How do we tackle malaria in South Africa?

A FEEDING female Anopheles stephensi mosquito on a skin surface, in the process of obtaining its blood meal through its sharp, needle-like labrum, which it has inserted into its human host. Ugandan Brian Gitta, 25, last year won a prestigious engineering prize for a non-invasive malaria test kit that it is hoped will be widely used across Africa. James Gathany CDC AP File

Malaria has plagued mankind for millennia and dates back to 3200 and 1304 BC- where evidence of the disease was found in Egyptian remains. Malaria was a leading cause of death in traders and settlers to Africa in the late 1400s and early 1500’s and the disease was referred to as the Killing fever. It was only in 1880 that a French army doctor – Lavern identified the parasite responsible for malaria and in 1897 a British Surgeon-Major Ronald Ross, made the association that malaria is transmitted by mosquitoes. In South Africa the first documented case of malaria was around 1836-1837, during the time of the Trek to Maputo- Mozambique.

Malaria continues to reign in many parts of the World, in the World Health Organisation’s 2018 Malaria Report malaria cases decreased globally from an estimated 239 million in 2010, to 217 million in 2016, a decline of 9%. Most cases in 2017 were estimated to have occurred in the WHO African Region (92%), followed by the WHO South-East Asia Region (5%) and the WHO Eastern Mediterranean Region (2%).

In the SADC (Southern African Development Community) region, the WHO estimates that three-quarters of the population is at risk of contracting malaria, with 35 million of these being children under five years of age and approximately 8.5 million being pregnant women. The level of Malaria transmission varies from highly endemic to stable all year-round.

Whilst many parts of Africa have a high burden of malaria, some Southern African countries including South Africa report relatively lower numbers. South Africa has made steady progress in reducing malaria morbidity and mortality over the past decades. Malaria cases have decreased by 73%: from 64,622 cases in the year 2000 compared to 17625 cases in the year 2018, and malaria deaths have also decreased by 74%, from 459 to 116 deaths between 2000 and 2018. The majority of the locally transmitted cases occur in the Limpopo Province – mainly in the Vhembe and the Mopani Districts with the lowest burden province being Kwazulu- Natal.

The key challenges that South Africa faces to sustaining its control programme and eliminating the disease are varied. These challenges can be categorised as technical financial and operational. On the technical front, movements of persons into and outside South Africa from neighbouring countries and from non-endemic to endemic parts poses a threat to local transmission of the disease. In addition, malaria teams are often baffled by transmission in areas where all the mosquito vector suppression strategies are in place.

This begs the questions as to where are these cases arise from? Human behaviour for prevention and treatment of malaria is also cause for concern.  This stems from mainly the issue of prevention of mosquito breeding, mosquito avoidance and presenting themselves to the clinics when malaria signs and symptoms manifests.

With regards to ensuring adequate resourcing for malaria interventions, provinces are often above budget for rendering effective services. This is by no fault of their own, as malaria outbreaks and epidemics do from time to time occur at localised levels in the malaria affected provinces of South Africa. Thus requiring additional resources to be mobilised at short notice. Funding malaria programmes are not only required for implementation efforts but also for implementation science to monitoring the effectiveness of interventions.

South Africa justifiably, relies very strongly on mosquito vector control to ensuring that the preventive aspects of the programme is addressed, however adequate coverage of this intervention is often times threatened due to older technologies. Coupled with this, coverage of screening and treatment components of the programme is often times hindered by increased population movements into the country and undocumented migrants that do not seek treatment early.

The key issues to tackling malaria effectively in South Africa will be source reduction both from within and outside the country. In this regard, South Africa is undertaking screening and treatment in hotspot municipalities and localities, moreover there is strong collaboration with Mozambique and Eswatini to control malaria at the source.

The National Treasury has made additional resources available to bolster provincial efforts to tackling malaria in South Africa. This is in line with “Zero Malaria Starts With Me” a continent-wide Campaign which seeks to mobilise resources and recognize global efforts to control malaria and also highlight the need for continued investment and sustained political commitment for malaria prevention and control.

This Campaign is co-led by the African Union Commission and the RBM Partnership to End Malaria, and supported by African leaders to get more people involved in the fight against the disease that kills over 400,000 Africans every year. Implementation research is ongoing to determining where the sources of local transmission and innovative approaches to tackling malaria mosquito control. Coupled with this, there is transmission blocking drugs that are being rolled out to prevent onward transmission from persons to mosquitoes. The other key intervention is educating communities at risk and travellers South Africa has set a target of finding at least 160 000 undiagnosed patients in each financial year on improving prevention and treatment seeking behaviours.

Malaria is a life-threatening disease caused by parasites that are transmitted to people through the bites of infected Anopheles mosquitoes, which generally bite at night. Malaria is preventable, treatable and curable. Everyone in malarious areas is at risk of contracting malaria, but there are some higher risk groups including, children under five years of age, pregnant women, people with compromised immune systems, travellers from non-endemic areas and immigrant workers.

If not diagnosed and treated within 24 hours, malaria can progress to severe illness and death. Travellers from non-endemic areas to malaria endemic areas and countries are vulnerable to the disease and need to take preventative measures. Malaria symptoms appear within 10-15 days after the infective mosquito bite.

The symptoms include, fever, headache, chills and vomiting. Early malaria diagnosis and treatment reduces disease severity and prevents deaths. If persons suspect that they have malaria, they should immediately consult their health care provider to be tested and treated. Individuals are therefore advised to take personal protection methods when visiting malaria endemic areas within and outside South Africa.

Dr Yogan Pillay is the Deputy Director General for Communinicable and Non-Communicable Diseases, Prevention, Treatment and Rehabilitation at the National Health Department.