International Journal of Community Medicine and Public Health | October 2020 | Vol 7 | Issue 10 Page 4157
International Journal of Community Medicine and Public Health
Odoko JO et al. Int J Community Med Public Health. 2020 Oct;7(10):4157-4163
http://www.ijcmph.com
pISSN 2394-6032 | eISSN 2394-6040
Review Article
Epidemiology of malaria as it relates to utilization of insecticide treated
nets among pregnant women and under five years children in
South-South Nigeria
Joseph O. Odoko1*, Ezekiel U. Nwose2, Samuel D. Nwajei1, Emmanuel A. Agege1,
John E. Moyegbone1, Eunice O. Igumbor1
INTRODUCTION
The world success on malaria elimination has been
reported to be slowed compared to initial progress.1 There
was no much difference of global malaria cases between
2010 to 2018 despite malaria intervention availability.2
This is especially in Africa, and Nigeria in particular
where it is a major public health problem.3,4 Among the
vulnerable population to malaria infection are pregnant
women and children under 5-years. These are the
subpopulation groups who are exposed to malaria related
anemia that highly contributes to death if effective
intervention is not taken.5
The 2016 report indicate that 99% of malaria cases in
sub-Saharan Africa are caused by Plasmodium
falciparum, P. vivax is the common parasite.6 WHO
recommends use of long-lasting ITNs (LLINs);
intermittent preventive treatment in pregnancy (IPTp)
with sulfadoxine-pyrimethamine (SP) and prompt
diagnosis as well as effective treatment among pregnant
women during antenatal care services.7 Yet, malaria
interventions are threatened by resistance of malaria
vectors to pyrethroids used in all ITNs , which has been
on the increase from between 2010 and 2016.8 It is agreed
that to achieve universal ITN coverage, affected countries
with malaria infections need to subscribe to supportive
ABSTRACT
Pregnant mothers and children under five years are exposed to malaria infection. One of the WHO recommendations
on prevention of malaria is the use of insecticide treated nets (ITNs). The use of ITNs is still low in Nigeria. Is to
access challenges and improvement on use of ITNs among pregnant mothers and care givers of children under five in
Bayelsa, Delta and Rivers state respectively. Review of articles related to use of ITNs among pregnant mothers and
under five years children were adopted using The American Journal of Human Genetics among 28 studies. Malaria is
responsible for 30% childhood and 11% maternal mortality despite the availability on use of ITNs. ITNs were 62.8%
effective in reducing febrile episodes and 84.1% effective in reducing marked levels of malaria parasitemia. Mass
distribution of bed-nets has increase ownership of ITNs resulting to 81.5% in Nigeria. Free ITNs has resulted in
universal household ownership but the use of the nets is still very low in Nigeria. Malaria interventions are threatened
by pyrethroids used in all ITNs. Irritation and suffocation are challenges to utilization of ITNs. In health promotion on
use of ITNs, manufacturers’ improvement on quality of ITNs is an epidemiological factor that could enhance the use
among the vulnerable groups.
Keywords: Malaria epidemic, Global reports, ITNs, Mass distribution, Ownership, Utilization
1Department of Public and Community Health, Novena University, Ogume, Nigeria
2School of Community Health, Charles Sturt University, Orange, NSW Australia
Received: 19 June 2020
Revised: 06 August 2020
Accepted: 09 September 2020
*Correspondence:
Dr. Joseph O. Odoko,
E-mail: odokojosy@gmail.com
Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.
DOI: http://dx.doi.org/10.18203/2394-6040.ijcmph20204390
Odoko JO et al. Int J Community Med Public Health. 2020 Oct;7(10):4157-4163
International Journal of Community Medicine and Public Health | October 2020 | Vol 7 | Issue 10 Page 4158
program to reach global malaria targets for 2020 and
beyond (Figure 1).6
Figure 1: Global malaria target for 2020-2030 relative
to 2015.
Adapted from ‘The E-2020 initiative of 21 malaria-eliminating
countries: 2019 progress report’.8
There has been decline in malaria infection in Africa due
to increase investment to eliminate malaria but sustaining
it has been a difficult issue for indigenous malaria cases
in African countries.9 WHO recommend one ITN for
every two people at risk of malaria; hence Nigeria has
been involved in free mass distribution of LLINs to
vulnerable populations.3 The renewed target for roll back
malaria (RBM) in Nigeria now includes to control
malaria with targeted key performance indices including
• 80.0% of children <5years and pregnant women to
use ITN.10
• 74% of ownership of ITNs in households through
mass distribution.11
Despite the evidence that the use of ITNs decreases
malaria related mortality and morbidity, its use is still low
as reported by the 2013 Demographic Health survey in
Nigeria.4 There is evidence that ITNs coverage or
ownership seems to have achieved the RBM target.
