Malaria and Neglected Tropical Diseases in Nigeria

Malaria and Neglected Tropical Diseases in Nigeria

Prof. Eyitayo LamboHonourable Minister

Federal Ministry of HealthAbuja, Nigeria

MALARIA

Malaria in Nigeria– Malaria is endemic in Nigeria– Mainly caused by P. falciparum and transmitted by

anopheles mosquito– Malaria is responsible for 60% of outpatient visits,

30% of childhood mortality, 25% infant mortality and 11 maternal mortality

– Over 90% of the population is at risk– 50% of the population will have at least one

attack/year– Close to 300,000 children die of malaria EACH YEAR– N132 billion is lost to malaria annually in form of

treatment costs, prevention, loss of man hours etc.

Abuja Targets by 2005

• At least 60% of those suffering from malaria will have access to effective and affordable treatment within 24 hours of the onset of symptoms

• At least 60% of pregnant women who are at risk for malaria, especially those in their first pregnancies, have access to intermittent preventive treatment (IPT)

• At least 60% of those at risk for malaria, particularly children under age five and pregnant women, sleep under insecticide-treated nets

Key achievements

• Development of policies &guidelines • Updating of Strategic Plan• Advocacy• Training & capacity development(4000)• Promotion of interventions (ITN 4.2 m, IPT

500,000 doses, ACTs 2.5 m doses, IVM)• Monitoring and evaluation and research• Partnerships & resource mobilization

Malaria: Challenges

• Growing parasite resistance (P. falciparum) to commonly used therapies

• New drugs more expensive• Widespread use of the private sector• Poor-quality/substandard drugs• Reliance on external sources of financing for

new therapies (GFATM)

Malaria: Challenges (contd)

• Large population needs large resources

• Poverty

• Human resources (training & retraining)

• Fragmented efforts at malaria control

• Coordination of partners

• Weak health systems

FINANCIAL RESOURCES

77.50110.5582.92124.68GAPS

160160130130ESTIMATED TOTAL RESOURCES NEEDED

82.5059.4547.085.32TOTAL RESOURCES AVAILABLE

70.1547.1046.614.95EXTERNAL RESOURCES

12.35(est)

12.350.470.37DOMESTIC RESOURCES

2007200620052004

Financial contributions in US $ ( in millions)

BREAK DOWN OF EXTERNAL SOURCE (in US${million})

2007200620052004

70.1547.146.614.95TOTAL EXTERNAL SOURCE

-1.0--EXXON MOBIL

1.451.10.750.5HARVEST FIELD LTD

0.31.01.250.85UNICEF

6.62.02.92.4USAID

1.81.11.241.2WHO

302020-DFID

3020.920.47-GLOBAL FUND

ESTIMATED GAPS IN COMMODITIES QUANTITY & COST

1million2 m5.25mDFID: 10.5m0.25million

0.5 M13 MSP doses Annually

65.8 Million

50 Million

Requirements

ACTS Annually

LLINS (over 5 years)

Commodities

Total:56.8m<5yrs:20m>5yrs:36.8m

35m

Quantity

T:93.6m<5yrs:20m>5yrs:73.6m

Total:9mGF:8mPartners:1m

Total:9mGF:8mPartners:1m

1million1million

234.5mTotal Cost: 40.5mGF: 11.5mUNICEF:2mDFID:26.8m

Total:6.05mGF:1.75mUNICEF:0.3mDFID:4m

21.6m4million

Cost (US$)Cost (US$QuantityCost (US$

Quantity

GAPSExternal Sources (Ordered/Distributed/Expected)

Domestic Sources (Ordered/Distributed/Expected)

Other cross cutting issues not included in the costing

• Integrated Vector Management• BCC (Strategic Communication)• Capacity Building• Distribution/commodity management• M & E/Operations research• Programme management• Partnership building

Way forward

• SCALING UP TO ACHIEVE NATIONAL COVERAGE FOR IMPACT REQUIRES:– INNOVATIVE APPROACHES– INSTITUTIONALIZING CAPACITY BUILDING– STRENGTHENING SYNERGIES WITH

OTHER PROGRAMMES (RH, IMCI ETC)

Way forward (cont’d)

