Benin

Benin is geographically divided into three main regions: southern, central, and northern. The southern region is a sub-equatorial coastal zone that experiences two rainy seasons, from April to July and from October to November, as well as two dry seasons, from August to September and from December to March. The central plateau region is characterized by a Sudan-Guinea climate, while the northern region is hilly and has a Sahelian climate. The northern region has one rainy season, which occurs from May to October, and one dry season, which occurs from November to April. Due to these geo-climatic variations, there are three malaria transmission zones in Benin: the southern region, which has heterogeneous transmission; the central region, which is holo-endemic; and the northern region, which experiences seasonal peaks during the rainy season.[1]

Malaria is the leading cause of mortality among children under five years of age and morbidity among adults. It accounts for 40% of outpatient consultations and 25% of all hospital admissions. [1] Benin is among the fifteen countries with the highest number of malaria cases and deaths: 2.1% of global malaria cases and 1.8% of global malaria deaths in 2022 [2]. It accounts for 4% of malaria cases in West Africa.[2]

There was no change in malaria cases between 2021 and 2022. The number of cases remained at 383 per 1000 of the population at risk. However, there was a decrease in deaths by 3.9%, from 0.86 to 0.82 per 1000 of the population at risk, during the same period. [2]

Ownership of insecticide-treated nets (ITNs) improved from 25 percent in 2006 (DHS) to 92 percent in 2017 (DHS). In addition, the mortality rate for children under five years of age dropped from 125 in 2006 (DHS) to 96 in 2017 (DHS). However, the IPTp3+ rate remains stubbornly low at less than 20 percent (DHS 2017); DHIS1-based routine data in 2021 have shown IPTp3 uptake rates ranging from 23 percent to 47 percent throughout the country’s 12 departments. The early care-seeking rate in case of fever in children under five years of age is 53 percent (DHS 2017).[1]

The disease places a significant economic strain on Benin’s development. The World Bank estimates that households in Benin spend approximately one-quarter of their annual income on the prevention and treatment of malaria.[4]

Severe Malaria Case Management

The National Malaria Case Management (NMCM) guidelines follow WHO guidelines and standards. This is geared towards the attainment of 99% of all suspected malaria cases tested, 99% of all confirmed malaria cases correctly treated, and 100% of severe malaria cases correctly managed in public and authorized private health facilities and at the community level. For severe malaria, treatment guidelines recommend injectable artesunate as the first-line treatment; second-line treatment would be injectable artemether, and third-line would be quinine. These initial therapies for severe malaria would be followed by a full course of Artemisinin Combination Therapies (ACTs) to avoid artemisinin monotherapy.[1]

Artesunate Rectal Capsules (ARC) are the recommended pre-referral intervention  for children under five with severe malaria from primary health facilities to the hospitals where severe malaria is treated.[6] Due to overall concerns for the handling of medicines by nonmedical professionals, Benin’s policy does not allow the use of artesunate rectal artesunate capsules at the community level. [1]

Malaria in pregnancy 

It has been observed that despite the adoption of the WHO 2016 recommendation for a minimum of eight antenatal care (ANC) contacts and the revision of the NMCP's guidelines to provide up to five doses of intermittent preventative treatment for protection against malaria (IPTp) at monthly intervals beginning in the second trimester of pregnancy until delivery, a gap between ANC attendance and receipt of IPTp persists. This is evident from a routine data in the country's 12 departments, recording a sharp decline in the national IPTp3+ uptake from 47% of eligible women in 2021 to 13.7 % in 2022.[1]

The NMCP launched a community IPT pilot in 2018 in five health districts, using the US President's Malaria Initiative funding. This intervention uses outreach strategies with local health teams visiting rural areas to provide women with check-ups and administer IPT. The results obtained indicated that in 2019 in the Savè-Ouèssè, Abomey, Djidja, Agbangnizoun, and Tchaourou health districts, IPTp3 coverage increased from 21.6% to 23.2%, 27.8% to 28.5% and 14% to 17%, respectively. [6]

Seasonal malaria chemoprevention (SMC) 

SMC has been implemented since 2019 in the top four districts out of 15 health districts initially that meet at least one of the criteria from the World Health Organization (WHO). As of 2023, 15 of the total 33 communes in five districts will be implementing 5 cycles of SMC in children aged 3 months to five years.

Perennial Malaria Chemoprevention 

Benin is one of several countries participating in a Unitaid-supported project aimed at evaluating the implementation of intermittent preventive treatment in infants known as perennial malaria chemoprevention. In the model for Benin, children will receive a minimum of eight SP treatments, coinciding with the MOH’s recommended immunization schedule for children.

NMCP’s National Strategy for Malaria Social and Behavioral Change Communication 2021–2025 (Stratégie Nationale de Communication pour le Changement Social et Comportemental contre le Paludisme 2021–2025; SNCCSC) fully aligns with and contributes to the country’s vision of “a Benin without malaria by 2030”.

In terms of indoor residual spraying, six municipalities, out of the 30 eligible, benefit from the IRS in the four departments in the North and the Hills.

Digital tools for SMC and ITN campaigns were introduced in 2020.

Challenges in addressing uncomplicated and severe malaria [1]  

• With the adoption in 2019 of injectable artesunate as the first-line treatment for severe malaria, there is a pressing need to fill stocks at all levels of the distribution system.  
• Although 53% of patients or their caregivers in the case of children eventually seek treatment, only 28% do so promptly.  
• The limited catchment area of community health agents. This shortage makes it difficult for caregivers in remote communities to seek prompt, proper care. 
• Health workers who are non-skilled, and not trained in malaria guidelines are the most likely to receive patients in health facilities. 
• More than 50% of pregnant women attend at least 4 antenatal care visits (ANC 4).  However, only 14% of women reported receiving at least 3 doses of IPTp. 
• Insecticide resistance, in particular resistance to pyrethroids, a crucial chemical on ITNs, continues to be a major threat to vector control.