However, utilization is quite low and a far cry as most of
the owners are not utilizing their nets due to various
factors.12 A study to identify factors that are meant to be
eliminated for effective utilization of ITNs among
pregnant mothers and care givers of under five years
children in Bayelsa State, Delta State and Rivers State
within South-South Nigeria will go a long way to
influence stake holders in promoting the health of the
vulnerable population against malaria infection.
GLOBAL MALARIA CASES AND MORTALITY
Global report on malaria in 2015 indicates that malaria
infections were about 212 million cases and had caused
429,100 deaths. Majority of the affected populations are
more of children and pregnant mothers.13 In 2016, 91
countries experienced 216 million malaria cases, with 5
million cases higher than the previous year. The mortality
rate due to malaria was recorded at 445, 000 deaths which
was similar to figures reported in 2015.6 These indices
show that the global burden of malaria did not seem to be
a continuous or consistent declining trend in the past
decade. Indeed, the 2017 data appear worse than 2015
(Figure 2).5 It is acknowledged that cases of malaria
reduced globally between 2010 and 2018 from 71 to 57
cases per 1000 population at risk. That of 2014 to 2018
which was 57 cases 85% higher among 20 countries in
Africa Region and India.7,8
Figure 2: Numbers of malaria cases and deaths at
baseline, 2015 vs. 2017.
Figure 3: Increase in ITN distribution by healthcare
venue.
Prevention of malaria with use of ITNs
WHO recommends use of LLINs, IPTp and SP as well as
prompt diagnosis and effective treatment of malaria
% Reduction in case
incidence No of malaria-free
countries
40
10
75
20
90
35
2020 2025 2030
0
100
200
300
400
500
600
700
2017 2015 2010 2017 2015 2010
Cases (millions) Deaths (thousands)
219 214 239
451 435
607
Malaria cases/deaths
0%
1%
2%
3%
4%
5%
6%
7%
Immunization Public health
centres Antenatal
care
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International Journal of Community Medicine and Public Health | October 2020 | Vol 7 | Issue 10 Page 4159
infections as main stay among pregnant women during
antenatal care services.7 In 2016 intervention against
malaria infection with the use of ITNs shows that 54% of
people at risk of malaria in sub-Saharan Africa were
sleeping under it. This ITNs utilization rate is not near the
goal of universal access.6 Between 2016 and 2018, 578
million ITNs were distributed by producers worldwide,
out of which 50% went to Africa and India. The African
countries include Côte d’Ivoire, Democratic Republic of
Congo, Ethiopia, Ghana, Nigeria, Uganda and the United
Republic of Tanzania. Globally, 80% of ITNs were
distributed through mass distribution campaigns, 10% in
antenatal care facilities and 6% as part of immunization
programs (Figure 3).8
Challenges in progress of malaria control as it concerns
ITNs
Lack of sustainable and predictable international and
domestic funding, humanitarian crisis in malaria endemic
territories, poor climate conditions, emergence of parasite
resistance to antimalarial treatment and mosquito
resistance to insecticides are noticed in some countries.6
Malaria intervention are threatened by resistance of
malaria vectors to pyrethroids used in all ITNs, which has
been on the increase from between 2010 and 2016.8
Irrespective of the slow progress in elimination of
malaria, there is hope of progress and lessons to be learnt
in countries. For instance, Algeria in Africa is among the
few countries that have reported zero indigenous cases for
a minimum of two consecutive years (Figure 4), and are
certificated malaria free.5
Countries
2010
2011
2012
2013
2014
2015
2016
2017
2018
Paraguay
(America)
Algeria (Africa)
El Salvador
(America)
China (Western
Pacific)
Figure 4: Countries that have achieved malaria-free
status in ≥2 years.
Adapted from ‘The E-2020 initiative of 21 malaria-eliminating
countries: 2019 progress report’.
