MALARIA: Nigeria: Pregnant women and battle against malaria

Oluwole Ige : 30 May 2011



Pregnant women at an ante-natal clinic

Malaria, from the medical point of view, is caused by female mosquito known as anopheles, which drops its Plasmodium into the system of individuals after biting. It is no respecter of status, gender and age. Besides, it is one of the highest killer-diseases in Africa. Some experts even claim that malaria kills more than the dreaded HIV/AIDS, especially in Sub-Saharan Africa. The new dimension to the scourge of the disease is its ravaging effects on the population of pregnant women in Nigeria.

Recently, the Ogun State Commissioner for Health, Dr Isiaq Salako, hinted that about 4, 500 pregnant women die of malaria in the country annually.
Though, the figure appears insignificant, considering the over 150 million population of Nigeria, it is an established fact that the disease remains a great threat to the population particularly expectant mothers.
According to Dr Adelakin Makanjuola, a consultant gynaecologist, malaria is a parasitic infection transmitted to humans through the bites of infected female anopheles mosquitoes. About 60 species of the anopheles mosquito are major transmitters of the disease. There are four different types of malaria parasites, plasmodium falciparum, P. malariae, P. ovale, and P. vivax. Within each species there are many variant strains. Worldwide, P. falciparum and vivax cause the vast majority of clinical cases and nearly all of the deaths and serious morbidity.
In Africa, P. falciparum, the most dangerous of the parasites, causes over 90 per cent of all malaria infections. So far, entomologists have identified over 2000 species of mosquito, but only the anopheles mosquito actually transmits malaria. In Africa, the major vector of malaria is An. gambiae, and there are many members of this group of mosquito. The parasite after spreading rapidly through the bloodstream to the liver, emerges again into the blood stream, finally to settle in the red blood cells, where it multiplies and emerges in bursts of new organisms.
These parasites, because of their large numbers, can cause particular damage to the nervous system, liver, and kidney. The resulting disease in humans can be devastating, especially in young children and adults including, pregnant mothers and their unborn babies as well as Nigerians in diaspora who have been away from Nigeria or other malarious zones for more than two years and have either not developed natural immunity or have lost it.
This group is also very vulnerable to cerebral malaria which can result in death within hours. Others die later from the infection either from overwhelming anaemia, liver or kidney failure. Generally speaking, with untreated malaria, up to 20 per cent of persons infected with falciparum malaria will die. The stark reality of this scourge in Nigeria is as follows: In Nigeria, there is an estimated 25 per cent -30 per cent of mortality in children under five, or an estimated 300,000 deaths each year due to malaria.
The campaign slogans aimed at battling the endemic disease are endless and their messages catchy to drive home the need to avoid environmental and sanitary conditions are, capable of fuelling the spread of the malaria. Such slogans include: “Roll back malaria; Counting malaria out; Effective malaria treatment, and Free Africa from malaria now, among others. The improper disposal of refuse, stagnant water, gross inadequate access to right medication and inability of many families to access preventive facilities like bed nets have been identified as factors aiding malaria infections.
Despite the aggressive campaigns against the disease and the huge financial and manpower commitments by the Federal Government, donor agencies, including the World Health Organisation (WHO), Global Fund and other stakeholders in the health sector, malaria continues to constitute a serious health challenge, with the 110 million clinically diagnosed cases in Nigeria annually.
From its debilitating effects, investigations by the United Nations Children Fund (UNICEF) revealed that the disease imposes a heavy social and economic burden, which resulted into a loss of about N132 billion annually in prevention, cost treatment and productivity loss in Nigeria. Such loss came in form of hours lost due to illness, deaths of members of the working population; impaired child development and absenteeism from work as a result of the disease.
Worst hit by the malaria endemic are the children and pregnant women. It adversely affects children under the age of five and pregnant women in Sub-Saharan Africa, leading to the death of nearly 3, 000 every day.
Apart from little children and infants, pregnant women are found to be highly susceptible to malaria attacks. Generally, expectant mothers have been medically proven to be four times more prone to malaria parasites than those not pregnant. Reports by medical experts indicate that when women become pregnant, their immunity and disease resistance level become low, therefore, they will be more or less helpless when malaria parasites strike.
It is not uncommon for some pregnant women, having frequent bouts of malaria fever and this has made it mandatory for them to seek medical treatment immediately, with a view to avoiding its negative consequences. Experts and consultant gynaecologists hold the view that malaria attack on pregnant women could lead to low blood pressure, premature labour, abortion, stillbirth, low weight babies, anaemia and possibly preventable death, if timely action is taken to reverse its trend.
The United Nations (UN) has done a lot in its quest to totally eradicate malaria. The Roll Back Malaria (RBM) and the Global Malaria Action Plan (GMAP) are some of the intervention strategies made by organisations and individuals to help deliver the world, including Nigeria from the shackles of malaria.
Despite the clear evidence that many pregnant women could be saved from the complications of malaria through the use of insecticide-treated nets (ITNs) and intermittent preventive treatment, many still succumb to death occasioned by malaria parasites. Towards this end, concerned health care practitioners have raised alarm, cautioning that if the situation is not checked on time, the target to checkmate the incidence of malaria in pregnancy will not be met and the gloomy pictures of the endemic disease will continue to wreck havoc on Nigerian women and their unborn babies.
