Unravelling factors associated with malaria parasitaemia among children 6-24 months to inform malaria interventions in Nigeria: evidence from 2021 Malaria Indicator Survey.

BACKGROUND: As an additional two million malaria cases were reported in 2021 compared to the previous year, concerted efforts toward achieving a steady decline in malaria cases are needed to achieve malaria elimination goals. This work aimed at determining the factors associated with malaria parasitaemia among children 6-24 months for better targeting of malaria interventions. METHODS: A cross-sectional study analysed 2021 Nigeria Malaria Indicator Survey dataset. Data from 3058 children 6-24 months were analyzed. The outcome variable was children 6-24 months whose parasitaemia was determined using a rapid diagnostic test (RDT). Independent variables include child age in months, mothers' age, mothers' education, region, place of residence, household ownership and child use of insecticide-treated net (ITN), exposure to malaria messages and knowledge of ways to prevent malaria. Logistic regression analysis was conducted to examine possible factors associated with malaria parasitaemia in children 6-24 months. RESULTS: Findings revealed that 28.7% of the 3058 children aged 6-24 months tested positive for malaria by RDT. About 63% of children 12-17 months (aOR = 1.63, 95% CI 1.31-2.03) and 91% of children 18 to 24 months (aOR = 1.91, 95% CI 1.51-2.42) were more likely to have a positive malaria test result. Positive malaria test result was also more likely in rural areas (aOR = 1.79, 95% CI 2.02-24.46), northeast (aOR = 1.54, 95% CI 1.02-2.31) and northwest (aOR = 1.63, 95% CI 1.10-2.40) region. In addition, about 39% of children who slept under ITN had a positive malaria test result (aOR = 1.39 95% CI 1.01-1.90). While children of mothers with secondary (aOR = 0.40, 95% CI 0.29-0.56) and higher (aOR = 0.26, 95% CI 0.16-0.43) levels of education and mothers who were aware of ways of avoiding malaria (aOR = 0.69, 95% CI 0.53-0.90) were less likely to have a malaria positive test result. CONCLUSION: As older children 12 to 24 months, children residing in the rural, northeast, and northwest region are more likely to have malaria, additional intervention should target them in an effort to end malaria.

Baseline prevalence of molecular marker of sulfadoxine/pyrimethamine resistance in Ebonyi and Osun states, Nigeria: amplicon deep sequencing of dhps-540.

BACKGROUND: Chemoprevention plays an important role in malaria control strategy. Perennial malaria chemoprevention (PMC) using sulfadoxine/pyrimethamine (SP) is a WHO-approved strategy to combat malaria in young children and may lead to drug pressure. Introducing SP-PMC may therefore be compromised due to the emergence of Plasmodium falciparum resistant to SP, particularly mutation at K540E of the dihydropteroate synthase (dhps) gene. Molecular surveillance of resistance markers can support assessment of antimalarial efficacy and effectiveness. High prevalence of 540E is associated with reduced effectiveness of SP, and areas with more than 50% prevalence are considered unsuitable for intermittent preventative treatment in pregnancy (IPTp) implementation. Assessing 540E prevalence is an important undertaking before implementation of SP-PMC. METHODS: We conducted a rapid surveillance of dhps-540E to assess the suitability of SP as PMC in field studies from Ebonyi and Osun states in Nigeria. We used an in-house developed amplicon deep-sequencing method targeting part of the dhps gene. RESULTS: Our data reveal that 18.56% of individuals evaluated carried the 540E mutation mixed with the WT K540. Mutant variant 540E alone was not found, and 80% of isolates harboured only WT (K540). Clonal analysis of the sequencing data shows a very low proportion of 540E circulating in both states. CONCLUSIONS: Our data show that both states are suitable for SP-PMC implementation and, based on this finding, SP-PMC was implemented in Osun in 2022. Continuous monitoring of 540E will be required to ensure the chemoprevention effectiveness of SP in Nigeria.

Use of insecticide treated nets in children under five and children of school age in Nigeria: Evidence from a secondary data analysis of demographic health survey.