AFRICA: SUB-SAHARAN MALARIA CASES AND
MORTALITY
So much can be said of malaria in Africa e.g. 15 countries
in Sub-Saharan Africa responsible for about 80% of the
world malaria infection.3 Malaria has been identified for
decades as a public health problem in Sub-Saharan
Africa. It has caused a high rate of and death among
women of child bearing age and children under one year
old in Africa. One of the five highest deadly diseases in
Sub-Saharan Africa is malaria.14 According to the WHO
2017, there were 216 million cases of malaria in the
world and 445,000 deaths took place in 2016 of which
90% of the deaths occurred in Africa continent and 80%
of the reported case is from Sub-Saharan Africa. All ages
and sexes are affected by malaria, although low immunity
level among pregnant mothers and under five years
children has been an underlining factor responsible for
high rates of death.15 Plasmodium falciparum is the most
highly rated parasite over P. vivax that causes malaria
infection in Africa. In fact, WHO reported that
• In every 50 seconds, a child dies of malaria hence a
constraint to socio-economic development.16
• Malaria is wide spread among 76 countries in Africa
and Asia.8,17
• In the 2019 global malaria report,19 countries in sub-
Saharan Africa and India contributed 85% of the
global burden. In other perspectives, Africa
contributed 93% (Table 1); while Nigeria is one of 6-
countries that accounted for 54% of all malaria cases
(Figure 5).7
Figure 5: Nigeria as most affected global cases.
Table 1: Global malaria cases according to WHO
report of 2019.
Year
Estimated
cases (millions)
95% CI
Estimates
2010
251
231 - 278
2017
231
211 - 259
2018
228
206 - 258
Distribution of occurrence of malaria-2018 cases
(%)
African region
93.0
South-East Asia
3.4
Eastern Mediterranean
2.1
Rest of World
1.5
Total
100.0
Nigeria
25%
DR Congo
12%
Uganda
5%
Cote
d'Ivoire
4%
Mozambiq
ue
4%
Niger
4%
Rest of
World
46%
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International Journal of Community Medicine and Public Health | October 2020 | Vol 7 | Issue 10 Page 4160
Policy on malaria prevention with the use of ITNs in
Africa
WHO in 1992 emphasize that ITNs is the best and
reliable preventive strategy against malaria burden.
Ghana as a signatory to the May 2006 Abuja Declaration.
As part of the objective of the RBM, agenda was to raise
ITNs ownership to 80% and utilization to 60% by 2010.
Further target set for 2015 was to achieve 100%
ownership and 80% usage.14
The WHO recommends utilization of ITNs as the main
strategy towards control of malaria by all ages and sexes.
Distribution of free ITNs should be the main intervention
in national malaria control strategy in all Sub-African
countries. WHO target of 85% coverage is a vital key
performance index to distribution of ITNs supply.
Adjunct to this recommendation is one ITN for every two
people who are at risk of malaria.3 The Abuja declaration
in 2000 by African leaders for the provision of 60% of
ITNs for African children by 2005 is yet to be achieved
by Sub-Saharan countries, despite their effort to meet
universal coverage.18 Most countries are below the set
target of protection coverage.16
Constraints and achievements in Malaria Control with
the use of ITNs in Africa
Funding of malaria programs by donors has been scarce
in Sub-Saharan African countries. Thus, making the fight
against malaria a difficult task. Poor awareness or
knowledge about malaria preventive measures, and
misunderstanding between couples on use of ITNs is
reported in previous investigations.19 Factors identified as
challenges for ownership ITNs include, but not limited
to:16
• Awareness or knowledge: level of understanding on
use of bed nets,
• Demographic factors: age, sexes, marital status, and
occupation
• Access to healthcare: distance to nearest antenatal
care,
• Affordances: access and cost including availability of
transport as well as house-hold size
Studies from Africa reveal that ownership of bed nets
cannot be interpreted as utilization of the ITNs. The latter
makes it far from meeting the target of universal
coverage. Utilization of ITNs has been reported to be as
low as 9.6%. Reasons for non-utilization of ITNs in
Africa are perceived un-comfortability and hotness
created by ITNs, low understanding of malaria
prevention. Inadequate separate sleeping rooms, poor
quality of ITNs and inadequate ITNs to the house hold
members.14
The issue of poor quality underpins failure rates. Re-
emergence of malaria has been experienced in Senegal,
Western Kenya, Gambia, Benin, Tanzania and Uganda
where ITNs have been utilized. These situations warrants
the need to study the main challenge of resistance to ITNs
of the mosquitoes that causes malaria.20 In Sub-Saharan
Africa, it is estimated that the population of users of ITNs
have gone up from less than 2% in 2000 to 67% in 2015.
