Figure 1 shows the designated study area.  The area includes the three malarious Provinces of South Africa, Swaziland and southern Mozambique. A protocol of agreement is in place between the three countries as part of the Lubombo Spatial Development Initiative (SDI) that recognises the importance and provides the mandate for formal collaborative malaria research and control within the SDI.

The area under discussion falls within a historical endemic malaria area. Malaria control measures are in place in the South African and Swaziland sectors of the proposed development area, and this area encompasses the risk areas for malaria in the two countries. No control measures are in place in the Mozambique sector.  The areas are contiguous and can be considered one system in regard to the broad ecological and climatological factors driving malaria transmission.

People cross national borders for various reasons including health care seeking, employment, family ties, tourism etc. The malaria case data from South Africa indicate that 3.5 – 23%, 14-64% and 4.7-50% of the malaria cases notified in KwaZulu Natal, Mpumalanga and Northern Province respectively were classified as imported (SA Malaria Information System).

All three countries undertake population census monitoring and a Malaria Information System is in place in the three malarious provinces of South Africa, is under development for Swaziland and will be extended to the Mozambique sector as outlined in the GIS section of this proposal.

General epidemiological data

The incidence of malaria at district level is shown in Figure 1 and the annual case total for the respective provinces and Swaziland are included. Malaria is distinctly seasonal in the region. Plasmodium falciparum accounts for the majority of infections with P.malariae and P.ovale infections varying between 0 and 15% between surveys  (B Bredenkamp, J Govere unpublished PCR identifications).

Geographic Information System Platform

A geographic information system (GIS) platform, in collaboration with the Provincial Malaria Control Programmes, has been developed for the malaria areas of South Africa and coupled to a malaria health information system (MIS). Health information systems are vital to structure malaria control such as drug distribution, house spraying, etc. This combined system has proved invaluable in research design with regard to selection of study sites, randomisation of sampling, patient follow up, spatial analysis of data and intervention assessment.

Drug resistance sentinel sites

Mpumalanga and KwaZulu-Natal have repeatedly conducted sentinal site studies; Northern Province has started to conduct such a study, as has Mozambique; no such studies have as yet been initiated in Swaziland. In vivo studies began in KwaZulu and Mpumalanga in January 2000 to evaluate the baseline clinical and parasitological failure of SP montherapy in these sites.

Structure of the Health System

The distribution of health care facilities is illustrated in Figure 5 . National malaria treatment policy in South Africa stipulates SP as first-line therapy, with quinine recommended for patients requiring hospital admission.  National malaria treatment and prophylaxis guidelines are available.  A user-friendly clinic manual has been widely distributed, along with a summary wall chart and annual training sessions in certain areas.  Degree of implementation of these guidelines varies between provinces and reasons for this idiosyncratic policy implementation will be investigated as part of the study. 

Malaria Epidemiology in Mozambique