Insight

Setting the pace for malaria burden reduction

Algeria is the second country in the World Health Organisation (WHO) African Region to be officially recognised as malaria-free, after Mauritius, which was certified in 1973. In Nigeria, achieving same feat may appear to be an arduous task, adapting to new malaria treatment guidelines, anticipating artemisinin drug resistance with a view to averting the trend, among others, could set the country on the journey to a malaria-free nation, writes APPOLONIA ADEYEMI

The last three months were traumatic for 14-year-old Tade Malaika, who had been severely ill. Two weeks before his death, the once vibrant Junior Secondary School (JSS) 3 student had developed a gaunt frame and sunken eyes. He became a shadow of his former self. Going by his physical features days before his demise, news of his death was not surprising. What was, however, shocking was that his death was attributed to malaria.

His body had hardly been deposited in a morgue in Abeokuta, the capital of Ogun State, when the news about the cause of his death spread like bush fire in the harmattan. “It is a lie! Don’t say it again. Do you mean that ordinary malaria killed Tade?” a close friend of his mother asked. “The doctors that cared for him for two days before he passed on confirmed that his health challenges emanated from malaria,” replied Tade’s bereaved mother, Mrs. Aina Malaika. Another sympathiser, who was in the late Tade’s home to pay condolences to Mr and Mrs Malaika, said: “If this is true, it is time one took malaria and how to prevent the disease seriously.”

“Wonders shall never end,” she added as joined other mourners in the home of the late Tade. Malaria is a life-threatening disease caused by a parasite transmitted to humans by the female anopheles mosquito. Although malaria is a preventable and treatable disease, if diagnosed and treated early, the duration of malaria infection can be considerably reduced which, in turn, could lower the risk of complications and sometimes death.

In Nigeria, data from the Federal Ministry of Health (FMOH) shows that malaria accounts for 60 per cent of outpatient visits and 30 per cent of hospitalisations among children under-five years. Deaths from malaria occur mostly from those with severe malaria, which contributes to between 10 to 25 per cent of the burden of death in children that are admitted in most emergency paediatric units, said Olugbenga Mokuolu, a professor of paediatrics at the University of Ilorin (UNILORIN).

According to Mokuolu, who is the Malaria Technical Director, National Malaria Elimination Programme (NMEP) at the Federal Ministry of Health (FMoH), about four per cent of malaria cases have the tendency to become severe and severe malaria carries approximately 10 per cent mortality; the reason is that by the time it is severe the patient is not contending with only malaria but with complications that have risen, all of which can kill the person. He said: “By the time the malaria is severe it is most likely that the affected patient does not have adequate blood.

“The person can die either because of inadequate blood or because of the severity of the malaria itself. So, there are many complications that are associated with severity. “That is why our key strategy is to prevent people with malaria infection from becoming severe because at that stage, you are really running against the clock.”

The case of Tade, undoubtedly, transited into severe malaria. Actually, Tade’s diagnosis, which tested positive for malaria, was conducted two days before his death. That was when he presented at the private hospital in Akute where he was rushed to in an emergency.

Three months earlier, the infection had manifested as flu-like symptoms, associated with high fever, headache, fatigue, among others but Tade’s mother, a trader selling cooked groundnuts to make a living, said she couldn’t afford to pay for a microscopy test to determine the presence of malaria parasite in the blood samples taken from her son. Worse still, while Tade’s ailment lasted, she had relied on medicines sourced from local drug sellers, many of whom were merchants without needed training on drugs.

Sadly, instead of getting better, the condition of her son had deteriorated badly, rendering him incapacitated. This drew the sympathy of neighbours who not only rushed him to the private facility but contributed the initial fees deposited on demand. However, the onset of treatment prompted a quick diagnosis by the caregivers, which showed the presence of plasmodium parasite,which causes malaria, in Tade’s blood sample. Although this detection was to pave the way for appropriate treatment, it was too late as his condition had already transited to severe malaria, resulting in anaemia.

