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Background: Malaria is a priority global health disease with high morbidity and mortality especially among children under-five and pregnant women. Malaria elimination requires an effective surveillance system. The malaria surveillance system in Benue State was evaluated to assess its attributes and performance in line with set objectives. Methods: The updated United States Centers for Disease Control and Prevention guideline for evaluating surveillance systems was used. The surveillance system's key attributes was quantitatively and qualitatively assessed. Semi-structured questionnaires were administered to all Local Government Area (LGA) Roll Back Malaria (RBM) focal persons and five key informants were interviewed at the State level. The Benue State District Health Information System-2 (DHIS-2) malaria data and monthly summary forms were reviewed from January 2015 to December 2019. Results: A total of 46 RBM focal persons and 5 key-informants participated. About 56.9% were males, the mean-age 43.8 (SD ± 9.3) years and 32 (62.8%) had ≥ 20-year experience on malaria surveillance with mean-year-experience 20.8 (SD ± 7.8) years. All 46 (100%) RBMs understood the case definition; 43 (93.5%) found it easy-to-fill the standardized data tools and understood the data flow channels. The malaria surveillance system in Benue is simple, acceptable and useful to all stakeholders, 36 (70.6%) found switching from the paper-based to the electronic-data tools with ease and 45 (88.2%) stated that analysed data were used for decision-making. Data flow from LGA to State is clearly defined, however majority of the data is collected from public health facilities through the DHIS-2 Platform. The overall timeliness and completeness of reporting was 76.5% and 95.7%, respectively, which were below the ≥ 80% and 100% targets, respectively. Conclusions: The malaria surveillance system in Benue State is simple, useful, acceptable, and flexible, but it is not representative and timely. Public–private and public-public-partnerships should be strengthened to encourage reporting from both private and tertiary health facilities and improve representativeness, and frequent feedback to improve reporting timeliness. [ABSTRACT FROM AUTHOR]

Background: The level of access to intermittent preventive treatment for malaria in pregnancy (IPTp) in Nigeria is still low despite relatively high antenatal care coverage in the study area. This paper presents information on provider factors that affect the delivery of IPTp in Nigeria. Methods: Data were collected from heads of maternal health units of 28 public and six private health facilities offering antenatal care (ANC) services in two districts in Enugu State, south-east Nigeria. Provider knowledge of guidelines for IPTp was assessed with regard to four components: the drug used for IPTp, time of first dose administration, of second dose administration, and the strategy for sulphadoxine-pyrimethamine (SP) administration (directly observed treatment, DOT). Provider practices regarding IPTp and facility-related factors that may explain observations such as availability of SP and water were also examined. Results: Only five (14.7%) of all 34 providers had correct knowledge of all four recommendations for provision of IPTp. None of them was a private provider. DOT strategy was practiced in only one and six private and public providers respectively. Overall, 22 providers supplied women with SP in the facility and women were allowed to take it at home. The most common reason for doing so amongst public providers was that women were required to come for antenatal care on empty stomachs to enhance the validity of manual fundal height estimation. Two private providers did not think it was necessary to use the DOT strategy because they assumed that women would take their drugs at home. Availability of SP and water in the facility, and concerns about side effects were not considered impediments to delivery of IPTp. Conclusion: There was low level of knowledge of the guidelines for implementation of IPTp by all providers, especially those in the private sector. This had negative effects such as non-practice of DOT strategy by most of the providers, which can lead to low levels of adherence to IPTp and ineffectiveness of IPTp. Capacity development and regular supportive supervisory visits by programme managers could help improve the provision of IPTp. [ABSTRACT FROM AUTHOR]

Background: The use of data in targeting malaria control efforts is essential for optimal use of resources. This work provides a practical mechanism for prioritizing geographic areas for insecticide-treated net (ITN) distribution campaigns in settings with limited resources. Methods: A GIS-based weighted approach was adopted to categorize and rank administrative units based on data that can be applied in various country contexts where Plasmodium falciparum transmission is reported. Malaria intervention and risk factors were used to rank local government areas (LGAs) in Nigeria for prioritization during mass ITN distribution campaigns. Each factor was assigned a unique weight that was obtained through application of the analytic hierarchy process (AHP). The weight was then multiplied by a value based on natural groupings inherent in the data, or the presence or absence of a given intervention. Risk scores for each factor were then summated to generate a composite unique risk score for each LGA. This risk score was translated into a prioritization map which ranks each LGA from low to high priority in terms of timing of ITN distributions. Results: A case study using data from Nigeria showed that a major component that influenced the prioritization scheme was ITN access. Sensitivity analysis results indicate that changes to the methodology used to quantify ITN access did not modify outputs substantially. Some 120 LGAs were categorized as 'extremely high' or 'high' priority when a spatially interpolated ITN access layer was used. When prioritization scores were calculated using DHS-reported state level ITN access, 108 (90.0%) of the 120 LGAs were also categorized as being extremely high or high priority. The geospatial heterogeneity found among input risk factors suggests that a range of variables and covariates should be considered when using data to inform ITN distributions. Conclusion: The authors provide a tool for prioritizing regions in terms of timing of ITN distributions. It serves as a base upon which a wider range of vector control interventions could be targeted. Its value added can be found in its potential for application in multiple country contexts, expediated timeframe for producing outputs, and its use of systematically collected malaria indicators in informing prioritization. [ABSTRACT FROM AUTHOR]

