The effect of the COVID-19 lockdown on malaria transmission in South Africa.

BACKGROUND: For a country such as South Africa which is targeting malaria elimination, mobile and migrant populations pose a substantial risk to importation of malaria parasites. It has been hypothesized that halting cross-border movement of mobile and migrant populations will decrease the importation of malaria, however this option is not a politically, operationally, and financially viable prospect. It has social impacts as well, since families live on either side of the border and preventing travel will challenge family ties. Due to the COVID-19 pandemic and closure of ports of entry (land and air) for non-essential travel into South Africa, a unique opportunity arose to test the hypothesis. METHODOLOGY: An interrupted time series analysis was done to assess whether the post-lockdown trends (April-December 2020) in monthly reported imported and local cases differed from the pre-lockdown trends (January 2015-March 2020). The analysis was conducted separately for KwaZulu-Natal, Mpumalanga, and Limpopo provinces. RESULTS: On average, imported cases were lower in the post-intervention period in all three provinces, and local cases were lower in Mpumalanga and Limpopo, though no results were statistically significant. CONCLUSION: Since population movement continued after the travel restrictions were lifted, border screening with testing and treating should be considered for reducing parasite movement. Another option is reducing malaria cases at the source in neighbouring countries by implementing proven, effective vector and parasite control strategies and through a downstream effect reduce malaria entering South Africa.

Assessing Kwa-Zulu-Natal's progress towards malaria elimination and its readiness for sub-national verification.

BACKGROUND: The South African province of KwaZulu-Natal is rapidly approaching elimination status for malaria with a steady decline in local cases. With the possibility of achieving elimination in reach, the KZN malaria control programme conducted a critical evaluation of its practices and protocols to identify potential challenges and priorities to achieving elimination. Three fundamental questions were addressed: (1) How close is KZN to malaria elimination; (2) Are all systems required to pursue subnational verification of elimination in place; and (3) What priority interventions must be implemented to reduce local cases to zero? METHODS: Based on the 2017 World Health Organization Framework for Elimination, twenty-eight requirements were identified, from which forty-nine indicators to grade elimination progress were further stratified. Malaria data were extracted from the surveillance system and other programme data sources to calculate each indicator and semi-quantitatively rate performance into one of four categories to assess the provinces elimination preparedness. RESULTS: Across the key components a number of gaps were elucidated based on specific indicators. Out of the 49 indicators across these key components, 10 indicators (20%) were rated as fully implemented/well implemented, 11 indicators (22%) were rated as partially done/somewhat implemented/activity needs to be strengthened, and 12 indicators (24%) were rated as not done at all/not implemented/poor performance. Sixteen indicators (33%) could not be calculated due to lack of data or missing data. CONCLUSIONS: The critical self-evaluation of programme performance has allowed the KZN malaria programme to plan to address key issues moving forward. Based on the findings from the checklist review process, planning exercises were conducted to improve lower-rating indicators, and a monitoring and evaluation framework was created to assess progress on a monthly basis. This is scheduled to be reviewed annually to ensure continued progress toward meeting the elimination goal. In addition, multiple dissemination meetings were held with both provincial senior management and operational staff to ensure ownership of the checklist and its action plan at all levels.

Effectiveness of 24-h mobile reporting tool during a malaria outbreak in Mpumalanga Province, South Africa.

BACKGROUND: As surveillance is a key strategy for malaria elimination in South Africa, ensuring strong surveillance systems is a National Department of Health priority. Historically, real time tracking of case trends and reporting within 24 h-a requirement in South Africa's National surveillance guidelines-has not been possible. To enhance surveillance and response efficiency, a mobile surveillance tool, MalariaConnect, was developed using Unstructured Supplementary Service Data (USSD) technology. It was rolled out in health facilities in malaria endemic areas of South Africa to provide 24-h reporting of malaria cases. METHODS: To evaluate the efficiency of the mobile tool to detect an outbreak data were extracted from the paper based and MalariaConnect reporting systems in Bushbuckridge from 1 January to 18 June 2017. These data were subject to time series analyses to determine if MalariaConnect provided sufficient data reliably to detect increasing case trends reported through the paper system. The Chi squared test was used to determine goodness of fit between the following indicator data generated using MalariaConnect and paper reporting systems: timeliness, completeness, and precision. RESULTS: MalariaConnect adequately tracked case trends reported through the paper system. Timeliness of reporting increased significantly using MalariaConnect with 0.63 days to notification compared to 5.65 days using the paper-system (p < 0.05). The completeness of reporting was significantly higher for the paper system (100% completion; p < 0.05), compared to confirmed MalariaConnect cases (61%). There was a moderate association between data precision and the reporting system (p < 0.05). MalariaConnect provided an effective way of reliably and accurately identifying the onset of the malaria outbreak in Bushbuckridge. CONCLUSION: Timeliness significantly improved using MalariaConnect and in a malaria elimination setting, can be used to markedly improve case investigation and response activities within the recommended 72-h period. Although data completeness and precision were lower compared to paper reporting, MalariaConnect data can be used to trigger outbreak responses.

Evaluating a 24-h mobile reporting system for malaria notifications in comparison with a paper-based system in South Africa, 2015.

BACKGROUND: As South Africa strives to achieve malaria elimination by 2018 (zero local cases) the country needs to strengthen its disease surveillance system by reducing the timeliness from case diagnosis to notification of key stakeholders in the malaria programme. This study evaluated the feasibility of a 24-h mobile reporting system, designed for speeding up malaria notifications, from primary healthcare facilities to district, provincial, and national malaria programmes in South Africa. METHODS: A prospective descriptive study utilizing primary data collected from structured interviews with healthcare workers in public healthcare facilities was used to compare two reporting systems (24-h mobile reporting system and the paper-based reporting system) in malaria endemic provinces (Limpopo, Mpumalanga and KwaZulu-Natal). Data on completeness of reporting, simplicity, user acceptability and technical limitations were analysed. A Wilcoxon signed-rank test was used to compare the time difference between the two reporting systems. RESULTS: There were 1819 cases of malaria reported through the paper-based system, and 63.2% (1149) of those cases were also reported through the 24-h mobile reporting system. Out of the 272 healthcare workers who were interviewed, 40% (108) had seen malaria patients and reported a case through the 24-h mobile reporting system. The median time for cases to be reported through the 24-h mobile reporting system was significantly shorter at < 1 day (range < 1 to 31 days) compared to the paper-based system at 3 days (range 2 to > 39 days) (p < 0.001). It was found that 26% (28) were able to use the system and send reports within 2 min, 94% (256) were willing to continue to use the system. Of the 108 healthcare workers who reported a case, 18.5% (20) experienced network challenges. CONCLUSIONS: The 24-h mobile reporting system is user friendly and trained healthcare workers are willing to use the system, despite network limitations. The 24-h mobile reporting system reduces the time required for diagnosed cases to be notified by the health care facility to district, provincial and national levels. The 24-h mobile reporting system is a feasible option for malaria notification in South Africa and will assist with early detection of malaria outbreaks.