As the Federal Government approved the use of R21/Matix-M Malaria Vaccine in Nigeria, VINCENT KURAUN re-examines the disease that is said to kill more people in the country than other diseases and how it can be contained.
As of today, Nigeria has the highest malaria burden globally with an estimated 100 million cases each year and thousands of deaths recorded on an annual basis in the country.
According to the World Malaria Report 2022, Nigeria recorded 31 per cent of the 619,000 deaths recorded globally. Of this global figure, Africa recorded a total of 599,000 deaths within the period.
It was based on the move to stem the tide of the malaria phenomenon that the Federal Government gave provisional registration approval to the new R21 malaria vaccine developed by scientists at the University of Oxford, United Kingdom and manufactured by the Serum Institute of India. The approval came just days after Ghana became the first country in the world to approve the vaccine.
Announcing the development at a press briefing in April, the Director General of the National Agency for Food and Drug Administration and Control (NAFDAC), Professor Mojisola Adeyeye, said the vaccine is indicated for prevention of clinical malaria in children from the age of five months to 36 months.
The approval was given a few days before the country joined the rest of the world to commemorate this year’s World Malaria Day (celebrated 25 April every year). The theme of this year’s edition was: “Time to deliver zero malaria, invest, innovate, implement.”
But apart from the much anticipated vaccine, what other measures has the Nigerin government put in place to contain the serious effects of malaria and if the deadly disease can be eradicated totally.
A consultant family physician with the Lagos University Teaching Hospital (LUTH), Dr Juliet Nebe, confirmed to Sunday Tribune that malaria still remains the leading cause of death in Nigeria.
According to her: “Yes, malaria is still the leading cause of death in Nigeria.” Citing the recent global study, she said, “According to a new global study, malaria was the leading killer disease in Nigeria, resulting in 192,284 deaths in 2015. In 2020, Nigeria recorded the highest malaria deaths globally. Young children and pregnant women are the most affected groups.”
A consultant family physician at St Raphael Divine Mercy Specialist Hospital, Ikorodu, Lagos State, Dr Adokiye Berepiki, also averred that thousands of lives are still lost to malaria, particularly in Africa. He quoted from a 2022 report which affirmed the violence of the disease globally.
According to him: “The World Malaria Report 2022 shows that Nigeria recorded 31 per cent of the 619,000 deaths recorded globally. Of this number, Africa recorded a total of 599,000 deaths within the period.”
A senior resident doctor at R Jolad Hospital, Gbagada, Lagos State, Dr Idang Aniedi James, while speaking on the issue, said: “In Africa, there were about 247 million cases of malaria recorded in 2021. The burden is so much in the whole world and here in Nigeria,
“In 2021, 600,000 global malaria deaths occured in the whole world and out of this figure, Nigeria accounted for about 31 per cent. That is to tell you that Nigeria has a very huge malaria burden.”
Speaking on why more attention should be given to management of malaria, Dr Idang said: “Malaria is a common parasitic infection in our environment, especially here in West Africa and sub-Saharan Africa and it has a major adverse effect on humanity.
“So that is why there is a need for us to pay attention to the management of malaria. In fact, it is said that nearly every minute, a child that is less than five years old dies of malaria in the whole world and this disease is not an incurable disease, it is a disease that is preventable and treatable but in spite of this, many children die of it including adults.”
Giving more insight into the fatality rate of malaria in Nigeria, Dr Nebe said the WHO World Malaria Report 2021 showed that Nigeria accounted for 32 per cent of global malaria deaths in 2020 while maintaining the highest number of infections during the same period at 27 per cent. Case numbers increased by 5.3 per cent between 2017 and 2020, from 298 to 314 per 1000 of the population at risk and at 306/1000 in 2021. Deaths increased by 4.7 per cent, from 0.92 to 0.97 per 1000 0f the population at risk during that period.”
