Almost all Nigerians are at risk of getting malaria
By Azoma Chikwe
Mr Arthur Acho, 57, a civil servant, had fever and high temperature, he consulted the family physician who referred him to do a test. He was diagnosed of malaria and traces of typhoid fever. But instead of returning to the hospital for treatment, he simply bought his favourite anti-malarial in a pharmacy, took it and got well after three days.
Few days later, his wife, Stella , aged 48, also came down with fever, headache and other symptoms. She was also diagnosed of malaria and some traces typhoid fever. When treated for malaria, she got back to her feet.
Same week, one of their kids, Maxwell, 18, also took ill and was also diagnosed of malaria and traces of typhoid fever. He was treated of malaria and he got well. In three of them, the level of typhoid in their blood samples were negligible.
Speaking with Health and Wellbeing,at a private health facility in Lagos, Mr Acho said the only ailments that had ravaged his home is malaria and typhoid fever.” I can’t remember anybody being treated of any other disease in my home apart from malaria and typhoid fever. Each time we go to the lab, the diagnosis can be predicted, it is either malaria or typhoid fever or both. My wife, my son and I had bouts of malaria simultaneously this week. I brought my son here for treatment.”
The story of the Achos is a common in Nigeria. Most patients that are sent to the lab are diagnosed of either malaria or typhoid fever or both. It became a trend that people wondered whether the lab results were true. The psychology of some had been influenced by the trend that if they do a lab test and the result did not contain malaria or typhoid fever or both, they will doubt the result and crosscheck with another lab. Some sick people had walked up to doctors, demand to be treated for malaria and insisted that is the only ailment they suffer. Others tell laboratory scientists that if the result did not contain malaria or typhoid, then the sample tested was not theirs, that they understood their bodies very well. This kind of mindset concerning malaria and typhoid fever are common in our environment because of the high prevalence of the disease.
Some had blamed the recurrent malaria and typhoid fever results churned out from our labs on quackery . They said the labs are manned by quacks who told the people what they wanted to hear. Others said the labs are under-equipped, lacked equipment and reagents to detect other diseases except malaria and typhoid fever.
However, experts who spoke with Health and Wellbeing confirmed the lab results were true. They said the prevalence of plasmodium, the parasite that causes malaria in Nigerians is over 90 per cent. “ If you test 10 Nigerians for malaria parasite, almost ten of them will test positive to it,” National Secretary, Guild of Medical Laboratory Directors of Nigeria (GMLD), Mr Benjamin Ubah, said.
Consultant Surgeon, Dr Emmanual Enabulele, said the lab results were true when he said, “ I see malaria patients daily.”
Their position varied with that of the National Malaria Eradication Programme(NMEP). Dr Godwin Ntadom, Head of Case Management, NMEP, who said the malaria prevalence in “Lagos State is about two per cent, though there are some States that it is about 35 percent.” Ntadom and his team blamed the regular malaria and typhoid results produced by labs in the country on quackery and substandard labs, and urged people to test themselves with malaria test kits. Perhaps, the data that Lagos State has a malaria prevalence of two(2)per cent was generated using Rapid Diagnostic test(RDT) with malaria test kits.
The NMEP promotes RDTs while not condemning microscopy or lab tests. They argued that fever is one of the common signs and symptoms of malaria, which can also be found in other illnesses. Despite this fact, research shows that majority of Nigerians treat all fevers with antimalarial medicines without consulting a health provider and testing with RDT or microscopy to confirm malaria.” RDT is an easy, safe and effective way to confirm whether the fever is malaria. This can also prevent clients from wasting time and money,” Ntadom stated. Meanwhile, experts has described Rapid Diagnostic test with malaria test kits as very insensitive in picking the malaria parasite and had recommended microscopy.
However, Ntadom was optimistic when he said that the target for malaria elimination in Nigeria is 2035, while eradication target is 2045. In its fact sheet NMEP noted that “ almost all Nigerians (97 per cent) are at risk of getting malaria.” According to National Malaria Indicator Survey(NMIS), malaria prevalence has declined from 42 per cent in 2010 to 27 per cent recently, but it still poses a significant risk to Nigerians.
