermore, the public health physician said it is not unusual for patients with coronavirus infection to manifest symptoms of malaria, typhoid, pneumonia, among other ailments. What is key is for health care professionals to treat those diseases, be it malaria, typhoid or pneumonia so as to prevent these ailments from further compromising the immunity of the COVID-19 patient.

Testing before treatment policy

While unravelling the confusion, a professor of Paediatrics at the University of Ilorin (UNILORIN), Olugbenga Mokuolu, who is the Malaria Technical Director, National Malaria Elimination Programme (NMEP) at the Federal Ministry of Health (FMoH), explained that COVID-19 presents with fever and it is a new disease. That fever may sometimes be the only symptom that people will see; there may be other minor symptoms and the fever could go away thereafter.

He said: “Malaria also has fever as a predominant manifestation. So, even in regular medical practice, we recognise those types of overlap. It wasn’t unduly too extraordinary that such confusion arose, to the extent that COVID-19 is still being confused with malaria in this environment.

“What is important is to move in as knowledge is increasing, in order to help pass the appropriate message. “That is why as far back as April 2020, we already began to make a lot of public messaging stating: ‘That fever that you have could be malaria and that people should get tested.’

The reason was to make people understand that they may have a treatable condition, rather than out of fear, sentence themselves to a different type of medical condition. “Hence, affected persons were encouraged to undertake testing so that if it is negative for malaria, we would also have achieved the added advantage of being able to know that they don’t have malaria.” According to him, subsequently, such persons can be investigated for other medical conditions. This is not a new policy. Since 2010, the WHO recommended that all suspected cases of malaria should receive a diagnostic test before starting treatment.

Explaining why this measure is useful, a Consultant Medical Parasitologist, Prof. Wellington Oyibo, who is the Director, Research and Innovation Office at the University of Lagos (UNILAG), said conducting medical test before the treatment of malaria is the most effective way to eliminate malaria in Nigeria. According to him, there are misconceptions between general fevers and malaria fever.

“People treat malaria using drugs bought over the counter. When they do not get better, they feel the drugs are not effective,” Oyibo said. When malaria diagnosis proves positive for the parasite, the WHO-recommended medications, which are the artemisinin combination therapy (ACT), are promptly administered on patients, effectively targeting the plasmodium parasite. Oyibo, however, reasoned that doing medical test before treatment is the best solution in tackling malaria.

Sadly, more than 10 years after that WHO recommendation to test malaria before treatment, a lot of treatment without diagnosis has persisted in the country, often blamed on poverty and majorly due to negative attitude to resist behavioural change that is based on scientific evidence and innovations. Although there has been an improvement in the level of malaria testing conducted in public and private facilities, the majority of malaria cases in both urban and rural areas, especially those managed in unorthodox settings, are treated without testing. That is why many Nigerians present with fever promptly assume it is malaria.

“Yes, the moment I felt that pounding headache, and body pain, I knew it was malaria. Those signs were clear malaria symptoms,” Adaeze Obi, a bank cashier, told her mother who she requested to purchase an anti-malarial drug for her use.

It is also very common to find those who administer anti-malarial medicines on themselves monthly, irrespective of whether or not they present with fever symptoms. Leye Aiyedun, a computer analyst and resident of Lagos, who practices this, said he uses the malaria drugs as a prophylaxis to prevent malaria, which he claims infects him monthly. While most elite, health care workers and facilities have adapted the WHO recommendations on testing before treatment, the majority of the rural and urban poor continue to treat malaria without testing. They just assume that malaria is not a serious disease that should bother them, but these are wrong assumptions because based on available statistics, malaria is a killer disease.

Among the most at risk population are preg-nant women and children under five. According to Mokuolu, there has been a progressive reduction in the burden of malaria in Nigeria. Data from the FMoH shows that in 2010, the burden of malaria in Nigeria was 48 per cent; in 2015 it dipped to 27 per cent, while in 2018, it further reduced to 22 per cent. How to sustain the progressive reduction in malaria burden in the country is the issue at stake presently, especially considering the negative impact of COVID-19 in all aspects of malaria fight – prevention, diagnosis, treatment, among other campaigns to eliminate the disease.

The goal of the Roll Back Malaria (RBM) Partnership to End Malaria is to combat malaria disease at global, regional, country and local levels. Dr. Abdourahmane Diallo, CEO of the RBM Partnership to End Malaria, said in 2020, the fight against malaria got harder, but so did the resolve of the global community. Countries’ heroic efforts helped prevent a doubling of malaria deaths in sub-Saharan Africa last year.

There is no doubt that COVID-19 hindered many people with complicated malaria and the not-so-severe cases, from accessing care in facilities during peak of the coronavirus lockdown from April to June 2020. Most patients, including those who suffered malaria infection, deliberately kept away from hospitals. With inadequate provision of personal protective equipment (PPE) for health care workers, the Nigeria Medical Association (NMA), the umbrella association of medical doctors in the country, advised its members to view every medical case in hospitals as potential COVID-19 case. That was the straw that broke the camel’s back.

