Pasquale, Harriet Akello

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South Sudan Medical Journal   Vol 13. No 5. December 2020                                                                      174EDITORIALThe Ministry of Health of the Republic of South Sudan has just approved an ambitious 5-year National Malaria Strategic Plan 2020-2025 to control and prevent malaria, the third since South Sudan became an independent country in 2011. The launching ceremony on the 11th December 2020 was attended by senior officials of the Ministry of Health, the World Health Organization, UNICEF and malaria implementing partners. The Undersecretary of the Ministry of Health reiterated his government’s commitment to mobilise resources to combat malaria, despite the country’s economic hardship and immense natural disasters, which have triggered a call for humanitarian assistance for the population seriously affected by floods. This plan is different from previous ones because the selected effective interventions are based on evidence generated locally. These include: Seasonal Malaria Chemoprevention  (SMC)  based on the excellent results from a Médecins Sans Frontières (MSF) Spanish study which showed a reduction in disease burden and death in children; shifting to more enhanced pyrethroid insecticide and the synergist piperonyl butoxide (PBO) insecticide treated nets (ITN) based on local evidence of widespread vector resistance to pyrethroid use in conventional ITNs; and scaling up Indoor Residual Spraying (IRS) for the protection of vulnerable populations in Internally Displaced Persons (IDPs) and refugee camps to include large municipalities with a high disease burden. Finally, the strategy taps into the private sector domain through collaborative public-private partnerships in order to introduce and promote marketing of innovative personal protective tools such as repellents in a form of lotions and mosquito coils. This addresses the issue of residual transmission due to outdoor biting as a result of possible change of mosquito behaviour driven by the South Sudanese culture of staying outdoors much of the night. This strategy has bold and ambitious goals to reduce malaria morbidity and mortality by 80% from the 2019 levels and to reduce the malaria parasite prevalence by 50% from the 2017 levels. The plan has six main objectives to achieve by 2025:1. To strengthen and sustain the management and coordination capacity of the malaria programme at all levels; 2. To protect 80% of the population at risk by recommended malaria prevention methods; 3. To achieve 100% parasitological diagnosis and treatment of all presented malaria cases according to the national guidelines; 4. To increase to at least 80%, community and health worker knowledge, attitudes and practices on malaria prevention and control; 5. To strengthen malaria emergency preparedness and ensure timely malaria control responses in all communities affected by conflict, natural disaster or epidemics; 6. To ensure 80% of health facilities routinely report on core malaria indicators.  The implementation of this plan will be done through a multi-sector approach, with focus on community-based interventions, derived by scaling up of the community based health system called the Boma Health Initiative (BHI) to improve access to interventions. To have sustainable interventions, the overall implementation of this plan will be based on Three principles: One country strategy, One coordinating authority – the National Malaria Control Programme (NMCP), and One monitoring and evaluation framework. It will be mainly driven and owned by the government, which is expected to invest more in health with increased support for malaria control and prevention. While partners are encouraged to mobilise additional resources to compliment government efforts, they are expected to align their plans to this strategic plan and use the one malaria monitoring and evaluation framework to track progress and the one coordination mechanism lead by the National Malaria Control Programme. Regular reviews and studies will be conducted to monitor progress, to evaluate the impact of interventions and to generate evidence to support policy change. We invite all potential donors, interested implementing partners, both national and international Non-Governmental Organizations, the private sector, and other government line ministries to support the implementation of this malaria strategic plan.South Sudan’s New National Malaria Strategic Plan 2021-2025 is a Game ChangerDr. Harriet Akello PasqualeDirector National Malaria Control Program, National Ministry of Health, Republic of South SudanEmail: harrietpasquale@gmail.com 

South Sudan’s New National Malaria Strategic Plan 2021-2025 is a Game Changer

The whole of South Sudan is endemic for malaria, with high transmission in the country throughout the year. Malaria is the leading cause of illness and death in children under five years. In 2019, the malaria incidence (all ages) was estimated at 246 per 1,000 populations (239 per 1,000 for children under-five -years) representing 5,067,464 cases.



Vector control is a key intervention for malaria prevention with Insecticide Treated Nets (ITN) being the main method used by the population. Chemoprevention for malaria for pregnant women is mainly administered through ante-natal clinics. Seasonal malaria chemoprevention is a new strategy that South Sudan has just piloted in Yambio.



By 2014-2019, 6,397,512 ITNs had been distributed. However, the 2017 Malaria Indicator Survey showed that only about 41.7% of children aged under five years had slept under an ITN the previous night, and that only 27% of households owned at least one ITN for every two people. There has been increases in the percentage of pregnant mothers receiving 2 doses of Intermittent Preventive Treatment in Pregnancy (IPTp2).



