Scaling up Seasonal Malaria Chemoprevention (SMC) implementation in Nigeria Amid COVID-19
Dr Jamilu Ibrahim Nikau
Map of Nigeria showing SMC eligible states
Malaria is one of the most important infectious diseases that bedevilled humanity for centuries. The global malaria eradication program of the 1950s-1960s has resulted in a drastic reduction in the disease's burden globally, with many countries getting rid of malaria local transmission of the infection. The success of the eradication program was less evident in Sub Saharan Africa. However, the launching of Roll Back Malaria (RBM) partnership in 1998 and the 2001 Abuja Declaration by African Heads of States have invigorated support against the parasitic infection. Annual malaria deaths reduced from 1 million to 435,000 annually from 2000 to 2018.
Nigeria has also recorded noticeable success in its malaria control efforts. For example, the prevalence of the disease reduced to 23% from 43% between 2010 and 2018. Yet Nigeria currently has the highest burden of malaria, contributing to 25% of global malaria cases in 2018. The country's malaria fight is coordinated by the National Malaria Elimination Programme (NMEP) of the Federal Ministry of Health. The National Malaria Elimination Programme, in collaboration with states and partners, has developed an integrated package of interventions to prevent and ultimately eliminate malaria in the country. Its components include use of Long Lasting Insecticidal Nets (LLINs), Indoor Residual Spraying (IRS), Larval Source Management (LSM), Seasonal Malaria Chemoprevention (SMC), case management etc.
SMC involves administration of full intermittent treatment courses of Sulphadoxine Pyrimethamine and Amodiaquine (SPAQ) to children aged 3-59 months during the peak of malaria transmission, i.e. the rainy season in the Sahel parts of Africa. In a transmission season referred to as a Round, the drugs are given for three days to the eligible at monthly interval called Cycles by trained Community Drug Distributors (CDDs).
Children under the age of 5 years are worst affected by malaria. Most of the malaria deaths occur in this age group, and some infected children end up with long-term disabilities. SMC was recommended by the WHO following years of research to find drugs that will be safe and effective in significantly cutting the effect of malaria in worst-hit areas. SMC is proven to be safe and reduce up to 75% of malaria episodes, lower the rate of progression of uncomplicated malaria to severe malaria, cut down the incidence of anaemia etc. Nine states in the northern part of the country are eligible for SMC in Nigeria.
The National Malaria Elimination Programme in collaborations with states and Roll Back Malaria partners planned to cover 11,912,759 eligible children with SMC in 2020. A total of 4,172, 928 children were reached with the intervention last. Therefore, this year's target represents over 280% increase in protected children. This will be the first year SMC will be implemented in all the nine eligible states since its introduction in Nigeria in 2013.
SMC eligible states
The emergence of the COVID-19 has seriously affected the implementation of public health intervention globally. A modelling study conducted by the World Health Organization (WHO) on the potential impact of the pandemic revealed worsening of malaria mortality in Sub Saharan Africa if the implementations of proven interventions are reduced or halted.
The planning of the 2020 SMC Round experienced a significant setback in March when social distancing measures were mandated across the country. Several critical preparatory activities had to be suspended. For example, microplanning that involves enumeration of children in benefiting settlements, assessing the availability of human resources and facilities to support drug distribution came to a stop. Other activities delayed include advocacy/sensitization meetings, personnel selection, training, coordination meetings etc. Being a time-bound intervention, any delay in rolling out SMC will result in a reduction of its benefit to targeted children.
Consequently, the National Malaria Elimination Programme's SMC Technical Working Group (SMC-WG) with guidance from the WHO and other partners revised the SMC implementation guidelines and included adaptations that will enable SMC to be conducted in the context of the pandemic with a significant reduction of COVID-19 transmission risk. Meetings of the SMC-WG became more frequent, from taking place quarterly to being carried fortnightly to review progress and tackle challenges.
The COVID-19 adapted plan minimize activities that involve physical contacts with a large number of people as per the Nigeria Centre of Disease Control (NCDC) guidelines. Many of these activities were conducted virtually or were staggered when they have to be done in-person. Personnel Protective Equipment (PPE) like face masks, hand sanitizers hand gloves etc. are to be strictly enforced during SMC activities. Some drugs were airfreighted into the country and there was a redistribution of Sulphadoxine Pyrimethamine and Amodiaquine between some states to beat the commencement dateline.
These proactive measures have facilitated states and implementers to deploy SMC as per the plan developed before the emergence of the pandemic. Funding for this year's campaign came from the Global Fund for Borno, Kano, Katsina and Yobe states while the United State President's Malaria Initiate (PMI) supported Zamfara state. Bauchi, Jigawa, Kebbi and Zamfara states were funded by philanthropic funding from Give Well Ventures. Key partners providing technical support to states on SMC include the WHO, Malaria Consortium, GHSC-PSM, MSF etc.
The international grants Nigeria is currently implementing SMC and other life-saving malaria control interventions will cease one day. Therefore, it is imperative for governments at all levels to increase resources dedicated to the fight against malaria and other infectious diseases to enable the country to attain goal 3, target 3.3 of Sustainable Development Goal (SDGs) and tap some resources money from our robust private sector.
With all set for a successful campaign in 2020, it is imperative for state governments and benefiting communities to take full ownership of the intervention by providing enabling environment to implementers supporting their areas. Caregivers of benefiting children also have a critical role to play by cooperating with CDDs going house-to-house to give the drugs and ensure their children complete the monthly treatments to reap the full benefits of SMC. The 2020 SMC Round will be delivered between July and October.
Dr Jamilu Ibrahim Nikau works with the National Malaria Elimination Programme (NMEP) as the Focal Person of Seasonal Malaria Chemoprevention (SMC). He can be reached via firstname.lastname@example.org.