Rolling back malaria

The MRC's Malaria Research Lead Programme plays a pivotal role in the malaria control component of the Lubombo Spatial Development Initiative. The effort has proved hugely successful, as the drop in malaria incidence reveals.

An area of unparalleled beauty, the Lubombo region encompasses the south of Mozambique, Swaziland's Lubombo mountains, the warm waters of the Indian Ocean and the northern part of KwaZulu-Natal.

It includes the St Lucia wetlands that became a world heritage site in December 1999, and the diving, snorkeling and fishing havens of Ponto da Ouro in Mozambique, and Kosi and Sodwana Bays in South Africa. The area also boasts six major interlinking ecosystems, and is internationally known for the diversity of its plant life, its excellent game reserves and for having some of the most extensive unspoilt coastline on the eastern seaboard of Africa. And it's an area being intensively developed through the Lubombo Spatial Development Initiative to become a globally competitive economic zone by boosting ecotourism and creating sustainable employment.

Yet, one disease stood in the way of plans becoming a reality: malaria (Latin for 'bad air'). It scared tourists from coming to the area, and also played havoc with worker turnout figures at the MOZAL aluminium smelter (the biggest aluminium smelter in the southern hemisphere).

So, in October 1999, the Lubombo malaria protocol and trinational malaria programme was launched, in which the MRC's Malaria Research Lead Programme fulfils a pivotal role. This includes chairing the regional management commission, and providing secretarial and financial management and research support.

The objective was to extend malaria control to Maputo Province, Mozambique, to reduce malaria in the border areas of South Africa and Swaziland and to develop a regional monitoring and evaluation system. The project was managed by the malaria control programme managers, public health specialists and scientists from the three countries who form the Regional Malaria Control Commission (RMCC): South Africa, Mozambique and Swaziland.

The programme has almost completed its fourth year of operation. Gains have been spectacular from a regional perspective. There has been a 90% reduction of malaria cases in KwaZulu-Natal, a 75% reduction in Mpumalanga, a 90% reduction in Swaziland and an 88% reduction in Zone 1, Maputo Province, southern Mozambique since the start of the operation.

"As a result of this success, the project is being viewed as the model for scaling up malaria control activities in southern Africa. It has also provided an opportunity for determining the cost of treatment of malaria patients as well as vector (mosquito) control. And, for the first time, the startup costs for introducing vector control into rural and peri-urban areas have been determined," says Dr Brian Sharp, director of the MRC's Malaria Research Lead Programme.

The control programme uses a multi-pronged approach: the mosquitoes are kept at bay by an extensive house-spraying programme. As a result of this, many previously highrisk areas are now nearly free of malaria. For instance, during the summer of 1999, over half of the tourist facilities in KwaZulu-Natal were in highrisk areas; currently, only about four percent are.

But all was not plain sailing. The spectre of drug and insecticide resistance raised its head, which resulted in an increase in malaria cases and deaths. But the introduction of a new malaria treatment (ACT, an artemisnin-based combination therapy), instead of the standard use of sulphadoxine/ pyrimethamine, decreased confirmed malaria cases and deaths by over 75% within one year of introduction. The incremental implementation of combination therapy to all sectors of the LSDI is co-ordinated by the University of Cape Town through the RMCC.

This map shows the reduction in malaria rates in the various regions.

Studies have shown high levels of resistance against pyrethroid, the insecticide most commonly used against the Anopheles funestus mosquitoes (the main carrier of the disease). This has caused a policy change: DDT in South Africa is now used under carefully controlled conditions, but in Mozambique carbamate insecticides are being used - also with great success.

"Ongoing studies are in place to determine the resistance of these mosquitoes to other insecticides and to evaluate rotational insecticide use," says Dr Sharp.

According to him, the success of the malaria control programme has had a very positive impact on the socio-economic development in the region, as well as in the quality of life of the local residents. The tourists are pouring into the region because one of the biggest tourist attractions in KwaZulu-Natal, Lake St Lucia, is now malaria free.

A worker sprays residual insecticides inside a house in order to control mosquitoes.

"The biggest reason for the success of this programme is the fact that the three regions collaborated so well, which was made possible by the excellent work of the malaria control programmes in each country and the support from governments and the private sector. Malaria doesn't recognise international borders," he says.

Initial funding for the project was provided by the South African Business Trust and continued co-funding was provided by the SA Department of Health, the MOZAL aluminium smelter, the SA Department of Science and Technology and the Mozambique Ministry of Health.

The successes achieved by the malaria control component of the LSDI was highlighted by the allocation of US$ 22 million from the Global Fund against AIDS, TB and Malaria; a fund set up to reduce the impact of these diseases in developing countries. The previous Environmental Affairs and Tourism Minister, Mr Valli Moosa, also announced a R432 million investment into ecotourism into the KwaZulu-Natal area. This marks the largest rural ecotourism boost yet for KwaZulu-Natal.