Objectives of Lubombo SDI Malaria Control Programme:
4. Develop a regional GIS-based Malaria Information System (MIS). STATUS: In place in 3 countries.
5. Develop a regional malaria control programme. STATUS: In place, covering 200 000 Km²
Progress on Objective 5. Maputo Province: Establishment of a Regional Malaria Control Programme
In order to develop a regional malaria control programme, a number of different activities had to be implemented.
1. Regional management
The Regional malaria Control Commission (RMCC) is the co-ordinating and decision-making body of the LSDI programme. The RMCC is tasked with facilitating the extension of control to the Mozambique sector. The RMCC meets quarterly and the venue for meetings is rotational between countries. Decisions impacting on the project are made by consensus and supported by evidence on specific issues and the broad experience of its members, with all members having equal input. The RMCC is responsible for reviewing the progress of the project in the respective countries and finding solutions to problems that may occur. The RMCC then presents its findings and recommendations to Governments, funders and the Regional Co-ordinating Mechanism (RCM). The RCM was set up as a GFATM requirement in 2003 to ensure good governance and appropriate expenditure of the Global Fund allocation.
2. Spray programme in southern Mozambique
Malaria vector control through indoor residual spraying (IRS) of houses was introduced in Zone 1 in Mozambique with bendiocarb at 400mg per m2 in November 2000. IRS was undertaken twice annually. The programme was incrementally extended, with insecticide being applied twice annually starting in Zone 1A in February 2001, Zone 2 in October 2002 and in Zone 3 in February 2004 The four Zones comprise an area of 20617 km2 covering 7 districts.
House spraying with DDT started in Swaziland in 1981 and in the malaria-affected provinces of South Afrrica in 1946. The application rate was 2g per m2. For a brief time in the mid-1990s, pyrethroid was used in South Africa but DDT was reintroduced to counter the effects of pyrethroid resistant Anopheles funestus. All spraying was conducted throughout using Hudson expert pumps with 4001 nozzles. Spraying personnel and managers were trained in spraying techniques, safety measures and personal protection equipment appropriate to the insecticide.
3. KAP in all countries
A number of Knowledge, Attitude and Perception (KAP) studies were conducted in Mozambique and Swaziland during 2007. During 2007, KAP surveys were carried out at community level in Maputo Province and Swaziland to identify lack of knowledge, with the intent of designing IEC strategies towards development of focussed malaria education programmes.
4. Prevalence monitoring of Antimalarial Resistance Markers
One of the major factors contributing to the continuing world wide malaria burden has been the emergence and rapid spread of resistance to both chloroquine (CQ) and sulfadoxine-pyrimethamine (SP) in the human malaria parasite, Plasmodium falciparum. In response to these increasing levels of antimalarial drug resistance the WHO recommended that artemisinin combination therapy (ACT) become standard antimalarial policy.
Recent studies have shown that the efficacy of an ACT is compromised if the artemisinin derivative is combined with an ineffective partner drug. It is therefore imperative that the efficacy of the partner drugs are closely monitored to ensure that effective ACTs are being utilised. In 2004 the ACT, artesunate plus SP replaced CQ as the antimalarial of choice in Mozambique. Phased ACT implementation commenced in Matutuine District, Maputo Province in 2004 and by 2006 all districts within this province had shifted to artesunate plus SP.
Prior to ACT implementation in Maputo Province, studies conducted by the MRLP showed the prevalence of two of the five mutations essential for SP in-vivo resistance were at baseline levels. This finding supported the use of artesunate plus SP in Maputo Province. However, through continual surveillance for these five resistance markers, it was found that the prevalence of the dhps markers began increasing following ACT introduction. By 2007 the prevalence of all five mutations was well over 30% which is an early warning sign of imminent SP therapeutic failure and potential reduced efficacy of artesunate plus SP. Based on this finding it was recommended that the first line antimalarial treatment, particularly in Maputo Province, be changed to an ACT that did not contain SP as a partner drug. The Provincial Ministry of Health in Maputo Province heeded this recommendation and will changing their first line antimalarial treatment to artemether plus lumefantrine in 2008.
5. Malaria Vector Species and infection rates
Baseline entomological surveys conducted identified Anopheles funestus and An. arabiensis as the main vectors of malaria in southern Mozambique. Malaria vector numbers, as monitored by daily exit trap catches from 147 traps at 28 localities, show dramatic reductions after spraying. Numbers of An. gambiae s.l. decreased rapidly after the first spray round and have continued to remain low. Of the sample of mosquitoes from the post spraying collections and subject to specific species identification, An. arabiensis numbers decreased proportionately (36% of the total) with the other members of the complex becoming proportionately more prevalent; An. merus 55% and An. quadriannulatus 9%.
Molecular analysis to determine sporozoites rates was carried out on all positively identified mosquitoes. Sporozoite rates varied widely between Zones and between pre and post-spraying. The pre-spraying rate for An. gambiae s.l. ranged from 0,84% to 10,9% (n=784) and post-spraying rates ranged from 0-1,22% (n=471) The pre-spray sporozoite rate for An. funestus s.s. ranged between 4.69% and 5.28% (n=763). Post-spray rates ranged between 0 and 2.7%. (n=339) No other A. funestus member species was found to be infected.
6. Mosquito Resistance
Insecticide resistance monitoring is an ongoing component of the monitoring and evaluation of the IRS programme.
7. Capacity development
The foundation of a successful, efficient and effective spraying programme is optimally trained staff at every level. Experience in this regard was lacking in Mozambique, and training was therefore a key priority before a spraying programme could be introduced. It was also conducted on an ongoing process once spraying started. Training of field staff, whether spray operators or supervisors, followed a similar pattern i.e. 85% practical and 15% theory. However, supervisors received more in-depth training on environmental hazards, toxicity, first aid and safe handling/disposal of insecticides.
Training of supervisors and spray persons has taken place each year. The Mozambican programme mangers assisted Mpumalanga in training their spray operators in 2002. Training was extended to include intervention assessment and in this regard, window-trap caught mosquitoes were morphologically identified in Mozambique, and residual efficacy bio-assays carried out. The latter required the maintenance of an insectary and the ability to undertake both susceptibility and biochemical resistance testing which are increasingly being done in the country and will lead to a postgraduate degree.
Training has been undertaken to equip field entomologists with the necessary research techniques, field staff to use global positioning system (GPS) receiver hand-held units, office staff in the use of the MIS and insectary staff in Maputo. Intervention assessment with regard to development has been assessed through various studies investigating perceptions of tourists and tourist facility operators to malaria and its impact on this sector.
Human resource capacity has been built in both the implementation of ACTs and RDTs and in monitoring and evaluation of these interventions. Effective ACT and RDT deployment required strengthening of the healthcare infrastructure including in service training of all healthcare providers, including community healthcare workers. Introductory training includes drug and RDT management, malaria diagnosis using RDTs (and microscopy), assessment of disease severity, treatment guidelines, indications for referral, record keeping and pharmacovigilance. This training is supported by regular on-site supervisory visits and the provision of malaria treatment guidelines, drug management manual, pharmacovigilance handbook and adverse drug reaction reporting forms. To date, at least 468 healthcare workers have participated in this training programme, well in excess of the target of 300.
Academic training of core contributors to the LSDI is provided when the RMCC identifies a specific gap in knowledge or skill that is needed to meet the objectives of the LSDI. There are currently 15 professionals receiving such academic training at Diploma, Masters or PhD level, with 7 from Mozambique and 8 from South Africa. Fields of further training include public health, tourism, drug and insecticide resistance, and drug safety.