Tropical Health Matters

The Demographic and Health Survey for 2018 in Nigeria has released preliminary findings. These cover insecticide Treated Nets (ITNs), Intermittent Preventive Treatment of malaria in pregnancy (IPTp), and treatment of children with Artemisinin-Based Combination Therapy (ACT).

The key findings have been converted into graphs.  We can see that ITN ownership by a household (HH) is greater in rural areas, but overall reaches only a national average of 60% of households having at least one net. People may recall that the 2010 target by the Roll Back malaria Partnership was 80% for all key indicators with the hope that by attaining and then maintaining 80% coverage or more, malaria incidence would drop and elimination would be on the horizon.

Nigeria is not among WHO’s Elimination by 2020 (E2020) countries, and it is not clear when transmission will move in that direction when key interventions are still not reaching targets. This is due also to the fact that 60% of households covered does not mean that residents are protected. In fact only 30% meet the goal of universal net coverage with at least one net for every two household members.

On the positive side, comparison of household net ownership and wealth status appears to favor the poorer households. 72% of the poorest households have at least one net compared to 48% of the highest income quintile.  Unfortunately the gap between rich and poor narrows when it comes to the target of 1 net for 2 people.

Although these days we stress universal coverage of all household members, DHS still collects data on what are often termed ‘vulnerable’ groups, children below the age of 5 years and pregnant women.  Just over half of each group slept under an ITN the night before the survey. It is obvious that access plays a role, so in those households that actually own at least one net 74% of children and 82% of pregnant women slept under an ITN. These figures might even be higher if the target of 1 net per two people were met.

Nigeria is a huge and diverse country in terms of geography, epidemiology and ethncity. The country has 6 regions that are used for planning and analysis purposes. The map attached shows that there are major regional variations in households owning at least one net and households having at least one net for every 2 people residing there.

There is better coverage of at least one net per household in the northern zones than the southern, with the Northwest achieving 86% and then 42% for covering two people with one net.  When it comes to that latter measure, the remaining 5 regions are all in the 20% level, meaning that for most of the country, there is a long way to go to achieve universal net coverage.

Intermittent preventive treatment of pregnant women  with sulphadoxine-pyrimethamine (SP) has been a long standing intervention to protect women and their unborn children from the devastating effects of malaria. For at least six years now, WHO has recommended that pregnant women take three or more monthly doses of IPTp from the 13th week of pregnancy, onward.

A challenge to getting IPTp is contact with antenatal care services, and only 67% of women who delivered a child in the 5 year preceding the survey attended ANC even once.  Not surprisingly, only 40% of those pregnant women received two doses of IPTp and only 17% got three doses.

Finally, only 28% of children with fever in the two weeks prior to the survey took ACT, although we are not certain about the proportion who had been tested. It is difficult to interpret this finding since we do not know what proportion of those with fever might have been tested and found to harbor malaria parasites. ACTs should only be given to those with positive parasitological tests.

DHS and its sister survey, the Malaria Indicator Survey are performed at approximately three-year intervals. These data sources are valuable for evaluating past interventions and planning new. Clearly some serious planning is needed to address the shortfalls in malaria intervention coverage and save more lives.

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