LSDI

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.

Map showing malaria control areas in LSDI

Vector Control

The malaria vector control component in Mozambique has been implemented in phases (See map above) starting with Zone 1, 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 over the course of the 7 year period (2000 – 2007).

General Objectives

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. Reduce malaria incidence in the border areas of South Africa and Swaziland from 250 per 1000 to less than 20 per 1000. STATUS: Achieved

2. Reduce malaria infections from 625 per 1000 to less than 200 per 1000 within three year after the start of IRS in Maputo Province. STATIUS: Achieved

3. Provide updated tourist information booklets containing definitive malaria risk maps and prophylaxis guideline. STATUS: Achieved

4. Develop a regional malaria control programme. STATUS: In place, covering 200 000 Km²

5. Develop a regional GIS-based Malaria Information System (MIS). STATUS: In place in 3 countries.

6. Implement definitive diagnosis and effective treatment. STATUS: RDTs and ACTs in place in all health facilities

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) who are equally committed to. 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.

Background