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Malaria and Neglected Tropical Diseases in Nigeria
Prof. Eyitayo LamboHonourable Minister
Federal Ministry of HealthAbuja, Nigeria
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
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
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 $1 million) per year to expand nationally• Join with Roll Back Malaria to distribute
bednets, using RB/LF treatment network
Biharziasis (schistosomiasis):The Disease
•Parasite from snail vector penetrates skin in contaminated fresh water•Adult worms reside in veins of bladder, intestines•Numerous eggs damage bladder, intestines, liver, kidneys, lungs•Causes bloody urine, bloody diarrhea, heart failure, liver and kidney disease•Estimated 30 million Nigerians require praziquantel treatment (world’s #1)
Bilharzia: Interventions
• Health education & community mobilization
• Annual oral mass drug administration (praziquantel)
• Expensive!– Praziquantel not donated (costs
US$.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