Roll Back Malaria, progress so far

In Nigeria, the statistics of malaria related health throes mirrors the African picture Malaria is highly

endemic in Nigeria where it accounts for 60% outpatient visits to health facilities, 30% childhood death,

and 11% of maternal death (4,500 die yearly) .The financial loss due to malaria annually is estimated

to be about 132 billion naira in form of treatment cost, prevention, loss of man-hours etc. [1].

This disease has afflicted humans for periods spanning over millenniums even though it has been better

understood in the last 2 centuries. In fact certain evolutionary studies have associated the burden of the

infection and its related mortality and morbidity to certain genetic and genomic evolutional changes

like the human Red Blood Cell polymorphisms such as the Sickle cell trait, Thalassaemia,

Ovalocytosis, Glucose-6-Phosphate Dehydrogenase deficiency etc. [2].

Efforts to properly identify, characterize and control this disease has also spanned across centuries.

Notable among them include:

a) Hippocrates (460–370 BCE), the "father of medicine", related the presence of intermittent

fevers certain with climatic and environmental conditions and classified the fever according to

periodicity: Tertian fever febris tertiana (fever every third day), and quartan fever febris

quartana (fever every fourth day) [3].

b) The identification of the public health impact of Malaria was well illustrated in its contribution

to the fall of the Roman Empire: The ‘Roman fever' refers to a particularly deadly strain of

malaria that affected the Roman Campaigns and the city of Rome throughout various epochs in

history. An epidemic of Roman fever during the fifth century AD may have contributed to the

fall of the Roman Empire [4].

c) Two major discoveries that have been seen retrospectively to be fundamental to the treatment of

Malaria were
 1) The use of Artemisin plant, Artemisa annua (Qing-hao) in ancient China. Qing-hao was first

recommended for acute intermittent fever episodes by Ge Hong as an effective medication in the 4th-

century Chinese manuscript Zhou hou bei ji fang, usually translated as ("Emergency Prescriptions kept

in one's Sleeve"). His recommendation was to soak fresh plants of the artemisia herb in cold water,

wring it out and ingest the expressed bitter juice in its raw state to relieve the febrile state. [5].

2) The Discovery of the effectiveness of Cinchona leaves in the treatment of episodes of

intermittent fever observed by Spanish Missionaries to the Americas [6]. It then was imported into

Europe by the Jesuit Missionaries and eventually will become a primordial material for the

development of earlier antimalarial medications.

These two would prove to be the important in the development of the future Malaria chemotherapy.

d) The next major movement in Malaria control is the demonstration of the plasmodium parasite

as the aetiological agent in several varied clinical cases associated with fever and Chills. The

causal relationship of the parasite to the disease was established in 1880, when French physician

Charles Louis Alphonse Laveran, working in the military hospital of Constantine, Algeria,

observed pigmented parasites inside the red blood cells of malaria sufferers. He also noted that

quinine removed the parasites from the blood. Laveran called this microscopic organism

Oscillaria malariae and proposed that malaria was caused by this protozoan [7]. This work

which was confirmed by further studies in 1885, by Ettore Marchiafava, Angelo Celli and

Camillo Golgi, Italian biologists who studied the reproduction cycles of malaria in human blood

(Golgi cycles). Golgi observed that all parasites present in the blood divided almost

simultaneously at regular intervals and that division coincided with attacks of fevers [8]. For

the above work, Laveran received a Nobel Price for Physiology and Medicine in 1907 [9].

e) Next would be the remarkable isolation of the Anopheline mosquitoes as the source of Malaria

transmission within the human population. The earlier discovery of Mosquitoes as the vectors
 of Yellow fever in 1881 [10], lead to investigation of their association with Malaria outbreaks

and the eventual demonstration in 1897 by Sir Ronald Ross, a British an army surgeon working

in Secunderabad India, that malaria is transmitted by mosquitoes [7]. This discovery would

become the basis for the application of vector control in Malaria prevention and would play a

key role in many Malaria control initiatives.

