Evaluation of antimalarial chemotherapeutic practices and outcomes in the southwest region of Nigeria
With over 100 million cases of morbidity annually worldwide; control, elimination and eradication of malaria still remains a major challenge, particularly in sub-Saharan Africa. In some endemic countries, aggressive malaria control has reduced the malaria burden to a point where malaria elimination is becoming feasible. Nevertheless, sustained malaria control is crucial to prolong this downward trend for endemic countries. A major factor that affects the effective treatment of malaria is the lack of awareness of the recommended treatment guidelines and standardised protocols to routinely decipher the quality of the available drugs in the regions. Nigeria bears more than a quarter of the global burden of malaria, with 97% of the population at risk of the disease. The high rate of counterfeit and substandard drugs in Nigeria is therefore a barrier to effective case management of malaria. Therefore, this project proposes to qualitatively and quantitatively analyse chemotherapeutic practices and outcomes at an individual and community level in two selected states (Lagos and Osun) in the South West Region of Nigeria, in a bid to define barriers to effective case management. A quantitative approach, involving the use of questionnaires was used to explore the current pattern of malaria treatment and antimalarial drug use in Osun and Lagos State communities, pharmacies and hospitals. The study also investigated the different socio-economic factors affecting treatment behaviours in the communities. Commonly used antimalarial drugs, including Artemether combination drugs (ACTs) were also randomly sampled from the communities to check for substandard and counterfeits using in-vitro culture and FT-IR techniques. In Lagos and Osun urban regions of the study, ACTs contributed to primary treatment choice (60% and 59% respectively), although this was often a result of self-medication (50% and 46% respectively). The majority of the people in the rural regions (74% in Lagos and 57% in Osun) preferred non-ACTs, with a high level of self-medication. A strong significant association was found between employment, salary earned, hospital treatment and adherence to recognised malaria treatment recommendations (P < 0.001) in both urban regions. However, in the rural regions, only hospital treatment showed a significant association to recognised malaria treatment recommendations (P < 0.001). Also, there was also a strong association (P < 0.001) for self-medication and place where antimalarial was purchased in the Lagos rural region which was not observed in the Osun rural region. The gender of client also had a significant association (P < 0.001) with the type of store where treatment was received in Osun rural area but not in Lagos rural area. Hospital data further shows that the rural regions are the most challenging places to experience malaria infection. With already poor treatment practices in place, 81% of the suspected cases of malaria in Osun State rural area were confirmed positive. When compared to Lagos urban and Osun urban areas, where 65 % and 53% were confirmed to be positive, this shows the urgent need for improved intervention programmes to promote better treatment practices in the rural regions. However, low confirmation of malaria cases in the urban regions also illustrates the danger of self-medication that occurs when patients visit pharmacy stores and drug vendors since often no form of diagnosis is offered at these establishments prior to treatment. While all of the ACT samples tested with Fourier Transformed–Infrared spectroscopy showed consistency with ACT reference drugs, some chloroquine (22%) and sulphadoxine-pyrimethamine (20%), did not show consistency with reference samples; particularly if acquired from the rural regions. Moreover, some ACTs, primarily if acquired from the rural regions (65%), showed low efficacy against Plasmodium falciparum in vitro cultured parasites compared to reference samples. In addition to the ongoing intervention programmes creating awareness about effective malaria control and management of malaria, it is important to intensify efforts, especially in the rural regions, since this thesis work highlights that adherence to treatment practice is low and there is a high risk of treating malaria with either a counterfeit drug or a substandard antimalarial. Creating a platform for effective case management of malaria infections will require collaboration across international and national boundaries, bringing together intervention programs and influencing health policy.
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