Challenges of Malaria Elimination in Nigeria; A Review

Abstract

In 2010 deaths from malaria in Nigeria were the highest recorded worldwide. This was a strange phenomenon since so much effort has been geared towards eradicating this dreaded disease in the country, hence the need to critically investigate the reasons for these challenges confronting eradication efforts. There is need to identify some of the setbacks confronting malaria elimination in Nigeria. Some of the challenges x-rayed include: inadequate healthcare infrastructure in the rural areas, poor drug distribution, increases in drug resistant parasites, increase in insecticide resistant mosquitoes, poverty leading to poorly constructed rural dwellings with cracks and crevices, and individuals' non-compliance with the control program due to high level of illiteracy. Much work still need to be done to reduce malaria incidence to a minimum level in Nigeria. No single individual method can be used to achieve a successful malaria control program. Strategic control methods must involve some combination of effective clinical control, vector control, reduction in contact of the mosquito with its human host, improved sanitation, and better health education and malaria prevention programs. If these efforts are sustained, over time Nigeria may succeed in eradicating malaria.

Full text

International Journal of Infectious Diseases and Therapy
2017; 2(4): 79-85
http://www.sciencepublishinggroup.com/j/ijidt
doi: 10.11648/j.ijidt.20170204.14
Challenges of Malaria Elimination in Nigeria; A Review
Onah Isegbe Emmanuel1, *, Adesina Femi Peter2, Uweh Philomena Odeh3, Anumba Joseph Uche4
1Federal College of Veterinary and Medical Laboratory Technology, National Veterinary Research Institute, Vom-Jos, Nigeria
2Biology Department, Faculty of Science, Federal University of Technology, Akure, Nigeria
3Biology Department, College of Advanced and Professional Studies, Makurdi, Nigeria
4Federal Ministry of Health, National Arbovirus and Vectors Research Centre, Enugu, Nigeria
Email address:
onahisegbe@gmail.com (Onah I. E.), femi.adesina@outlook.com (Adesina F. P.), uwehpo@gmail.com (Uweh P. O.),
anumbajoe@gmail.com (Anumba J. U.)
*Corresponding author
To cite this article:
Onah Isegbe Emmanuel, Adesina Femi Peter, Uweh Philomena Odeh, Anumba Joseph Uche. Challenges of Malaria Elimination in Nigeria;
A Review. International Journal of Infectious Diseases and Therapy. Vol. 2, No. 4, 2017, pp. 79-85. doi: 10.11648/j.ijidt.20170204.14
Received: September 23, 2017; Accepted: October 16, 2017; Published: December 8, 2017
Abstract: In 2010 deaths from malaria in Nigeria were the highest recorded worldwide. This was a strange phenomenon
since so much effort has been geared towards eradicating this dreaded disease in the country, hence the need to critically
investigate the reasons for these challenges confronting eradication efforts. There is need to identify some of the setbacks
confronting malaria elimination in Nigeria. Some of the challenges x-rayed include: inadequate healthcare infrastructure in the
rural areas, poor drug distribution, increases in drug resistant parasites, increase in insecticide resistant mosquitoes, poverty
leading to poorly constructed rural dwellings with cracks and crevices, and individuals’ non-compliance with the control
program due to high level of illiteracy. Much work still need to be done to reduce malaria incidence to a minimum level in
Nigeria. No single individual method can be used to achieve a successful malaria control program. Strategic control methods
must involve some combination of effective clinical control, vector control, reduction in contact of the mosquito with its
human host, improved sanitation, and better health education and malaria prevention programs. If these efforts are sustained,
over time Nigeria may succeed in eradicating malaria.
Keywords: Malaria, Elimination, Nigeria, Mosquito, Control
1. Introduction
Malaria has a worldwide distribution, affecting people of all
ages, with an enormous burden amounting to 300-500 million
clinical cases per year [1]. Globally ten new cases of malaria
occur every second, which is a major public health problem in
the tropics where about 40% of the world population lives. It is
responsible for more than a million deaths each year, of which
90% occur in sub-Saharan Africa [2].