– HEALTH SYSTEMS STRENGTHENING

– STRENGTHENING PARTNERSHIP

– SUSTAINABLE FINANCING STRATEGIES

– MOTIVATING ENVIRONMENT FOR HEALTH WORKERS

– ENABLING ENVIRONMENT FOR PRIVATE SECTOR

– DEVELOPING NEW TOOLS

FIVE NEGLECTED DISEASES in Nigeria

Guinea Worm, River Blindness, Elephantiasis, Bilharzia and Leprosy

Guinea worm (Guinea worm (DracunculiasisDracunculiasis): ): The DiseaseThe Disease

• Transmitted by drinking copepods in contaminated water

• Disability averages 2-3 months for large % of population

• Estimated $2.6 billion naira per year losses for southeast rice farmers

• School absenteeism could exceed 60%

Guinea worm: InterventionsGuinea worm: Interventions• Health education and

social mobilization• Use of cloth filters• ABATE® larvicide• Safe water supply• Case containment

653,492640,008

394,082

281,937

183,169

75,752

39,77416,374 12,282 12,590 13,420 13,237 7,869 5,344 3,820 1,459 495 115

1988* 1989* 1990* 1991* 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005**

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

Nigeria Guinea Worm Eradication ProgramNumber of cases of dracunculiasis reported: 1988 -2005**

Num

ber o

f cas

es

* Epidemiologic year, e.g., July 1, 1988 -June 30,1989** provisional data January - July 2005

Guinea worm: ProgressGuinea worm: Progress

DISTRIBUTION OF 495 CASES OF DRACUNCULIASIS: 2004

Number of Cases Reported0

1 - 99

100 - 999

1,000 - 9,999

10, 000 +

NIGERIA GUINEA WORM ERADICATION PROGRAM

DISTRIBUTION OF 270,804 CASES OF DRACUNCULIASIS REPORTEDJULY 1990 - JUNE 1991, BY LGA

0

1 - 99

100 - 999

1,000 - 9,999

0

1 - 99

100 - 999

1,000 - 9,999

DISTRIBUTION OF 13,420 CASES OF DRACUNCULIASIS: 1998

25

16

13

12

8

7

7

6

3

3

3

2

1

1

Ezza North, Ebonyi

Ado, Benue

Agaie, Niger

Odeda, Ogun

Obafemi Owode, Ogun

Ohawkwo, Ebonyi

Oorelope, Oyo

Obi, Benue

Paikoro, Niger

Obubra, Cross Rivers

Borgu, Niger

Lapai, Niger

Magama, Niger

Ishielu, Ebonyi

0 5 10 15 20 25 30

Nigeria Guinea Worm Eradication Program14 LGAs reporting 107 (93%) of 115 cases of dracunculiasis reported

during Januarary - June 2005* Number of cases

* provisional

Guinea Worm Eradication ProgramStatus of Eradication Efforts: 2005

Formerly Endemic Countries

1994

1997

1993

1996

1997 1998

1997

1998 Last Indigenous case reported

Currently Endemic Countries (<100 cases)

Currently Endemic Countries (100+ cases)

2001

2003

2004

2004

Guinea worm: ChallengesGuinea worm: Challenges

• Sustain interventions until last case• Adequate surveillance in freed areas

immediately• Three years post-Guinea worm

surveillance nationwide (WHO certification)

• Estimated cost of above: 65 million naira (US$ 0.5 million) per year

• Transmitted by black fly bites

• Impaired vision, blindness, severe itching, disfigured skin

• Estimated 27 million Nigerians need treatment (world’s #1)

River Blindness (Onchocerciasis):The Disease

River Blindness Map of Nigeria

Onchocerciasis: Interventions

• Annual oral mass drug administration (donated MectizanⓇ

by Merck)• Health education &

community mobilization

0

5,000,000

10,000,000

15,000,000

20,000,000

1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Other Treatment ProgramsCarter Center

* Nigerian Federal and State MOH Treatments assisted by TCC, Lions Clubs, CMB, HKI, IEF, MITOSATH, SSI, UNICEF. TCC treatments from 1992-1995 by RBF. Source of provisional 2004 non-Carter Center figure: Nigerian Federal Ministry of Health, “15 Years of Onchocerciasis Control in Nigeria” Report by the National Onchocerciasis Control Program, Feb 2005 .