Dr Adokiye also added that “as of 2019, the main causes of death from infectious diseases were malaria 12 per cent, diarrhoea 11.36 per cent, lower respiratory tract infections 10.85 per cent and HIV/AIDS. 5.18 per cent. This shows that malaria leads in the percentages represented in the number of deaths from infectious diseases in Nigeria.”
Antimalarial drug resistance
Speaking on why there is malaria drugs resistance in some cases, Dr Adokiye said: “Resistance to antimalarial medications refers to the ability of the malaria parasite to survive and multiply despite the administration of the dosage of the drug.
“And this resistance to antimalarials involves mutation of the parasite to the medications and the causes of resistance to antimalarials medications include; parasite mutation rate, overall parasite load, the strength of the drug selected, the treatment compliance and poor adherence to malaria treatment guidelines.”
Dr Nebe, while also speaking on the drugs resistance, said, “the development of resistance to drugs poses one of the greatest threats to malaria control and results in increased malaria morbidity and mortality.
“Resistance to currently available antimalarial drugs has been confirmed in plasmodium falciparum which is the major cause of malaria in Nigeria. Chloroquine-resistant falciparum first developed independently, subsequently, resistant to the other currently available antimalarial drugs, such as sulfadoxine/pyrimethamine, mefloquine, halofantrine and quinine.
“Although resistance to these drugs tends to be much less in some areas of the world, the impact of multi-drug resistant malaria can be extensive. Most recently, resistance to the artemisinin and non-artemisinin components of artemisinin-based combination therapy has also emerged.
“Several factors facilitate the emergence of resistance to existing antimalarial drugs. These factors include the parasite mutation rate, the overall parasite load, the strength of drug selected, the treatment compliance and poor adherence to malaria treatment guidelines. Improper dosing, poor pharmacokinetic properties and fake drugs lead to inadequate drug exposure on parasites. Poor-quality antimalarial (falsified antimalarial without active pharmaceutical ingredient) may aid resistance by increasing the risk of hyperparasitaemia, recrudescence, and hypergametocyopaenia,” She explained.
Dr Idang attributed the resistance to chronic abuse of antimalarial medications. According to him, “the resistance of malaria drugs is mainly because of the misuse of antimalarial medications.Antimalarial medications have been terribly abused in Nigeria. The WHO advocates that we should first of all test before we treat and after treating, we should track.
“There are three Ts – test, treat and track – but we found out that most people don’t do that first T of testing, once they have some symptoms that look like malaria, they begin to treat immediately and so many people don’t even track.
“So, because people treat without testing, they tend to take malaria drugs without even having malaria. So these kinds of people tend to develop resistance and secondly, most of them, when they are taking these drugs, they take underdose.
“Also most of these antimalarial drugs must be taken with a special kind of diet, oily diet. Diet that contains oil as well as milk because this oily diet increases the absorption into the bloodstream. If the food is not good enough, by the time they take the medication, most of the drug will be excreted instead of being absorbed into the system.
“That is why it is best to take these medications with food. It should be taken after a meal and the type of food should be a fatty meal. Those are some of the reasons people are developing resistance to malarial drugs.”
Corroborating Dr Idang’s claim, Dr Nebe said: “antimalarial drugs are still very effective if right diagnosis is made and malaria confirmed, right drugs are administered and absorbed at the appropriate doses with good compliance and adherence.”
Explaining why people continue to get malaria in Nigeria despite the measures in place, Dr Adokiye said: “We still continue to have malaria partly due to a number of reasons; poor preventive measures such as; not clearing bushes and presence of stagnant water which serve as breeding ground for the vector which is the anopheles mosquito, lack of use of insecticide treated nets/long lasting insecticidal nets, not fumigating the environment and resistance to antimalarials.”
Stressing the need for orientation, Dr Idang said: “The preventable measures include education. The general populace must be educated about the preventable measures and secondly, they must also be educated about the treatment and possible symptoms of malaria.
“So, what are the modes of prevention? We must make use of insecticide-treated mosquito nets, it is very important. People should make it a habit to sleep under insecticide-treated mosquito nets.
“Also, people should make sure there are nets on their windows as well as our doors. It will go a very long way in preventing malaria.
