Reviewing South Africa’s malaria elimination strategy (2012–2018): progress, challenges and priorities

Abstract

Background With a sustained national malaria incidence of fewer than one case per 1000 population at risk, in 2012 South Africa officially transitioned from controlling malaria to the ambitious goal of eliminating malaria within its borders by 2018. This review assesses the progress made in the 3 years since programme re-orientation while highlighting challenges and suggesting priorities for moving the malaria programme towards elimination.Methods National malaria case data and annual spray coverage data from 2010 until 2014 were assessed for trends. Information on surveillance, monitoring and evaluation systems, human and infrastructure needs and community malaria knowledge was sourced from the national programme mid-term review.ResultsMalaria cases increased markedly from 6811 in 2013 to 11,711 in 2014, with Mpumalanga and Limpopo provinces most affected. Enhanced local transmission appeared to drive malaria transmission in Limpopo Province, while imported malaria cases accounted for the majority of cases reported in Mpumalanga Province. Despite these increases only Vhembe and Mopani districts in Limpopo Province reported malaria incidences more than one case per 1000 population at risk by 2014. Over the review period annual spray coverage did not reach the recommended target of 90 % coverage, with information gaps identified in parasite prevalence, artemether-lumefantrine therapeutic utilization, asymptomatic/sub-patent carriage, drug efficacy, vector distribution and insecticide resistance.ConclusionsAlthough South Africa has made steady progress since adopting an elimination agenda, a number of challenges have been identified. The heterogeneity of malaria transmission suggests interventions in Vhembe and Mopani districts should focus on control, while in KwaZulu-Natal Province eliminating transmission foci should be prioritized. Cross-border initiatives with neighbouring countries should be established/strengthened as a matter of urgency since malaria importation poses a real threat to the country’s elimination efforts. It is also critical that provincial programmes are adequately resourced to effectively conduct the necessary targeted elimination activities, informed by current vector/parasite distribution and resistance data. More sensitive methods to detect sub-patent infections, primaquine as a transmission-blocking drug, and alternative vector control methods need to be investigated. Knowledge gaps among malaria health workers and affected communities should be identified and addressed.

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

“…Significant population migration between the Ehlanzeni District and neighbouring malaria-endemic regions, including Mozambique, Swaziland and Zimbabwe, was recently noted. 22 The increasing distribution and abundance of An. merus, coupled with a possible increase in the Plasmodium parasite reservoir, may lead to an increase in the incidence of locally acquired malaria in Mpumalanga Province, necessitating the exploration of new vector control strategies specifically directed against populations of this species.…”

High levels of imported asymptomatic malaria but limited local transmission in KwaZulu-Natal, a South African malaria-endemic province nearing malaria elimination

“…4 Clinton Health Access Initiative, Pretoria, Gauteng, South Africa. 5 Department of Medicine, University of California-San Francisco, San Francisco, USA. 6 Office of Malaria Research, South African Medical Research Council, Durban, KwaZulu-Natal, South Africa.…”

“…KwaZulu-Natal bore the brunt of the 1999/2000 malaria epidemic, reporting in excess of 40 000 cases and over 300 deaths in 2000 [5]. Drivers of the outbreak included the establishment of sulfadoxine-pyrimethamine resistant Plasmodium falciparum parasites [6,7] and the emergence of pyrethroid-resistant Anopheles funestus vector populations [8].…”

“…Since 2005, KZN has accounted for less than one percent of South Africa's malaria burden, with its three endemic districts, uMkhanyakude, King Cetshwayo and Zululand (Fig. 1b), achieving and maintaining very low transmission intensity status [12] since 2010 [5]. This, despite the regional upsurges in malaria cases in 2014 [13], and most recently in 2017 [2], when South Africa reported over 30,000 cases, the highest number of cases since the 1999/2000 epidemic.…”

A Seasonal Autoregressive Integrated Moving Average (SARIMA) forecasting model to predict monthly malaria cases in KwaZulu-Natal, South Africa

“…Limpopo presents the highest burden of malaria in SA, with an incidence ranging from 1.7 to 2.4 cases per 1 000 population at risk, while KZN has the lowest burden of disease (0.01 -0.10 cases per 1 000 population at risk). [1][2][3] SA aims to eliminate malaria by the year 2020 and prevent the resurgence of malaria transmission in subsequent years. [2] There is therefore a pressing need to develop robust and reliable predictive models that can strengthen the public health service in decision-making for effective targeted strategies to combat and eliminate malaria transmission.…”