It is recommended that the Ministry of Health train entomologists and technicians for vector surveillance, and that the National Malaria Programme conduct entomological surveillance and insecticide resistance monitoring and create stratification maps using entomological data

Harriet Akello Pasquale

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Malaria Prevention Strategies in South Sudan

The whole of South Sudan is endemic for malaria, with high transmission in the country throughout the year. Malaria is the leading cause of illness and death in children under five years. In 2019, the malaria incidence (all ages) was estimated at 246 per 1,000 populations (239 per 1,000 for children under-five -years) representing 5,067,464 cases. Vector control is a key intervention for malaria prevention with Insecticide Treated Nets (ITN) being the main method used by the population. Chemoprevention for malaria for pregnant women is mainly administered through ante-natal clinics. Seasonal malaria chemoprevention is a new strategy that South Sudan has just piloted in Yambio. By 2014-2019, 6,397,512 ITNs had been distributed. However, the 2017 Malaria Indicator Survey showed that only about 41.7% of children aged under five years had slept under an ITN the previous night, and that only 27% of households owned at least one ITN for every two people. There has been increases in the percentage of pregnant mothers receiving 2 doses of Intermittent Preventive Treatment in Pregnancy (IPTp2). It is recommended that the Ministry of Health train entomologists and technicians for vector surveillance, and that the National Malaria Programme conduct entomological surveillance and insecticide resistance monitoring and create stratification maps using entomological data.
Key words: malaria prevention, South Sudan, Insecticide Treated Net (ITN), vector control, Intermittent Preventive Treatment in&nbsp; Pregnancy (IPTp)

