After a significant decline of malaria cases in Niger over the last three years, there has been an alarming resurgence of the disease this summer. This resurgence has called into question the prevention efforts implemented since the last malaria peak in 2012.
This year the medical authorities in the Madaoua health district have recorded 6,695 malaria cases in the second week of October—a number that more than doubles the 3,901 cases registered during the same period in 2015. Doctors Without Borders/Médecins Sans Frontières (MSF) has responded to the emergency by setting up additional health structures and recruiting temporary medical staff in the Tahoua, Zinder, Maradi and Diffa regions. About 60,000 children have been treated.
The sudden increase in malaria cases calls for a close look into the cause of the resurgence and the action needed in order to fight it.
“The number of admissions this year has been exceptional, even compared to 2012,” said Hamsatou Seydou Abdou, an MSF nurse at the inpatient therapeutic feeding center (ITFC) at Madaoua hospital.
In addition to the peak in malaria transmission, there is also an increase in acute malnutrition as a result of the hunger gap (a seasonal period of food insecurity) which coincides with the rainy season. “I remember that at the height of the peak in 2012," said Seydou Abdou, "we had 250 children hospitalized at most. But this year, we had more than 400 beds. You have to be constantly on alert, like guards!”
A call to action
Following the malaria spike of 2012, several measures were adopted by the health authorities with the support of MSF such as the distribution of mosquito nets treated with insecticide, the implementation of a chemoprevention program, and the epidemiological monitoring of cases.
Thanks to these measures, the number of people with malaria had dropped by more than 70 percent in 2014. However, cases started to reappear little by little and now cases have more than doubled during the same period in 2016.
“The decrease in mortality at the ITFC"—from 16 percent in 2012 to 6.1 percent in 2016—"indicates a progress which can be attributed both to the prevention campaign and also to the continuous improvement in the quality of care,” said Dr. Carol, MSF medical coordinator in Niger. “There is no doubt that the prevention efforts must be continued, but today it is very soon to explain the specific reasons for this resurgence. We can only put forward hypotheses and propose action plans accordingly.”
Prophylaxis for seasonal malaria prevention consists of administering treatment to children three months to five years old during the four peak months when the incidence of the disease is at its highest. In the Magaria and Dungass districts of Niger, 109,390 children have benefited from this program, representing 93.4 percent of the population in this age group in the targeted areas.
Assessing prevention programs
This year, organizational problems and a lack of means have affected the prevention campaign. For example, there was a shortage of rapid diagnostic tests at some health centers between the months of June and August when malaria transmission is at its peak.
Treatment administration is also a critical factor for program success. This year, MSF’s center for epidemiological research, conducted a study at six centers in the Magaria district, in the Zinder region, to assess the urgency of a seasonal malaria chemoprevention program implemented in the field.
“Perhaps there was some slackening after the success of the first prevention campaigns, but there are many factors that can cause an unexpected increase in transmission,” Dr. Carol said. “We’re also in the process of assessing the impact of the rains, which, as well as arriving earlier than usual this year, have been very heavy, and this has encouraged the spread of malaria. Neither can we rule out the possibility that a resistance to the pharmacological treatment used for the chemoprevention has developed. MSF is conducting, together with Epicentre (the organization's public health and epidemiology research center), some studies on this topic.”
Further south, in the Maradi region, MSF teams have confirmed an influx of patients from Nigeria. “In September, up to 52 percent of our patients came from Nigeria," explains Felix Kouassi, MSF’s head of mission in Niger. “People cross the border to come to the centers where MSF works and where the healthcare is free. But this poses a serious problem for the effectiveness of our prevention program, which is only reaching 50 percent of the target population. This situation is leading us to consider the need to carry out malaria prevention activities beyond Niger's border.”