BACKGROUND AND OBJECTIVE: Use of insecticide treated nets (ITN), one of the most cost-effective malaria interventions contributes to malaria cases averted and reduction in child mortality. We explored the use of ITN in children under five (CU5) and children of school age to understand factors contributing to ITN use. METHODS: A cross-sectional study analyzed 2018 Nigeria Demographic and Health Survey data. The outcome variable was CU5 or children of school age who slept under ITN the night before the survey. Independent variables include child sex, head of household's sex, place of residence, state, household owning radio and television, number of household members, wealth quintile, years since ITN was obtained and level of malaria endemicity. Multi-level logistic regression model was used to access factors associated with ITN use among children. RESULTS: In total, 32,087 CU5 and 54,692 children of school age were examined with 74.3% of CU5 and 57.8% of children of school age using ITN the night before the survey. While seven states had more than 80% of CU5 who used ITN, only one state had over 80% of school children who used ITN. ITN use in CU5 is associated with living in rural area (aOR = 1.20, 95% CI 1.14 to 1.26) and residing in meso endemic area (aOR = 3.1, 95% CI 2.89 to 3.54). While In children of school age, use of ITN was associated with female headed households (aOR = 1.14, 95% CI 1.09 to 1.19), meso (aOR = 3.17, 95% CI 2.89 to 3.47) and hyper (aOR = 14.9, 95% CI 12.99 to 17.07) endemic areas. Children residing in larger households were less likely to use ITN. CONCLUSIONS: This study demonstrated increased use of ITN in CU5 from poor households and children living in rural and malaria endemic areas. Findings provide some policy recommendations for increasing ITN use in school children.

Misuse of Artemisinin Combination Therapies by Clients of Medicine Retailers Suspected to Have Malaria Without Prior Parasitological Confirmation in Nigeria.

BACKGROUND: Prompt and effective case detection and treatment are vital components of the malaria case management strategy as malaria-endemic countries implement the testing, treating and tracking policy. The implementation of this policy in public and formal private sectors continue to receive great attention while the informal private retail sector (mostly the patent and propriety medicine vendors [PPMVs]) where about 60% of patients with fever in Nigeria seek treatment is yet to be fully integrated. The PPMVs sell artemisinin combination therapies (ACTs) without prior testing and are highly patronized. Without prior testing, malaria is likely to be over-treated. The need to expand access to diagnosis in the huge informal private health sector among PPMVs is currently being explored to ensure that clients that patronize retail drug stores are tested before sales of ACTs. METHODS: A cross-sectional multistage study was conducted among 1279 adult clients, 20 years and above, who purchased malaria medicines from 119 selected PPMVs in five administrative areas (States) of Nigeria, namely: Adamawa, Cross River, Enugu, Lagos and Kaduna, as well as the Federal Capital Territory, Abuja. Exit interviews using a standard case report questionnaire was conducted after the purchase of the antimalarial medicine and thick/thin blood smears from the clients' finger-prick were prepared to confirm malaria by expert microscopy. RESULTS: Of the 1279 clients who purchased malaria medicines from the PPMV outlets, 107 (8.4%) were confirmed to have malaria parasites. The malaria prevalence in the various study areas ranged from 3.5% to 16%. A high proportion of clients in the various study sites who had no need for malaria medicines (84%-96.5%) purchased and used antimalarial medicines from the PPMVs. This indicated a high level of over-treatment and misuse of antimalarials. Common symptoms that are widely used as indicators for malaria such as, fever, headache, and tiredness were not significantly associated with malaria. Nausea/vomiting, poor appetite, chills, bitter taste in the mouth and dark urine were symptoms that were significantly associated with malaria among the adult clients (P<.05) but not fever (P=.06). CONCLUSION: Misuse of ACTs following overtreatment of malaria based on clinical diagnosis occurs when suspected cases of malaria are not prior confirmed with a test. Non-testing before sales of malaria medicines by PPMVs will perpetuate ACT misuse with the patients not benefiting due to poor treatment outcomes, waste of medicines and financial loss from out-of-pocket payment for unneeded medicines.

When it just won't go away: oral artemisinin monotherapy in Nigeria, threatening lives, threatening progress.