                               Vol 13. No 5. December 2020  South Sudan Medical Journal 187MAIN ARTICLEIntroductionThe whole of South Sudan is endemic for malaria, with high transmission in the country throughout the year. Malaria accounts for about 66.8%  of all health facility visits in the outpatient departments 30% of all hospital admissions and 50% of all cause of deaths in the hospitals.  Malaria is the leading cause of illness and death in children under five years.[1]  Malaria transmission is all year-round, peaking at the end of the annual rainy season from June to November. Transmission is higher in the southern parts of the country compared with the northern parts.[2]In 2019, the malaria incidence (all ages) was estimated at 246 per 1,000 populations (239 per 1,000 for children under-five -years) representing 5,067,464 cases. This was significant increase (43%) from 2013 when incidence stood at 171 per 1,000 populations.[4] Over this same period, malaria mortality (all ages) increased marginally from 45 per 100,000 to 49 per 100,000 population - Health Management Information Systems (HMIS) reports.[3]Vector control is a key intervention for malaria prevention in South Sudan. Long lasting insecticidal nets (ITNs) are the main method used by the population. Indoor residual spraying and larval source management including larviciding are used on a limited scale mainly in refugee camps and camps hosting internally displaced persons. In addition, South Sudan also implements malaria Malaria Prevention Strategies in South SudanHarriet Akello PasqualeDirector, National Malaria Control Program National Ministry of HealthRepublic of South SudanCorrespondence:Harriet Akello Pasquale harrietpasquale@gmail.com Submitted: November 2020 Accepted: December 2020 Published: December 2020Citation:Pasquale. Malaria Prevention Strategies in South Sudan. South Sudan Medical Journal 2020; 13(5):187-190 © 2020 The Author (s) License: This is an open access article under CC BY-NC-NDAbstractThe whole of South Sudan is endemic for malaria, with high transmission in the country throughout the year. Malaria is the leading cause of illness and death in children under five years. In 2019, the malaria incidence (all ages) was estimated at 246 per 1,000 populations (239 per 1,000 for children under-five -years) representing 5,067,464 cases.Vector control is a key intervention for malaria prevention with Insecticide Treated Nets (ITN) being the main method used by the population. Chemoprevention for malaria for pregnant women is mainly administered through ante-natal clinics. Seasonal malaria chemoprevention is a new strategy that South Sudan has just piloted in Yambio.By 2014-2019, 6,397,512 ITNs had been distributed. However, the 2017 Malaria Indicator Survey showed that only about 41.7% of children aged under five years had slept under an ITN the previous night, and that only 27% of households owned at least one ITN for every two people. There has been increases in the percentage of pregnant mothers receiving 2 doses of Intermittent Preventive Treatment in Pregnancy (IPTp2).It is recommended that the Ministry of Health train entomologists and technicians for vector surveillance, and that the National Malaria Programme conduct entomological surveillance and insecticide resistance monitoring and create stratification maps using entomological data.Key words: malaria prevention, South Sudan, Insecticide Treated Net (ITN), vector control, Intermittent Preventive Treatment in Pregnancy (IPTp).South Sudan Medical Journal   Vol 13. No 5. December 2020                                                                      188MAIN ARTICLEchemoprevention for special vulnerable populations such as pregnant mothers and children under five years of age.ITNs are distributed through mass campaigns conducted every three years. The mass campaigns target all households in the whole country. To complement the mass campaigns and ensure that they are always available in the community, ITNs are also distributed through other continuous distribution channels. These include through the Expanded Programme of Immunization (EPI) at the time a child receives her third dose of pentavalent vaccine, through a woman’s first visit to the ante-natal clinic (ANC)  and through emergency distribution whenever there is displacement of populations.Chemoprevention for malaria (Intermittent Preventive Treatment in Pregnancy - IPTp) in pregnant women is mainly administered through ANCs. All pregnant women (except those allergic to sulpha components, or on cotimoxazole for HIV IO prophylaxis) are given at least 3 doses of Sulphadoxine Pyremethamine starting from the second trimester. Seasonal malaria chemoprevention (SMC) is a new strategy that South Sudan has just piloted in Western Equatoria state in Yambio[5]). SMC targets children aged 3 to 59 months who receive a complete treatment of antimalarial drug on a monthly basis for 4 to 5 months during the peak malaria transmission using a combination of Sulphadoxine Pyremethamine and Amodiaquine. SMC is now included in our malaria prevention strategy in the new National Malaria Strategic Plan 2020 – 2025 - see Editorial and figure 4. Early access to a prompt and effective malaria diagnosis and treatment within 24 hours of onset of treatment can interrupt malaria transmission. Malaria Case management is also a core malaria intervention in South Sudan. Malaria Parasitological diagnosis is mainly done using rapid diagnostic test at all health case levels. Microscopy is used mainly in major hospitals and Primary Health care centres. However, 50% of cases are still clinically diagnosed. Malaria RDT testing is rolled out at the community level to improve patient care by community health workers. Malaria is treated using an artemisinin combination treatment. The first line treatment for malaria in South Sudan is Artesunate Amodiaquine, Dehydroartesunate piperaquine is an alternative treatment used mainly in private health facilities. Arthemether Lumefantrine is the second line treatment for malaria. Severe malaria is mainly treated with artesunate injection for during the critical stage of illness and as soon as the patient recovers, the treatment is completed with a full cause of Artesunate amodiaqune or Arthemether lumefantrine. Other drugs used for treating severe malaria are Quinine and Arthemether injections.[6]Despite the universal coverage in ITNs and usage of Indoor Residual Spraying (IRS) in targeted areas of South Sudan, the scale up of malaria diagnosis and treatment, current evidences show that these core interventions have not had significant impact to interrupt malaria transmission. Malaria incidence continue to rise from 171 per 1000 population in 2013 to 251 per 1000 population in 2019. [2,4] The number of recorded malaria deaths also increased from 1,321 deaths in 2013 to 4,873 in deaths in 2019. This has called for a need of exploring other innovative interventions to complement the core intervention. The new malaria strategic plan is an opportunity to do things differently.Figure 1. South Sudan Trends of malaria transmission (HMIS report 2015-2019 [2,4])Figure 2. South Sudan Malaria Epi map 2017 from Malaria Indicator Survey prevalence data                               Vol 13. No 5. December 2020  South Sudan Medical Journal 189MAIN ARTICLEMain AchievementsBy 2014-2019, 6,397,512 ITNs had been distributed. The Malaria Strategic Plan (MSP) of 2014/15-2020/21 (revised in 2017) targeted 85% of under-five-year-old children to sleep under a net, and 95% ownership of at least one net per household.