Background: Knowing the extent and spread of insecticide resistance in malaria vectors is vital to successfully manage insecticide resistance in Africa. This information in the main malaria vector, Anopheles funestus sensu stricto, is completely lacking in the most populous country in Africa, Nigeria. This study reports the insecticide susceptibility status and the molecular basis of resistance of An. funestus as well as its involvement in malaria transmission in Akaka- Remo, a farm settlement village in southwest Nigeria. Results: Plasmodium infection analysis using TaqMan protocol coupled with a nested PCR revealed an infection rate of 8% in An. funestus s.s. from Akaka-Remo. WHO susceptibility tests showed this species has developed multiple resistance to insecticides in the study area. Anopheles funestus s.s. population in Akaka-Remo is highly resistant to organochlorines: dieldrin (8%) and DDT (10%). Resistance was also observed against pyrethroids: permethrin (68%) and deltamethrin (87%), and the carbamate bendiocarb (84%). Mortality rate with DDT slightly increased (from 10 to 30%, n = 45) after PBO pre-exposure indicating that cytochrome P450s play little role in DDT resistance while high mortalities were recorded after PBO pre-exposure with permethrin (from 68 to 100%, n = 70) and dieldrin (from 8 to 100%, n = 48) suggesting the implication of P450s in the observed permethrin and dieldrin resistance. High frequencies of resistant allele, 119F in F0 (77%) and F1 (80% in resistant and 72% in susceptible) populations with an odd ratio of 1.56 (P = 0.1859) show that L119F-GSTe2 mutation is almost fixed in the population. Genotyping of the A296S-RDL mutation in both F0 and F1 samples shows an association with dieldrin resistance with an odd ratio of 81 (P < 0.0001) (allelic frequency (R) = 76% for F0; for F1, 90 and 10% were observed in resistant and susceptible populations, respectively) as this mutation is not yet fixed in the population. Conclusion: The study reports multiple insecticide resistance in An. funestus from Akaka Remo. It is, therefore, necessary to pay more attention to this major malaria vector for effective malaria control in Nigeria. [ABSTRACT FROM AUTHOR]

Background: Poor malaria knowledge can negatively impact malaria control programmes. This study evaluates knowledge distribution in the domains of causation, transmission, vulnerability, symptoms, and treatment of malaria. It assesses the association between a caregiver's knowledge about malaria and ownership and use of insecticidetreated nets (ITNs) by children. Methods: Some 1939 caregivers of young children were recruited through a school-based survey in two Nigerian states. A 20-item, multi-dimensional survey instrument was developed and used to rank each caregiver's knowledge in five dimensions (cause, transmission, vulnerability, symptoms, treatment of malaria). Scores for each domain were used to create an aggregate knowledge score for each caregiver. The outcome measures were ITN ownership, and ITN use the night and week before the study. Regression models were used to evaluate the relationship between caregiver's knowledge (individual domains and aggregate score) and ownership and use of ITN after controlling for likely confounders. Results: The main predictor of ITN use was ITN ownership (r = 0.653; p < 0.001); however, ownership only explains 43 % of variance in net use. Total knowledge index for the study population was significantly associated with both ITN ownership (r = 0.122; p = 0.001) and use (r = 0.095; p = 0.014). The spectrum of caregiver's knowledge of malaria and its causes captured in the various domains was, however, found to be poor. Fifty percent of the respondents knew that malaria is transmitted by female mosquitoes and 65 % still believe that too much exposure to the sun is a risk factor for malaria. Knowledge of populations most vulnerable to malaria (83 %) and knowledge of malaria transmission (32 %) were the domains with the highest and lowest average correct answers. Conclusions: There is a need to improve ITN coverage in Nigeria as ITN ownership was associated with ITN use. Additionally, treating knowledge as a multi-dimensional phenomenon revealed that a lot of misperceptions about malaria still exist. Distribution of ITNs through the public/private sector may need to be augmented with tailored behavioural change communication to dispel myths and improve the multi-dimensional knowledge of malaria in the local population. [ABSTRACT FROM AUTHOR]

