Implementing malaria control in South Africa, Eswatini and southern Mozambique during the COVID-19 pandemic.

The COVID-19 pandemic has strained healthcare delivery systems in a number of southern African countries. Despite this, it is imperative that malaria control and elimination activities continue, especially to reduce as far as possible the number and rate of hospitalisations caused by malaria. The implementation of enhanced malaria control/elimination activities in the context of COVID-19 requires measures to protect healthcare workers and the communities they serve. The aim of this review is therefore to present innovative ideas for the timely implementation of malaria control without increasing the risk of COVID-19 to healthcare workers and communities. Specific recommendations for parasite and vector surveillance, diagnosis, case management, mosquito vector control and community outreach and sensitisation are given.

Implementing malaria control in South Africa, Eswatini and southern Mozambique during the COVID-19 pandemic

The COVID-19 global pandemic reached South Africa (SA), Mozambique and Eswatini in March 2020.[1] Since then an exponential increase in SARS-CoV-2 infections has severely stretched SA's healthcare system, especially in terms of in-hospital treatment of severe cases. The impact of COVID-19 in Mozambique and Eswatini at the time of writing has been comparatively mild, but is increasing. It is therefore imperative to reduce as far as possible the number and rate of hospitalisations caused by trauma and other diseases, including malaria. Malaria incidence in SA is seasonal and peaks in the wetter summer months, especially during January to April.[2] Although malaria incidence in SA is currently low, the risk of outbreaks is always present, with the most recent having occurred in 2017 and, at a more localised level in Limpopo Province, in 2019. The reasons for these latest outbreaks are varied and include unusually high rainfall and cross-border movement of migrant populations, fuelling local transmission. These issues are particularly pertinent to COVID-19 in SA's malaria-affected districts. They highlight the importance of mitigating factors contributing to high malaria incidence and consequent hospitalisations, which may be further exacerbated by COVID-19/malaria coinfections and the re-opening of SA's borders with those neighbouring countries with higher malaria transmission intensities.

Changing distribution and abundance of the malaria vector Anopheles merus in Mpumalanga Province, South Africa.

Background: The malaria vector Anopheles merus occurs in the Mpumalanga Province of South Africa. As its contribution to malaria transmission in South Africa has yet to be ascertained, an intensification of surveillance is necessary to provide baseline information on this species. The aim of this study was therefore to map An. merus breeding sites in the Ehlanzeni District of Mpumalanga Province and to assess qualitative trends in the distribution and relative abundance of this species over a 9-year period. Methods: The study was carried out during the period 2005-2014 in the four high-risk municipalities of Ehlanzeni District. Fifty-two breeding sites were chosen from all water bodies that produced anopheline mosquitoes. The study data were extracted from historical entomological records that are captured monthly. Results: Of the 15 058 Anopheles mosquitoes collected, 64% were An. merus. The abundance and distribution of An. merus increased throughout the four municipalities in Ehlanzeni District during the study period. Conclusion: The expanded distribution and increased abundance of An. merus in the Ehlanzeni District may contribute significantly to locally acquired malaria in Mpumalanga Province, likely necessitating the incorporation of additional vector control methods specifically directed against populations of this species.

Contexte : Le vecteur du paludisme, Anopheles merus, sévit dans la province de Mpumalanga en Afrique du Sud. Comme sa contribution à la transmission du paludisme en Afrique du Sud reste à vérifier, une intensification de la surveillance est nécessaire afin de fournir des informations de départ sur cette espèce. Le but de cette étude a donc été de cartographier les sites de reproduction de An. merus dans le district d'Ehlanzeni de la province de Mpumalanga et d'évaluer les tendances qualitatives de la distribution et de l'abondance relative de cette espèce sur une période de 9 ans.Méthodes : Cette étude a été réalisée pendant la période de 2005 à 2014 dans les quatre municipalités à risque élevé du district d'Ehlanzeni. Cinquante-deux sites de reproduction ont été choisis dans tous les plans d'eau qui ont produit des moustiques de l'espèce anophèle. Les données de l'étude ont été extraites de registres entomologiques historiques qui sont saisis chaque mois.Résultats : Sur les 15 058 moustiques Anopheles recueillis, 64% ont été An. merus. L'abondance et la distribution d'An. merus ont augmenté dans les quatre municipalités du district d'Ehlanzeni pendant la période d'étude.Conclusion: La distribution en expansion et l'abondance accrue d'An. merus dans le district d'Ehlanzeni peut contribuer significativement au paludisme acquis localement dans la province de Mpumalanga et nécessite l'incorporation de méthodes de lutte vectorielle supplémentaires spécifiquement dirigées contre les populations de cette espèce.

