Effect of Artemether-Lumefantrine Policy and Improved Vector Control on Malaria Burden in KwaZulu–Natal, South Africa

Abstract

BackgroundBetween 1995 and 2000, KwaZulu–Natal province, South Africa, experienced a marked increase in Plasmodium falciparum malaria, fuelled by pyrethroid and sulfadoxine-pyrimethamine resistance. In response, vector control was strengthened and artemether-lumefantrine (AL) was deployed in the first Ministry of Health artemisinin-based combination treatment policy in Africa. In South Africa, effective vector and parasite control had historically ensured low-intensity malaria transmission. Malaria is diagnosed definitively and treatment is provided free of charge in reasonably accessible public-sector health-care facilities.Methods and FindingsWe reviewed four years of malaria morbidity and mortality data at four sentinel health-care facilities within KwaZulu–Natal's malaria-endemic area. In the year following improved vector control and implementation of AL treatment, malaria-related admissions and deaths both declined by 89%, and outpatient visits decreased by 85% at the sentinel facilities. By 2003, malaria-related outpatient cases and admissions had fallen by 99%, and malaria-related deaths had decreased by 97%. There was a concomitant marked and sustained decline in notified malaria throughout the province. No serious adverse events were associated causally with AL treatment in an active sentinel pharmacovigilance survey. In a prospective study with 42 d follow up, AL cured 97/98 (99%) and prevented gametocyte developing in all patients. Consistent with the findings of focus group discussions, a household survey found self-reported adherence to the six-dose AL regimen was 96%.ConclusionTogether with concurrent strengthening of vector control measures, the antimalarial treatment policy change to AL in KwaZulu–Natal contributed to a marked and sustained decrease in malaria cases, admissions, and deaths, by greatly improving clinical and parasitological cure rates and reducing gametocyte carriage.

Spatial Targeted Vector Control Is Able to Reduce Malaria Prevalence in the Highlands of Burundi

“…24 During the first 2 years of the intervention, the first-line treatment was sulfadoxine-pyrimethamine (SP), later replaced by an artemisinin-based combination therapy (ACT) because of high SP resistance, 26 ACT use should improve cure rates, decrease gametocyte carriage, and may reduce malaria transmission where this is unstable. 27,28 In the control areas of Karuzi, malaria transmission was higher after ACT implementation, 18 despite more than 20% of the study population having taken an antimalarial treatment. One reason could be the unreliability of the treatment history by the study population, i.e., antimalarial treatment would not be as frequent as estimated by the survey.…”

International population movements and regional Plasmodium falciparum malaria elimination strategies

“…eradication | migration | network analysis | imported malaria | community detection S ignificant progress is being made in reducing the morbidity and mortality attributed to malaria globally (1)(2)(3)(4)(5)(6)(7)(8)(9)(10), encouraging the Global Malaria Action Plan (GMAP) (11) to articulate a long-term vision for malaria eradication through shorter-term local efforts to eliminate malaria. A total of 34 of the 107 malaria endemic countries have declared they have a national policy for malaria elimination or are pursuing spatially progressive elimination within their borders (11)(12)(13).…”

Case management of malaria: Treatment and chemoprophylaxis

“…However, between 1993 and 2000 malaria case numbers began rising sharply, peaking in 2000 with over 40 000 cases reported in KZN. [24] An in vivo efficacy trial revealed the 42-day cure rate following SP treatment had fallen from above 75% in 1997 to 11% by 2000. [25] Retrospective genetic analyses on samples collected during a community-based prevalence survey in 2000 confirmed the presence of highly SP-resistant parasites, with 47% of all parasites analysed in carrying the SP quintuple mutation associated with SP treatment failure.…”

“…[24] Although malaria morbidity declined by 99% following this policy change, [24] the SP quintuple mutation remained extremely prevalent in the province. By 2012, 75% of the parasites analysed carried the mutation (J Raman, unpublished data).…”