Epidemiological Overview
Generally, malaria is widespread throughout most of the tropics globally. However, according to Bradley (1992), the epidemiology of malaria has been characteristically varied across the globe because of malaria’s largely diverse vectorial capacity (p. 1). Out of the approximately 3.4 billion people who are globally prone to malaria infections annually, about 1.2 billion are at a higher risk. The World Health Organization (2013) reports that in 2012 alone more than 207 million people developed symptomatic malaria. Between 2000 and 2010, the figures released by the WHO report are, to some extent, encouraging as the number of reported annual malaria incidences in 34 malaria-eliminating countries decreased by 85 % from 1.5 million to 232, 000 cases (WHO, 2013). However, from the same report, the global malaria deaths reached a high of 1.82 million in 2004 and considerably fell to 1.24 million in 2010. Among the deaths reported in 2010 were 714,000 children below the age of 5 and 524,000 individuals above the age of 5. However, shockingly, the World Health Organization (2013) reports that over 80% of malaria deaths occur in the sub-Saharan Africa. Shockingly, the Nigeria Malaria Indictor Report (2012) reports that Nigeria and the Democratic Republic of Congo account for over 40% of the total malaria deaths globally. This revelation has led to several concerted efforts in the two leading countries aimed at addressing the prevalence of malaria.
Malaria Situation in Northern Nigeria
Nigeria is ranked as one of the most populous countries in Africa with a population of approximately 170 million according to the 2013 population statistics and an estimated annual growth rate of 2.6% (Malaria Operation Plan, 2013). The 2010 United Nations Development Program Human Development Index ranks Nigeria at position 142 out among 169 countries (WHO, 2013). The country has an estimated under-five mortality rate of 157 per 1000 live births and maternal mortality is estimated at 545 per 100,000 live births according to the 2008 Demographic and Health Survey (Okafor & Oko-Ose, 2012). The southern part of Nigeria is significantly advantaged in almost all social and economic indicators. In this regards, both the child mortality and maternal mortality are relatively higher. For instance, Okafor & Oko-Ose (2012) illustrate that the under-five mortality rates are about one and a half times higher while the maternal mortality rates are about three times higher as compared to some northern parts of Nigeria. Contrastingly, despite the high income attributed to the sales of crude oil, no significant improvement has been recorded and majority of the Nigerians, especially the Northerners live in abject poverty (Malaria Operation Plan, 2013).
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About 97% of the Nigerian population is at risk of Malaria infection with the majority being those living in Northern Nigeria according to a research conducted by the Nigeria Malaria Index Survey (2010). Specifically, research has found out that incidences of malaria transmissions account for over 60% of outpatient visits and 30% of inpatients in Nigerian healthcare institutions. Incidentally, malaria infection is a primary cause of children mortality and contributes to an estimated 225,000 cases of deaths annually (WHO, 2013). Malaria also contributes to an estimated 11% of maternal mortality and about 105 of low birth weight according to NMCP Strategic Plan 2009-2013.
The geographic location of Nigeria makes the climate condition to be ideal for malaria transmission nearly throughout the country. In fact, the remaining 3% of the entire country’s population, who are relatively at a low chance of infection, actually live in the mountainous regions in the southern parts of Nigeria (Jos Plateau State) with an altitude of between 1,200 to 1,400 metres. A series of studies have been conducted to elucidate the effect of seasonal changes on epidemiological index of malaria transmission in Northern Nigeria. Undeniably, the climatic condition of Northern Nigeria is seasonal with rainy seasons in May-October, dry season in December-March and transitional period in April-November (Malaria Operation Plan, 2013). However, studies on the prevalence of malaria in Northern Nigeria have shown that malaria transmission has been predominant during the rainy season and lowest during the dry season.
Gender Distribution and Prevalence of Malaria Transmission
Generally, studies have shown that Plasmodium infections appear more common in the male than in the females in Northern Nigeria. For, example, a study conducted to ascertain malaria occurrences among children aged six months to eleven years in Benin City presented a shocking result. According to the findings of the research, malaria transmission from 2004 to 2009 in male averaged at 57 % while during the same period under review, the transmission in females was at an average of 43% (Okafor & Oko-Ose, 2012). A similar research conducted in the Northern Nigeria’s Ebonyi and Edo States in 2004 made a similar conclusion. This prevalence has been attributed to the fact that males expose their bodies more than females especially when the weather is hot. In that regards, males are more likely to be bitten by mosquitoes. On the other hand, Okafor & Oko-Ose (2012) explain that females tend to stay indoors, helping out with normal household chores. This significantly reduces their contact with the mosquito vector. Either, studies have shown that females have relatively better immunity to parasitic diseases due to their hormonal and genetic composition.