Marco de referencia: Anopheles merus, vector del paludismo, está presente en la provincia de Mpumalanga de Suráfrica. Puesto que no se ha determinado su contribución a la transmisión del paludismo en el país, es necesario intensificar la vigilancia, con el fin de aportar información de referencia sobre esta especie. El objetivo del estudio fue cartografiar los criaderos de An. merus en el distrito de Ehlanzeni de la provincia de Mpumalanga y evaluar la evolución cuantitativa de la distribución y la abundancia relativa de esta especie durante un período de 9 años.Métodos: El estudio se llevó a cabo del 2005 al 2014 en cuatro municipios de alto riesgo de transmisión del distrito de Ehlanzeni. Se escogieron 52 criaderos de todas las masas de agua productoras de mosquitos anófeles. Los datos del estudio se extrajeron de los registros entomológicos históricos que se captan cada mes.Resultados: De los 15 058 mosquitos anófeles recogidos, el 64% correspondía a An. merus; su abundancia y distribución aumentó en los cuatro municipios del distrito de Ehlanzeni durante el período del estudio.Conclusión: La ampliación de la distribución y el aumento de la presencia de An. merus en el distrito de Ehlanzeni pueden contribuir de manera significativa a los casos de paludismo adquiridos localmente en la provincia de Mpumalanga, y es probable que sera necesario incorporar otros métodos de control de vectores dirigidos específicamente contra las poblaciones de esta especie.

Larval salinity tolerance of two members of the Anopheles funestus group.

The Anopheles funestus group (Diptera: Culicidae) is one of the main species groups involved in malaria transmission in the Afrotropical regions. Basic research into this group has been limited because its members are eurygamic (they tend not to mate in confined spaces), which makes laboratory colonization difficult. Currently, only a few An. funestus Giles colonies are available and no colonies of other members of the group have been established. As information on the larval biology of members of the An. funestus group is limited, the present study aims to determine the effects of different salt concentrations on survival rates of the aquatic stages of two members of the An. funestus group, Anopheles funestus and Anopheles rivulorum Leeson. There were statistically significant negative trends in hatch rate and larval survival rate in An. funestus with increasing salt concentrations, with no larvae surviving to pupae at concentrations that included >15% seawater. Anopheles rivulorum, by contrast, showed no significant trends in hatch rate or larval survival with increasing salt concentrations. This is the first report on salinity tolerance in An. rivulorum. A basic understanding of these variations in salinity tolerance provides vital information on the biology, ecology and colony rearing of members of the An. funestus group.

Re-defining the extent of malaria transmission in South Africa: implications for chemoprophylaxis.

BACKGROUND: Malaria case numbers reported in South Africa have reduced considerably over the last decade, necessitating a revision of the national risk map to guide malaria prevention, including the use of chemoprophylaxis. OBJECTIVES: To update the national malaria risk map based on recent case data and to consider the implications of the new transmission profile for guiding prophylaxis. METHODS: The geographical distribution of confirmed malaria cases detected both passively and actively over the last six malaria seasons was used to redefine the geographic distribution and intensity of malaria transmission in the country. RESULTS: The national risk map was revised to reflect zones of transmission reduced both in their extent and their intensity. Most notably, the area of risk has been reduced in the north-western parts of Limpopo Province and is limited to the extreme northern reaches of KwaZulu-Natal Province. Areas previously considered to be of high risk are now regarded to be of moderate risk. CONCLUSION: Chemoprophylaxis is now only recommended from September to May in the north-eastern areas of Limpopo and Mpumalanga Provinces. The recommended options for chemoprophylaxis have not changed from mefloquine, doxycycline or atovaquone-proguanil.