Carter Center-Assisted treatments and total Mectizan treatments provided in Nigeria, 1989-2004*

River Blindness: Progress

Estimated 74% of at risk populationTreated in 2004

Onchocerciasis Nodule Prevalences in 23 Villagesof Plateau and Nassrawa States

51.2%

2.9%0%

10%

20%

30%

40%

50%

60%

1992 1999/2000

Perc

ent N

odul

e Pr

eval

ence

River Blindness: Progress

94% reduction

Impact of Eight Years of Mass Ivermectin Treatment for Onchocerciasis on the Prevalence of Poor Visual Acuity in a Cohort of 411 Persons

in Imo State, Nigeria

0 5 10 15 20

VisualImpairment

19952002

94% reduction

River Blindness: Challenges

• Need to sustain mass treatments indefinitely• APOC assistance ending, with little state

funding and no FGN funding to make up the difference

• FGN & States need to release funds to maintain this achievement

• Estimated cost of above: 130 million naira (US $1 million) per year to sustain

Elephantiasis (Lymphatic Filariasis-LF): The Disease

• Transmitted by mosquito (same vector as malaria)

• Chronic, painful swelling of limbs and genital organs

• Damage to kidneys in children• Potentially eradicable (no animal

reservoir)• Estimated 8-10 million Nigerians

infected (world’s #3)• Only 13 of Nigeria’s states assessed so

far

Draft Aug 25, 2005: LF Endemicity in Nigeria, based on ICT card testing for antigenemia, by LGA

Elephantiasis (LF): Interventions• Health education & community

mobilization • Annual oral mass drug

administration (donated albendazole and Mectizan)

• Mosquito nets• The Carter Center is assisting

Plateau & Nasarawa States since 2000

Carter Center-assisted LF Treatments, Plateau & Nasarawa States,Nigeria

3,531,820

159,555

675,681

1,661,242

3,236,2063,112,889

2,168,355

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

4,000,000

2000 2001 2002 2003 2004 2005* 2005

* Treatments in 2005 through July

Annual Treatment Objective

LF: Progress

Average Lymphatic Filariasis ICT Results in Seven Sentinel Villages (n = 2,000)

45.1%

10.0%

0%

10%

20%

30%

40%

50%

60%

2000 2004

Perc

ent I

CT

test

s po

sitiv

e

Average Lymphatic Filariasis Mosquito Infection Rate (W. bancrofti) in 9 Sentinel Villages (n > 1,000)

5.2%

1.1%

0%1%2%3%4%5%6%7%8%9%

10%

2000 2004

Perc

ent M

osqu

ito In

fect

ion

78% reduction

80% reduction

LF: Progress

• 3.2 million treatments in 2004 of 3.5 million needed in the 2 states

• LF infection rates in blood (LF antigen) reduced by 78% (from 45% to 10%) between 2000-2004

• LF-infected mosquitoes reduced by 80% (from 5% to 1%) between 2000-2004

• Successfully integrated LF with River Blindness (RB), Schistosoma Haematobium(SH) and Malaria interventions in 2 states

LF: Challenges

• Need to sustain mass treatments for 5+ years• Need to complete mapping of other 23

Nigerian states• Need to scale up interventions to reach

nationwide• Need FGN and states to provide funding• Estimated cost of above: 130 million naira

(US $1 million) per year to expand nationally• Join with Roll Back Malaria to distribute

bednets, using RB/LF treatment network

Biharziasis (schistosomiasis):The Disease

•Parasite from snail vector penetrates skin in contaminated fresh water•Adult worms reside in veins of bladder, intestines•Numerous eggs damage bladder, intestines, liver, kidneys, lungs•Causes bloody urine, bloody diarrhea, heart failure, liver and kidney disease•Estimated 30 million Nigerians require praziquantel treatment (world’s #1)

Prevalence of Hematuria in NigeriaNational Postal Questionnaire, 1998

Percent Prevalence

Bilharzia: Interventions

• Health education & community mobilization

• Annual oral mass drug administration (praziquantel)