Age Factor and Malaria Prevalence
Based on age, studies have shown that children aged ½ – 2 years have the highest prevalence in malaria transmission (Okafor & Oko-Ose, 2012). According to the research conducted in Benin City in Northern Nigeria among children aged ½ to 11 years, it was realized that children aged ½ -2 years recorded the highest prevalence of 58.6% followed by the age bracket 3 – 5 years at 30.5% and the least being age group 9-11 years at 2.9%. Basically, we can conclude that children under the age of 5 years are more prone to incidences of malaria transmission.
In general, malaria transmission is in a declining trend. A finding carried out in 1999, for instance, in Erunmu in southwest Nigeria reported about 80% malaria parasite prevalence among school children. A similar research conducted in Benin City, according to Okafor & Oko-Ose (2012) clearly showed this decline in prevalence. In 2004, the prevalence among children of ½ – 11 years was 47%. By 2009, the prevalence had dropped considerably to 32%. Through the period under consideration, the overall prevalence of malaria was reported at 36.4%. In a nutshell, this decline can be attributed to the effect of some preventive measures against malaria that has been adopted by the Nigerian Government.
Health Determinants and their Influence on Malaria Prevalence
Many factors combine together to affect the health of individuals and communities in a particular area. The Health Impact Assessment (2014) explains that the environment and the circumstances that people live in extensively determine whether people are healthy or not. To a larger extent, factors such as where an individual lives, the state of the environment, genetics, income, education level and our relationship with friends and families all have significant impact on health. However, on a more specific note, determinants of health include the social and economic environment, the physical environment and the individual’s characteristics and behaviors (The Health Impact Assessment, 2014). This paper will elucidate the impact of socio-economic environment and the physical environment on malaria transmission in Northern Nigeria based on both social economic environment and the physical environment.
The Social and Economic Environment
Malaria has predominantly been linked with poverty and the reduction of the propensity of malaria has become a major priority for the Nigerian Government for a long period of time. In particular, malaria is a leading cause of both child and maternal mortality and morbidity in Northern Nigeria that is relatively of a lower social and economic rating (WHO, 2013 and Nigeria Malaria Indicator Survey 2010). The economic burden of malaria illness on households accounts for almost 50% of total economic burden of illnesses in the Northern regions of Nigeria. Further, multiple studies have noted that individuals of lower social and economic status bear a disproportionate burden of the parasitic disease and have poor health seeking habits and at times lack necessary health facilities. Generally, research has shown that up to 58% of malaria transmission occurs in the poorest 20% of the world population who, incidentally, receives the worst care and has disastrous consequences from the illness (WHO, 2013). More specifically, there is a heavy malaria burden on the poor than on the rich as demonstrated by recent studies in Northern Nigeria States and in the cities states. According to this research, individuals with an estimate income of less than N300 per day (earning less than a dollar per day) were less likely to perceive malaria as a preventable disease and subsequently recorded more incidences of malaria per month as compared to those who earned less than N300 per day (Yusuph, 2010).
Arguably, the rural dwellers of the Northern Nigeria have a higher risk of infection than their counterpart urban residents. The current statistics indicate that between 6% – 28% of the malaria burden may occur in urban areas which comprise only 2% of the entire African surface (Yusuph et al., 2010). There could be a relationship between this predominance to the socio-economic status of people living in both rural and poverty-ridden regions. Evidently, members of lower socio-economic societies live in environments that offer little or no protection against mosquitoes and they are also less likely to afford the insecticide-treated mosquito nets. Clearly, higher social and economic status groups and urban residents posses more malaria preventive tools and therefore, report few incidences of malaria. In addition, low socio-economic status groups are unlikely to pay either for effective malaria treatment or for transportation to a health facility capable of treating the scourge.
The Physical Environment
Geographically, malaria is transmitted due to the interaction between the malaria mosquito parasite and the human environments (The Health Impact Assessment, 2014). The geographical location of Northern Nigeria presents a key ingredient to the breeding and existence of the malaria-causative parasite. The Progress & Impact Series Country Reports (2012) describes Nigeria’s climate as tropical climate with alternating wet and dry seasons throughout the year which is suitable for malaria transmission. Presence of mangrove swamps, the rain forest, the guinea-savannah, the Sudan-savannah and the Sahel-savanna that extends from the South to the North of Nigeria determine the intensity, seasonality and duration of malaria transmission. On the other hand, apart from the climatic condition, the Northern States of Nigeria have access to inadequate physical facilities, safe water, medical facilities and poor infrastructure that presents a daunting challenge to the prevention or treatment of malaria infections.
