Effect of artemether-lumefantrine policy and improved vector control on malaria burden in KwaZulu-Natal, South Africa

Between 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

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

BACKGROUND: Between 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 FINDINGS: We 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%. CONCLUSION: Together 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

Seven years of regional malaria control collaboration--Mozambique, South Africa, and Swaziland.

The Lubombo Spatial Development Initiative is a joint development program between the governments of Mozambique, Swaziland, and South Africa, which includes malaria control as a core component of the initiative. Vector control through indoor residual spraying (IRS) was incrementally introduced in southern Mozambique between November 2000 and February 2004. Surveillance to monitor its impact was conducted by annual cross-sectional surveys to assess the prevalence of Plasmodium falciparum infection, entomologic monitoring, and malaria case notification in neighboring South Africa and Swaziland. In southern Mozambique, there was a significant reduction in P. falciparum prevalence after the implementation of IRS, with an overall relative risk of 0.74 for each intervention year (P < 0.001), ranging from 0.66 after the first year to 0.93 after the fifth intervention year. Substantial reductions in notified malaria cases were reported in South Africa and Swaziland over the same period. The success of the program in reducing malaria transmission throughout the target area provides a strong argument for investment in regional malaria control

Number of Notified Malaria Cases in KwaZulu–Natal by Month (January 1993–December 2003)

<p>The number of cases is given in relation to season (peak transmission from January to May, inclusive) and timing of significant malaria control interventions: <i>A</i> indicates reintroduction of DDT for IRS of traditional structures in KwaZulu–Natal in March 2000; <i>B</i> indicates introduction of IRS in southern Mozambique in October 2000; and <i>C</i> indicates implementation of AL as first-line treatment of uncomplicated <i>falciparum</i> malaria in KwaZulu–Natal in January 2001.</p

Scatter Plot of Individual Patient Gametocyte Densities

<p>The gametocyte densities (per microlitre) are given over time following treatment with SP (2000) and AL (2002).</p

Map of Umkhanyakude District, Northern KwaZulu–Natal, South Africa

<p>The map indicates the following: the malaria risk by section and the four sentinel facilities for malaria morbidity and mortality review (Ndumo clinic, and Mosvold, Manguzi, and Bethesda rural district hospitals); the communities selected for the household (HH) survey and FGDs; and the Manguzi district hospital where sentinel safety surveillance and Ndumo Clinic where the SP (2000) and AL (2002) in vivo therapeutic efficacy studies were conducted.</p