Background: Experience of seasonal malaria chemoprevention (SMC) is growing in the Sahel sub-region of Africa, though there remains insufficient evidence to recommend a standard deployment strategy. In 2012, a project was initiated in Katsina state, northern Nigeria, to design an appropriate and effective community-based delivery approach for SMC, in consultation with local stakeholders. Formative research (FR) was conducted locally to explore the potential feasibility and acceptability of SMC and to highlight information gaps and practical considerations to inform the intervention design. Methods: The FR adopted qualitative methods; 36 in-depth interviews and 18 focus group discussions were conducted across 13 target groups active across the health system and within the community. Analysis followed the 'framework' approach. The process for incorporating the FR results into the project design was iterative which was initiated by a week-long 'intervention design' workshop with relevant stakeholders. Results: The FR highlighted both supportive and hindering factors to be considered in the intervention design. Malaria control was identified as a community priority, the community health workers were a trusted resource and the local leadership exerted strong influence over household decisions. However, there were perceived challenges with quality of care at both community and health facility levels, referral linkage and supportive supervision were weak, literacy levels lower than anticipated and there was the potential for suspicion of 'outside' interventions. There was broad consensus across target groups that community-based SMC drug delivery would better enable a high coverage of beneficiaries and potentially garner wider community support. A mixed approach was recommended, including both community fixed-point and household-to-household SMC delivery. The FR findings were used to inform the overall distribution strategy, mechanisms for integration into the health system, capacity building and training approaches, supportive interventions to strengthen the health system, and the social mobilization strategy. Conclusions: Formative research played a valuable role in exploring local socio-cultural contexts and health system realities. Both opportunities and challenges for the introduction of SMC delivery were highlighted, which were appropriately considered in the design of the project. [ABSTRACT FROM AUTHOR]

Background Despite recent improvements in malaria prevention strategies, malaria case management remains a weakness in Northern Nigeria, which is underserved and suffers the country's highest rates of under-five child mortality. Understanding malaria care-seeking patterns and comparing case management outcomes to World Health Organization (WHO) and Nigeria's National Malaria Control Programme (NMCP) guidelines are necessary to identify where policy and programmatic strategies should focus to prevent malaria mortality and morbidity. Methods A cross-sectional survey based on lot quality assurance sampling was used to collect data on malaria care-seeking for children under five with fever in the last two weeks throughout Sokoto and Bauchi States. The survey assessed if the child received WHO/NMCP recommended case management: prompt treatment, a diagnostic blood test, and artemisininbased combination therapy (ACT). Deviations from this pathway and location of treatment were also assessed. Lastly, logistic regression was used to assess predictors of seeking treatment. Results Overall, 76.7% of children were brought to treatment-45.5% to a patent medicine vendor and 43.8% to a health facility. Of children brought to treatment, 61.5% sought treatment promptly, but only 9.8% received a diagnostic blood test and 7.2% received a prompt ACT. When assessing adherence to the complete case management pathway, only 1.0% of children received WHO/NMCP recommended treatment. When compared to other treatment locations, health facilities provided the greatest proportion of children with WHO/NMCP recommended treatment. Lastly, children 7-59 months old were at 1.74 (p=0.003) greater odds of receiving treatment than children ⩽6 months. Conclusions Northern Nigeria's coverage rates of NMCP/WHO standard malaria case management for children under five with fever fall short of the NMCP goal of 80% coverage by 2010 and universal coverage thereafter. Given the ability to treat a child with malaria differs greatly between treatment locations, policy and logistics planning should address the shortages of essential malaria supplies in recommended and frequently accessed treatment locations. Particular emphasis should be placed on integrating the private sector into standardized care and educating caregivers on the necessity for testing before treatment and the availability of free ACT in public health facilities for uncomplicated malaria. [ABSTRACT FROM AUTHOR]