He was promptly referred to a tertiary facility in Abeokuta, but Tade breathed his last while on the way to that hospital. Following his unexpected death, the concerns of Tade’s friends and relations prompted questions: what exactly happened? How could this young lad have succumbed to common malaria infection? Mrs. Malaika disclosed that throughout the months that her son was ill, she couldn’t afford to take him to either a public or private hospital for proper care. According to her, Tade relied more on self-medication sourced from roadside drug sellers. Besides, much of the intervention he received was from several unorthodox places, the majority of which were not licensed. This is a major factor inhibiting the fight against malaria in Nigeria, according to Mokuolu.

There is no doubt that when people without training on drugs prescribe and dispense medicines, it could negatively impact treatment outcomes. Tade may have been a victim of this particular challenge. Explaining the impact of the wrong prescription/inappropriate malaria medicine dosage on treatment, the immediate past National Chairman of the Association of Community Pharmacists of Nigeria (ACPN), Dr. Albert Alkali, said in treatment, if a patient does not take the right dosage, the malaria parasite could develop resistance and such resistant strain could become very difficult to clear.

“With that, we could have a lot of multiplication of resistant strains,” added Alkali, who is a pharmacist. He stressed that malaria is a dangerous and killer disease especially in children. “The malaria parasite could multiply and break the whole cell within thousands of seconds and before you knew it, the affected child has become anaemic if not properly managed,” the pharmacist added. Alkali, however, lamented that Nigerians are spending too much on malaria because of the use of wrong medicines, counterfeit drugs, and poor drug dosage, among others.

Artemisinin drug resistance typically refers to a delay in the clearance of malaria parasites from the bloodstream following treatment with an Artemisinin Combination Therapy (ACT). As a result, the artemisinin compound is less effective in clearing all parasites within a three-day period among patients who are infected with artemisinin-resistant strains of malaria.

The Malaria Technical Director at NMEP, Mokuolu, said there has been resistance to many antimalarial drugs globally over time until the global community got into the artemisinin group of compound and “they offered us a significant respite especially when later on we also discovered the concept of combination treatment which is why we call it the Artemisinin-based combination therapy.” He noted that the driver of that combination is the artemisinin compound because it is fast acting; it is very efficacious and for a long time there was no resistance reported against it.

However, there has been observed resistance to artemisinin in the Great Mekong Region of Southeast Asia, which has potential to spread to other parts of the world. Mokuolu said: “Then in 2014, we did a study that looked at the ‘Tracing Artemisinin Resistance Collaboration.’

When that study was done it showed clearly that some areas in Southeast Asia region: Miama, Thailand and others reported Artemisinin resistance. “As of the time of that study, two African sites were involved in the 22 sites, Nigeria and Kenya, and there was no documented resistance from our end (Nigeria) in Africa.

We have continued therefore to use ACT.” Despite the lack of artemisinin resistance in Nigeria, which the WHO recommends as the drug of choice for the treatment of malaria, there have been grumblings that the medication is not working.

While debunking this claim, which is a widely held belief among different segments of the society, Mokuolu said those questioning the effectiveness of ACTs should get tested before getting malaria treatment because many conditions called malaria in the country are not malaria. According to him, the government, through NMEP, is monitoring the efficacy of this drug. “We did that in 2014 and the result showed that there was no resistance in the country. We did that in 2018, again, we still didn’t have ‘the resistance matter’.

We have also done the study in 2020 and the result of the analysis is being awaited,” he added. Giving her perspective on repeated claims that ACTs are not effective, a Fellow of the Pharmaceutical Society of Nigeria (PSN), Folasade Lawal, who is also a member of the Clinical Pharmaceutical Society of Nigeria, said it is sincerely sad that many people in Nigeria treat malaria when they don’t have it. She added: “When they sneeze, they claim it is malaria; when they cough, they say it is malaria; and when they blink, they claim it is malaria.

“When they purchase the ACT drug, use it and the initial symptoms continue they will tell you that the ACT did not work.” Lawal, who is an Associate Member of the Royal Pharmaceutical Society, said sometimes, Nigerians who visit her pharmacy, seeking malaria treatment, don’t have classic symptoms. She said: “Some of them might say: ‘My mouth is bitter; I was in the sun’.

