In this interview with Sade Oguntola, Professor Olugbenga Mokuolu, a consultant pediatrician and the Nigeria Malaria Technical Director, National Malaria Elimination Programme, talks about malaria and what is critical to ending its burden in Nigeria.
What is the prevalence of malaria in Nigeria?
Currently, Nigeria is said to have about 61 million cases. Prevalence is about 23% when a general check is made on children up to 10 years. Africa still faces a steep challenge with malaria because 90 percent of the 241 million cases and 95 percent deaths were from the continent. Nigeria is responsible for 27 percent of this caseload and about 31 percent of the global malaria deaths.
What innovation can be adopted to reduce the malaria burden and save lives?
Innovation has to do with new tools or new ways of using the same device. In this regard, innovation has to do with looking at existing tools for improvements or new tools. Retooling includes the use of new generation long-lasting insecticidal nets (LLINs) to combat the problems of insecticide resistance. On this note, Nigeria has been using the Piperonyl butoxide (PBO)-LLINs in the last two years for the net campaigns to address insecticide resistance issues.
Other tools include the use of indoor residual spray (IRS) to rapidly reduce the burden of malaria in very high burden areas and the introduction of seasonal malaria chemoprevention (SMC). In this intervention, children under five are given specific antimalarials in monthly cycles of 4 cycles in states or areas with high intensity of seasonal rainfall patterns.
In addition is retooling of existing drugs for curtailment of the emerging challenges of artemisinin resistance; need for new medications to improve the landscape for treatment; diagnostic tools like diagnostic panels with integrated multiple test kits possibly for a one-stop distinction of viral, bacterial or malaria infections.
Adoption and deploying of the malaria vaccine as a complementary strategy is also important as well as innovative funding mechanisms through public and private partnerships. Similarly is developing a business case and having an assured market for manufacturers of malaria commodities while leveraging that assured market for ensuring affordable prices of the commodities.
How close is Nigeria to achieving the 2030 targets of the WHO global malaria strategy?
Currently, we have made progress, but we are still off the trajectory for the 2030 targets. This was, however, as per the last conducted surveys in 2018. With some additional innovative interventions like the massive scale-up of SMC and the use of PBO nets, it is possible that the 2021 malaria indicator survey may offer new information about our current trajectory.
Malaria can also cause low blood sugar, kidney failure, or seizures. Are there other lesser-known symptoms of the mosquito-borne disease? How is malaria related to things like malaise, joint stiffness, muscle pain, anemia, and shortness of breath?
Malaria causes a progressive illness. When someone gets infected, the parasite multiplies. When these parasites burst the cells in the blood, they release a variety of substances that are responsible for the fever, joint pains, headaches, and all the feelings of being unwell (malaise). At this stage, we call it uncomplicated malaria. This is usually the stage we go for treatment with our primary care physician or other sources. If this is not treated effectively or in some category of persons, the disease progresses, and life-threatening complications set in. These comprise loss of consciousness, convulsions, extreme paleness, fast breathing or breathing difficulties, dark urine, and so on. At this level of illness, it is called severe malaria. The individual must be hospitalized for critical care.
Is it all mosquitoes that transmit malaria, and is it all bites of mosquitoes that lead to malaria disease?
Specifically, malaria is transmitted by the bite of the female anopheles mosquito. The interesting thing about this mosquito is that it does not make noise. It bites silently. It bites mostly at night.
How true is it that no single tool available today can solve the problem of malaria?
This is very true, but we need to understand the context of that answer. Malaria is the product of interactions between man, his environment and the mosquito which acts as a vector. By vector, we mean an intermediary that allows the parasite to develop without causing any harm to the host and thereby facilitates transmission. So, from first principles, the effective solution to malaria include – addressing the vector, killing them or preventing them having contact with man, destroying their natural habitats to ensure that mosquitoes do not survive, preventing the onset of illness in man, treating the illness when it occurs or preventing the ability to transmit the illness from one person to another.
