Investigation

THE SCOURGE OF MALARIA: Where are the treated nets?

It appears many Nigerians are no longer using the longlasting insecticidal nets freely distributed by government and non-governmental agencies to combat the scourge of malaria, said to be the most prevalent disease in the country. ISIOMA MADIKE, in this report, attempts to find out why, especially as malaria remains a major component of the raging coronavirus

Ade, five, struggled to free himself from the mesh of the Long Lasting Insecticide Net (LLIN) draped over his spring bed. He had just woken from a mosquito-free sleep but as he struggled, his best effort seemed to get him into deeper trouble. Monsuratu, his mother, reached out, disentangled him and folded the net, carefully placing it on the railings of the bed. It will be unfolded at night and draped over Ade’s bed once again when he goes to sleep. Such a seemingly tiring daily ritual can keep Ade alive and protected from malaria, the number one killer of children in this tiny slum of Small Kuramo, in the Jakande/ Ajah axis of Eti-Osa Local Government Area of Lagos State.

According to a World Bank Malaria Control Booster Project report, one out of every three children under five years dies of malaria in developing countries of which Nigeria is one of them. Ade is five and had been sleeping under a mosquito net since 2016.

As he stepped down from the bed, he stretched, yawned and reached out for a steaming bowl of ‘Koko,’ a staple breakfast meal made of ground millet. The long-lasting insecticide nets, according to medical experts, have proved more efficient than the conventional Insecticide Treated Nets (ITNs) because they do not need re-treatment and have a life span of three to five years. Monsuratu was given an insecticide treated net a few years ago but it has not been retreated and is rather worn out; although it is still being used.

In poor neighbourhoods like Small Kuramo, it is common for families to continue to use conventional insecticide nets without proper re-treatment; this reduces their effectiveness considerably. One of the reasons is that the chemicals for re-treatment are not readily available and have a cost that families cannot always afford.

This, however, may be the reason government has continued to stress the importance of LLIN, particularly those living in mosquito-prone localities. But investigations have shown that many residents of such neighbourhoods have dumped the nets freely distributed to them via primary health centres to combat the scourge of malaria. This attitude follows allegations of severe adverse reactions, body itching and rashes, which they claimed to have experienced shortly after sleeping under the net.

Mrs. Abike Balogun, who lives at the popular Oluwole Housing Estate, Ogba, an outskirt of Lagos, told Saturday Telegraph that she and her friends had not been using the nets since they were given in July, 2014. This, according to her, was because of the adverse reactions experienced by one of her neighbours who had been using the net since 2013. Balogun narrated how she was once woken up in the middle of the night by the wailings of her neighbour, a woman,and her two children. “They complained of intense itching and the whole neighbourhood had to gather to assist by rubbing palm oil all over their body. We also heard that the net had killed someone in Agege some time ago. Although we cannot verify that as some people said it was a rumour.

But one has to be careful since life has no duplicate,” she added. However, Balogun is not alone in her fears. A petty trader, Mrs Elizabeth Nwaka, also told this reporter that many people in her community have stopped using the LLIN following another rumour that a baby died from inhaling the chemical in the net.

Nwaka lives at the Akute area of Ogun State. She denied the claims that the baby’s mother did not comply with the instructions given to her. She said: “The woman spread it out for three days to lessen the effect of the chemical as instructed by the health officials when she went to collect it.

Yet, the child died after one week of usage from the effect of the chemical in the net. Many people believed the baby must have inhaled much of the chemical on the net. Those already using it had to throw theirs away while some of us who had not started, never bother to try it again.” There are others who also complained that the chemical on the net irritate their eyes.

“My last child in the boarding house at Odogbolu in Ogun State came back home because of COVID- 19 pandemic with a swollen eye. After the doctor’s examination, it was traced to the treated net we gave to him to use at school. The doctor then advised us to stop him from using it for the time being so as not to damage his eye.

“The man was sincere to tell us the truth. Although his thinking was that the boy didn’t use it properly, that he may not have diffused it before use. But to be forewarned is to be forearm as the saying goes. We had to ban it totally in our house because we cannot see another eye to buy once the God’s given one is impaired. We became afraid and since then, none of us wants to touch the net talk less of using it.” Balogun and Nwaka are not isolated cases. Patricia Obi had her experience with the treated net as well.

“The net caused a big confusion for me,” she said. “The first three days I used it, my body itched for eternity. I thought it could harm me. When the problem persisted, my brother had to consult our family doctor, who explained the reason for the itching. He asked if I sun-dried the net or spread it inside my house.

I told him I did none of such. “He then enlightened us on the procedure. He said that the first thing to do when one brings the net home is to spread it inside the house for a whole day and not in the sun. It was after that, according to the doctor, one could use the net. He said if the technique is carefully followed, it would not itch much, even if the person is allergic to it. He also stressed that doing so would help the efficacy of the chemical in the net and improve its durability.”

The story is not different from another mother of four who identified herself simply as Oluwatoyin. She claimed to have stopped using the net following rashes which she experienced shortly after sleeping under the net. “I’d rather battle with mosquito than die from the chemicals on the net.

Since then I have been managing with the door and window nets in my house and those have been fine for me and my family,” she said. There are many more stories similar but with different variations among the residents sampled across Lagos and Ogun states.