The 20th century produced many major efforts, notable of which include

* The synthesis of Quinine as the active antimalarial agent found in Cinchona plants in 1918 and the

Chloroquine in 1930.

* The Production of insecticides that were highly effective in vector control: Dichloro-diphenyl-

trichloroethane (DDT) and Pyrethrum.

* Joint Global efforts to attack Malaria directed by the World Health Organisation.

Global Malaria Eradication Programme 1955

In May 1955, the 8th World Health Assembly adopted the Global Malaria Eradication

Programme, based on the widespread use of DDT against mosquitoes and of antimalarial drugs to treat

Malaria and to eliminate the parasite in humans [11]. As a result of the campaign, malaria was

eradicated by 1967 from all developed countries where the disease was endemic and large areas of

tropical Asia and Latin America were freed from the risk of infection. The campaign was only launched

in three countries of tropical Africa since it was not feasible in the others. Despite these achievements,

improvements in the malaria situation could not be maintained indefinitely by the time-limited, highly

prescriptive and centralized programmes. Also vector Resistance to DDT and Malaria parasites to

chloroquine began to affect the programme [11]. This would lead to its abandonment in 1969 following

the recognition that eradication was not achievable in many areas amid calls from several studies

linking the use of DDT to human cancers, threat to wildlife and environmental pollution [12]
Global Malaria Control Strategy 1992

Next in 1992, A Global Malaria Control Strategy was endorsed by a ministerial conference on Malaria

and confirmed by the World health Assembly in 1993 [13]. This new strategy was based largely upon

the primary health care approach and required flexible, cost-effective, sustainable and decentralized

programs based upon disease, rather than parasite control, adapted to local conditions and responding

to Local needs [11]. This marked the beginning of a renewed interest in Malaria control.

Roll Back Malaria Initiative 1998

Armed with lessons learnt from the previous Malaria campaigns and attracted by the increased call for

a renewed effort to eradicate Malaria, the World Health Organization would propose and then launch

the Roll Back Malaria initiative in 1998.

The launch of the Roll Back Malaria initiative by WHO in 1998 [14][15] stimulated increased financial

investments in Malaria control, the adoption of Artemisinin-based combination therapies (ACT) for

the treatment of Malaria patients and the large scale deployment of insecticide-treated nets (ITN) and

to a lesser extent house spraying as mosquito control measures [15].

Politically the launch of RBM 1999 was well received especially in the African continent. African

heads of states met in Abuja on April 25, 2000, to express commitment to the Roll Back Malaria (RBM)

initiative having recognized the public health and economic burden the disease has placed on the

continent as well as the barrier it constitutes to development and poverty alleviation. In addition to

signing and ratifying the Convention on the Right of the Child (CRC), they appreciated the momentum

offered by The Roll Back Malaria (RBM) movement to help reduce malaria burden. They pledged to

implement the strategies and actions of RBM, initiate actions at regional level to ensure

implementation, monitoring and management of RBM, provide resources at the country level to

facilitate the realization of RBM objectives and to work with other partners in malaria endemic areas

[16]
Roll Back Malaria Nigeria

In Nigeria, the RBM Nigeria was launched in 1998 as part of the global movement for enlisting broad-

based participation in scaling up Malaria control efforts [17] and following the protocol proposed by

the RBM, National Malarial Control Programme (NMCP) had developed strategic plans to meet up

with the 2010 deadline to reduce Malaria burden by 50% which has since inception directed the

national efforts to eliminate the disease. The 2011 WHO annual malaria report showed that The

National Malaria Control Program delivered about 17 million ITNs during 2005-2007 (6.6 million

Long Lasting Insecticidal Nets), enough to cover only 23% of the population at risk. The programme

delivered 4.5 million single dose packages of ACT in 2006 and 9 million in 2007, far below total

requirements. Funding for malaria control was reported to have increased from US$17 million in 2005

to US$60 million in 2007, provided by the government, the Global fund and the World Bank[18].