From this simple illustration, we can appreciate that no single solution can address every dimension of the malaria programme. That is the critical lesson we have learnt in the fight against malaria and that is why we promote a package of interventions consisting of prevention, treatment, and avoiding continuous transmission.
What other diseases can you get from mosquitoes apart from malaria?
There are a number of other diseases. Some of these include Zika virus infection, yellow fever, West Nile fever, and Dengue fever. Some of these are transmitted by other types of mosquitoes as well.
Drug-resistant malaria is emerging in Africa. What is the situation in Nigeria and what can Nigeria do to get ready for this?
Currently, what have been identified are resistance markers in Uganda and Malawi. The situation is being monitored closely as this is for now referred to as partial resistance. As you rightly observed, the National Malaria Elimination Programme, under the leadership of Dr. Mrs. Perpetua Uhomoibhi, together with partners are responding to this development. There has been some technical consultation to review the situation. Currently, there is a study about the use of Tripple ACTs i.e. adding a third drug to existing ACTs to prevent resistance.
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In Africa, it is said that some malaria parasites are evading detection tests, causing an urgent threat to public health. Can you explain?
Malaria rapid diagnostic tests are of two types. There is a third type that is not in common use. Of the two in common use, there is one that is most widespread in use. This type of mRDT is based on detecting the presence of a certain substance on the wall of the parasite. This substance is called Histidine Rich Protein II (written as PfHRP-2). In a very small fraction of malaria parasites, this PfHRP-2 is missing. Hence in those cases, the test may be erroneously reported as negative (false negative). Space and technicality may not allow me to give a full description. However, please be informed that the rate of occurrence of this phenomenon is so low in Nigeria and in many countries that it has no impact on the reliability of the mRDT.
New research from Uganda and Mali suggests malaria exposure might lower the incidence of severe disease, hospitalisation and death for people exposed to SARS-CoV-2, the virus that causes COVID-19. What is your view on this?
It is probably true. The fact remains that COVID-19 was less frequent and less severe among African countries, particularly the lower income African countries. So, if we trace the COVID-19 trajectory in Africa, the incidence is much lower in countries endemic for malaria, most of which are lower and low-middle income countries, and some other characteristics. From that epidemiological point, we need to ask what is unique about these countries. This is compounded by the fact that African-Americans in America or the blacks in other countries are disproportionately affected by COVID-19. That will appear to rule out a genetic basis of this relative protection from COVID-19. The pattern of distribution is pointing strongly in the direction of environmental factors primarily modulating the disease and this may play some roles in the response of persons exposed to those environmental factors.
This is how science operates. Steps include a careful observation of the pattern of distribution of a disease, drawing up a hypothesis of the associations and exploring the hypothesis through some experiments (as in the studies you referred to). Thereafter, there will be a presentation to relevant authorities for peer review and now an adoption of the finding to inform other actions. I must say that while the stated study may be providing some evidence to support the malaria exposure theory, the claims will still be properly researched before definite statements will be made by the WHO.
How can Nigeria advance equity, build resilience and end malaria?
By equity, we are referring to every eligible person receiving antimalarial commodities or services according to their need irrespective of age, gender, location, or financial status. So, we need to maintain the current approach of universal distribution for some of the interventions, strengthen community systems to reach people in hard-to-reach areas, get products freely to the general masses, or ensure they are affordable.
On resilience, we need to increase budgetary allocation to malaria so that services are not interrupted. Contributions from partners can be used to address items distributed through mass campaigns; building and expanding capacities in other areas of malaria interventions such as entomology, molecular skills, putting in place robust surveillance systems. After that, we need protocols for responding to unforeseen major health problems such as pandemics and epidemics. These measures and the innovations indicated previously are critical elements toward ending malaria. This year’s catchphrase is ‘Every Effort Counts’. We must do all possible to engage everyone. Mobilise the community health workforce towards the quality of care; engage the private sector and promote public enlightenment.