Vector-Borne Malaria Control in the Republic of South Africa - Article Example

Vector-Borne Malaria Control in the Republic of South Africa Name Institution Epidemiology Malaria occurs in 108 countries that are home to about 3 billion people globally (White et al., 2014). Although preventable, treatable and curable, it is still very deadly, causing about 584,000 deaths out of approximately 198 million reported incidences in 2013 alone (WHO, 2015). These are mostly from Africa where approximately 90% of all deaths occur (Blumberg et al., 2014). In South Africa, 95% of the infections are linked to Plasmodium Falciparum, from the vector Anopheles Arabiensis mosquito (Maharaj et al., 2012). The main risk groups are young children below 5 years and expectant women, although it affects virtually anyone (Khosa et al., 2013). It is however restricted mainly to low altitude border areas below 1,000 m above sea level, specifically in three provinces of Kwa-Zulu Natal, Limpopo and Mpumalanga (Moonasar et al. 2012). There is limited transmission in other areas but about 10% of all people residing in the malaria-endemic regions are always at risk (Maharaj et al., 2012). The Country’s Malaria Control South Africa has an old anti-malaria programme that seeks to eliminate malaria transmission to zero by 2018 (Maharaj et al., 2013). According Blumberg et al. (2014), it has however managed to progressivel y neutralize the problem. Long-term funding and political commitment has ensured much success as the government has sought to break the transmission cycle by strengthening active surveillance, application of molecular tests, monitoring any insecticide or drug resistance, advocacy and strengthening of cross-border initiatives. Malaria morbidity and mortality in South Africa has generally been on a decline to the extent it is now possible to talk of malaria elimination. As from 1980 and 1987, chloroquine-resistant plasmodium led to a lot of failures in chloroquine treatment leading to a policy change in relation to drugs. SP was henceforth used as a first-line drug but in 1999/2000, this was also becoming obsolete (Morri et al., 2013). Maharaj et al. (2013) explain that due to sustained efforts, annual cases have been maintained a less than 10,000 for a while unlike other African countries where malaria is always at extreme proportions. There were for instance 8,750 in 1995. However, because of noted drops in treatment and insecticide efficacy, the number of cases and subsequent deaths rose sharply as from 1996 to their peak in 2000, which They present graphically: Fig.1. Reported Malaria-related Cases and Deaths in South Africa (1995 – 2011) In 1996, there was a 67% increase on the 1995 figure, then more than 60,000 cases and 400 deaths in 2000. The increase in number of deaths in that duration is linked to the drop in efficacy of sulphadoxine-pyrimethamine (SP) as a drug. This was followed by introduction of a more effective treatment, Artemisinin Combination Therapy (ACT). The fight against malaria also became a regional collaborative issue, leading to a steady decline to 26, 506 during 2001 and further below 10,000 as at 2011 (Maharaj et al. (2013). Current Disease Control Strategies The South African ministry spearheads the malaria control effort with national guidelines usually in line with guidelines from global agencies such as the CDC and WHO. According to Khosa et al. (2013) interventions applied include: a. Insect-treated Nets (ITNs) There are Long-Lasting Insecticidal Nets (LLINs) which are often given out in public health programmes. The government recommends such usage by all people who are at risk and in most living settings. It is hoped that everyone sleeps under an LLIN every night b. Indoor Residual Spraying (IRS) This involves the use of insecticides in killing mosquitoes and therefore malaria transmission. The IRS strategy goes hand in hand with focal larviciding as part of its vector control. Carbamaes, deltamethrin and DDT are the chemicals used in South African IRS c. Health Promotion This is used in influencing people’s behavior towards both curative and preventative elements of malaria control. For prevention, it is ensured that communities adopt what they are taught by spray operators in the course of IRS campaigns, especially with regard to taking preventive personal measures to avoid being bitten. On cure, health promotion strategies assist communities to identify the disease’s symptoms and signs and go for treatment as early as possible. Channels used include radio, sports and community events d. Case Management Diagnosing and treating of malaria is offered for free in all public health facilities. There has also been initiation of Rapid diagnostic tests (RDTs), while suspected cases of malaria are identified using either them or microscopy. Every positive case is recommended for treatment within a day and there is prescription of treatment only when a case has been confirmed rather than presumptively. ACTs are used in handling simple cases as a policy issue e. Cross-Border Malaria Initiatives Because the disease is mainly found along borders, the government has opted to work with neighboring countries in two main initiatives. The Lubombo Spatial Development Initiative brings together Swaziland, South Africa and Mozambique governments in helping the shared region of Lubombo to become more economically developed. The idea is that eliminating malaria will lead to more tourism hence development of the area. The Trans-Limpopo Malaria Initiative (TLMI) on its part seeks malaria reduction in the Limpopo province of South Africa and Matabeleland South Province of Zimbabwe through harmonizing strategy and synchronizing malaria interventions f. Intermittent Preventive Treatment (IPT) This is a complete therapeutic administration of anti-malarial drugs on expectant women during prenatal visits whether or not infected. It takes the form of sulfadoxine-pyrimethamine that is provided for all women in areas of between moderate and high malaria incidence. It is