The most pathetic development is that most times, the victims do not show any symptom of illness. Clinical records show that the malaria parasites attack the placenta even at low infection rates and this invasion of the placenta leads to ill health for the mother, which may precipitate abortion of the foetus as well as premature labour.
More frightening is the recent world malaria report, which indicated that Nigeria accounts for a quarter of all malaria cases in the 45 malaria-endemic countries in Africa. This revelation obviously brings to the front burner the daunting challenges of malaria in the country. Thus, pregnant women, who are identified as one of the groups at high risk of the effects of malaria infection, need special protective measures to ensure their survival and improve birth outcomes.
Therefore, sleeping under insecticide treated nets remains one of the key strategies for protecting expectant mothers and their newborns from malaria-carrying mosquitoes and seeking medical care after suspecting symptoms of malaria would also go a long way in combating the disease.
In an interview with the Nigerian Tribune, Dr Bukola Adesina, a gynaecologist, at the University College Hospital (UCH), Ibadan said malaria as a disease affects pregnant women in Nigeria, just like any other person. She described Nigeria as an endemic country as far as malaria infection is concerned.
“It is endemic in Nigeria. It is important to make a demarcation. It depends on what part of the world you are living because this determines to a large extent how you will react or respond to malaria,” she stated.
According to her, people get infected all year round, “though individuals, who live in endemic area or zone, have some level of immunity” but they still get infected after being bitten by mosquitoes that transmit malaria parasites into their body systems.
“When a woman becomes pregnant, her immunity mechanism will reduce. The malaria will live in the placenta of the woman. The placenta provides a safer abode for the malaria parasites and it is the supply link between the baby and the mother. After occupying the placenta region, malaria parasite will disturb the supply of nutrients to the baby; hence, the baby is starved and this negatively affects the weight of the baby,” Dr Adesina remarked.
While observing that Nigeria’s prenatal mortality ranked among one of the highest in the world, the gynaecologist maintained that malaria, which makes pregnant women to develop anaemia contributes to maternal mortality rate.
“It is observed that when the malaria parasite load is so much in the system of an expectant mother, the baby dies before delivery. There is no robust data capturing system in Nigeria. Worldwide, 10 per cent of maternal mortality is related to anaemia, which is a fallout of malaria,” Dr Adesina hinted.
She further listed reasons pregnant women die as a result of haemorrhage-bleeding, hypertension with seizures-convulsion, obstructed labour, abortion and infection, adding that part of the measures put in place by the federal government to combat maternal mortality include the provision of access to effective health care, Intermittent Preventive Therapy (IPT), Insecticide Treated Nets (ITNs) and prompt treatment of malaria with Artemisin Combination Therapy (ACT).
Dr Adesina, who canvassed for the effective education of the people, particularly pregnant women about the myths of malaria on the part of the government, said some people still believed erroneously that exposure to the sun could cause malaria infection, stressing the need for all to seek information about the disease.
According to her, poverty also contributed largely to the spread of malaria infection in Nigeria, advising that government should address poverty squarely as a veritable means of combating the scourge, saying that some people could not even seek medical services because of their inability to pay for the medicare.
Part of the short term measures that can be adopted by the government, Dr Adesina said, involve active collaboration with the mission homes and Traditional Birth Attendants (TBAs) because some pregnant women in Nigeria still patronise them for delivery services.
Said she, “the government should liaise with these mission homes and TBAs on the need to educate pregnant women to make use of Insecticide Treated Nets (ITNs) and create awareness about the danger that malaria poses to the health and survival of pregnant women in Nigeria”.
Continuing, Dr Adesina contended that “opinion leaders, religious groups, market women associations, civil society organisations, Non Governmental Organisations (NGOs) and health institutions are major stakeholders that government should work in synergy with to really have headway in the fight against malaria.
Some pregnant women who spoke to the Nigerian Tribune expressed concerns and fears over the debilitating effects of malaria parasites on their present status, lamenting that the infection had done irreversible damage to them in the past.
Mrs Sakirat Adebimpe regretted that she lost four months old pregnancy to malaria in 2009. She said “I do not treat malaria with kid’s gloves any longer because of the bitter experience I had in June 2009. I was attacked by malaria fever, though, I went to the hospital to treat it, I eventually had a miscarriage due to the extent of damage it had wrecked on my pregnancy then. The doctor observed that if I had reported at the hospital earlier, the malaria could not have affected the pregnancy.”
The 36 year-old woman, who is already carrying a six month pregnancy added that “nowadays, I attend ante-natal clinic regularly and if I feel or suspects any symptom of malaria, I hurriedly visit hospital to access appropriate medical services, with a view to warding off any advance from malaria parasites.”
In her own submission, Mrs Ijeoma Nwachukwu had this to say, “I have always adopted preventive measures to combat malaria. I am quite aware of the dangers that malaria poses to pregnant women and this has made it mandatory for me and my children to sleep inside Insecticide Treated Net [ITN] so as to avoid mosquitoes’ bites that cause malaria. Besides, I attend antenatal clinic and also go for medical checks regularly to avoid any untoward development”.
Several factors have been postulated as accounting for limited successes in eradicating malaria, which include lack of political will and commitment of successive Nigerian governments in tackling it, poor awareness and appreciation of the magnitude of the malaria burden right across the board, poor health facilities and practices by individuals and in communities and resistance to drugs and insecticides by malaria parasites.
http://tribune.com.ng/index.php/features/22651-pregnant-women-and-battle-against-malaria-scourge