Malaria deaths as sentinel events to monitor healthcare delivery and antimalarial drug safety.

OBJECTIVES: To identify case management, health system and antimalarial drug factors contributing to malaria deaths. METHOD: We investigated malaria-related deaths in South Africa's three malaria endemic provinces from January 2002 to July 2004. Data from healthcare facility records and a semi-structured interview with patients' contacts were reviewed by an expert panel, which sought to reach consensus on factors contributing to the death. This included possible health system failures, adverse reactions to antimalarials, inappropriate medicine use and failing to respond to treatment. RESULTS: Approximately 177 of 197 cases met inclusion criteria for the study. Delay in seeking formal health care was significantly longer for patients who sought traditional health care [median 4; inter-quartile range (IQR) 3-7 days] than for patients who did not (median 3; IQR 1-5 days; P = 0.033). Patients with confirmed or suspected HIV/AIDS were significantly more likely to use traditional approaches (25%) than those with other comorbidities (0%; P = 0.002). Malaria was neither suspected nor tested for at a primary care facility in 23% of cases with adequate records. Initial hospital assessment was considered inadequate in 74% of cases admitted to hospital and in-patient monitoring and management was adequate in only 27%. There were 32 suspected adverse reactions to antimalarial therapy. CONCLUSION: A confidential enquiry into malaria-related deaths is a useful tool for identifying preventable factors, health system failures and adverse events affecting malaria case management.

Therapeutic efficacy of sulfadoxine-pyrimethamine for Plasmodium falciparum malaria.

OBJECTIVES: To assess the therapeutic efficacy of sulfadoxinepyrimethamine (SP) after 5 years of use as first-line treatment of uncomplicated Plasmodium falciparum malaria, and thus guide the selection of artemisinin-based combination therapy in Mpumalanga, South Africa. DESIGN: An open-label, in vivo therapeutic efficacy study of patients with uncomplicated P. falciparum malaria treated with a single oral dose of SP, with response to treatment monitored clinically and parasitologically on days 1, 2, 3, 7, 14, 21, 28 and 42. SETTING: Mangweni and Naas public health care clinics, Tonga district in rural Mpumalanga. SUBJECTS, OUTCOME MEASURES AND RESULTS: Of 152 patients recruited sequentially, 149 (98%) were successfully followed up for 42 days. One hundred and thirty-four patients (90%) demonstrated adequate clinical and parasitological response. Of the 15 patients (10%) who failed treatment, 2 (1.3%) had an early treatment failure, and polymerase chain reaction confirmed recrudescent infection in all 13 patients (8.7%) who had late parasitological (N = 11) or clinical (N = 2) failure. Gametocyte carriage was prevalent following SP treatment (84/152) and this has increased significantly since implementation in 1998 (relative risk 2.77 (confidence interval 1.65 - 4.66); p = 0.00004). CONCLUSION: Asexual P. falciparum parasites in Mpumalanga remain sensitive to SP, with no significant difference between the baseline cure rate (94.5%) at introduction in 1998, and the present 90% cure rate (p = 0.14). However, since gametocyte carriage has increased significantly we recommend that SP be combined with artesunate in Mpumalanga to reduce gametocyte carriage and thus decrease malaria transmission and potentially delay antimalarial resistance.

Effectiveness of short-course quinine and single-dose sulfadoxine-pyrimethamine in the treatment of Plasmodium falciparum malaria in Mpumalanga Province, South Africa.