given periodically all through pregnancy except in the first trimester Additional Strategies to Improve Vector Control Biological Measures Where possible, biological control should be taken up. According to Ghosh et al. (2005), this involves use of parasites or parasitoids, pathogens or predators in the maintenance of reduced density of some other organism. There is the trend towards use of bio-control agents instead of chemical insecticides because of the latter’s residual effects, increased resistance to insecticides, reduced popularity of indoor sprays and high prices of chemical sprays. Kamareddine et al. (2012) observe that larvivorous fish are one of the most advocated measures in dealing with mosquitoes for instance. Direct Observed Therapy (DOT) At the moment, availability of malaria drugs is very easy. Although this ensures that treatment is easier, it implies more improper use of medicines for instance through taking inadequate or erratic dosages. According to Morri et al. (2013), this in turn leads to drug pressure which is unnecessary and therefore resistance of parasites. To avoid this, potential drug sellers could be trained on advising customers about dosages and even monitoring drug intake. This sort of approach has been successfully used in Tuberculosis control, especially the drug resistant variety. Alternatively, there can be withdrawal of potential drugs so that they can no longer be sold over the counter but rather found only in health facilities. This is a better option as it will not have any direct financial cost implications. Integrated Vector Management (IVM) IVM will go beyond just integrating the other interventions that are in place and have been successful so far, instead emphasizing strategies that will make malaria control compatible with the South African health system. It will incorporate decision-making that will be founded on institutional and human resources while engaging communities in the promotion of its sustainability. It will encourage an integrative and multi-disease approach while promoting a systematic use of different interventions which will be in synergy and in combination with one another (Matthews, 2011). Malaria has a close link to poverty and can be dealt with through further investment in the improvement of the local environments, education of populations within the affected areas and active engagement of communities. There will be ensuring of support to community participation within malarial areas, building of technical capacity and establishment of guidelines to educate and inform all participants. The insecticides used in malaria control definitely pose a risk to both the environment and human health so an integrated approach to disease control would be best founded on ecological and social practices while utilizing local resources. Such a strategy will seek to diversify the methods used in malaria control and reduction of reliance on pesticides (Matthews, 2011). The combination of interventions that are well-adapted to local situations is important in ensuring that malaria control is sustainable. The effectiveness of non-pesticidal control will start with an understanding of the disease’s epidemiology. This in turn relies on various factors for instance people’s behavior and distribution, local vector ecology and biology and environmental conditions within target areas. Implementation of IVM IVM combines the various interventions to create a better, systematic mosquito control. According to Radcliffe et al. (2008), its two main features are: i. Contextual characteristic. It will come up with combinations of interventions that include IRS and ITNs according to local epidemiological and ecological conditions ii. Cost-effectiveness as the central decision making criterion. There is a great emphasis on community participation and awareness In implementation therefore, the local situation will be well analysed so that the interventional strategy will be holistic and appropriate to the available vectors and conditions. It will offer a basis for a gradual reduction of intensive pesticide use, application of non-pesticide interventions and restriction of insecticides only to emergencies (Matthews, 2011). It will offer a holistic strategy that will address local socio-economic, ecological, cultural and political factors so that the general health and living conditions of locals will be enhanced while simultaneously protecting biodiversity and the environment, promoting sustainable development and boosting poverty reduction and rural development. In this regard, its objectives will be: Effective reduction of pathogen transmission and adult populations of vectors Having interventions that are environmentally, politically, economically, ecologically and socially acceptable Having management strategies which do not have negative side effects such as drug resistance or environmental degradation Having an understanding of the transmission cycles, life patterns and natural forces regulating the existence of vectors Flexibility in the ability to change tools and strategies with biological and surveillance data The IVM strategy implementation framework will go beyond just the health sector to include multiple stake-holders. Success will be ensured through continuous legislation, monitoring and evaluation which will be subject to a lot of concerted action and commitment by the government and international bodies such as the WHO which has so far been very active (Morri et al., 2013). Like in the other interventions that have so far shown success, it will heavily rely on the understanding of ways in which environmental factors impact on the various mosquito species and the most effective ways of reducing contact between human beings and the vectors, the survival of vectors and the amount of pathogen transmission. It will set out decision-making criteria, principles, targets and time-frames that will be then incorporated in national health-related policies that will in turn be supported by regulations and legislations (Radcliffe