MALARIA: Nigeria: disease has remained a source of serious concern across the country

AS the global community, on the surface, appears to be intensifying efforts aimed at eradicating malaria, available statistics show that, indeed, the war against the deadly disease is not recording as much success as it should and this reality is evident in Nigeria as in most other countries where malaria continues to be a major health challenge.

Eleven years after Nigeria's National Malaria Control Programme (NMCP) was officially launched, the disease has remained a source of serious concern across the country, with about 500,000 deaths recorded annually, mostly of children and pregnant women.
According to statistics released by the National Coordinator of the NMCP, Dr. Babajide Coker, Nigeria contributes a quarter of the malaria burden in Africa, and a staggering 90 per cent of her citizens are at risk of the lethal disease.
Dr. Coker who gave the figures at a recent event to commemorate this year's World Malaria Day (WMD) also revealed that the scourge still accounts for about 60 per cent of all clinic attendance and is responsible for 30 per cent of childhood deaths in the country.
WMD was first observed on April 25, 2008 "to provide stakeholders including governments at all levels with an opportunity to raise awareness and increase knowledge on control" of the disease worldwide.
Before then, 44 African leaders had, in Abuja on April 25, 2000, held the first summit on malaria, where they affirmed their commitment to roll back malaria and set interim targets for the actualization of their goals for Africa.
At the summit, April 25 every year was declared "African Malaria Day" and renamed World Malaria Day in 2008 to reflect the global dimensions of the disease.
Though Nigeria joined the rest of the world to mark another WMD on April 25 this year, the fact that the disease remains a major challenge 11 years after a concerted continent-wide campaign was launched against it means that various strategies adopted to eradicate the scourge are far from achieving results.
For instance, under the National Malaria Strategic Plan, 2009-2013, malaria related morbidity and mortality was projected to have been reduced by 50 per cent last year.
Similarly, a total of 35,618,160 Long Lasting Insecticides Nets (LLINS) have been distributed in 22 states representing 56.6 per cent of the December 2010 targets.
Given the current poor performance of the NMCP in meeting set targets, it is almost certain that Nigeria will not achieve the global target of zero malaria deaths by 2015, which is also the target date for the achievement of the Millennium Development Goals (MDGs).
In order to improve on the performance of the NMCP, we recommend an urgent summit of all stakeholders- federal, states and local governments, donor agencies, community leaders and non-governmental organizations (NGOs) involved in the fight against malaria.
Such an emergency summit, which should be convened by the Federal Ministry of Health in conjunction with NMCP should immediately review all targets set for the total eradication of the scourge, overhaul the machinery for the implementation of the control programme and evolve new, effective strategies for attainment of the targets already set.
We believe that the outcome of such a gathering will enable stakeholders including the World Health Organisation (WHO) to redouble their efforts towards eradication of the killer disease.
Similarly, since malaria is a disease of the tropics and can be eradicated, we suggest that the Federal Government implement its plan to strengthen indigenous pharmaceutical companies for anti-malaria medicines production.
Such financial assistance will boost local production of anti- malaria drugs that have been adjudged effective in the cure of malaria.
This, ultimately, will reduce the present large scale importation of anti-malaria drugs some of which are fakes.
As we have noted in the past, the National Agency for Food, Drugs Administration and Control (NAFDAC) must redouble its efforts and be more alive to its responsibility of checking the importation of unwholesome drugs since fake drugs have been identified as a major hindrance to the effective prosecution of the war against malaria and other killer diseases.
Also, we strongly recommend that governments and corporate bodies take keener interest in research and adequately fund relevant institutes and universities in the country so that they can intensify the search for more potent cures for malaria.
In line with the theme of this year's celebration of WMD, "Achieving progress and impact" all stakeholders including development partners, donor agencies and governments must relaunch and intensify enlightenment campaigns in all the nooks and crannies of the country, especially on how to prevent the disease.
Government should also go the extra mile to ensure that the LLINs are not only given free of charge but get to those who really need them.
Treatment for malaria should also be free, especially for children, pregnant women and the elderly, to ensure that none from this class of vulnerable people dies because they could not afford money for treatment of malaria
http://allafrica.com/stories/201105120663.html