BACKGROUND: Oral artemisinin monotherapy (AMT), an important contributor to multi-drug resistant malaria, has been banned in Nigeria. While oral AMT has scarcely been found for several years now in other malaria-endemic countries, availability has persisted in Nigeria's private sector. In 2015, the ACTwatch project conducted a nationally representative outlet survey. Results from the outlet survey show the extent to which oral AMT prevails in Nigeria's anti-malarial market, and provide key product information to guide strategies for removal. RESULTS: Between August 10th and October 3rd, 2015 a total of 13,480 outlets were screened for availability of anti-malarials and/or malaria blood testing services. Among the 3624 anti-malarial outlets, 33,539 anti-malarial products were audited, of which 1740 were oral AMT products, primarily artesunate (n = 1731). Oral AMT was imported from three different countries (Vietnam, China and India), representing six different manufacturers and 11 different brands. Availability of oral AMT was highest among pharmacies (84.0%) and Patent Propriety Medicine Vendors (drug stores, PPMVs) (38.7%), and rarely found in the public sector (2.0%). Oral AMT consisted of 2.5% of the national anti-malarial market share. Of all oral AMT sold or distributed, 52.3% of the market share comprised of a Vietnamese product, Artesunat®, manufactured by Mekophar Chemical Pharmaceutical Joint Stock Company. A further 35.1% of the market share were products from China, produced by three different manufacturers and 12.5% were from India by one manufacturer, Medrel Pharmaceuticals. Most of the oral AMT was distributed by PPMVs accounting for 82.2% of the oral AMT market share. The median price for a package of artesunate ($1.78) was slightly more expensive than the price of quality-assured (QA) artemether lumefantrine (AL) for an adult ($1.52). The median price for a package of artesunate suspension ($2.54) was three times more expensive than the price of a package of QA AL for a child ($0.76). CONCLUSION: Oral AMT is commonly available in Nigeria's private sector. Cessation of oral AMT registration and enforcement of the oral AMT ban for removal from the private sector are needed in Nigeria. Strategies to effectively halt production and export are needed in Vietnam, China and India.

The impact of behaviour change communication on the use of insecticide treated nets: a secondary analysis of ten post-campaign surveys from Nigeria.

BACKGROUND: Mass distribution campaigns of insecticide-treated nets for malaria prevention are usually accompanied by intensive behaviour change communication (BCC) to encourage hanging and use of nets. However, data on the effectiveness of these communication efforts are scarce. In preparation for the next round of mass campaigns in Nigeria, a secondary analysis of existing data from post-campaign surveys was undertaken to investigate the influence of BCC on net hanging and use. METHODS: Surveys were undertaken between 2009 and 2012 in ten states in Nigeria using standardized questionnaires. Two-stage cluster sampling was used to select households in each study site. Outcomes were defined as the effects of BCC message exposure and recall on knowledge, attitudes, perception as well as intentions and actual use. From the univariable analysis, potential confounders and explanatory variables were identified and key effects explored in multivariable linear or logistic regression models; terms in the models were kept if they had a marginal significance with p < 0.2. To quantify the effects from BCC, a treatment effect model was used with an inverse-probability weight regression adjustment. RESULTS: More than half of the respondents (58.4 %; 95 % CI 56.0, 60.7) had heard a message about net use or hanging during or after the distribution campaign, with media cited as the most common source of information. Attitude towards net use was positively linked to the number of messages recalled and was overall better in the northern study sites. The number of messages recalled was also the strongest predictor of knowledge (p < 0.001). All BCC outcomes showed a significant increase in net use, which was strongest for the confidence to take action regarding nets with an overall effect of 17 %-point increase of net use comparing poor and excellent confidence levels. Intention to use every night increased net use by 15 %-points and discussing net use in the family by 8 % points. All these effects were statistically significant (p < 0.001). CONCLUSIONS: Multichannel BCC campaigns as well as other media were effective in contributing to an increase in net culture, hanging and use, particularly by vulnerable groups.

Presumptive treatment of malaria from formal and informal drug vendors in Nigeria.

