Annual Report 2001 MALARIA CONTROL IN THE LUBOMBO SPATIAL DEVELOPMENT AREA The Lubombo Spatial Development Initiative (LSDI) is a programme by the governments of Mozambique,
Swaziland and South Africa to develop the Lubombo region into a globally competitive economic zone. The geographic area targeted by this initiative is broadly defined as eastern Swaziland, southern Mozambique and
north-eastern KwaZulu Natal and is linked by the Lubombo mountains. It also aims to create sustainable employment and equity in access to economic opportunity in the region. In July 1999 President Mbeki, President Chissano and His Majesty, King Mswati III, signed the General Protocol which puts in place a platform for regional cooperation and delivery. In October of 1999, the Lubombo
Malaria Protocol and tri-national malaria programme was launched. In December of 1999, the World Heritage Convention Act was promulgated and the Greater St Lucia Wetlands Park inscribed on the World Heritage
Convention list. In June 2000 the three countries signed the Lubombo Transfrontier Conservation and Resource Area Protocols (TFCA). Malaria Control Although the malaria control project addresses a number of aspects central to increasing the effectiveness of
malaria control in the two highest risk malaria provinces in South Africa and those in Swaziland, the primary emphasis was to extend malaria control to southern Mozambique. There is increasing consensus that even if
malaria control measures are optimal in South Africa and Swaziland (i.e. effective drugs and insecticides in place), disease incidence can only be further reduced by a regional approach to control. Fifty seven million Rand is currently spent by government as direct costs on malaria control in KwaZulu-Natal
and Mpumalanga Provinces (excluding a further R27 million for emergency funding during 2000/2001). A successful regional approach to malaria control should reduce disease incidence in South Africa and therefore
these direct costs. There is increasing evidence that malaria control is a positive precursor to development and the situation prior to
malaria control in South Africa supports this view, given the well documented negative effects of malaria on tourism and agricultural development in the 1930's. The project is managed by the Regional Malaria Control Commission (RMCC), comprised of malaria control
programme managers, public health specialists and scientists from the three countries. Baseline surveys were carried out at 8 localities in Mozambique; 4 localities in Swaziland; and 3 localities in
South Africa to document the extent of the malaria problem. Surveys on parasite prevalence, mosquito numbers indoors, and Knowledge, Attitudes and Perceptions (KAP) regarding malaria were completed in December 1999, with a second parasite prevalence survey carried out in June 2000. Traps to catch mosquitoes exiting from houses were fitted to homes at each of the 8 sentinel sites. These are cleared daily by the homeowners
and the mosquitoes preserved in labeled and dated containers for analysis. Parasite prevalence surveys will be undertaken each year in June to evaluate the efficacy of the intervention. The baseline malaria survey conducted in Southern Mozambique in December 1999 showed average malaria infection rates (children aged 2 to <15 years of age) of 64%, with infections at Catuane, just across the border
from Ndumu Game Reserve, the highest risk area in South Africa, greater than 90%. 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. Computer-based Malaria Information Systems (MIS) were developed and implemented for the partner-sectors.
The success of the malaria control programme will not only be measured using process (e.g. spraying 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 next 5 years. The tourism survey (88 tourist facilities) conducted in the LSDI area during 2000, found that malaria was
perceived as the principle negative determinant on bed occupancy. Cancellations were recorded from tourist
facilities in all the districts of the LSDI during the last malaria season (2000), with an average cancellation figure of 44% being recorded in southern Mozambique. Small geographic scale malaria risk maps are being produced so that appropriate malaria risk information can
be distributed to tourist facility owners, tourists and the media. A tourist information booklet providing appropriate information regarding prophylaxis in risk areas has been produced and released to tourism facilities
Malaria Control Programme Management Management of the programme consists of five tiers: i. Tri-Lateral Ministers meeting ii. LSDI management iii. RMCC management iv. Management structures in Mozambique v. Research and control management Management structures were set up at a Provincial and District level in Zone 1, Mozambique that permitted the
implementation of the programme with the help of external experts (RMCC and scientists) while at the same time building capacity at both the National and Provincial level in Mozambique. The foundation of a successful, efficient and effective spraying programme are optimally trained staff at every
level. This was lacking in Mozambique and training was therefore a key priority before a spraying programme could be introduced and as an ongoing process once spraying had 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. During the year under review, 79 trainers, supervisors and spray operators were involved in four main training sessions. Training was extended to include intervention assessment and in this regard, window trap caught mosquitoes were morphologically identified in Mozambique, residual efficacy bio assays were carried out, the latter requiring the maintenance of an insectary and both susceptibility and biochemical
resistance testing which will lead to an MSc degree for Sonia Casimiro, are increasingly being done in country. An important factor identified prior to the implementation of the spraying programme was the necessity to
adequately supervise the spray operations. Due to the vast area to be sprayed, supervision of spray operators' activities on a daily basis was virtually impossible. A fourth generation relational database (Microsoft Access)
was therefore designed as an information repository for all spraying activities and the data generated from computerized reports made it possible to evaluate productivity and spraying performance on an ongoing basis. The initial technical proposals identified pyrethroids as the insecticide to be used in the spraying component of
the LSDI. However, with the discovery of high levels of pyrethroid resistance in An. funestus, meetings were
held with the RMCC, national and international experts to recommend an alternative to the use of this insecticide. Based on data, it was unanimously agreed the best course of action would be to use DDT. The
alternative recommendation was that a carbamate such as Bendiocarb be used. The latter was used due to Mozambique declining to allow DDT to be used. More recently carbamate resistance (Propoxur) has been
reported from an area in close proximity to the control area and studies are currently in place to assess the situation in the control area. Increasing levels of insecticide resistance and a limited number of available insecticides, restrict the options in
respect to the residual house spraying programme in southern Mozambique. Discussions emanating from the discovery of pyrethroid and carbamate resistance have emphasized the need to consider rotational insecticide
use as the only way forward and to avoid fixing resistant genes in the vector population. DDT would of necessity have to be one of the insecticides used in an annual rotation scheme. These finding have implications for the
future of malaria control in the region. From an operational perspective, the project of starting a malaria control programme in a largely underdeveloped
rural area was successful and the necessary skills to run the control programme and its evaluation are in place. There have been certain constraints on the project and these include: a. extensive flooding in southern Mozambique in early 2000 which washed away roads and necessitated delaying of spraying. b. Resistance by Anopheles funestus to synthetic pyrethroids and possibly carbamates have restricted
the options in terms of pesticides available. c. The fact that Government funding for 2001 for the project had not yet become available. Annual Report 2001