MALARIA: Nigeria: Maternal deaths still high

19 May 2011 : Olayinka Olukoya
Maternal deaths still high in Nigeria - Expert •Malaria kills 4,500 pregnant women in Nigeria yearly -Ogun Health Commissioner

A reproductive health expert, Dr Ejike Oji, says maternal mortality rate is still high in Nigeria and requires urgent attention to check the trend.
Oji is the Country Director of IPAS Nigeria, a non-governmental organisation that protects women's health and advances women's reproductive rights.
He told the News Agency of Nigeria (NAN) in Port Harcourt, on Wednesday, that in spite of efforts made by government and stakeholders, maternal mortality rate was still high in Nigeria.
He said that Nigeria was second to India in maternal deaths in the world.
“If you look at the maternal mortality rate, which is an indicator of maternal health in any country, a few years ago, our maternal mortality was one thousand one hundred.
“But the last check has now put it at 545 maternal deaths for every hundred thousands live births.
“But you can see that 545 is still huge, is still very, very high when you compare it to some countries who have maternal mortality of about five, four.
“And that means , it is translating to about fifty something thousand women dying annually in Nigeria.
“That is a lot of women dying. In fact, Nigeria contributes second largest maternal deaths in the world after India.
“And you know, India is 1.2 billion and we are just about 152 million. So, India is 10 times our size and we are second to them in terms of total maternal deaths in the world,” he said.
Meanwhile, Ogun State Commissioner for Health, Dr Isiaq Salako, has disclosed that about 4,500 pregnant women die of malaria in the country annually.
Salako spoke during a symposium to commemorate this year’s World Malaria Day, which took place in Abeokuta, the Ogun State capital, on Wednesday.
Describing malaria as a major public health problem which ravages Nigeria’s population, the commissioner lamented that the scourge affects the growth and development of the country.
He also estimated that 50 per cent of the population had at least one episode of malaria each year while children below five years of age had two to four attacks of malaria each year.
Malaria, he stressed, remains a great threat to the survival of the young African children, accounting for 30 per cent of all childhood deaths.
The commissioner, who addressed participants at the symposium, stated that the major burden of diseases in the African region, including Nigeria, is attributable to vector-borne diseases.
He said: “The disease malaria is no respecter of age, sex or tribe. People of all ages have regular attacks throughout their lives.
“However, young children and pregnant women are most at risk of severe malaria and death.
‘’Malaria also contributes to other children deaths by affecting immunity to other diseases. Successful malaria control measures could therefore result in a large reduction of deaths more than that due to malaria alone.”
‘’We must all be concerned in malaria in pregnancy, whether we are still within the child-bearing age or not. It is our responsibilities to make sure that we do everything humanly possible to prevent and control the menace of malaria in our society.
‘’For us in Ogun State, we believe that prevention is better than cure. It is not only better to prevent malaria, but it is also cheaper. He urged pregnant women not to hesitate to always go for ante-natal.
According to him, it was estimated that 80 per cent to 90 per cent of global clinical malaria cases (300 million) and malaria-related deaths (one million) occur on the African continent in Nigeria.
He added that about 40 per cent of the population of the world is at risk and about 300 to 500 million cases occur globally every year.
http://tribune.com.ng/index.php/news/22203-maternal-deaths-still-high-in-nigeria-expert-malaria-kills-4500-pregnant-women-in-nigeria-yearly-ogun-health-commissioner