Malaria is caused by four different protozoa in the
plasmodium genus: either Plasmodium vivax, which is more
prevalent in low endemic areas, P. ovale, P. malaria, and P.
falciparum, the most dangerous of the four. The P.
falciparum has a life cycle in the mosquito vector and also in
the human host. The Anopheles gambiae mosquito is the
vector responsible for the transmission of malaria. The
prevalence of malaria is dependent on the abundance of the
female anopheles species, the propensity of the mosquito to
bite, the rate at which it bites, its longevity and the rate of
development of the plasmodium parasite inside the mosquito.
When the female mosquito bites and sucks the blood of a
person infected with malaria parasites she becomes infected;
she then transmits the parasites to the next human host she
bites. Malaria incubates in the human host for about eight to
ten days. [3]. The spread of malaria needs conditions
favorable to the survival of the mosquito and the plasmodium
parasite. Temperatures of approximately 70 - 90 degrees
Fahrenheit and a relative humidity of at least 60 percent are
most conducive for the mosquito [4].
Nigeria is at an alarming pace, as been the most populous
country in Africa. The success of its malaria control
programs will have a significant impact on the overall control

International Journal of Infectious Diseases and Therapy 2017; 2(4): 79-85 80
of malaria in the region. Because a large proportion of the
population in Nigeria’s rural areas lives in poverty [5], a
control plan focused on those areas will be effective. Also,
there are factors that are responsible for the increase in the
resurgence of malaria that must be addressed in malaria
transmission and control. These factors include the large-
scale resettlement of people usually associated with
ecological changes and conflicts, increasing urbanization
disproportionate to the infrastructure, drug resistant malaria,
insecticide resistant mosquitoes, inadequate vector control
operations and public health practices.
The year 2000 went down in history as the year in which
the most influential alliance (till date) in efforts to eradicate
malaria converged in Abuja, Nigeria. That was the Roll Back
Malaria (RBM) Partnership, and the targets set have come to
be known as the ''Abuja Targets''. One of the goals set by the
RBM Partnership was that by 2010, 80% of patients with
malaria would be diagnosed and treated with effective
antimalarial medicines [33].
Over 1 decade later, malaria remains a public health
concern in the world's poorest countries, Nigeria chief among
them. As at 2010, deaths from malaria in Nigeria were the
highest recorded worldwide [6]. In 2005, artemisinin-based
combination therapies (ACTs) were adopted as the first-line
treatment for uncomplicated malaria in Nigeria [5]. This is a
strange phenomenon since so much effort has been geared
towards eradicating this dreaded disease in Nigeria. Hence
the need to critically investigate the reasons or challenges
confronting eradication efforts of Malaria in Nigeria.
1.1. Global Malaria Burden
About 107 countries and territories involving about 3.2
billion people are still at risk of malaria attack as at 2004 [6].
Present estimates suggest that around 350–500 million
clinical disease episodes occur annually [7]. Around 60% of
clinical cases and over 80% of the deaths due to malaria
occur in Africa south of the Sahara [8]. It is the second
leading cause of death from infectious diseases in Africa,
after HIV/AIDS and is also a leading cause of mortality in
under-five children accounting for 20% of death and
constitutes 10% of the total disease burden of African
continent [9]. Malaria kills a child somewhere in the world
every 30 seconds. Over 90% of the malaria burden occurs in
Sub-Saharan Africa [10-11]. In endemic areas, malaria
infection in pregnancy is believed to account for up to a
quarter of all cases of severe maternal anemia and for 10-
20% of low birth weight babies [10].
Each year more than 500,000 women die during pregnancy
or childbirth [12] and more than four million babies die in the
first 28 days of life, accounting for 38% of mortality in
children five years of age or under worldwide [13-14].
Maternal malaria infection is estimated to account for three
to eight percent of all infant deaths [15]. Nigeria, Democratic
Republic of Congo (DRC), Ethiopia, Sudan and Uganda
account for nearly 50% of the global malaria deaths [16].