Modification of nets into pyrethroid treated bed nets has
help to reduce vector increase, number of infection rates
in Anopheles populations leading to decline in malaria-
associated cases and death rates in African countries.20
However, the study in Benin, Equatorial Guinea and
Malawi have shown that distribution and utilization of
new ITNs provide more advantages to reduce malaria
burden despite pyrethroid ITNs resistance than use of old
ITNs.21 Therefore, it must be acknowledged that
regardless of poor quality, ownership and utilization of
the available ITNs is a sine qua non.
NIGERIA: MALARIA CASES AND MORTALITY
Epidemiology on utilization of ITNs among pregnant
mothers and under five children in Nigeria
Nigeria is among 11 countries that account for 70% in the
world malaria deaths rate.22 Malaria is a major public
health problem in Nigeria and it is responsible for 30%
childhood and 11% maternal mortality, despite the
availability of effective interventions.4 100% of the
Nigerian populations are at risk of malaria infection.
Nationally, the malaria burden accounts for 60% of
outpatient visits to health facilities.23 Malaria infection is
endemic in Nigeria, and everybody is at risk with a
prevalence of 919 per 10,000 (9%) of population.10
Nigeria leads other ten African countries with a high
burden of malaria and accounted for 25% of total malaria
cases (Figure 5), and 19% of malaria deaths worldwide in
2017.24
According to the statistics of the Nigerian National
Malaria Control program, the burden of malaria includes
60% of outpatient visits to health facilities (Figure 6); and
an estimated annual loss of 132 billion Naira in the form
of treatment and prevention costs, and loss of man-hours,
amongst other losses.25 The geographic spread of the
malaria burden is heterogeneous in the country, with the
highest prevalence among children ages 6 to 59 months in
the North Central, North East and North West regions,
and the lowest prevalence in the South East region.23
Policy of malaria prevention on use of ITNs in Nigeria
The Government of Nigeria, through the National Malaria
Elimination Programme (NMEP) and in collaboration
with partners, is scaling up malaria prevention and
treatment interventions in line with the goals of the
National Malaria Strategic Plan (NMSP) 2014-2020.
NMEP employs a mixed-model approach for ITN
distribution that includes free mass distribution
campaigns and continuous distribution of ITNs to
supplement the mass campaigns. Continuous distribution
relies on several routine health service delivery channels:
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International Journal of Community Medicine and Public Health | October 2020 | Vol 7 | Issue 10 Page 4161
immunization campaigns; antenatal care (ANC); the
integrated maternal, newborn, and child health week;
school-based distribution; community-based distribution;
and, distribution through the commercial sector.23 as
previously indicated in the narrative (Figure 3), the
majority of households receive free ITNs from different
venues and through mass distribution campaigns.23
For instance, the Rivers State government of Nigeria has
distributed more than two million nets, during the
Immunization Plus days, and stand-alone campaigns, in
its effort to meet the target of providing two ITNS per
household in the State. Although, the usage of the nets is
still very poor.25 Another report indicates high proportion
of households in two other states (87% in Bauchi and
72% in Cross River) had at least one ITN during mass
distribution between 2010 and 2011.26
Figure 6. Statistics of malaria burden in Nigeria.25
Challenges in malaria control with the use of ITNs in
Nigeria
Despite the common occurrence of malaria during
pregnancy, there was a limited knowledge and use of
recommended anti-malarial intervention by women
attending antenatal clinics. Many pregnant women who
due to poverty and/or lack of education do not go for
antenatal care and have no access to preventive malaria
care. These categories of women may present when the
disease is severe. Inconsistent and/or inappropriate use of
bed-nets has been reported to be a challenge.4 In Rivers
State, it was discovered that a large proportion of the nets
were not used over beds and mattresses, but as screens for
windows and doors; probably to escape the discomfort
from heat that is a common complaint amongst users of
the net.25
Further, the more disadvantaged households were less
likely to have a ITN,26 and only one-third of those who
owned bed-nets slept under the net during the night
preceding the survey, thus, highlighting the alarming gap
between net ownership and utilization. The most common
reason, given for not using the nets was suffocation or hot
condition due to lack of proper air circulation in the net.