They cited different reasons, ranging from itching to intense heat. But the Coordinator, National Malaria Control Programme, Dr. Nnenna Ezeigwe, was quoted to have said that the problem of body itch being experienced by some people could be traced to their failure to adhere to instructions on the usage of the net. “You know when people get the net, they are supposed to open and spread it outside, under a shade, not under the sun. It must be shielded from the sun. It must be spread under that shade for 24 hours before they start using it.

If that is done, that itching is not likely to occur. If they take it to the sun, the chemical will not be effective the way it is supposed to be. “The itching however, does not last on the body and there is no likely health hazard, using the net.

We do give this information to the public when we give these nets out to the people. The problem is that, if you observe, hardly would you see a place where these nets are distributed that you would not see people rushing to collect it. “At the end of the day, the people will not listen to get information on how to use them but they will head straight to their homes. The heat is a psychological thing. What I mean is that some people might have been hot before they come into the net and perhaps their bed; the room may be hot too.

By the time they lie down, they shortly discover they are hot. It is not the net that really makes them get hot; it is the temperature they came with from outside before they lay inside the nets. “The net is perforated enough to reduce any possibility for heat affecting anyone sleeping inside it. However, I can’t say that Nigerians are telling lies by complaining about this. Some people might think that it is hot for them. In that case, I don’t know how better they can protect themselves except if they want to adopt the IRS that is, spraying their rooms with correct chemicals,” Ezeigwe added.

Incidentally, one of the most common symptoms of coronavirus is fever, which is majorly caused by mosquitoes. In humans, malaria parasites grow and multiply first in the liver cells and then exponentially in the red blood cells. It is the blood stage of the parasite lifecycle that causes the symptoms of malaria in humans. Malaria is usually classified as asymptomatic, uncomplicated or severe. Asymptomatic malaria can be caused by all plasmodium species; the patient has circulating parasites but no symptoms. Uncomplicated malaria can be caused by all plasmodium species.

Symptoms generally occur seven-10 days after the initial mosquito bite. Symptoms are nonspecific and can include fever, moderate to severe shaking chills, profuse sweating, headache, nausea, vomiting, diarrhoea and anaemia, with no clinical or laboratory findings of severe organ dysfunction. Complications include severe anaemia and end-organ damage, including coma (cerebral malaria), pulmonary complications (for example, oedema and hyperpnoeic syndrome) and hypoglycaemia or acute kidney injury. Severe malaria is often associated with hyperparasitaemia and is associated with increased mortality. The Country Manager, Corporate Alliance on Malaria in Africa (CAMA), Ochuko Keyamo-Onyige, quoting the African Union’s Centers for Disease Control and Prevention in Africa, said in Africa the number of coronavirus cases is fast increasing.

This, according to him, is because Africa is a continent heavily burdened with malaria and poor health systems. He said there are increasing fears that COVID-19 could impact the fight against malaria, which claimed 405,000 lives in 2018, with Africa accounting for 94 per cent of the global burden. According to the Global Fund, COVID- 19 could derail progress on HIV, TB and malaria through disruption to access treatment or other interventions, or to supply chains of critical medicines and medical supplies. Experience from the 2015 Ebola outbreak in West Africa suggests that unless mitigating action is taken, additional deaths from existing diseases such as malaria can be comparable or greater than those from the outbreak itself.

“We are seeing that the virus has a more severe impact on people with underlying health conditions and so it is logical to hypothesize that we may see more severe COVID-19 illness in a population that is malnourished, has malaria as well as a mound of other infections,” said Dr. Ngozi Erondu, an associate fellow in the Global Health Program at Chatham House in London.

“There’s not enough data at the moment to quantify those risks,” she added. Nigeria is said to have the highest number of malaria cases in the world, contributing 23 per cent to the global malaria burden, according to available statistics. In view of the high prevalence, the Federal Government has consistently advocated the use of long-lasting insecticidal nets as the most effective way to combating the scourge. The states have also keyed in into this programme. For instance, well over a million insecticides treated nets are said to have been distributed in Lagos State since 2000 to mothers of children under the age of five years. This is usually done either during integrated programmes with immunisation campaigns or during stand-alone campaigns in many if not all of the local government areas of the state.

The state government began the pilot scheme of the Indoor Residual Spraying (IRS) in two high malaria burden areas within Ikorodu Local Government and Otto-Awori Local Council Development Areas. According to the then state Commissioner for Health, Dr Jide Idris, the safe and effective nature of treated nets in combating mosquitoes and other harmful insects explained the community interventions. The commissioner noted that the cosmopolitan nature of the state coupled with the abundant distribution of coastal areas encouraged the development of stagnant water responsible for the breeding of anopheles mosquito.

This, he said, contributes to the stable pattern and continuous transmission of malaria all year round. He added: “Morbidity and mortality trend of malaria cases continued to worsen due to the spread of drug resistant strains of plasmodium, crumbling infrastructure of Primary Healthcare Centres and poor utilisation of insecticide treated bed nets. The malaria surveillance reports as summarised in the annual Integrated Diseases Surveillance and Response indicated that the previous malaria control interventions did not show significant impact as the prevalence of malaria cases continues to rise.” Insecticide treated nets are low cost and are said to be highly effective way of reducing the incidence of malaria in people who sleep under them.

This, according to medical experts, has been conclusively shown in a series of trials to substantially reduce child mortality in malaria-endemic areas. By preventing malaria, treated nets 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.

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