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Eliminating malaria in South Africa

From 6 - 11 October 2013 the 6th MIM Pan-African Malaria Conference "Moving towards malaria elimination: Investing in research and control" was held in Durban. For South Africa the most important issue discussed was certainly the announcement that the country is determined to eliminate local transmission of malaria by 2018.

This decision is based on the progress that has been made in the past years, as discussed in the Roll Back Malaria Progress and Impact series South Africa report (1). Nationwide, malaria morbidity and mortality decreased by 89% and 85% respectively between 2000 and 2012, from 64 500 to 6847 malaria cases, and from 460 to 70 deaths. In 2012, 69% of reported malaria cases were imported (of which 70% were from Mozambique). In 2008 I published an article on malaria in Limpopo in which also a decreasing trend in the incidence rate over time was found (period 1998 - 2007) (2).

This reduction in disease burden is due to the malaria control interventions that have been implemented. Indoor residual spraying (IRS) coverage of targeted structures was 88% on average in malaria-endemic provinces (KwaZulu-Natal, Mpumalanga and Limpopo) between 2000 and 2012. Rapid diagnostic tests (RDTs) were rolled out nationwide in 2003 and all suspected malaria cases are now diagnosed using microscopy and/or RDTs. All positive cases are treated within 24 hours, and treatment is only prescribed once cases are confirmed (not presumptively). Artemisinin-based combination therapies (ACTs) were introduced for uncomplicated case management subsequent to parasitologically confirmed diagnosis in KwaZulu-Natal in 2001, in Limpopo in 2004, and in Mpumalanga in 2006.

The national budget for malaria control increased significantly reaching an average of R250 million annually between 2009 and 2012. The plan is to increase this further (actual amount is unclear from the reporting) for the next four years to reach the elimination goal (3).

Elimination interventions are focused on cross-border collaborations with Mozambique, Swaziland and Zimbabwe, integrated vector management (spraying, bed nets), robust health promotion activities, a solid active surveillance programme and treatment.

The October issue of the South African Medical Journal had a supplement with an extensive set of articles on malaria further elaborating on the issues above.

One article provides an extensive historical overview of malaria control interventions, with a focus on vector control through IRS (using DDT) and the use of surveillance techniques. Probably the most important lesson over the years has been the need for constant surveillance of vectors and parasites to avoid increased transmission likewise the 1999/2000 epidemic (4).

Another article describes the epidemiology of malaria for the period 1995 - 2012, showing a significant reduction in reported cases since 2000 and highlighting the fact majority of notifications is currently imported (5).

A further article deals with malaria diagnosis focussing on RDTs and microscopy (6). And also treatment is the focus of an article, detailing how effective drug policy has reduced malaria morbidity and mortality, in particular the shift from monotherapy to ACT for the management of uncomplicated malaria (7).

The last article describes the epidemiological stages of the WHO malaria elimination continuum and South Africa's progress along it (8). It must be realized that importation of malaria cases from neighbouring countries poses a significant threat to malaria elimination efforts in South Africa.

Finally, the National Department of Health has changed the malaria risk map for travellers, now showing the whole of KwaZulu-Natal province rated as 'low risk' (only non-drug measures to prevent mosquito bites are recommended) and only parts of Mpumalanga and Limpopo are still 'moderate risk' (antimalarial drugs are recommended from September to May for all travellers).

References:

  1. WHO. Roll Back Malaria Partnership. Progress & Impact Series. Focus on South Africa. Geneva: WHO; 2013. Link to report 
  2. Gerritsen AA, Kruger P, van der Loeff MF, Grobusch MP. Malaria incidence in Limpopo Province, South Africa, 1998-2007. Malar J. 2008;7:162. Link to article
  3. Times Live. R8 billion over next four years going into Malaria fight. 10 October 2013. Link to article 
  4. Coetzee M, Kruger P, Hunt R, et al. Malaria in South Africa: 110 years of learning to control the disease. S Afr Med J. 2013;103(10 Suppl 2):770-778. Link to article 
  5. Maharaj R, Raman J, Morris N, et al. Epidemiology of malaria in South Africa: From control to elimination. S Afr Med J. 2013;103(10 Suppl 2):779-783. Link to article 
  6. Frean J, Poonsamy B, Shandukani B, et al. Case management of malaria: Diagnosis. S Afr Med J. 2013;103(10 Suppl 2):789-793. Link to article 
  7. Ukpe IS, Moonasar D, Raman D, et al. Case management of malaria: Treatment and chemoprophylaxis. S Afr Med J. 2013;103(10 Suppl 2):794-798. Link to article 
  8. Moonasar D, Morris N, Kleinschmidt I, et al. What will move malaria control to elimination in South Africa? S Afr Med J. 2013;103(10 Suppl 2):801-806. Link to article 
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Africa Health News

Africa Health News is a new website that brings together health news, events and career opportunities from African countries. Monthly updates are send out to a large group of interested subscribers. I started this website in the beginning of 2016 and Emily Christopher, Megan Harker and Steven Nonde are currently writing articles for it.

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    Alex

    Interesting article

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