• Expensive!– Praziquantel not donated (costs

US$.15-0.20/treatment)– Mapping of disease expensive– Sanitation expensive– Snail control expensive

• TCC assisting parts of Plateau, Nasarawa, Delta states

Carter Center-assisted Bilharzia Treatments,Plateau, Nasarawa & Delta States, Nigeria

44,830

84,165

151,863

196,568

57,551

208,859215,343

0

50,000

100,000

150,000

200,000

250,000

2000 2001 2002 2003 2004 2005* 2005 ATOTreatments began

in Delta State

* Treatments in 2005 through July. Program awaits clearance of praziquantel to continue treatments.

Bilharzia: Progress

Average Schistosomiasis Dipstick Positivity, Pankshin and Akwanga LGAs (n = 300)

47%

8%

0%

10%

20%

30%

40%

50%

60%

1999 2004

Perc

ent D

ipst

icks

Pos

itive

Bilharzia: Challenges

• Tedious, expensive mapping now requires testing children in every community nationwide

• Need to scale up activities to reach at risk areas nationwide (FGN, state funding)

• Estimated cost of above: 260 million naira (US $2 million) per year to expand nationally

• Nigeria needs to manufacture praziquantel as soon as possible, at a better price (currently 11 naira tablet)

Leprosy: The disease• A chronic debilitating disease

caused by mycobacterium leprae

• Transmitted by droplet inhalation

• 500,000 new cases globally in 2004

• 41,824 registered cases in Africa in 2004

• 250,000 in Nigeria in 1989• Dropped to 5,348 in 2004• 10% are children• 12.5% are WHO grade 2

indicating very late detection• Current prevalence 0.3 per

10,000 population

Leprosy: Progress/Achievements

• NTBL Control Programme established in 1989

• The WHO leprosy elimination target of <1 case per 10,000 population was achieved at national level since 1998

• Leprosy control integrated into PHC nationwide

Leprosy: Progress/Achievements (CONT’D)

• NTL training centre, Zaria achieved international standard and serves as the National Reference Centre for human resource development

• All leprosy patients get free MDT since 1995• Leprosy Elimination Campaign and Special

Action Projects towards Elimination of Leprosy are on going in many states

Leprosy: Challenges • Achieving leprosy

elimination at sub-national level

• Expanding LEC and SAPEL; especially in Adamawa, Benue, Cross River, Ebonyi, Gombe, Jigawa, Kano, Nassarawa, Taraba, Sokoto, Yobe and Zamfara

• Improving early detection and cure rates

Leprosy: Challenges (CONT’D)

• Promotion of physical and socio-economic rehabilitation

• Poor funding• Donor fatigue at a critical point of leprosy

elimination in the country

Way forward

• Guinea worm disease: 99.9% reduction in cases since 1988 (eradication in 2006?)– NEEDED: 65 million naira annually to finish

eradication and maintain nationwide surveillance for 3+ yrs

• River Blindness: 74% coverage nationwide in 2004– NEEDED: 130 million naira annually to sustain

treatments indefinitely• LF: coverage in 2 states; 13 states mapped

already.– NEEDED: 130 million naira annually to scale up

nationally

Way forward (CONT’D)

• Bilharzia: partial coverage in 3 states; medicine expensive and not donated– NEEDED: 260 million naira annually to scale up nationally;

consider Nigerian manufacture of praziquantel• LEPROSY:

– Improve funding to achieving leprosy elimination– States and LGAs to fund activities for early case detection

especially in Adamawa, Benue, Cross River, Ebonyi, Gombe, Jigawa, Kano, Nassarawa, Taraba, Sokoto, Yobe and Zamfara

– Social welfare Departments/Ministries to support promotion of physical and socio-economic rehabilitation of cured patients with disabilities

Summary

• Potential Benefits– Better health for millions of Nigerians

including less malaria mortality– Increased agricultural productivity– Better school attendance– Enhanced ability of children to grow,

develop, and learn– Substantial overall economic return on

investment– Manifestation of Nigerian leadership

• Total need: 600,000,000 naira/year (US $4.5 million/year) for NDs

It is far more costly to neglect these diseases than it is to control them