LSDI

The Lubombo SDI malaria programme has shown impact as measured directly by a significant decrease in malaria disease burden, by an increase in malaria control capacity, by positive perceptions in the tourism industry, and by creation of a regional malaria monitoring system, all only made possible by the broad nature of the collaboration and the political support of the programme. Success is based on many factors but is largely attributable to the commitment of all partners, as well as sound decision-making and implementation strategies, based on experience and supported by good scientific infrastructure and evidence.

Status of 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).

Objective 1: Reduction of malaria incidence in border areas in South Africa and Swaziland

Map illustrating reductions in the incidence of Plasmodium falciparum parasites in South Africa and Swaziland and prevalence in Mozambique between the baseline in 1999 and survey in 2006.

Map showing Prevalence decrease in Maputo province 2008

1.1 South Africa

The South African border areas most influenced by the LSDI malaria programme are Komatipoort District in Mpumalanga and Ingwavuma District in KwaZulu-Natal. Initially parasite prevalence surveys were conducted in KwaZulu-Natal. By 2001, these parasite prevalence rates had dropped to below 5%. Malaria incidence rates reduced from the 1999/2000 baseline year to 2006/2007 by >99%. Incidence data for the two affected localities are given below. Although the scale of the disease differs in the different localities, the disease trends are similar. Significant reductions were made in these border regions once malaria control interventions had been implemented in adjacent areas in Mozambique. Since 2002/2003 the number of cases decreased markedly and has remained low ever since.

Komatipoort Incidence 1999 - 2007

Ingwavuma Incidence

1.2 Swaziland

Annual parasite prevalence surveys were conducted at four sentinel sites in Swaziland. By 2004 the average prevalence rate was 0.25%. It was no longer statistically valid to collect prevalence data and incidence rates were used since there was a well functioning Malaria Information System in place. The malaria incidence rates have been dramatically reduced by >90%

Swaziland Incidence

Objective 2: Reduction of malaria infections in Maputo province

Since June 2000, annual parasite prevalence surveys have been conducted at sentinel sites in in southern Mozambique. Currently, annual surveys are conducted at 28 sentinel sites in Maputo Province. In Zone 1 baseline prevalence surveys were conducted in December 1999 and June 2000 before spraying began. Since there was no evidence of any difference in prevalence between these two surveys in children at the 7 sites (p=0.82), site specific data from these two years were combined into a 2 year pre-spraying baseline and compared with prevalence values obtained from post spraying surveys undertaken annually in June from 2001, to June 2007. The latest survey found that prevalence rates had decreased drastically and are among the lowest in the province. In Zone 1 the average infection rate from all sites at baseline was 62 %, which reduced to 1.9% in June 2007. In Zone 1A, overall prevalence of infection at baseline in June 2000 was 86%. Currently the prevalence rate in this Zone stands at 12.6%.

In Zone 2, overall prevalence of infection at baseline was 70% in June 2002, reducing to 29.8% in June 2004, after spraying and dropping to 5.1% in June 2007. In Zone 3 the prevalence was 69.6% pre spraying and after successive spray rounds, the prevalence rate as at June 2007 is 15.2%. In Zone 2A baseline surveys in 1999 and 2000 showed a 76% prevalence, spraying was started in 2001 but due to financial constraints a permanent field officer was not assigned to the area and the spraying programme did not follow a fully structured plan as in the other areas until 2003 when funding allowed. Parasite prevalence decreased below baseline levels but not as dramatically as in other areas until 2004, when prevalence at 2 sites recorded 39% and 6% respectively. In June 2007, the lowest prevalence in the entire LSDI region in Maputo Province was 0.83%.

Objective 3: Provision of Malaria Risk Maps and Prophylaxis Guide

The tourism component of the project was successfully completed. Surveys were conducted in Mozambique and Swaziland.Updated malaria and prophylaxis advice booklets have been distributed to tourist facilities. In the 1999/2000 malaria season, 18% of tourist facilities were in areas where 5 - 25 malaria cases per 1000 people were recorded, and 68% were in areas where the incidence was <5 per 1000 people. A major reduction in malaria cases was achieved by the 2003/2004 malaria season. None of the tourist facilities were in 5-25 malaria cases per 1000 people and 98% where in areas where < 5 malaria cases per 1000 people where recorded. The Greater St Lucia Wetland Park Authority has designated 10 development nodes within the park where local and international concerns will develop a wide range of tourist facilities from low-impact cabins to luxury hotels. The tourism data is increasingly influencing tourism policy. SA tourism is using the “Malaria Free” campaign to enhance its international marketing strategy.

See Malaria and Tourism

Objective 5: Development of a GIS-Based Malaria Information System

A Malaria Information System (MIS) is a computerised system allowing the input, management and output of malaria case data used for management and research. It includes a spatial component using a geographical information system (GIS) and the spatial data collected includes administrative boundaries, population, health facility locations, towns and other relevant information. New sources of data are continuously sought to ensure that the appropriate scales are provided and that the data is current. The MIS is continually customised to minimise end-user skill requirements and to optimise access to different data sets. Input screens mirror data collection forms and automatic-linking and drop-down lists minimise data errors.

Malaria Information Systems were developed and implemented for each of the three countries participating in the LSDI. This computerised system allows the input, management and output of malaria case data which is used for both management and research purposes. It includes a spatial component using a geographic information system which is being customised to minimise end-user skill requirements and optimise access to the different data sets.

The MIS provide for the management of two types of malaria-related data: 1. Health facility diagnosed malaria cases, and 2. Information relating to the malaria control activities, namely indoor residual spraying. The data entered into the MIS include in- and out-patient data of confirmed and clinically diagnosed malaria cases. The input screens mirror the data collection forms and the automatic-linking and drop-down list minimises data entry errors. Information collected during routine spray activities is collated and entered into the MIS and plays a key role in monitoring as well as planning spray activities Pre-designed outputs are provided in the form of maps, graphs or tables. This allows problems to be identified and addressed on an ongoing basis.

Ensuring the effective and efficient functioning and use of the MIS not only requires technical expertise relating to the data in the system, but necessitates managing the information flow process both before it reached the MIS and afterwards. This requires local ongoing technical expertise of information officers (IO) with the skills to operate and develop the MIS. Spatial data has been collected for the region and includes administrative boundaries, population, health facility locations, towns and other relevant information. New sources are continually sought to ensure that current data at appropriate scales are provided.