High rates of maternal and prenatal mortality have been
observed in the different regions of Sudan; both malaria and
anemia were the major causes of these high levels of
mortality [17-19].
Figure 1. Global Map of Malaria Endemicity, 2010. (WHO, 2010; World Malaria Report 2010).

81 Onah Isegbe Emmanuel et al.: Challenges of Malaria Elimination in Nigeria; A Review
Figure 2. Prevalence of Malaria in Nigeria (WHO, 2016).
1.2. Distribution of Malaria Vector in Nigeria
Correct analysis of the distribution of specific malaria
vectors is one of the prerequisites for meaningful
epidemiological studies and for planning and monitoring of
successful malaria control or eradication programmes [20].
Many Anopheles species has been reported in Nigeria. An.
gambiae and An. funestus complexes has been reported as the
two major Anopheles species in Southern Nigeria that are
vectors of malaria with An. moucheti and An. nili [21-20].
The An. gambiae group consists of at least seven species
which includes An. gambiae and An. arabiensis which are
good vectors of malaria and are known to coexist in most
part of West Africa [20].
In Northern Nigeria, An. gambiae was reported as the only
Anopheles species in Sokoto metropolis [23] also An.
gambiae, An. arabiensis and An. funestus was reported as the
mosquito species in Kastina metropolis, Katsina state [24],
while in Yola, the dry season mosquito collection for
anophelines were; An. gambiae complex (64%), An. funestus
complex (17%), An. pharoensis (9%) and An. rhodesiensis
(5%) and the wet season collections were; An. gambiae
complex (56%), An. funestus complex (19.6%), An.
pharoensis (11.4%) and An. rhodesiensis (7%) [25]. In a
survey of mosquito in mid-western Nigeria, 3 Anopheles
species (An. gambiae, An. Pseudopunctipennis and An.
funestus) was reported [26]. In a study at Ajumoni Estate, a
peri urban area of Ogun state, Southwest, Nigeria, Anopheles
mosquito constituted 18.85% of all captured mosquito [27].
Two Anopheles species; An. gambiae and An. funestus were
reported in Enugu, Southeast Nigeria [28].
1.3. Malaria Vector Control Practices in Nigeria
There are many factors that affect the control of malaria in
Nigeria. This varies from region to region, depending on
human knowledge, attidude and method of control. Ignorance
as well as illiteracy (especially among rural dwellers) and
financial impoverishment are part of these factors [29].
Studies have revealed that human knowledge, attitude and
adoption of the various recommended applicable methods of
personal and household protection against mosquito vary
remarkably in different endemic regions of tropical countries
[30-31]. Also, from a descriptive cross sectional study in two
rural farming communities in Oyo state, using a pre-tested
semi-structured questionnaire, the following findings were
made [32] (table 1).
Table 1. Methods respondents used for prevention of mosquito bites in their homes.
Methods Used for Prevention of Mosquito Bites in Home Fasola Community (N=199) (%)
Soku Community (N=204) (%)
Total (%)
Killing of mosquito with broom 79 (21.9) 125 (128.0) 204 (25.3)
Mosquito coil 93 (25.8) 100 (22.3) 193 (23.9)
Electric fan 54 (15.0) 97 (21.7) 151 (18.7)
Insecticide sprays 63 (17.0) 33 (7.4) 96 (11.9)
Window/door screen 33 (9.2) 49 (11.0) 82 (10.2)
Insect repellent body cradle 14 (3.9) 25 (5.8) 39 (4.8)
Insecticide treated bed nets (ITNs) 22 (6.1) 17 (3.8) 39 (4.8)
Mosquito cradle 2 (0.6) 1 (0.2) 3 (0.4)
Source: (Oladepo et al., 2010).
His findings also revealed that only few of the repondents (11.2%) had the knowledge about the cause of malaria.

International Journal of Infectious Diseases and Therapy 2017; 2(4): 79-85 82
Majority of the respondents stated its causes to be
consumption of contaminated food and water, staying long in
the sun and dirty surrounding. As part of its effort to reduce
and eliminate malaria incidence, and for each country to
achieve the United Nations Millennium Development Goals,
the WHO Global Malaria Programme (WHO/GMP)
recommends the following:
(1) Diagnosis of malaria cases and treatment with effective
medicines.
