Integrated Test Treat and Laval Source Management (ITTL) as a tool for malaria elimination in Nigeria

Malaria is still a major public health problem in Nigeria though it is preventable. It also constitutes a major barrier to social and economic development. The disease is caused by an infected female anopheles mosquito. Some of its symptoms are fever, headache, vomiting, diarrhoea, profuse sweating and anemia. The disease kills over 300,000 persons per […]

Malaria is still a major public health problem in Nigeria though it is preventable. It also constitutes a major barrier to social and economic development.

The disease is caused by an infected female anopheles mosquito. Some of its symptoms are fever, headache, vomiting, diarrhoea, profuse sweating and anemia.

The disease kills over 300,000 persons per year while about 100 million malaria cases are recorded annually in the country.

Over 90% of the population in Nigeria is at risk while children and pregnant women are more vulnerable to the disease. Malaria also poses high economic burden to Nigerians, resulting in 10% annual decrease in Gross Domestic Product (GDP) and N880 billion loss yearly by Nigerians due to personal treatment costs, prevention costs, loss of man hours at work and school. The amount could pay the annual salary of approximately four million Nigerians on minimum wage.

Inspite of the efforts the Federal Government and development partners have made to control malaria in the country, the burden of the disease in terms of morbidity and mortality is still very high.

Many experts have said that it is important to go beyond control to elimination of the disease. This therefore underscores the need for strategies towards ending the disease in the country.

The global target against malaria is to eliminate it by 2030.The Economic Community of West African States (ECOWAS) heads of state government in 2007 resolved to eliminate malaria in the sub-region by 2015. Nigeria has keyed into this approach of promoting malaria elimination through Integrated Vector Management (IVM) with increased emphasis on larviciding.

Experts say malaria can be eliminated in Nigeria. They say the country could be a malaria free society with the right approaches and innovation. This becomes more important especially with other African countries achieving elimination of the scourge.

Among countries in Africa that have achieved malaria elimination, according to Dr Godwin Ntadom, Chief Epidemiologist of the Federation, are Botswana, Namibia, Rwanda and Zambia. He however said no country in West Africa has been able to achieve elimination yet.

Controlling malaria includes reducing new infections; the number of people currently infected and those that fall sick or die from malaria. Reducing the disease burden to a level where it is no longer a public health problem involves prevention strategies that include use of anti-malaria drugs and insecticide treated mosquito nets.

Eliminating malaria on the other hand implies stopping the transmission of the disease in the country. This involves interruption of local mosquito-borne malaria transmission to ensure zero incidence of locally contracted cases. The first step towards elimination is through control measures.

Olugbenga A Mokuolu, a Professor of Paediatrics and Child Health and Director, Centre for Malaria Care, University of Ilorin Teaching Hospital, nurses no doubt that Nigeria can eliminate malaria.

Speaking during a forum with the media on malaria, Prof Mokuolu said “The signals are promising. The current tools are effective. New tools are needed to further accelerate current gains. We have achieved about 50% reduction in the last 10-15 years. But critically, malaria will never be eliminated by a single quick fix method.

“It has to be a sustained and highly integrated and coordinated strategy,” he said.

One programme that has proven to be affective in the elimination of malaria in other countries is that of Larval Source management. Several studies and analyses carried out on its efficacy at international and local levels have certified it okay.

The Integrated Malaria Test, Treat, Cure and Larviciding (ITTL) project for the elimination of malaria in Nigeria was conceived on the directive of a former Health minister who asked rollback malaria partners to develop new strategies to help the country achieve a malaria free society. The ITTL project would also complement the current malaria intervention strategies in Nigeria.

The National Malaria Elimination Programme (NMEP) also helped in the development of the project.

It is aimed at ensuring that testing is carried out before treatment, to reduce misdiagnosis and treatment with Artemisinin-Based Combination Therapy (ACT) which is the recommended treatment for malaria in the country.

The larviciding component ensures that mosquitoes at the larval stage do not grow into malaria carrying adult mosquitoes.

Larviciding has been piloted in Lagos, Nasarawa, Jigawa, Ogun and Rivers States, findings reveal.

