La Cote d'Ivoire
Malaria facts
Malaria is endemic in Côte d’Ivoire and the entire population is at risk of being infected with the disease. Transmission occurs throughout the year, with peak incidence during the rainy seasons in April to July in the center of the country and, along its coastline in the north, between July and September. [1]
Plasmodium falciparum accounts for 98 to 99% of malaria cases in Côte d’Ivoire. The main vectors are Anopheles gambiae s.s., An. coluzzii, and An. funestus s.s. As of 2021, the primary vector in Côte d’Ivoire remains An. gambiae s.l. (94 percent of all Anopheles collected). All An. gambiae s.l. are resistant to all pyrethroids with moderate-to-high resistance intensity. The resistance level of the major vector, An. gambiae s.s., to the insecticides used to impregnate mosquito nets is significant throughout the country and ranges from 39 to 95% for permethrin, 75 to 100% for deltamethrin, and 50 to 100% for alpha-cypermethrin in study areas.[1]
Fifty-eight of the Cote d’Ivoire’s 113 districts have a high level of endemicity with 300 to 499 cases per 1,000 persons. The national annual incidence rate is 441 cases per 1,000 among children under five years of age and 173 cases per 1,000 persons in the general population.
The country is among the ten with the highest rates of malaria cases and deaths – in 2020, it accounted for 3.0% of global cases and deaths, 2.4% of global deaths, and 6% of malaria cases in West Africa. Progress in malaria prevention and control has stagnated in recent years, with the estimated number of cases decreasing 1.8% between 2020 and 2021 (from 276 cases per 1000 population to 271 per 1000). However, the number of malaria-related deaths decreased 3.7% over the same period (from 0.56 per 1000 population to 0.54).[2]
The national strategy for malaria prevention in pregnancy includes provision of insecticide-treated mosquito nets (ITNs) at the first antenatal care visit, and intermittent preventive treatment for pregnant women (IPTp) in malaria-endemic area starting at 13 weeks gestational age, for a minimum of three doses.[1]
Severe malaria case management
The National Malaria Control Programme (NMCP) in Côte d’Ivoire was established in 1996. The current national strategic plan, Plan Strategique National de Lutte Contre le Paludisme 2021–2025 (NMSP) was adopted in 2020. The main objectives of the NMSP 2021–2025 are to reduce both malaria incidence and malaria-related mortality by 75% by 2025 from the 2015 baseline.[1]
Malaria control interventions
Case management
Microscopy is used to confirm malaria diagnosis in the public and private-not-for-profit (faith-based) sectors at all regional and district reference hospitals. Rapid diagnostic tests (RDTs) are used to confirm malaria diagnosis at health centers and at the community level, or in any health care facility whenever microscopy is unavailable.[1]
The first-line treatment for severe malaria is intravenous (IV) or intramuscular (IM) artesunate; the first-line treatment for severe malaria in pregnancy is IV quinine. At peripheral health facilities, pre-referral treatment of severe disease with IM artesunate or IM artemether is recommended. For community health workers, pre-referral treatment of severe disease in under 5s with rectal artesunate (50 mg) is recommended.[3]
There is no fee for RDTs or artemisinin-based combination therapies (ACTs) in public and private not-for- profit health facilities for children under 5 years of age and pregnant women. [2] Emergency diagnosis and treatment (which includes severe malaria) are free of charge for patients of all ages. [2] For older children and adults, all RDTs and ACTs are provided free of charge in public health facilities. [2] RDTs and ACTs should be provided free of charge in private for-profit facilities for children under 5 years of age and pregnant women, although this may not always occur.[2]
Insecticide-treated nets (ITNs)
There are no recent data on the distribution of ITNs in the population. In 2016, 51% of the population reported sleeping under a net the previous night. The same survey found that 60% of children under 5 and 53% of pregnant women slept under a net the previous night.[1] A new Demographic and Health Survey (DHS) is currently underway.[1] A mass distribution campaign is planned for 2024.[1]
Malaria in pregnancy
Malaria prevention in pregnancy (MiP) is a key intervention in the NMSP 2021–2025. The main objectives outlined in the Plan are that at least 80% of pregnant women sleep under ITNs by 2025 and at least 80% of pregnant women receive at least three doses of sulfadoxine-pyrimethamine (SP) during their last pregnancy by 2025.