BACKGROUND: Despite policies that recommend parasitological testing before treatment for malaria, presumptive treatment remains widespread in Nigeria. The majority of Nigerians obtain antimalarial drugs from two types of for-profit drug vendors-formal and informal medicine shops-but little is known about the quality of malaria care services provided at these shops. AIMS: This study seeks to (1) describe the profile of patients who seek treatment at different types of drug outlets, (2) document the types of drugs purchased for treating malaria, (3) assess which patients are purchasing recommended drugs, and (4) estimate the extent of malaria over-treatment. METHODS: In urban, peri-urban, and rural areas in Oyo State, customers exiting proprietary and patent medicine vendor (PPMV) shops or pharmacies having purchased anti-malarial drugs were surveyed and tested with malaria rapid diagnostic test. A follow-up phone survey was conducted four days after to assess self-reported drug administration. Bivariate and multivariate regression analysis was conducted to determine the correlates of patronizing a PPMV versus pharmacy, and the likelihood of purchasing an artemisinin-combination therapy (ACT) drug. RESULTS: Of the 457 participants who sought malaria treatment in 49 enrolled outlets, nearly 92% had diagnosed their condition by themselves, a family member, or a friend. Nearly 60% pharmacy customers purchased an ACT compared to only 29% of PPMV customers, and pharmacy customers paid significantly more on average. Multivariate regression results show that patrons of PPMVs were younger, less wealthy, waited fewer days before seeking care, and were less likely to be diagnosed at a hospital, clinic, or laboratory. Only 3.9% of participants tested positive with a malaria rapid diagnostic test. CONCLUSIONS: Poorer individuals seeking care at PPMVs are more likely to receive inappropriate malaria treatment when compared to those who go to pharmacies. Increasing accessibility to reliable diagnosis should be explored to reduce malaria over-treatment.

How do risk preferences relate to malaria care-seeking behavior and the acceptability of a new health technology in Nigeria?

BACKGROUND: To reduce the burden of disease from malaria, innovative approaches are needed to engender behavior change. One unobservable, but fundamental trait-preferences for risk-may influence individuals' willingness to adopt new health technologies. We explore the association of risk preferences with malaria care-seeking behavior and the acceptability of malaria rapid diagnostic tests (RDTs) to inform RDT scale-up plans. METHODS: In Oyo State, Nigeria, adult customers purchasing anti-malarial medications at selected drug shops took surveys and received an RDT as they exited. After an initial risk preference assessment via a simple lottery game choice, individuals were given their RDT result and treatment advice, and called four days later to assess treatment adherence. We used bivariable and multivariable regression analysis to assess the association of risk game choices with malaria care-seeking behaviors and RDT acceptability. RESULTS: Of 448 respondents, 63.2% chose the lottery game with zero variance in expected payout, 27.9% chose the game with low variance, and 8.9% chose the game with high variance. Compared to participants who chose lower variance games, individuals choosing higher variance games were older, less educated, more likely to be male, and were more likely to patronize lower quality drug shops, seek care immediately, and report complete disability due to their illness. In contrast, individuals choosing lower variance games were more likely to follow the correct treatment directions and were more likely to report an increase in their willingness to pay for an RDT compared to other risk groups, our two measures of RDT acceptability. Differences in estimated associations between risk game choices and selected care-seeking behaviors remained after controlling sociodemographic confounders. CONCLUSIONS: The uptake of health diagnostic information in terms of translating the RDT experience into willingness to pay for an RDT and treatment adherence to test results may vary according to risk preferences. Hence, health promotion communications may want to be crafted bearing in mind differences in uptake among people of different risk preferences to encourage wider RDT adoption and more rational malaria treatment. Estimates will serve as the basis for power calculations for an expanded study.

An assessment of the quality of advice provided by patent medicine vendors to users of oral contraceptive pills in urban Nigeria.