From then onwards, seeking care at public facilities, which was affordable for many lessprivileged and low-income citizens, became like a camel passing through the eye of a needle. Those were the days when the ordeal of malaria patients and those seeking care for other ailments, was not pleasant; while some resorted to ignoring medical care, others chose self-medication, both with dare consequences.

Many unexplained deaths were recorded in Nigeria during that dark period. The good news, however, is that with the ease of the lockdown in the country in August, normal business and social activities gradually returned and hospitals have once again become accessible to malaria patients and people suffering other medical conditions.

Highlighting the serious impact COVID-19 had on malaria, Mokuolu told the New Telegraph that owing to the general restriction of movement arising from the coronavirus lockdown, many sick patients, including those that suffered malaria, hesitated to seek care in health facilities until they had clear evidence that they were severely ill before attempting to go on the road.

“That lockdown, because it was global, disrupted the supply of materials: testing kits for COVID-19, testing kits for malaria, long lasting insecticidetreated nets (LLINs), malaria preventive medicines, sulfadoxine pyrimethamin, among others.

“There was fear in accessing hospitals because they are sources of convergence of everyone with different types of illness. “There was a reduction to some extent in the use of health facilities based on the belief that it could be a fertile soil to acquire COVID-19.

“There was also the uncertainty and fear among health workers, who were conscious of the potential impact of the devastation that COVID-19 could cause; at a time many health facilities did not have sufficient PPE, when they cannot decipher whether the person standing before them is COVID-19 positive or not,” Mokuolu said.

There were also media reports showing that health workers were disproportionately the most affected from the early stages of the disease. They constituted a significant number of those being admitted into the isolation centres. As of June 2, at least 812 health workers have tested positive for COVID-19, according to the Minister of Health, Dr. Osagie Ehanire.

The exact number of health workers who have been infected with coronavirus in Nigeria so far could not be ascertained as of the time of filing this report. As health workers became infected, they were promptly isolated, meaning that they could not come to work, making most hospitals to rationalise the patient list they were attending to.

There were also health workers who were significantly above 55 years who needed to stay away from hospitals based on current guidelines at that time. Even before economic and social life gradually returned to normal, the FMoH through the Presidential Task Force on COVID-19, in line with WHO advisory, released from time to time, the NMEP consequently put up the Business Continuity Plan (BCP), a detailed evaluation of the risk assessment, showing major areas of potential disruptions in malaria elimination activities, planned programme implementations and the modification arrangements.

In this particular instance, the professor of paediatrics explained that based on the programme, “when we are treating malaria, we are not just thinking of people coming to health facility to take treatment, we are now thinking of the higher national response to malaria.

“That means that we are talking about a planned preventive malaria intervention such as the distribution of LLINs, the implementation of seasonal malaria chemoprevention (SMC).” SMC is the intermittent administration of full treatment courses of anti-malarial treatment combination on children at risk, during the malaria season to prevent illness and death. Mokuolu disclosed that approximately 11 million eligible children from across nine states of the federation benefitted from SMC during the pandemic last year.

The states are Bauchi, Borno, Jigawa, Katsina, Kano, Kebbi, Sokoto, Yobe and Zamfara. On LLINs distribution, it couldn’t be done across the 36 states and the Federal Capital Territory (FCT) owing to the size of the country. Hence, last year, 17,398,201 nets were distributed across six states – Adamawa, Benue, Zamfara, Kwara, Osun and Plateau. Net distribution to FCT could not be carried out as funding arrangement was still ongoing; hence, that plan was rolled over to 2021.

Based on the prevailing COVID-19 circumstances, the NMEP shifted communication to virtual; hence, most of the meetings of the programme were mounted on virtual platforms. “With that, we were able to sustain conversation,” Mokuolu added. However, sustaining the progress of malaria fight amidst the coronavirus pandemic is a huge task but doable.

While calling for the sustenance of activities to eliminate malaria, Diallo said, “we need up-to-date data and to apply lessons from the COVID-19 response, innovating and adapting our approaches in real time to have maximum impact against malaria”.

There is no doubt that working together as a team and applying evidence-based ideas, the pace of progress so far, could be sustained and even surpassed. For example, together, the global malaria community has prevented 1.5 billion cases of malaria and saved 7.6 million lives, according to the 2020 World Malaria Report. This success has put the world on a path to ending malaria. Since 2000, 21 countries reached zero malaria cases for three consecutive years, 10 of these have been certified malaria free by WHO.

Despite the several hurdles to cross not only in curbing malaria in this environment but eliminating the disease completely, countries which have achieved malaria elimination have renewed hope that Nigerians could do the same. Part of what to do is shifting from being adamant to adapting positive attitude towards battling malaria, especially adhering to recommended guidelines on testing and treatment. At the country level, it will be useful to invest in research and development (R&D) and initiate innovative tools, medications, among others.

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