This pilot schemes involved state-wide larviciding using three different larvicides -Bacillus thuriengensisisraelensis (Bti), Bacillus Sphaericus (Bs) and Insect Growth regulator (IGR) Methorprene – which have been found to be very effective in malaria control and are safe and environmentally friendly.

The project has created five different packs that test and treat specific age groups such as infants, children, juniors, adults and pregnant women. The programme is also estimated to create approximately 150,000 direct jobs.

The ITTL project is made up of three components namely: Testing for malaria with Rapid Diagnostic Tests (RDTs); treating confirmed malaria cases with Atemisinin-Based Combination Therapies (ACTs); and mosquito control through Larviciding and simple Environmental Management.

The ITTL shows promise in complementing the ongoing deployment of nets, Rapid Diagnostic Tests (RDTs) and Atemisinin-Based Combination Therapies (ACTs) which is in line with the National Malaria Strategic Plan 2014- 2020.

It proposes an all-out assault on malaria, by reducing it by at least 75% in the next two years through an aggressive Test, Treat and Larval Source Management project that will be the biggest in sub-Saharan Africa.

The mosquito larviciding will be carried out in fixed, findable and few breeding sites nationwide.

The Economic Management Implementation Team has given clearance to the ITTL project and the proposal was subjected to vigorous scrutiny by due process and certificate of No Objection obtained in 2012 in favour of three companies – Ablantis Healthcare INTL (AHCL), Messrs Accounts Nigeria Limited and Messrs Harvestfields Industries Limited as Implementing Partners (IPs) for the ITTL Project in Nigeria.

The Integrated Vector Management (IVM) Strategy was approved by the National Council on Health in 2007.

The National Executive Council at the 57th NEC meeting on 20th November, 2014, gave approval for the implementation of the project; and the award of contracts for the ITTL project at a total sum of approximately $456m as stated in the due process certificate.

A former minister of Health, Professor Onyebuchi Chukwu, presented the project to the Federal Executive Council in October 2012. It approved it in principle and referred it to the National Executive Council (NEC) for buy-in.

The minister made presentation to NEC in September 2013 and the latter set up an ad hoc committee which included several dozen inter-governmental agencies as well as international development partners such as the World Health Organisation (WHO), United Nations Children’s Fund (UNICEF), Department for International Development (DFID) represented by Sunmap Nigeria, and the World Bank –which also contributed to the development of an implementation schedule.

At the 57th National Executive Council (NEC) meeting on 20th November, 2014, the Integrated Malaria Test, Treat, Cure and Larviciding (ITTL) Project was approved.

Some of the strategies approved by the National Executive Council then included ITTL Project Implementation plan; Commencement date of January 2015 for the project; a total budget of $456m for the project; scaling up of other Integrated Vector Management Methods; and the update amended in terms of funding (that seeks the Federal Government and Development Partners to fund the project).

Others included the domiciliation of funds in a dedicated account in the Central Bank of Nigeria (CBN) and disbursement using the accountability framework as developed by the Technical Working Group, as well as provision of enabling environment by government for the local production of anti-malarial commodities and larvicides.

According to the World Health Organisation (WHO), a controlled trial on the Integrated malaria vector control with microbial larvicides and insecticide-treated nets in western Kenya showed positive results.

“Many believe Integrated Vector Management (IVM), targeting both larval and adult mosquitoes, is the future for malaria control. While insecticide treated nets are currently the priority strategy, there is growing interest in attacking the aquatic stages of malaria vectors with microbial larvicides, in conjunction with environmental management.

WHO said larval source management and the use of microbial larvicides offer additional protection against malaria, adding that “Microbials are highly effective at killing mosquito larvae, highly specific in action and safe to use. Importantly, the risk that resistance will develop is very low and can be easily managed and reversed.”

“We have demonstrated that microbial larvicides reduced malaria vector mosquito larvae and adult females by 90%,” it also said.

Vector control in Africa should target all stages of the mosquito life cycle, the study suggested. Yet for the past 50 years it has focused almost exclusively on adult mosquito control. “Insecticide treated nets have not only saved thousands of lives; they have also restored confidence in vector control in Africa.

However, adult-based methods are limited in what they can achieve because adult mosquitoes feed outside houses and before sleeping hours.”

Experts hope that the implementation of the ITTL programme will end the scourge of malaria as a public health problem in Nigeria.