INTRODUCTION: Quinine therapy for 7 days remains the mainstay for treating hospitalised malaria cases in South Africa. However, limited resources, including available beds and staff, often result in early discharge of non-severe cases, with quinine tablets for outpatient use. The effectiveness of shorter course quinine therapy coupled with a long-acting antimalarial drug has never been established in Africa, in particular in a population without malaria immunity. METHODS: A study was conducted to evaluate the effectiveness of a 3-day course of therapy with quinine sulphate (10 mg/kg 8-hourly) followed by a single dose of sulfadoxine-pyrimethamine (SP) according to weight category, before discharge, for 133 hospitalised patients with uncomplicated Plasmodium falciparum malaria at Shongwe Hospital, Mpumalanga province, between February and July 1998. Study endpoints included clinical recovery and parasitological cure, including polymerase chain reaction (PCR) 42 days after initiating treatment. RESULTS: One hundred and thirty of 131 patients (99%) successfully followed up for 42 days demonstrated clinical and parasitological cure. The remaining patient, who had evidence of a recrudescent infection on PCR, was 1 of 61 patients who were still parasitaemic on discharge from hospital. CONCLUSION: The abbreviated course of quinine therapy coupled with a single dose of SP for the treatment of non-severe hospitalised cases of P. falciparum malaria, in an area with demonstrated low levels of SP resistance, was highly effective. This approach has potential benefits, including reduced duration of hospitalisation, fewer quinine-associated adverse events and protection against the evolution of quinine resistance by limiting unsupervised quinine therapy in the community. It may, however, be prudent to document a negative blood film before discharge from hospital.

Therapeutic efficacy of sulfadoxine-pyrimethamine in uncomplicated Plasmodium falciparum malaria 3 years after introduction in Mpumalanga.

OBJECTIVES: To assess therapeutic efficacy of sulfadoxine-pyrimethamine (SP) in treatment of uncomplicated Plasmodium falciparum malaria 3 years after introduction in Mpumalanga, South Africa. SETTING: Tonga district with a population of 116,418 and subject to seasonal malaria, with an average annual incidence of 3,200 cases. SUBJECTS: One hundred and nineteen malaria patients presenting to a sentinel surveillance clinic and recruited according to World Health Organisation (WHO) criteria. METHODOLOGY: Patients satisfying WHO inclusion criteria were treated with a single oral dose of SP and the response of infection to treatment in each patient was routinely monitored clinically and parasitologically on days 1, 2, 3, 7, 14, 21, 28 and 42 post-treatment. One hundred and ten patients completed follow-up to day 42 or evidence of clinical or parasitological failure. RESULTS: The cure rate at day 42 was 93.6% (103/110). Two patients (1.8%, RII) were early treatment failures on day 3, while recrudescence (4.5%, RI) occurred in 5 patients on day 28 (N = 3) and on day 42 (N = 2). CONCLUSION: In Mpumalanga P. falciparum remains sensitive to SP, with no significant difference between the baseline cure rate (94.5%) and the cure rate in the present study (93.6%).

Rapid immunochromatographic diagnosis and Rolling Back Malaria--experiences from an African control program.

Malaria is a re-emerging disease in much of Africa. In response, the World Health Organization launched the Roll Back Malaria (RBM) initiative. One of six key principles adopted is the early detection of malaria cases. However, the importance of definitive diagnosis and potential value of field deployment of rapid malaria tests in RBM has been largely ignored. The Lowveld Region of Mpumalanga Province, South Africa, is home to a predominantly non-immune population, of approximately 850000 inhabitants, who are at risk of seasonal Plasmodium falciparum malaria. Malaria treatment in this area is usually only initiated on detection of malaria parasites in the peripheral bloodstream, as many other rickettsial and viral febrile illness mimic malaria. The malaria control programme traditionally relied on light microscopy of Giemsa-stained thick blood films for malaria diagnosis. This review summarizes operational research findings that led to the introduction of rapid malaria card tests for primary diagnosis of malaria throughout the Mpumalanga malaria area. Subsequent operational research and extensive experience over a four-year period since introducing the ICT Malaria Pf test appears to confirm the local appropriateness of this diagnostic modality. A laboratory is not required and clinic staff are empowered to make a prompt definitive diagnosis, limiting delays in initiating correct therapy. The simple, accurate and rapid non-microscopic means now available for diagnosing malaria could play an important role in Rolling Back Malaria in selected areas.