(2) Distribution of insecticide-treated nets (ITNs), more
specifically long-lasting insecticidal nets (LLINs), to achieve
full coverage of populations at risk of malaria.
(3) Indoor residual spraying (IRS) to reduce and eliminate
malaria transmission.
2. Challenges of Malarial Control in
Nigeria
The major challenges to malaria control and prevention
intervention are basically grouped into behavioural and non-
behaviour factors. The behavioural factors relate to cultural
practices which promote mosquito breeding and mosquito
access to the people as well as failure of the risk populations
to use technologies proven to be effective for the treatment,
control and prevention of malaria promptly and
appropriately. The main non-behavioural factors include
geographical or ecological peculiarities, which also includes
the tropical and subtropical condition; rainfall, high humidity
and relative high temperature, the availability of mosquitoes
and the presence of plasmodia [33]. In Nigeria, some factors
that are actively contributing to the resurgence of malaria
include;
(1) Rapid spread of resistance of malaria parasites to
chloroquine and other quinolines
(2) Frequent armed conflicts and civil unrest
(3) High Vector abundance and transmission potential
caused by climate changes as well as water development
projects including dams and irrigation
(4) Poverty
(5) Misconceptions about Malaria
(6) Counterfeit and substandard drugs and Lack of access
to good health care systems
(7) Low Rate of Insecticide treated Net ownership and
Use.
2.1. Anti-malarial Drug Are Becoming Less Effective as the
Plasmodium Parasite Develops Resistance to Common
Drugs
Resistance to drugs like artemisinin (a vital component of
drugs used in the treatment of P. falciparum malaria) has
been reported in a growing number of countries in Africa
[34], pyrethroids, and the insecticides used in ITNs has been
reported in 27 countries in Africa and 41 countries
worldwide of becoming less effectives [35]. Unless properly
managed, such resistance potentially threatens future
progress in malaria control in Nigeria.
2.2. Displacement of a Population Due to Communal
Clashes, Conflicts and Insurgency
Large non-immune populations to endemic areas,
resettlement of refugees to deteriorated environments that
favour vector breeding (e.g., inadequate sanitation, marginal
land), disruption of disease control programmes, breakdown
of health systems [36-37], and impeded access to populations
for timely delivery of medical supplies [38-40]. There is
virtually no city in Nigeria that is not affected by communal
clashes leading to a breakdown of health systems and
impedes efforts in combating malaria.
2.3. Favorable Climatic Condition for Vector Breeding
Tropical areas such as Nigeria have the best combination
of adequate rainfall, temperature and humidity allowing for
breeding and survival of Anopheles mosquitoes. Temperature
is an important factor which through its effect on the
development of the malaria parasite and the vector greatly
influences the geographical distribution of malaria
transmission in general and malaria parasite species in
particular. The development of P. falciparum in the female
adult Anopheles requires a minimum temperature of 20°C
whereas the other human malaria species can develop at
temperature down to a minimum of 16°C. Higher than the
minimum temperature, the development of the parasite in the
vector accelerate with increasing Temperature [41].
2.4. Financial Status also Contributes to the Less Effective
Control and Prevention of Malaria in Nigeria [42 and
43]
At the household level, poor housing exposes people to
contact with infective mosquitoes, as insecticide treated nets
are unaffordable to the poorest if they must pay for them, and
lack of resources prevents people from seeking timely
healthcare [5]. Studies have revealed that a substantially
higher prevalence of malaria infection occurs among the
poorest population group [44], and that the poorest were most
susceptible to contracting malaria [45].
2.5. Lack of Knowledge About the Causes and Control of
Malaria
Misconceptions about the cause of malaria are reported in
researches from all over the globe [46]. A study in Benue
state, Nigeria showed that residents of both urban and rural
areas still have misconceptions about the cause of malaria.