Prevention Strategy based on Social and Economic Status
This paper has emphasized on the major public health challenges that high prevalence of malaria presents to the people of Northern Nigeria. The most biologically vulnerable group, as have been noted, are the children below the age of five and pregnant women, perhaps due to their comparatively lower immunity status (Mazumdar & Guha, 2013). Basically, most of the malaria transmissions occur among the poverty ridden residents of the Northern Nigeria. Social and economic background has been distinctively demonstrated by this paper as a major health determinant in malaria transmission in the northern parts of Nigeria.
With the highly perturbing statistical information on malaria transmissions and prevalence in Northern Nigeria, there is a need for an infective and inclusive preventive plan that addresses the most biologically vulnerable group and their social and economic factors that determines their health. Consequently, this papers outlines a four dimensional preventive strategy that is undoubtedly capable of containing the mortality and morbidity among children and expectant women. This preventive strategy summarily focus on management of transmission cases, prevention of malaria with insecticide-treated nets, indoor residual spraying to reduce transmission and finally the use of intermitted preventive treatment and the use of intermittent preventive treatment for pregnant women.
Prompt Diagnosis and Treatment
This strategy focuses on timely diagnosis and effective treatment of cases of malaria infections by use of relevant anti-malarial drugs. This strategy is aimed at ensuring that up to 80% of the population, mostly children below the age of 5 and the pregnant women, who are at risk of malaria take timely and necessary treatment at the initial stages of infection. Under this strategy, there is need for provision of free necessary anti- malarial drugs like Artmether-Lumefantrine (Mazumdar &Guha, 2013). There is also a need for a home based care management system especially for the most vulnerable population, that is, children below the age of five. The complexity of this strategy requires a multidimensional approach and involvement by the public sector, the private sector and the faith based health facilities for effectiveness.
Distribution of insecticide-treated nets (ITN)
This strategy is intended to prevent malaria transmission to a larger population especially the most vulnerable children under the age of 5 and the pregnant women. Under this strategy, pregnant women and children under the age of five are to be provided with free insecticide treated mosquito nets. These nets should be provided to the expectant women when they attend their ante natal care services in designated health facilities. This scheme also proposes the use of relatively long lasting insecticide nets so as to address the social and economic challenges that bedevils most of the vulnerable groups.
Indoor Residual Spraying
The Indoor Residual Spraying (IRS) is geared towards curtailing the transmission of malaria in both the pregnant women and children under the age of five. This program requires entomological monitoring and proper management of insecticide resistance especially among the ignorant population that are characteristic of a low social economic majority. It also requires behavior change communication with the target population and technical assistance and training especially to the personnel in the indoor residential spraying exercise.
Intermittent Preventive Treatment for Expectant Women
This last strategy primarily focuses on regulation of malarial prevalence among expectant women. Statistical data that only 58% of pregnant women by 2008 had access to antenatal care from relevant service providers while 62% of expectant women successfully delivered at home elucidates the extent of socio-economic disparity and the need for effective preventive treatment programs for pregnant women. Ideally, a couple of factors contribute to low utilization of health facilities by expectant women. Primarily, inadequate or poor quality of antenatal services, expensive cost of the services and ignorance on the need to attend antenatal services indisputably discourages expectant women from utilizing antenatal services from relevant health facilities. As a preventive measure to the challenges facing expectant women, this strategy identifies specific drugs that can effectively fight malaria in expectant women. The Intermittent Prevention Therapy (IPT) and Sulphadoxine-Pyrimethamine (SP) have been identified as effective malaria prevention among this vulnerable group. These drugs should be administered freely to the women since majority of them may not be able to afford such drugs.
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In conclusion, this paper reaffirms the need to address the malaria menace especially in the sub-Sahara Africa and other tropics. The paper lays emphasis on the prevalence of this scourge on children under the age of 5 and pregnant women. The paper also extensively discusses how socio-economic factors and physical environments contribute to the prevalence of malaria infections especially in poor neighborhoods in Africa and Northern Nigeria in specific. This paper presents a preventive strategy that focuses on the most vulnerably group.
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