The NMSP 2021–2025 attempts to align with the updated 2016 WHO ANC guidelines regarding intermittent preventive therapy during pregnancy (IPTp). The first dose of IPTp is administered at 16 weeks of pregnancy within the context of the country’s national recommended number of ANC visits, which is four. At least three subsequent doses of SP are recommended to be administered to pregnant women at four-week intervals and directly observed by the health center staff. ITNs are to be provided to women during the first ANC visit, and delivery of prompt appropriate management of malaria illness takes place throughout the pregnancy.
Côte d’Ivoire has seen an overall improvement in IPTp coverages (IPTp1, IPTp2, and IPTp3) in recent years. IPTp2 coverage increased from 59% in 2017 to 69% in 2020. Though the increase in IPTp3 among pregnant women has been steady over the recent years – 23% in 2016, 36% in 2017, 40% in 2018, 45% in 2019, and 47% in 2020 —the IPTp3 coverage is still below the national target of 80% of pregnant women. None of the health regions reached that target in 2018.
Seasonal malaria chemoprevention
Côte d’Ivoire's NMCP seing SMC as a promising malaria prevention strategy among children under five years of age conducted an analysis of the 2019 morbidity data to identify districts potentially eligible for SMC, based on current WHO guidelines.
In 2022, Cote d’Ivoire implemented SMC for the first time.
Health system
Previously, Côte d’Ivoire was divided into 20 health regions and 86 health districts. Since 2020, the country has reorganized into a new administrative structure consisting of 33 health regions and 113 health districts. [1] In Côte d’Ivoire, a significant proportion of the population seeks care in the private sector.
According to the Rapport Annuel sur la Situation Sanitaire (Annual Health Situation Report/RASS) the utilization rate of public sector health services was 47% in 2018. The same measurement was reported in 2017 as 48 percent. It follows that approximately 53% of individuals qualifying as suspect malaria cases seek care outside of public facilities. This percentage includes those seeking care/advice from the community, private health facilities, pharmacies, and traditional healers, as well as those not seeking care at all. According to the 2016 Multiple Indicator Cluster Survey (MICS), 13.5% of children under 5 years of age with fever presented to private facilities for care, while another 38.5% did not seek treatment at all.[1]
Although the national guidelines outlining appropriate malaria case management are distributed nationwide, it is not known which antimalarial medications are most commonly available in the private sector.[1]
Health data management
Routine malaria case data from health facilities (HFs) and community health workers are reported to the NMCP through District Health Information System 2 (DHIS2), and survey data are periodically reported in malaria indicator surveys (DHS and Multiple Indicator Cluster Survey [MICS]). In addition, the NMCP collects parasitological data through regularly occurring Therapeutic Efficacy studies to monitor for potential resistance to ACTs and SP.
Challenges in addressing uncomplicated and severe malaria
- Although malaria is the number one reason people are seen in health facilities, immediate health seeking for children is still delayed. Only about 63 percent of children under 5 with fever are brought to a health facility or community health worker as a first recourse within 24 hours.2
- Providers may default to the older strategy of treating fever cases as presumptive malaria even when there is no documented positive diagnostic test.2
- Among pregnant women who received sulfadoxine/pyrimethamine from a source other than a health center, 75.4% reported paying for the drug, while 24.3% of women who received their dose only from a health center reported paying for the drug.2
- Côte d’Ivoire's supply chain faces major challenges. Supply chain reform in 2014 significantly improved commodities storage and distribution from the Central Medical Store to the district level. At the district level, however, challenges remain with regards to the distribution of commodities to health facilities.2
Cote dIvoire malaria epidemiological profile
Severe malaria admissions and deaths in Cote dIvoire
Severe malaria policy and practice
National treatment guidelines |
|
Recommendation |
Treatment |
|
Strong |
IV/IM artesunate |
Recommendation |
Pregnancy |
|
Strong |
IV quinine |
Recommendation |
Pre-referral |
|
Peripheral health facilities |
IM artesunate or IM artemether |
|
Community level |
Rectal artesunate |
Pregnancy |
|
Recommendation |
Protection |
|
IPTp |
Sulfadoxine/pyrimethamine (3 doses) |
Sources of malaria financing in La Cote DIvoire