Malaria prevalence by regions are listed as follows : North Central –32%, North East – 26%, North West – 37%, South East – 14%, South South -19%, South West – 17%. However, the two per cent prevalence for Lagos State was unacceptable to experts, while NMEP blamed the recurrent malaria and typhoid fever results from our labs on quackery and inadequate labs.
Experts react
According to Ubah, “Most government agencies imported malaria test kits from Germany. Most of the NGOs into roll back malaria do not understand the rudiments of malaria microscopy and testing. Laboratory method remains the most sensitive and most accurate malaria parasite testing method. Malaria test kit is about five per cent accurate, it is not reliable and cannot be used as basis of assessment for prevalence or monitoring of malaria paracetamia.
“Medical laboratory scientists barely use malaria test kit, we only use it for research and not diagnostic purposes since the reliability for malaria parasite diagnosis is just about five percent or below. Nigeria is a tropical country and malaria paracetamia or plasmodiasis is high. Malaria is a tropical disease and it is only suffered by people in the tropics like Africans, Asians and some South American regions. And any data gathering that is relying solely on information produced in temperate regions about malaria paracetamia may be lacking in accuracy. Reason, we have instances of Nigerians or Africans who carried malaria to the temperate regions, because of lack of proper diagnosis, they could not treat it there, some died, because malaria parasite is alien to them in temperate regions. That is the problem of the malaria test kit and the likes that were made in Europe.
“When the agencies brought the malaria test kit, they went to public health facilities and introduced it to them and they began to use it, but those of us in the private sector used microscopy which is 95 per cent accurate in terms of diagnosis of malaria parasite, because we want to heal and keep our patients. So, for somebody to say malaria paracetamia in Lagos State is two per cent is not factual.
“Most of the data sampling that gave that figure were not done in the laboratory but on the road side. They put canopies on the roadside, gathered people and tested them with malaria test kit and because the parasite detecting power of the test kit is low, they concluded that those people do not have malaria. It is even wrong to conclude and generate data with one method. Those who are doing this data collection are not even trained medical lab scientists. They used graduates of biological sciences who are not parasitologists. A situation where pharmacy shops do malaria tests is not acceptable. Under the roll back malaria programme, they commissioned pharmacy shops to do malaria test using these tests kits.
“Practically, over 90 per cent of Lagosians are living with malaria parasites, it is only in some villages in Nigeria that you can think of lower statistics especially thosewho live on hilly landscapes, and there are no stagnant waters around.
“What we are talking about is parasite count, the population of parasites per white blood cells. Not whether it is there or not, because we know that over 90 per cent of Nigerians who live in urban areas have malaria parasites. They all have it, but it depends on the quantity of the parasite present. The malaria test kit picks the parasite when the number of malaria parasites is very high. I sevice some private hospitals and public hospitals in this community, our patients get well when they are treated with anti-malarials. And we get more patients refered to us from them. If they don’t get well, we will not get more referrals from them.
“If I have 10 patients, almost 10 of them will have malaria parasites and they come with symptoms. Remember, few healthy people go to labs to check themselves, most come sick, and when they are treated for malaria, they get well. My lab thrives on referral. An experienced lab scientists do not just do malaria test and conclude, there are other tests we do to confirm that a patient has malaria. Like full blood count. Why? The full blood count give the following – the patient’s red blood cell count, it gives the patient’s haemoglobin level, the patient’s white blood cell count, it differentiates the different types of white blood cells, and in a parasitic situation, eisinophil. And of a necessity, this full blood count must be done for children and pregnant mothers who are more vulnerable to malaria parasite attack. And in most cases, all these indicators are there like rise in eisinophyl level announces low PCV level. With all these indicators, if you are testing with the malaria test kit it may still test negative to malaria.
Dr Enabulele said,“It is a misleading figure. If you take that to handle malaria issues, a lot of people will die. Malaria test kits is for serological diagnosis with antibodies which is does not give accurate diagnosis. You cannot use serological test to assess the level of malaria in the country. Malaria can always be diagnosed by seeing the parasite in the blood, not only seeing the parasite but determining the quantity of the parasites in the blood.
“I see malaria patients daily.There is no private hospital that sees 10 patients that won’t see a malaria patient everyday. Both pregnant women and ordinary people. Virtually everybody will have malaria parasite in the blood, but they may not show signs and symptoms in the person until the level of parasites reaches to about 1 million per ml of the blood. Even then, when laboratory scientists see the one million parasites, they say one plus, if they write two plus, that means they saw more than one million per ml of blood.