This has largely been attributed to the hot tropical climate
of the sub-Saharan African region and agrees with
findings from other studies done in different African
countries where low bed net utilization has been
reported.27
Expectation of progress in malaria control with use of
ITNs
The efficacy and cost effectiveness of ITN in reducing
malaria has led to free or highly subsidized ITN to
pregnant women and under five children. Following the
recommendation by the WHO, the ITNs distributed by
the National Malaria Elimination Programme have been
LLIN brands. Household ownership of at least one LLIN
in Nigeria increased from 44% in 2010 to 69% in 2015.
This was the result of routine and periodic mass
distribution for rapid scale-up of LLINs in the
communities.24 ITNs coverage or ownership seems to
have achieved the RBM target.
Reports have indicated that sleeping regularly under ITNs
is the most effective way to prevent malaria among
children and that ITN was 62.8% success in reducing
febrile episodes, but more effective in reducing marked
levels of malaria parasitaemia.10
However, utilization is quite low and a far cry as most of
the owners are not utilizing their nets. Previous study
report shows that patient experience of discomfort, heat,
irritation and suffocation limits utilization, while
affordances and quality are further barriers to utilization.
It behooves on ITNs manufactures to improve the quality
of nets, while healthcare workers and government
agencies vigorously increase the campaign of creating
more awareness on how best to use the ITNs among
pregnant mothers.12
Figure 7: Effectiveness of ITNs in reducing febrile
episode vs mal parasitaemia.10
DISCUSSION
The objective of this epidemiological narrative review is
to articulate what is known regarding challenges and
0%
10%
20%
30%
40%
50%
60%
Outpatient Childhood
death Infant death Maternal
death
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Malaria parasitaemia Febrile episodes
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International Journal of Community Medicine and Public Health | October 2020 | Vol 7 | Issue 10 Page 4162
necessary improvement on use of ITNs among pregnant
mothers and care givers of children. The main aim of
developing strategies to prevent malaria infection is
because of evidence of high rate of malaria cases and
mortality in the world. Global malaria data released in
2019 indicate public health epidemiology that requires
concerted and enhanced effort to improve the situation,
especially in Nigeria that contributes a quarter of the
world’s burden. This is regardless of global report
indicating that progress in controlling malaria infection
has been stalled.28
Identified slow progress on malaria elimination is due to
factors such as poor funding in investment of malaria
control by many donor countries and agencies, emerging
of resistance to malaria commodities such as pyrethroid
ITNs by malaria vectors, poor attitude to effective
utilization of insecticide nets by owners of bed nets,
inadequate distribution of nets to vulnerable groups such
as pregnant mothers and children under five years. World
Health Organization best recommended strategy for
prevention of malaria is adoption of use of LLINs, and
two doses of SP for pregnant mothers and children under
five years.
Universal coverage on use of ITNs has been low due to
poor utilization by those who owns the nets encouraging
increase of malaria infection. Poor use of ITNSs increases
incidences of malaria episode, maternal and fetal anemia,
placental parasitemia, low birth weight and neonatal
mortality. Therefore, various State government should
contribute immensely for continuous distribution of ITNs
at various household and rigorous health education on
utilization to be the watch guide to health workers. This
translates to potential health promotion strategy of
monitoring pregnant mothers as well as care-givers to
change their attitude in the use of LLINs. By further
interpretation, antenatal clinics and immunization sites
constitute one of the avenues for such health promotion
vis-à-vis educational campaign.
CONCLUSION
As a result of various factors that have been a hindrance
to effective utilization of ITNs, WHO and regional
leaders should sustain the policy of free distribution of
nets to households. Perhaps, lessons need to also be learnt
from countries like Algeria and Paraguay that have
achieved malaria-free status. While manufacturers need to
improve on the quality of their products, monitoring of
utilization of the distributed nets is a sine qua non to
progress towards malaria-free target.
ACKNOWLEDGEMENTS
Author acknowledged all staff and research scholars of
department of public and community health, Novena
University, Ogume, Delta State as well as the Provost and
colleagues at Bayelsa State College of Health Technology
for their contributions towards the success of this work.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: Not required
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Cite this article as: Odoko JO, Nwose EU, Nwajei
SD, Agege EA, Moyegbone JE, Igumbor EO.
Epidemiology of malaria as it relates to utilization of
insecticide treated nets among pregnant women and
under five years children in South-South Nigeria. Int
J Community Med Public Health 2020;7:4157-63.