Some attributed malaria to spirits/charm, poor nutrition and
stress [47]. These are major socio-cultural setbacks in
malaria treatment and control. All these contribute to the
discrepancies in health seeking behavior and may cause delay
in seeking appropriate treatment.
2.6. Availability and Access to Standard Health Care
System and Drugs
Lack of good roads to the health centers, poorly equipped
centers, inadequate drugs for malaria treatment, substandard

83 Onah Isegbe Emmanuel et al.: Challenges of Malaria Elimination in Nigeria; A Review
antimalarial medicines and as well as available ratio of
patients to a doctor is alarmingly high. As a result of this, this
is encouraging patients to seek treatment from unauthorized
local service providers, which often lead to further
complications.
2.7. Insecticide Treated Nets (ITNs) and Its Use
Prevalence of mosquito net ownership varies greatly by
residence and region. According to the 2003 Nigeria
Demographic and Health Surveys (NDHS), only 12% of
households reported owning at least a net while 2% of
households report that they own an ITN [48]. Similarly in the
2008 (NDHS), data collected on measures to prevent malaria,
shows that 17% of household nationwide own at least a net
of any type, while 8% own at least an ITN. This shows that
ownership of mosquito nets is not widespread in Nigeria.
Financial status, unavailability, body reaction, alternative
barriers and ignorance also affects the wide spread of ITNs in
Nigeria [49]. The success of malaria control with ITNs has
been bogged down by problems of delivery, distribution,
usage and even acceptability of this method in Nigeria [50].
Public awareness and acceptance of insecticide treated nets
varies from community to community in countries where this
method of malaria control has been adopted.
3. The Way Out
(1) Accessibility to affordable primary health care centers
with standard equipment and drugs must be guaranteed.
Units within primary health care centers should be set up to
diagnose, treat and monitor malaria cases.
(2) Epidemiological surveillance is highly essential in any
control strategy, and is an essential guide in developing a
multi-dimensional approach. The malarial control units set up
should keep data on the epidemiological surveillance and the
information should be sent to the national malaria control
center.
(3) During seasonal outbreaks anti-malarial prophylaxis
should be provided for children under five and pregnant
mothers.
(4) Vector control using the barrier methods like bed nets
and wearing protective clothes should be encouraged. It is
important that people are also taught how to use and treat the
bed nets.
(5) Workers should be trained on how to spray the various
sites such as inner walls of houses and the surrounding
environment. Wearing protective clothes and noise mask are
very important during spraying and also residual spraying
should be done at least every six months
(6) There are some indigenous plants and trees which
indigenous people claim to contain anti-mosquito properties,
the National Agency for Food and Drug Administration and
Control should conduct research to verify such claims.
(7) More awareness and campaigns on fighting against
malaria, side effects of self-medication, making environment
clean, removing any structures and container that can aids the
breeding of mosquitoes, clearing of bush near house and mud
houses should be plastered and painted white.
(8) Individuals should approach the nearest health clinic
center for treatment
4. Conclusion
Much works still need to be done to reduce malaria
incidence to a minimum level in Nigeria. Presently, evidence
base strategies and action are on its prevention, diagnosis and
treatment, surveillance and research, and social mobilization.
The advance in the fight against malaria is largely due to the
mass distribution of treated mosquito nets, especially the
long lasting insecticide nets. A strategic plan to guide the
scale-up of larviciding nationwide has been prepared for IRS
(Indoor Residual Spray), and this was supported by Federal
government, state government, World Bank and other
international organizations. The Nigerian National Malaria
Control Policy and guidelines for the diagnosis and treatment
of malaria are also in place, especially for new guidelines on
parasite-based diagnosis and the use of Rapid Diagnostic
Technics to complement microscopy. This also focuses on
making it affordable and available at a low cost. Media are
raising awareness to educate, disseminate and advocate for
policy to fight against malaria. Journalists from all zones
have been trained to conduct in-depth reporting on malaria,
and radio and television broadcasts have been prepared and
disseminated nationwide. If these efforts are sustained, over
time Nigeria may succeed in eradicating malaria.
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