INTRODUCTION: In Nigeria about 50% of oral contraceptive pill users obtain their products from proprietary patent medicine vendors (PPMVs). This group of service providers are poorly trained and have very limited knowledge about contraception. This paper investigated the nature of the advice offered to simulated current and potential users of oral contraceptive pills. The main objective was to assess the nature and quality of advice provided by PPMVs to pill users. METHOD: This study is based on findings from a 'mystery client' approach in which three scenarios related to contraceptive pill use were simulated. Each of the 12 mystery clients simulated one of the following three scenarios: new pill users (new to family planning or switching from condom to pills); user seeking a resupply of pills; and dissatisfied pill users intending to discontinue use. Simple random sampling was used to select 410 PPMVs from a total of 1,826 in four states in Nigeria. Qualitative study using in-depth interviews was also conducted. RESULTS: A majority of the PPMVs had pills in stock on the day of the survey and resupplied pills to the clients. PPMVs also understood the reason and importance of referring clients who were new adopters of oral contraceptive methods to a health facility; 30% of the PPMVs referred new adopters to a health facility. However, demand from clients who do not want to go to health care facilities (for various reasons) necessitated the provision of oral contraceptive pills to 41% of the first time users. Some PPMVs prescribed treatment to mystery clients who presented with perceived complications arising from the use of pills, while 49% were referred to a health facility. CONCLUSION: The advice given by PPMVs often falls short of safety guidelines related to the use of oral contraceptive pills. There is a need to continuously update knowledge among the PPMVs to ensure that they provide quality oral contraceptive services as PPMVs bridge the gap between medical experts and users in rural communities.

SMS messages increase adherence to rapid diagnostic test results among malaria patients: results from a pilot study in Nigeria.

BACKGROUND: The World Health Organization now recommends parasitological confirmation for malaria case management. Rapid diagnostic tests (RDTs) for malaria are an accurate and simple diagnostic to confirm parasite presence in blood. However, where they have been deployed, adherence to RDT results has been poor, especially when the test result is negative. Few studies have examined adherence to RDTs distributed or purchased through the private sector. METHODS: The Rapid Examination of Malaria and Evaluation of Diagnostic Information (REMEDI) study assessed the acceptability of and adherence to RDT results for patients seeking care from private sector drug retailers in two cities in Oyo State in south-west Nigeria. In total, 465 adult participants were enrolled upon exit from a participating drug shop having purchased anti-malaria drugs for themselves. Participants were given a free RDT and the appropriate treatment advice based on their RDT result. Short Message Service (SMS) text messages reiterating the treatment advice were sent to a randomly selected half of the participants one day after being tested. Participants were contacted via phone four days after the RDT was conducted to assess adherence to the RDT information and treatment advice. RESULTS: Adherence to RDT results was 14.3 percentage points (P-val <0.001) higher in the treatment group who were sent the SMS. The higher adherence in the treatment group was robust to several specification tests and the estimated difference in adherence ranged from 9.7 to 16.1 percentage points. Further, the higher adherence to the treatment advice was specific to the treatment advice for anti-malarial drugs and not other drugs purchased to treat malaria symptoms in the RDT-negative participants who bought both anti-malarial and symptom drugs. There was no difference in adherence for the RDT-positive participants who were sent the SMS. CONCLUSIONS: SMS text messages substantially increased adherence to RDT results for patients seeking care for malaria from privately owned drug retailers in Nigeria and may be a simple and cost-effective means for boosting adherence to RDT results if and when RDTs are introduced as a commercial retail product.

Modelling geographical variations and determinants of use of modern family planning methods among women of reproductive age in Nigeria.

Summary Understanding the level, trend, geographical variations and determinants of use of modern family planning (FP) plays a major role in designing effective interventions leading to increased usage. This study assessed these characteristics of FP use in Nigeria using data from the 2003, 2005 and 2007 National HIV/AIDS and Reproductive Health Survey, a national population-based household survey. A Bayesian geo-additive procedure was used, which provides flexible modelling of non-linear and spatial effects at a highly disaggregated level of states. The findings reveal considerable geographical variation in the use of modern FP in Nigeria, with a distinct north-south divide. Furthermore, a significant trend in the use of modern FP was evident, with an increase between 2003 and 2005 followed by a decline between 2005 and 2007. The effect of respondent's age was non-linear, and use of modern FP was found to differ significantly between never-married and currently/formerly married respondents. Awareness of FP methods and knowledge of where to get/buy FP services/methods were found to be significantly associated with usage. The findings provide policymakers with tools to prioritize the use of scarce resources for implementing FP and reproductive health interventions.