“Use of Indoor Residual Spread (IRS) of insecticide is another way of malaria prevention, use of protective clothing, clothes that cover the entire body in the night because mosquitoes bite more in the night.
“Bushes around the environment should be cleared and stagnant water should be cleared and there is every need for regular weekly sanitation.
“Gutters should be covered and finally, there are vaccines that are available. There is a vaccine that is called RTS,S/ASO1. This vaccine came into use in 2021 and is recommended and approved by WHO. These are the various ways and also the use of biological methods of preventing malaria like genetically-engineered mosquitoes can also be bred and they can be spread in to the environment and when they mix with anopheles mosquitoes, they will produce offsprings that do not harbour plasmodium parasite, though not commonly used but very effective.”
He therefore advised the people to adopt strategies that would reduce the likelihood of being beaten by mosquitoes because, according to him, “when there is no mosquito bite, there will be no malaria. All the above prevention measures should be adopted and secondly, we should adopt strategies to reduce the resistance to antimalarial drugs.”
Malaria in pregnancy
Dr Margaret Obienu, who spoke about the danger of malaria in pregnancy, said: “Malaria, though a preventable and treatable disease, has remained a major public health concern, accounting for high levels of death.
“Sadly, the majority of malaria cases and deaths occur in sub-Saharan Africa. Pregnant women and children under five years are the most vulnerable to malaria.
“More than 25 million pregnant women are affected by malaria each year in both high and low endemic areas. In sub-Saharan Africa, malaria causes about 10,000 maternal deaths and 200,000 foetal deaths per year..”
Dr Obienu also added that “Malaria in pregnancy is associated with maternal, perinatal and neonatal morbidity and mortality.
“It poses significant risk to the pregnant women and the baby. In the pregnant woman, it could lead to miscarriage, severe anaemia and even death (from complications of severe malaria such as hypoglycemia, cerebral malaria, pulmonary oedema, acute kidney injury). In the baby, malaria could cause intrauterine foetal growth restriction, preterm delivery, low birth weight, congenital malaria and even stillbirth.”
Explaining how the effects of malaria in pregnancy can be prevented, Dr Obienu added that “WHO recommends a multi-pronged approach to prevent malaria in pregnancy.”
According to her, “this consists of preventive measures such as consistent use of long-lasting insecticide-treated nets, indoor residual spraying, use of insect-repellants, minimising skin exposure by wearing long-sleeved shirts and ankle length outfits, avoiding staying outdoors during peak activity periods of mosquito bites (dusk to dawn), use of air conditioning and ceiling fans and intermittent preventive treatment against malaria.
Speaking on the safety of taking anti malaria drugs during pregnancy, Obienu said it is very important to treat malaria quickly once diagnosed in pregnancy to prevent the adverse outcomes associated with it.
“There are antimalarials that have been reported safe in pregnancy. I would encourage pregnant women to seek medical advice from their doctors before using any medication.
“The high burden of malaria in pregnancy could be attributed to the fact that pregnancy is a period of increased susceptibility to malaria owing to decreased immunity, increased body surface area, increased blood flow in the skin and specific odour secretions during pregnancy, resulting in increased mosquito bites,” she added.
Advocacy from NMA
According to Dr Nebe, “The Nigerian Medical Association (NMA) has been advocating malaria elimination in Nigeria since the inception of the body.
“NMA is aware that advocacy is an important tool that the global malaria community should use to support the transition to elimination and sustain gains made in malaria control and it can leverage political commitment, create new funding opportunities and support partnerships.
“NMA had worked tirelessly in advocating eradication of malaria. Over the years, NMA has been the main body advocating malaria prevention, control and research in Nigeria.
“The NMA has been working with other stakeholders including the US President’s Malaria Initiative (PMI), the Department for International Development (DfID) in the United Kingdom, WHO and UNICEF on implementing malaria activities.
“Members’ commitment had been the basis through which research, provision of guidelines and implementation of the guidelines on the treatment of malaria is achieved.”
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