SUCCESS STORIES

SOUTH AFRICA: Comprehensive Program Battles Malaria on Several Fronts

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PROBLEM:

South Africa reduced malaria from a widespread health threat in the early 1930s to a well-controlled and rarely fatal disease restricted to portions of a few districts near the Mozambican border. However, cases began to rise again in the late 1980s, culminating in an eight-fold increase in malaria deaths in South Africa from 1996-1999. These epidemics were due to several factors, including increased irrigation, large numbers of people crossing the border from Mozambique, drug resistance (to chloroquine), and changes in mosquito behavior. In addition, growing numbers of South African households refused to comply with indoor residual spraying (IRS) using DDT, either by refusing entry or by replastering their walls once sprayed.

SOLUTIONS:

South Africa reversed the recent rise in malaria by using a comprehensive strategy that responded to problems as they arose and adjusted interventions appropriately. Success came primarily from combining IRS with effective antimalarial treatment using artemisinin combination therapy (ACT), which together reduced the reservoir of parasites in the local population. Second, programmers mapped every household in the malarious areas of the affected districts, linking this information with the health system database so every case of malaria could be traced to a house. Within two weeks, a team would spray houses of those who had come to the hospital with malaria, killing infected mosquitoes. Third, the program monitored resistance to insecticides, switching to DDT when deltamethrin was found to be ineffective. To increase compliance, deltamethrin was used in plastered and painted houses where DDT would have caused staining. Lastly, to reduce the number of infected people crossing the border into South Africa, the program expanded under the Lubombo Spatial Development Initiative (funded by The Global Fund for AIDS, Tuberculosis and Malaria), taking targeted IRS and treatment with ACTs to the bordering areas of Swaziland and southern Mozambique.

This combination of approaches reduced new cases of malaria in Swaziland and much of South Africa from 25 per thousand people to below five per thousand, and the percentage of people with malaria in Mozambique's southernmost region fell from 63% to 7.2%, an 88% reduction. In some of these areas, results nearly tripled the program's expectations: 100% of health facilities in southern Mozambique received an adequate supply of ACTs and 820,000 homes were sprayed with effective insecticides. Families are now spared weeks of debilitating illness and deaths of children and wage-earners, South African industries no longer lose thousands of productive work days, and the region can attract investment to further its economic growth.

LESSONS LEARNED:

A combined approach, along with effective management based on experience and sound technical evidence, was the key to success in the Lubombo Region. Effective monitoring allowed South Africa to respond to changes in transmission and household attitudes towards spraying to reduce the burden of malaria. Combining precisely targeted IRS with effective treatment achieved greater results at a lower cost than either approach could have done alone.

The South Africa example demonstrates the critical role of responsive management: a realization by health officials that they faced a complex problem with multiple causes, requiring a multi-faceted, integrated approach based on comprehensive and current information.

Useful references:

Le Seuer D, et al. 1995. Towards a rural information system. Case Studies from the South. International Development Research
Center, 1995.

Mabaso M, Sharp B, Lengeler C. 2003. Historical review of malarial control in southern African with emphasis on the use of
indoor residual house-spraying. Tropical Medicine & International Health, 9 (8) pp 846-856.

Results Profile: Lubombo Region, Rolling Back Malaria in Southern Africa. Friends of the Global Fight Against AIDS, Tuberculosis
and Malaria. February 2005.

Contacts for further details:

Dr. Brian Sharp
Director
Malaria Research Lead Programme
South African Medical Research Council
Durban, South Africa
Telephone +27 31 203 4700
Email: sharpb@mrc.ac.za

Dr. Rajendra Maharaj
Senior Specialist Scientist
Malaria Research Lead Programme
Medical Research Council,
Durban, South Africa
Telephone: +27 31 203 4700
Email: rajendra.maharaj@mrc.ac.za
111 Market Place, Suite 310
Baltimore, Maryland 21202
PH 410 659 6300
FAX 410 659 6266

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