They will come with some reasons to have malaria treatment. Some could say: ‘I know how my malaria does.’” According to Lawal, pharmacists always educate their clients on the importance of doing tests to determine the presence of malaria parasites before treatment.

“The challenge is that the majority are deterred from conducting tests because of the additional costs involved. “Some of them lament that after paying for the test, if the result is positive for the malaria parasite, they end up buying drugs again.

Hence, they often reason that it was better to forgo the test and just buy the ACT for treatment,” she added. Another major problem she highlighted is that the health system in the country approves antimalarials to be got from over-the-counter.

So, anyone can walk into a patent medicine store and buy them. Consequently, Lawal advised that if a rapid diagnostic test for malaria can be free for the public, it will help to address some of the numerous challenges of malaria in the country.

Highlighting other factors that could help to prevent artemisinin resistance, Lawal said it is imperative to promote rational use of antimalarial medicines; that is for the medicine to be used the right way, meaning that only those who test positive for malaria will use the ACT. Lawal also spoke on some necessary guidelines on drug use. “Timing is very critical for every drug therapy.

Timing is important because the drug goes through a lot of processes: It’s absorbed, released into the system and the length of time it’s there will determine how it tackles the parasite,” she said. The clinical pharmacist said if that level is sustained for enough time it will kill the parasite, but some of them may escape and when they do, they may become resistant because they escaped and they may be able to change their form or protect themselves from the drug next time they are exposed to it.

“This rational use of ACT begins with running a test, if positive for malaria, taking the right medication, which is ACT, taking the right dosage for the right length of time for the required number of days and of course at the least cost for that patient,” Lawal added. Researchers from the Fogarty International Centre at the National Institute of Health in Bethesda, Maryland, the United States of America (USA), reported in ‘The Lancet Infectious Diseases’ (May 2012 issue) that up to 42 per cent of antimalarial medications available across sub-Saharan Africa and Southeast Asia are either fake or substandard. Co-author, Dr. Joel Breman, Senior Scientist Emeritus, said, “Poor quality anti-malarial drugs are very likely to jeopardise the unprecedented progress and investments in the control and elimination of malaria made in the past decade.”

Scientific evidence shows that fake or substandard anti-malarial mediations do not have active ingredients and can encourage the development of resistant strains of malaria parasite. Although the National Agency for Food and Drug Administration and Control (NAFDAC) has introduced a text messaging system and other devices which help to determine fake drugs at the point of purchase, the use of such facilities will help consumers and healthcare providers go for genuine drugs and consequently rule out the possibility of drug resistance. Highlighting another major cause of drug resistance in the treatment of malaria, a Public Health Physician, Dr. Jide Idris, said it is also important for patients to comply with malaria medications as prescribed. According to Idris, who is the immediate past commissioner for health in Lagos State, in this environment, once a lot of people discover they have fever, they start taking drugs. If the fever relieves them, they stop the drugs.

“These are major causes of drug resistance,” he noted, adding that malaria parasite in the blood is also a living organism, reacting, and finding a way, too, to counter those drugs. Idris lamented that many Nigerians contribute to why malaria resists prescribed drugs. According to him, the malaria parasite is capable of becoming resistant to the action of anti-malaria drugs. This is due to small changes in the parasite DNA (point mutations). Over-prescription of antimalarial (confusion with other febrile diseases) and the uncontrolled selling of poor quality drugs contribute to the increase in drug resistant parasites. At present, the WHO has recommended that all countries experiencing resistance to conventional monotherapies, such as CQ or SP, should use combination therapies, preferably ACTs for Plasmodium falciparum malaria.

On his part, Mokuolu urged Nigerians to stop using monotherapies for the treatment of malaria, saying they are no longer efficacious. “As an individual, protect yourself, sleep under insecticide treated net,” he said. Similarly, he said keeping the environment clean including drainages is key to fighting malaria. Mokuolu urged Nigerians to access programmes provided by the government including seasonal malaria chemoprevention (SMC) treatment, free bed nets, among others.

Experts said with all hands on deck, ensuring the ‘zero malaria starts with me’ campaign, the implementations of the above measures will help to reduce malaria burden in the country as well as prevent unnecessary deaths such as the demise of Tade.

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