Background: The adoption of ACT as the first line treatment for uncomplicated malaria in Nigeria has concentrated attention on the role of testing in appropriate malaria treatment. There are calls at both national and global level for malaria treatment to be based on test result, but it is still unclear how testing can be incorporated into treatment-seeking and practices of health providers. This study explored community members and health providers' perceptions and experiences with malaria tests in south east Nigeria. Methods: The study was conducted in urban and rural areas of Enugu state in south-eastern Nigeria. A total of 18 focus group discussions with 179 community members including sub-groups of primary caregivers, adult men and adult women aged 15 years and above. Twenty- six (26) In-depth interviews were held with public and private health providers involved in prescribing medicines at public and private health facilities in the study area. Results: Both providers and community members were familiar with malaria tests and identified malaria tests as an important step to distinguish malaria from other illnesses with similar symptoms and as a means of delivering appropriate treatment. However, the logic of test-directed treatment was undermined by cost of test and a lack of testing facilities but above all concerns over the reliability of negative test results, with community members and providers observing inconsistencies between results and symptoms, and providers attributing inaccurate results to incompetencies of technicians. Recognition of malaria symptoms was deemed most important in determining the use of antimalarial drugs rather than the result of a malaria test. Conclusion: The results highlight important areas of intervention to promote appropriate malaria treatment. If tests are to play a role in patient management, demand and supply side interventions are needed to change people's attitude towards malaria test results. [ABSTRACT FROM AUTHOR]

Background: Nigeria's national standard has recently moved to artemisinin combination treatments for malaria. As clinicians in the private sector are responsible for attending a large proportion of the population ill with malaria, this study compared prescribing in the private and public sector in one State in Nigeria prior to promoting ACTs.w:\fmbatcẖout Objective: To assess prescribing for uncomplicated malaria in government and private health facilities in Cross River State. Method: Audit of 665 patient records at six private and seven government health facilities in 2003. Results: Clinicians in the private sector were less likely to record history or physical examination than those in public facilities, but otherwise practice and prescribing were similar. Overall, 45% of patients had a diagnostic blood slides; 77% were prescribed monotherapy, either chloroquine (30.2%), sulphadoxine-pyrimethamine (22.7%) or artemisinin derivatives alone (15.8%). Some 20.8% were prescribed combination therapy; the commonest was chloroquine with sulphadoxine-pyrimethamine. A few patients (3.5%) were prescribed sulphadoxine-pyrimethamine-mefloquine in the private sector, and only 3.0% patients were prescribed artemisinin combination treatments. Conclusion: Malaria treatments were varied, but there were not large differences between the public and private sector. Very few are following current WHO guidelines. Monotherapy with artemisinin derivatives is relatively common. [ABSTRACT FROM AUTHOR]

Objective: To explore the equity implications of insecticide-treated nets (ITN) distribution programmes that are based on user charges. Methods: A questionnaire was used to collect information on previous purchase of untreated nets and hypothetical willingness to pay (WTP) for ITNs from a random sample of householders. A second survey was conducted one month later to collect information on actual purchases of ITNs. An economic status index was used for characterizing inequity. Major findings: The lower economic status quintiles were less likely to have previously purchased untreated nets and also had a lower hypothetical and actual WTP for ITNs. Conclusion: ITN distribution programmes need to take account of the diversity in WTP for ITNs if they are to ensure equity in access to the nets. This could form part of the overall poverty reduction strategy. [ABSTRACT FROM AUTHOR]

Background: Despite the availability of effective malaria vector control intervention tools, implementation of control programmes in Nigeria is challenged by inadequate entomological surveillance data. This study was designed to assess and build the existing capacity for malaria vector surveillance, control and research (MVSC&R) in Nigerian institutions. Methods: Application call to select qualified candidates for the capacity building (CB) intervention training programme was advertised in a widely read newspaper and online platforms of national and international professional bodies. Two trainings were organized to train selected applicants on field activities, laboratory tools and techniques relevant to malaria vector surveillance and control research. A semi-structured questionnaire was administered to collect data on socio-demographic characteristics of participants, knowledge and access of participants to field and laboratory techniques in MVSC&R. Similarly, pre and post-intervention tests were conducted to assess the performance and improvement in knowledge of the participants. Mentoring activities to sustain CB activities after the training were also carried out. Results: A total of 23 suitable applicants were shortlisted out of the 89 applications received. The South West, South East and North Central geopolitical zones of the country had the highest applications and the highest selected number of qualified applicants compared to the South South and North East geopolitical zones. The distribution with respect to gender indicated that males (72.7%) were more than females (27.3%). Mean score of participants' knowledge of field techniques was 27.8 (± 10.8) before training and 67.7 (± 9.8) after the training. Similarly, participants' knowledge on laboratory techniques also improved from 37.4 (± 5.6) to 77.2 (± 10.8). The difference in the mean scores at pre and post-test was statistically significant (p < 0.05). Access of participants to laboratory and field tools used in MVSC&R was generally low with insecticide susceptibility bioassays and pyrethrum spray collection methods being the most significant (p < 0.05). Conclusions: The capacity available for vector control research and surveillance at institutional level in Nigeria is weak and require further strengthening. Increased training and access of personnel to relevant tools for MVSC&R is required in higher institutions in the six geopolitical zones of the country. [ABSTRACT FROM AUTHOR]