The first checkpoint for the RBM initiative was set to be at the year 2010 where the specific objectives

were : a) to reduce the Malaria burden by 50% b) Increase the number of under five children and

pregnant women who sleep under insecticide treated nets to 60% c) to ensure that at least 60% of all

pregnant women will have full access to intermittent preventive therapy for Malaria during their

Antenatal care visits d) to ensure that 60% of children under five receive rapid diagnostic and

therapeutic care within 24hourrs of onset of illness e) to develop an effective environmental

management strategy for RBM [19]. A number of studies have analysed the achievement of the

National Malaria Control Programme using these indices indicated above.

A study focusing on the use of ACT for treatment of cases would discover that ten years after the

historic Abuja meeting, only 5% of households in Benin City used ACTs for the treatment of malaria,

sourcing medicines chiefly from patent medicine stores and private hospitals [20].

A more comprehensive study evaluating the indices of the RBM initiative [21] The Study would yield

the following results

 1. ITN use among children under five: study showed a proportion of less than 20% compared to

Benin’s 80%. (expected is 60%)

2. ITN use among pregnant women: study showed a proportion of less than 20% compared to

Benin’s 80% (expected is 60%)

3. Pregnant women receiving IPT during an ANC visit: study showed a proportion less than 20%

compared to Zambia’s 80% (expected is 60%)

4. Malaria diagnostic test among children under five: study showed a proportion less than 10%

compared to Uganda’s > 70% (expected is 60%)

Major challenges to meeting up with National targets included

1. Insufficient funds.

2. Suboptimal administration of the programme by the Federal Ministry of Health

3. Conflicting interests between the National Malaria Control Programme and the private sector.

4. Low general staff Capacity

Another study would observe an apparent collapse of the Primary health care system in Nigeria. The

primary health care system is at the heart of the RBM. Most malaria deaths occur at home, without

confirmation of the diagnosis. The reality is that in the poorest, rural areas, where malaria takes its

highest toll, it is difficult to obtain accurate data and to derive meaningful malaria statistics. During

their illness, many patients struggle, often unsuccessfully to access basic health care. For those that

succeed, the care may be of dubious quality and ineffective [22].

While expected targets are yet to be met especially in many African countries, there has been an

increased call from the WHO to launch a new wave of assault on Malaria. In the World Health

Assembly of 2015 it would adopt the ambitious Global Strategy for Malaria eradication that would
bring the world to a reduction of Malaria burden to 90% by the year 2030 [23] the questions still

remains, how will we manage to clear the deficits and key in to the new attack.

An advantage the nation has is that its most important limiting factors have been identified by the

NMCP from the abundant data furnished by numerous research works such that all needed is to lay

down anew plans to readdress these challenges. The future could be looked towards with a more

enthusiasm as on the part of the Federal Ministry of Health, plans and well defined strategies have been

forged with a view to improving the Malaria picture. Worthy of note is the Advocacy, Communication

and Social Mobilization Strategic Framework and Implementation Plan [17] a collaborative effort by

several individuals, private and public organizations to produce more visible results in the years to

come.

Conclusion

Malaria control in Nigeria in line with the data obtained from various national and international

observations still remain an important Public Health challenge. It contributes the greatest burden of

morbidity and mortality amongst children under five years of age and pregnant women and also

significantly to the number of working hours lost to illnesses. A number of strategies have been

developed and initiated with a view to eliminating the disease from the country however poor

implementation has led to a failure to attain desired targets. While many of the contributing factors to

this failure continue to be identified, the future lies in a joint effort from both the public and private

sectors to tackle and eliminate these challenges. The global Malaria eradication goal to reduce Malaria

burden by 90% might appear ambitious but the progress seen in certain other countries points to its

possibility. In Nigeria however more emphasis should be put on overcoming the numerous hindrances

which would be of benefit not just to the control of Malaria but also in addressing other high burden

diseases such as HIV/AIDS and Tuberculosis.

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Jude Abor, alpha cell, 021 class.