MALARIA: Nigeria research provides insights on bednet use—and misuse

Marcy Erskine, International Federation of Red Cross and Red Crescent Societies; Toju Maleghemi, WHO Cross River State; Iyam Ugot, Special Advisor to the Governor of Cross River State, Community Health
Nigeria’s Cross River State Roll Back Malaria team is tasked with “finding” 500,000 previously distributed bednets to determine how many are still being used and why.
In Nigeria, the Cross River State Government has been a leader in public health, providing free primary health care to pregnant women and children under five* and working to improve health indicators and protect its residents from malaria-related illness and death. In 2008, the State Government, with support from the Canadian Red Cross and USAID, distributed over half a million nets—enough for each child under five attending a vaccination site during an integrated measles campaign.
In 2010, Nigeria’s Cross River State Roll Back Malaria (RBM) team was tasked with “finding” these previously distributed long-lasting insecticide-treated nets (LLINs) to determine how many were still “good” and how many new nets were needed in the next distribution cycle. A “good” net was defined by age: a net distributed in 2008 or later was considered good, while older nets were considered non-viable. The physical condition of the LLIN was not taken into account given the subjective nature of assessing hole size and viability of the net. Given that the estimated lifespan of the distributed nets is three years, it was expected that the majority of the nets distributed in 2008 would still be in use. However, the results of the household census undertaken by Nigeria Red Cross volunteers throughout the State to assess household LLIN needs “found” only 52 percent of the LLINs distributed during the campaign. Similar results have been seen in Senegal, where the National Malaria Control Program (NMCP) is leading a rolling distribution of a similar nature with support from NetWorks.
In Cross River State, the results of the household registration led the State project team to question why such a low number of nets was found and, subsequently, the Nigeria evidence-based health information system (NEHSI) staff were contacted. NEHSI, supported by the International Federation of Red Cross and Red Crescent Societies (IFRC) and the World Health Organization (WHO), conducted a qualitative study to find out what had happened to the previously distributed nets.
The results of the study were of immediate relevance to the net distribution and hanging program currently being rolled out. It was assumed that some people would not be honest about receiving or owning nets from the previous distribution, including ones not yet hung and used, and the survey found that this was actually the case in a number of surveyed households. Another interesting discovery was that more than two-thirds of people surveyed would only sleep under the bednets for about 6–12 months, at which point the nets were considered to be expired or no longer “good” and were either burned or used for another purpose, such as covering a kiosk or screening a window. About half of the survey respondents also believed that once a net had been washed more than twice, it was no longer effective, and nearly one-third of respondents believed that washing the net in cold water would destroy the insecticide and reduce its effectiveness.
This study was relatively inexpensive and easy to implement, and it provided new critical information that is already being used to inform Cross River State’s next phase of mosquito net distributions. It will also be useful to other countries trying to account for nets that are still “good” in households. The study raised concerns about not only the validity of planning net replenishment campaigns based on the age of the net alone, but also the potential difficulties with quantifying net needs when moving from low or moderate to high LLIN coverage based on assumptions of “existing” nets.
In Cross River State, targeted messaging is being developed to encourage residents to use their mosquito nets for the full three years (or longer) and to repair them when they are torn or damaged. A net awareness campaign is being considered to improve knowledge and practice regarding LLIN use, maintenance, and repair. An end process monitoring exercise is currently taking place to ensure that universal coverage has actually been achieved where distribution has taken place. The campaign used a house-to-house distribution and hanging method, with volunteers equipped with hammers, nails, and string in addition to LLINs. The effectiveness of this approach for ensuring LLIN utilization will be assessed later in the year.
In Nigeria as a whole, the progress to date is staggering. The country bears approximately 25 percent of the malaria burden in Africa among its population of 153 million. Under the leadership of the Government and the Federal Ministry of Health, and with support from partners, the country has distributed close to 30 million LLINs and plans to distribute another 28 million this year. Nigeria’s success is reflective of strong leadership, effective partnership, and an excellent coordinating mechanism. In addition to the strong role of the NMCP, State ownership is crucial. Cross River State’s Government has played a key role in the coordination of the current campaign to move from targeted to universal coverage. This qualitative study to “find” previously distributed nets was one of the first of its kind, and provides critical information for Nigeria and other countries seeking to undertake similar activities. The study also demonstrates the importance of regular quantitative and qualitative data collection and analysis to modify project planning.

* This is the overall health policy in Nigeria, but is not yet implemented by all states.
http://www.macepalearningcommunity.org/newsletter_nigeriabednet.htm