Community knowledge and perceptions about malaria and practices influencing malaria control in Mpumalanga Province, South Africa.

OBJECTIVE: To assess community knowledge and perceptions about malaria and its control in a rural setting. DESIGN: Descriptive cross-sectional survey. SETTING: Tonga district with a population of 116,418, seasonal malaria with an annual incidence of 3,200 cases. SUBJECTS: Female heads of 299 randomly selected households. METHODOLOGY: A total of 299 households were selected from a random sample of 30 clusters. Community knowledge and perceptions about malaria and its control were assessed by interviews with the female head of each of the 299 selected households. RESULTS: Respondents ranked malaria as the third most serious health problem facing the community after TB and AIDS. Seventy-two per cent (214/299) of respondents reported that they knew what malaria disease was and of these, 92.1% (197/214) mentioned mosquito bites as the cause of malaria. The respondents' understanding of the causal role of mosquitoes in malaria was significantly related to their knowledge about disease symptoms (P < 0.001). Reported community compliance with the malaria control programme (MCP) was satisfactory; 86.6% (259/299) of respondents reported that their homes had been sprayed during the past 2 years but 10.0% (30/299) did not know why homes were sprayed. Hospitals or clinics were the facilities where respondents most commonly sought treatment for fever; 66.9% (200/299) reported that they would seek treatment immediately after the onset of high fever. Specific practices such as replastering or washing of inside walls compromised the effectiveness of the MCP. Personal preventive measures were sometimes used against malaria (50.8%, 152/299) and use was positively associated with education level (P = 0.001). Respondents expressed their desire for more information about malaria and their willingness to contribute to the control of malaria in their community. CONCLUSION: The survey collected information which was directly relevant to the development of health education messages to increase community awareness of the problem of malaria, to emphasise the importance of early diagnosis and prompt treatment of malaria, to improve community understanding of the function of indoor residual spraying, and to enlighten the population of the role of mosquitoes in malaria transmission and the availability and benefits of personal protection measures against mosquito bites.

Using a geographical information system to plan a malaria control programme in South Africa.

INTRODUCTION: Sustainable control of malaria in sub-Saharan Africa is jeopardized by dwindling public health resources resulting from competing health priorities that include an overwhelming acquired immunodeficiency syndrome (AIDS) epidemic. In Mpumalanga province, South Africa, rational planning has historically been hampered by a case surveillance system for malaria that only provided estimates of risk at the magisterial district level (a subdivision of a province). METHODS: To better map control programme activities to their geographical location, the malaria notification system was overhauled and a geographical information system implemented. The introduction of a simplified notification form used only for malaria and a carefully monitored notification system provided the good quality data necessary to support an effective geographical information system. RESULTS: The geographical information system displays data on malaria cases at a village or town level and has proved valuable in stratifying malaria risk within those magisterial districts at highest risk, Barberton and Nkomazi. The conspicuous west-to-east gradient, in which the risk rises sharply towards the Mozambican border (relative risk = 4.12, 95% confidence interval = 3.88-4.46 when the malaria risk within 5 km of the border was compared with the remaining areas in these two districts), allowed development of a targeted approach to control. DISCUSSION: The geographical information system for malaria was enormously valuable in enabling malaria risk at town and village level to be shown. Matching malaria control measures to specific strata of endemic malaria has provided the opportunity for more efficient malaria control in Mpumalanga province.

Confidential inquiry into malaria deaths.

The results of a confidential inquiry into mortality attributed to malaria in South Africa's Mpumalanga Province are being used to guide the design of strategies for improving the management of cases and reducing the probability of deaths from the disease.