The malaria control component of the Lubombo Spatial Development Initiative (LSDI) was put in place to address the issue of high malaria transmission in an area targeted for accelerated agricultural and economic development. The LSDI was the brainchild of the Department of Environmental Affairs and Tourism in South Africa, which formed a trilateral initiative between the governments of Mozambique, South Africa and Swaziland, to develop the area bounded by the Lubombo Mountains into a globally competitive economic Zone, ensuring sustainable employment and equity in access to economic opportunity in the region. The geographic region targeted by this initiative is broadly defined as eastern Swaziland, southern Mozambique and north-eastern KwaZulu Natal. See map below. However, this area also straddled the highest risk malaria areas in the three countries, and it was realised early on that no development could occur in the region if the burden of malaria was not reduced.
As a result of this, the malaria component of the LSDI was conceived by the Medical Research Council and their collaborators in the three countries. In July 1999, the Heads of State of the three countries participating in the LSDI signed the General Protocol which put in place a platform for regional cooperation and delivery. The Lubombo Malaria Protocol of understanding was signed at ministerial level between the three countries in October 1999. The malaria control component of the LSDI project is managed by the Regional Malaria Control Commission (RMCC), a core group of experts comprised of malaria control programme managers, public health specialists and scientists from the three countries. The primary emphasis of the LSDI malaria control programme was to extend malaria control to southern Mozambique. There was increasing consensus that even if malaria control measures were optimal in South Africa and Swaziland (with effective treatment and insecticides in place), the disease burden could only be further reduced by a regional approach to control. Effective malaria control was realised to be an important precursor to development with the situation prior to malaria control in South Africa supporting this view, given the well documented negative effects of malaria on tourism and development. A brief document was submitted to the three country ministerial meeting in 1998, outlining the negative effects of malaria on development and proposing malaria control.
The LSDI malaria programme was targeted at creating a platform for development, the beneficiaries being communities in areas with the lowest socio-economic development in the region as well as tourism, business and governments. The Primary interventions A two pronged approach to malaria control has been implemented, namely, vector control using indoor residual spraying (IRS) and effective malaria case management.
The Lubombo SDI initially targetted Maputo Province for intervention. The initial plans for the establishment of malaria control infrastructure in Mozambique were limited to the Maputo Province which share borders with, and influence, malaria transmission in regions of both South Africa and Swaziland. Maputo province was divided into zones, with control initiatives being introduced in the southern zones initially, extending northwards. See map below The control strategies implemented in Maputo was however so successful, that it was decided to extend the LSDI area to include the Gaza Province which shares a border with the Limpopo Province in South Africa.
Malaria Control zones in Maputo province, Lubombo SDI
Lubombo SDI Malaria Control: Maputo Province
Vector Control
The malaria vector control component in Mozambique has been implemented in phases (See map above) starting with Zone 1, Maputo province in 2000, which is the area extending from the KwaZulu-Natal border to Maputo. Zone 1A is the area surrounding the MOZAL Plant which introduced malaria control as part of their social responsibility campaign, implemented in 2001. Phase three, initiated in 2002, focussed on Zone 2A comprising part of the Boane District, and Zone 2 and 3 extending north along the Kruger National Park border, covering an area of over 20 000 Km2. The contiguous malaria control area in the region now exceeds 100 0002 Km.
Case Management
Since effective malaria control requires both vector control and early effective treatment, the RMCC decided to extend their objectives to ensure that the best malaria treatment was introduced across the LSDI. Widespread use of artemisinin-based combination therapy (ACT) offers the benefits of not only improving cure rates, but, unlike other malaria treatments, of also directly decreasing malaria transmission and potentially slowing drug resistance. To optimise the synergistic effects of IRS and ACTs on reducing malaria transmission and thus disease burden, while minimising programme costs, the implementation of ACTs has been timed to follow the establishment of effective vector control.
The effectiveness of the malaria control programme over the past eight years has been assessed by the prevalence of malaria over time in Mozambique as well as the incidence of the disease in the neighbouring malarious areas of South Africa and Swaziland. The success of intervention cannot only be measured using process (e.g. spraying and artemisinin-based combination therapy coverage) and biological markers (e.g. parasite prevalence rates, health facility patient numbers and mosquito vector reductions), but also by the effects on tourism e.g. bed occupancy, job creation and risk perceptions, in all three countries.
While the aim of the initiative was to create a platform for development through the reduction of malaria cases, the objectives required a broad approach that would reduce the burden of disease and make the results known so as to attract development. From the baseline malaria seasons of 1999/2000 to the 2003/2004 season , the improvements in malaria control efforts have resulted in dramatic reductions in malaria incidence of over 99% in KwaZulu-Natal, over 86% in Mpumalanga and over 90% in Swaziland. Parasite prevalence in children has decreased by over 88% in Mozambique.