“Malaria parasite has two life cycles, in anopheles and in men. That is why it is difficult to develop a malaria vaccine. Even in men, at what stage of the parasite will the vaccine attack because the parasite keeps changing and each new stage comes with a new protein coat. Both in mosquito and in man, the parasite is undergoing different stages. Development of malaria vaccine has not been successful. Has the one they said they developed been clinically tried?
“By the time a patient is down with malaria, he or she is 50 per cent gone, because the rate of parasitemia will be so high and the destruction of the red blood cells equally high. Almost everybody in Lagos is a malaria parasite carrier. Because the type of anopheles that carry the parasite is what we call exogenous anopheles. Which means these mosquitoes are always outside, they are not inside. You can put mosquito nets to protect yourself inside, but when you come outside, they will bite you.
“There are three factors that attract mosquitoes, one, is high level of carbondioxide, two, high relative humidity and three, heat or warm environment. And all these three can be generated by man. You find that all these factors are very common in the tropics, so they are very good breeding grounds.
“About ten years ago, there was an concerted efforts bythe Federal Government to roll back malaria but that has lost steam. The presence of the parasite in the blood of Lagosians is over 90 per cent. Places that you may not have the parasite in the blood of residents of Lagos is among the elite in highbrow areas, but in other areas, it is endemic.”
The parasite
Malaria is caused by a parasite that is passed from one human to another by the bite of infected Anopheles mosquitoes. After infection, the parasites travel through the bloodstream to the liver, where they mature and are released. The parasites enter the bloodstream and infect red blood cells.
The parasites multiply inside the red blood cells, which then break open within 48 to 72 hours, infecting more red blood cells. The first symptoms usually occur 10 days to 4 weeks after infection, though they can appear as early as 8 days or as long as a year after infection. The symptoms occur in cycles of 48 to 72 hours.
Most symptoms are caused by:the release of the parasites into the bloodstream. Anemia resulting from the destruction of the red blood cells. Large amounts of free haemoglobin being released into circulation after red blood cells break open
Malaria can also be transmitted from a mother to her unborn baby (congenitally) and by blood transfusions. The disease is a major health problem in much of the tropics and subtropics. It is estimated that there are 300-500 million cases of malaria each year, and more than 1 million people die from it. It presents a major disease hazard for travelers to warm climates.
In some PARTS of the world, mosquitoes that carry malaria have developed resistance to insecticides. In addition, the parasites have developed resistance to some antibiotics. These conditions have led to difficulty in controlling both the rate of infection and spread of this disease.
Immunity
Most people who live in areas where malaria is common have got some immunity to the disease. Visitors will not have SUCH immunity, and should take preventive medications.
It is important to see your health care provider well before your trip, because treatment may need to begin as long as two weeks before you travel to the area, and continue for a month after you leave the area. In 2006, it was reported that most travellers from the United States who contracted malaria failed to take the right precautions.
The types of anti-malarial medications prescribed will depend on the area you visit. Travelers to South America, Africa, the Indian subcontinent, Asia, and the South Pacific should take antimalarials for prevention following doctors’ prescription. Even pregnant women should take preventive medications because the risk to the foetus from the medication is less than the risk of catching this infection.
People who are taking anti-malarial medications may still become infected. Avoid mosquito bites by wearing protective clothing over the arms and legs, using screens on windows, and using insect repellent.
Chloroquine has been the drug of choice for protecting against malaria. But because of resistance, it is now only suggested for use in areas where Plasmodium vivax , P. oval , and P. malariae are present. Falciparum malaria is becoming increasingly resistant to anti-malarial medications.
Many years of a single drug(monotherapy) for treatment of malaria around the world has led to resistance of the malaria parasite to these drugs once considered effective against them. As a result, the World Health Organisation(WHO) recommended a change to the use of a combination of drugs – artemisinin or its derivatives and one or more active ingredients. The umbrella term for these combination therapies is ACT, Artemisinin based company therapy.
For travelers going to areas where Falciparum malaria is known to occur, there are several options for malaria prevention, including use of Artemisinin based combination therapy(ACT).