[7] However,  the 2017 Malaria Indicator Survey (MIS),[2] showed that only about 41.7% of children aged under five years had slept under an ITN the previous night, that only 27% of households owned at least one ITN for every two people. There were no gains in ITN coverage as the percentage of pregnant women who slept under an ITN the previous night stayed flat at 50% and 51% in 2013 and 2017 respectively.[2, 4]The MSP targeted 5% of the  population on to be protected by IRS in the past 12 months, but the MIS 2017 did not capture any IRS indicator to assess progress of implementation.  However, the Mentor Initiative has conducted IRS in a few selected areas in  PoCs (Protection of Civilians) in Bentiu and Malakal and refugee camps in Maban and Jamjang and in the host communities of Bunj and Maban. The insecticide used currently is Actellic. There was an increase from 25.8% in 2013 to 56.6% 2017[2,4]  in the percentage of pregnant mothers receiving two doses of Intermittent Preventive Treatment in Pregnancy (IPT2) and ITN distribution through routine ANC.  Figure 3. Malaria Intervention coverage [2,4]There was an increase in the uptake of IPTp3+ (IPTp3 or more doses)  among pregnant women during the implementation period: A total of 2,740,000 doses were distributed between 2014 to 2019 through the focused antenatal care as part of the IPTp package for malaria prevention during pregnancy. There was close collaboration between the National Malaria Control Programme (NMCP) and the Reproductive and Maternal Health services to ensure optimum uptake of IPTp3+. Midwives from the public sector were trained to promote and provide IPTp3+ services.The policy guidelines for the implementation of the malaria vector control guidelines were developed. Annual assessments, mapping and larviciding of breeding sites during the dry season in PoCs (Malakal and Bentiu) and refugee camps (Maban) were done by trained community workers through a collaborating partner.Challenges and recommendationsChallenges include:• Measurement of entomological impact indicators was not planned during the 2014-2020 malaria strategic plan. Entomological surveillance and insecticide resistance monitoring were planned but not implemented. As such it is not possible to adequately assess the impact of the vector control interventions implemented in South Sudan• Limited capacity (human and infrastructure) for entomological impact assessments. A few entomology technicians have been trained but they are not adequately resourced to conduct simple entomological surveillance.It is recommended that:• The Ministry of Health engage and/or train Figure 4. Launch ceremony for the new National Malaria Strategic Plan 2021 - 2025 at the Ministry of Health (Source: WHO South Sudan)South Sudan Medical Journal   Vol 13. No 5. December 2020                                                                      190MAIN ARTICLEentomologists and technicians for sentinel sites or county level to facilitate vector surveillance, and the monitoring and evaluation of vector control activities in a timely manner.• The National Malaria Programme should conduct entomological surveillance and insecticide resistance monitoring and create stratification maps using entomological data.• The Ministry of health should explore scale up implementation of other vector control intervention such as IRS, larviciding and environmental management among others to prevent the spread of insecticide resistance from the widely used pyrethroid treated ITNs especially in areas where no impact has been documented with ITN aloneReferences1. Integrated Disease Surveillance and response (IDSR) and DHIS-2 data 2019   2. South Sudan Malaria Indicator Survey 2017. 3. Health Management Information Systems (HMIS) reports - 2015-20194. National Malaria Control Programme. Malaria Indicator Survey 2013 5. Médecins Sans Frontières Operational Centre Brussels. Seasonal Malaria Chemoprevention study Draft report6. South Sudan malaria case management Guidelines and training manual Republic of Sudan Federal Ministry of Health Directorate of Preventive Health Services. Malaria Case Management Training Manual, Part I  Learner’s Guide; Part II Tutor’s Guide. New Version7. Ministry of Health, Republic of South Sudan, South Sudan Malaria Control Strategic Plan 2014/16- 2021/22. Ministry of Health, Republic of South Sudan, Health Sector Development Plan 2012-2016.Malaria ResourcesPreventive malaria treatment among school-aged children in sub-Saharan Africa: a systematic review and meta-analysesCohee et al. Lancet October 2020  DOI: https://doi.org/10.1016/S2214-109X(20)30325-9 The burden of malaria infection in sub-Saharan Africa among school-aged children aged 5–15 years is underappreciated and represents an important source of human-to-mosquito transmission of Plasmodium falciparum. Additional interventions are needed to control and eliminate malaria. We aimed to assess whether preventive treatment of malaria might be an effective means of reducing P falciparum infection and anaemia in school-aged children and lowering parasite transmission.Preventive treatment of malaria among school-aged children significantly decreases P falciparum prevalence, anaemia, and risk of subsequent clinical malaria across transmission settings. Policy makers and programme managers should consider preventive treatment of malaria to protect this age group and advance the goal of malaria elimination, while weighing these benefits against potential risks of chemoprevention.Back to school for malaria prevention: a new tool in the era of malaria elimination?Eijk and Hill Lancet October 2020 DOI: https://doi.org/10.1016/S2214-109X(20)30347-8Children aged 5–15 years predominantly have the highest risk of asymptomatic malaria and gametocytaemia, and yet low use of long-lasting insecticide treated nets, which puts them at risk. …Currently, there is no WHO recommendation for malaria prevention among school children in sub-Saharan Africa. The systematic review by Lauren Cohee and colleagues offers the first comprehensive review and meta-analyses of the effects of different prevention strategies on outcomes in school children. The results deserve review by policy makers to identify what further evidence is needed before recommending school-based malaria programmes, and discussion with national programmes on how school-based strategies might be funded and implemented.  Importantly, malaria preventive strategies in schools will have health and educational benefits for children and can also contribute to reductions in community transmission. That is a goal worth fighting for.

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South Sudan’s New National Malaria Strategic Plan 2021-2025 is a Game Changer

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