Malaria control in the Lubombo region is based on:
- Vector Control
Community based House spraying programme: Anopheles funestus, Anopheles
arabiensis
- Parasite Control
Plasmodium falciparum
Case management
Drug policy See SEACAT website
The project is managed by the Regional
Malaria Control Commission (RMCC), comprising malaria control programme
managers, public health specialists and scientists from the three countries.
Vector control
Vector control through Indoor Residual Spraying (IRS) was introduced
in Zone 1 in Mozambique with Bendiocarb at 400mg per m2 in November 2000.
The malaria vector control component in Mozambique has been implemented in
phases starting with Zone 1, in 2000, which is the area extending from the
KwaZulu-Natal border to Maputo (See map)
. 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 Zones 2 and 3 extending north along the Kruger National
Park border, covering an area of over 20 0002 Km. The contiguous
malaria control area in the region now exceeds 100 0002 Km.
Table 1. Stepped wedge design of indoor residual spraying
intervention in Maputo province, Mozambique, with Bendiocarb at 400 mg per
m2.
| |
2000 |
2001 |
2002 |
2003 |
2004 |
Area in Km2 |
Zone |
Cumulative Spray rounds |
| 1 |
1* |
2# |
4 |
6 |
8 |
7592 |
| 1A |
* |
2 |
4 |
6 |
7/8 |
408 |
| 2 |
|
|
1* |
3 |
5 |
5723 |
| 2A |
* |
|
1 |
3 |
5 |
522 |
| 3 |
|
|
|
* |
2 |
6893 |
# spraying with Propoxur at 200mg per m2
* Baseline pre-spraying cross-sectional prevalence survey occurred
IRS started in Swaziland in the 1950’s. Spray dates during
the study period were September to December each year from 1999 to 2003. The
application rate was 2g per m2.
House
spraying with DDT in South Africa began in the 1950’s. In 1996, the
policy changed to the exclusive use of a pyrethroid. After the emergence of
pyrethroid insecticide resistance in the late 1990’s, DDT spraying was
re-introduced for traditional structures in KwaZulu-Natal in February 2000
followed by a second round in June 2000 and in October for each of the subsequent
years. The application rate was 2g per m2. DDT was re-introduced for house
spraying in Mpumalanga Province, South Africa, in October 2001 and in Limpopo
Province in October 2002.
All spraying was conducted throughout using Hudson expert pump
sprayers with 8001 nozzles. Spraying personnel and managers were trained in
spraying techniques, safety measures and personal protection equipment appropriate
to the insecticide.
Drug Policy
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.
Previously chloroquine was used as first line treatment and
Sulphadoxine/pyrimethamine (SP) as second line treatment in both Swaziland
and Mozambique, while in South Africa, SP was used as first line treatment.
However, growing resistance to both chloroquine and SP has been an important
contributor to the increased malaria morbidity and mortality across Africa,
including southern Africa.
Comprehensive baseline evaluations included:
- monitoring of therapeutic efficacy,
- drug safety,
- gametocyte carriage,
- drug availability and use,
- community perspectives on malaria treatment
- and an economic evaluation of costs and cost effectiveness
These studies provided evidence for selection and implementation
of the most effective malaria treatment available. They identified high levels
of SP treatment failure as a major contributor to the malaria epidemic in
KwaZulu Natal and prompted the rapid change in treatment policy by the Provincial
Malaria Control Programme to an artemisinin-based combination therapy (ACT),
artemether-lumefantrine (AL) in January 2001.
Widespread use of 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 indoor residual spraying (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.
KwaZulu-Natal was the first Ministry of Health in Africa to
implement an ACT malaria treatment policy, when it introduced Coartem in January
2001. The planned phased implementation of ACTs, which resulted in their introduction
in Mpumalanga in 2003 and in two districts in southern Mozambique in 2004,
is ahead of schedule and will ensure that ACTs will be in place throughout
the LSDI region by 2006.
Evaluation of direct impact
The effectiveness of the malaria control programme in the long-term
will be assessed by the incidence of malaria over time in Mozambique as well
as in the neighbouring malarious areas of South Africa and Swaziland. The
success of intervention is not only 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).