Objectives:
1. To reduce malaria incidence in the border areas of South Africa and Swaziland from 250/1000
to less than 20/1000. (Achieved)
2. To reduce malaria infections from 625/1000 to less than 200/1000 within three years after the
start of IRS in Maputo Province (Achieved).
3. Provide updated tourist information booklets containing definitive malaria risk maps and
prophylaxis guidelines. (Achieved).
4. Develop a regional malaria control programme. (In place covering > 200 000 km2)
5. Develop a regional GIS base Malaria Health Information System (MHIS). (In Place).
6. To establish definitive diagnostics and effective treatment. (RDTs and ACTs in place in all
health facilities)
7. To continue expanding the vector control intervention of the LSDI within the province of
Gaza. (vector control intervention fully functional in all but zone 7)
8. To expand the LSDI’s monitoring and evaluation programme in Gaza Province the strengthen
programme management. (In place).
9. To set skilled personnel in place at all levels to ensure effective malaria control and
sustainability of the intervention (Personnel in place, capacity development taking place).
The original objectives of the LSDI Malaria Control Programme are being met. This has largely been achieved through the strength of the partnership between MRC, UCT, Private partners and Governments (both National and Provincial). The partners share a common vision for ensuring malaria control in the region, primarily through indoor residual spraying and ACT implementation, with ongoing monitoring and evaluation to support evidence based decision making.
Lubombo SDI Phase 2: Gaza province
The initial plans for the establishment of malaria control infrastructure in Mozambique were limited to the Maputo Province which share borders with, and influence, malaria transmission in regions of both South Africa and Swaziland. The control strategies implemented in Maputo was however so successful, that it was decided to extend the LSDI area to include the Gaza Province which shares a border with the Limpopo Province in South Africa.
In accordance with the approach followed in Maputo Province, Gaza Province was divided into four zones. Malaria control interventions in Gaza will be phased in over a 5 year period, starting with Zone 4 in 2006. Based on the successes achieved in Maputo Province, indoor residual spraying (IRS) was chosen as the main intervention method for vector control.
Effective malaria control requires not only vector control but also early detection and effective treatment to control the parasite. Artemisinin-based combination therapy (ACT) has been shown to not only improve cure rates, but to directly decrease transmission and potentially suppress the development of drug resistance, and was used to complement IRS. To optimise the synergistic success of IRS combined with ACTs and to reduce programme costs, the Ministry of Health (MoH) took over the responsibility of ensuring the availability of ACTs at health facilities in Gaza. The prompt diagnosis of malaria in health facilities was improved by the introduction of rapid diagnostic tests (RDTs). The responsibility of providing RDTs and the roll out of IRS in the Gaza Province rested on the LSDI.
The impact and success of these interventions are monitored on an ongoing basis. The aim of the initiative in Gaza province is to half the burden of malaria by 2011 by developing necessary infrastructure for effective malaria control working in close collaboration with the Provincial Department of Health (DPS). Twelve districts have been earmarked for the implementation of IRS programmes over the 5 year implementation period. The main service delivery areas are (i) prevention through vector control, (ii) correct, timely, diagnosis and treatment, (iii) implementation of an effective monitoring and evaluation system and (iv) capacity development within the community and the National Malaria Control Programme.
The expected outcomes would be a drastic reduction in malaria transmission with a resulting surge in economic development and tourism to the region. Control activities in Gaza will also continue reduction of transmission in the Limpopo Province and will further contribute towards the goals of the bi-lateral agreement between the Provincial Departments of Health in both provinces. A final aim will be to increasingly transfer the skills obtained and developed through the project to the personnel in Gaza Province as well as to the National Malaria Control Staff in order to ensure the future sustainability of malaria control in the region.
Objectives
The Four major objectives of the LSDI project in Gaza are:
- To continue expanding the vector control intervention of the LSDI within the Province of Gaza.
- To ensure definitive diagnosis of malaria.
- To expand the LSDI’s monitoring and evaluation programme in Gaza Province to strengthen programme management.
- To set skilled personnel in place at all levels to ensure effective malaria control and sustainability of the intervention.
Control strategies
The most basic goal of malaria control is the prevention of disease transmission from infected to un-infected individuals. Prevention strategies include both controlling the vectors responsible for spreading the disease and controlling the prevalence of the parasites responsible for the disease. Based on successful interventions in the neighbouring Province of Maputo, IRS is implemented as the main intervention for vector control, complemented by the provision of RDTs for timely diagnosis and through the provision of ACTs for effective treatment of malaria cases.