Parasite prevalence
Parasite prevalence in children under 15 years of age was chosen
as the principal indicator of the effectiveness of the programme in its early
and middle phases.
Once prevalence reaches sustained low levels, incidence of
malaria cases will become more important as an indicator of the effectiveness
of the malaria control measures. The regional malaria information system was
developed towards measuring incidence.
Cross-sectional
parasite surveys were performed by the respective country malaria control
programmes at sentinel sites in the four Zones in Mozambique to which malaria
control was extended (See map), and
in South Africa and Swaziland at sentinel sites within 10 kilometres of the
Mozambique border. Rapid diagnostic tests (HRP-2 antigen tests, ICTTM and
Kat Medical) were used to assess prevalence of infection. Giemsa-stained thick
bloodsmear films were collected from the 1155 survey respondents from the
Mozambican sentinel sites and examined by skilled microscopists for validation
of the antigen test.
At each of the 26 Mozambican sites, at least one survey was
conducted prior to the intervention to provide estimates of pre-spraying baseline
prevalence of infection. Initial parasite prevalence surveys were conducted
in the respective zones in Mozambique in December 1999 (Zone1), June 2000
(Zone 1 and 1A), June 2002 (Zone 2) and June 2003 (Zone 3) with post-intervention
assessment in June of each subsequent year. Parasite prevalence surveys were
carried out in KwaZulu-Natal in December 1999, in June 2000, and in February
and June 2001. In Swaziland, surveys were done in December 1999 and in June
of each year thereafter. All age categories were sampled, with the exception
of the surveys in Mozambique after December 1999, which were confined to children
2 to <15 years of age.
Surveys Undertaken |
Period |
Zone |
Dec 1999 |
1 |
June 2000 |
1, 1A |
June 2001 |
1, 1A |
June 2002 |
1, 1A, 2 |
June 2003 |
1, 1A, 2, 3 |
| June 2004 |
1, 1A, 2, 3 |
In June 2004 the following sentinel sites were surveyed:
| Zone 1 |
Zone 1A |
Zone 2 |
Zone 3 |
| Bela Vista |
Beluluane |
Agostinho Neto |
Chobela |
| Catuane |
Beluluane C(24) |
Bobole |
Magude Sede |
| Changalane |
Djuba |
Corrumane |
Mapulanguene |
| Namaacha |
Malhapsene |
Machubo |
Motase |
| Ponto do Ouro |
Matola C |
Marracuene Sede |
Panjane |
| Salamanga |
Matola Rio |
Moamba Sede |
|
| Zitundo |
Mussumboloco |
Ressano Garcia |
|
| |
|
Sabie/Mavunguane |
|
Results
from the first prevalence survey revealed that there was a
marked difference in prevalence between the three countries. The lowest infection
rates were recorded in Swaziland where the prevalence ranged from 1 to 5%;
in KwaZulu-Natal, it was found to be between 9 and 42%; and in Mozambique
from 22 to 90%.
Mosquito vectors
Vector species, numbers and infectivity were monitored at
26 sentinel sites using mosquito counts in 134 exit traps on a daily basis
in the Mozambique sector.
SEACAT evaluation
Data have been collected at baseline and biannually, including
the data on the following endpoints: in vivo therapeutic efficacy, drug utilisation,
safety of anti-malarials (and other medicines), and costs to the public sector
provider and cost effectiveness.
Information on the following was also collected in selected
surveys:
Malaria case totals (laboratory-confirmed) for Swaziland and
South Africa were available from the MIS in these countries. The MIS document
malaria cases diagnosed at health facilities, which include active case detection
in South Africa. The system has been extended to Swaziland and implementation
is well under way in southern Mozambique where it supports the phased implementation
of definitive diagnosis and ACTs.
Impact of Malaria Control Programme
The extension of malaria control to the Mozambique sector
has had the effect of dramatically reducing disease transmission in this area
and has also resulted in a significant reduction in transmission in the highest
risk malaria districts in South Africa (Ingwavuma and Komatipoort) and
in Swaziland. See Project Progress
Funding
Malaria and
Tourism