et al., 2008). Luckily, only almost 10% or 4.9 million South African residents are in the malaria-prone areas therefore the target group will be relatively manageable (Maharaj et al., 2012). The underlying aspect in his proposition is that while the various techniques are applied well in mosquito control, programmatic approaches need to be linked to information about behavior and ecology of species, mosquito surveillance and health system data relating to malaria. Once this is done, there should be stable funding of mosquito control measures and more initiatives that will help to leverage mosquito control support by both community and government entities (Radcliffe et al., 2008). A Personal view on IVM as a Strategy IVM will be an improvement on the current interventions. This is because it will incorporate more collaboration with other stakeholders such as ministries, local communities and public health legislative and regulatory frameworks (Matthews, 2011). The most significant lesson that has been learnt from the South African case is that there is need for maximum government input into any strategy for success in malaria transmission reduction. Such cooperation however needs to include even more parties hence the viability of IVM. IVM has been around for a while, having been successfully used in western countries to control mosquitoes. Its operations are supposed to protect communities from both vector and non-vector mosquito species (Whittaker & Chancellor, 2014). Just like in many other nations, the IVM approach in South Africa faces challenges such as inadequate capacity building, lack of clear role definition in legislative and advocacy and a general absence of inter-sectoral linkages in the health sector (Maharaj et al., 2012) hence the need to start creating them for the benefit of future generations. The traditional approaches have not been fully effective in ensuring success. In South Africa, they have sought to emphasize vector control as the main goal and mostly applied IRS and/or ITNs (Morri et al.2013). I believe that when IVM is combined with effective malaria treatment and vector control, it is likely to cause a significant progress in the fight against malaria at less social cost. Emphasizing it as an approach is therefore likely to be more cost effective than the typical single-intervention control measures applied on malaria. An IVM will offer some advantages. First is its acceptability. According to Radcliffe et al. (2008), the aspect of participation is likely to ensure more commitment to the fight against the disease. This is because there will be a greater feeling of ownership and therefore belonging to the efforts. It will also be able to utilize the knowledge and expertise of a variety of people. Its cost is also minimal because it will simply involve the marshalling of already existing physical, human and financial resources, while reducing degradation and maximizing use of the environment. Its cost implication will in this view amount to simply the usual cost of a malaria control campaign, but with greater impact. IVM has been proven to have a positive impact. According to Whittaker et al (2014), there is documented success from Dar es Salaam, Tanzania during the late 1980's and into the 1990's when IVM components were used b the government in malaria control. There was also an observed reduction in rates of sporozoite prevalence and malaria incidence in Nigeria when various environmental management practices such as drainage and source reduction were implemented. In Zambia, towns that had a lot of vector-related transmission due to disturbed land from copper mining reported significant drops in transmission rates over a 3-5 five-year period when use of mosquito nets, filling up of larval pits and drainage were pursued together. I believe that ensuring all aspects involved in dealing with mosquitoes are addressed will require inter-sectoral collaboration. This is because the various ministries, departments, experts and community elements involved will provide the necessary information and guidelines. The best approach would be one in which in every one of the three main affected provinces for a start, the ministry of health will create an organizational partnership with other national and local departments that cover education, environment, tourism, and agriculture. The sanitation, water resource and engineering aspects of local government will also have to be linked and further to other community stakeholders such as community groups, businesses, educational institutions and non-governmental organizations. .Conclusion Malaria poses a great public health challenge, especially in Africa. South Africa has however managed to overcome it partly because of a smaller risk population and effective control measures. Its rather low incidence rates have led to governmental and international organizations opting for an elimination agenda for the disease in the country, as it is considered increasingly practical. Its control measures are however not completely adequate. This paper has therefore suggested the implementation of biological measures, Direct Observed Therapy and Integrated Vector management to improve performance. It especially calls for IVM as a solution that will be more cost effective and in line with ideals such as public participation and its subsequent benefits which will be a solution to existing limitations in strategy and therefore ensure greater success. References Blumberg, L, Frean, J and Moonasar, D. (2014). Successfully Controlling Malaria in South Africa. South African Medical Journal. Vol. 104 (3 Suppl 1):224-227 Ghosh, A, Mandal, S, Bhattacharjee, I and Chandra, G (2005). Biological Control of Vector Mosquitoes by Some Common Exotic Fish Predators. Turkish Journal of Biology. Vol. 29: 167-171 Kamareddine, L. (2012). The Biological Control of the Malaria Vector. Toxins. Vol. 4: 748-767 Khosa, E, Kuonza, L, Kruger, P and Maimela, E. (2013). Towards the Elimination of Malaria in South Africa: a Review of Surveillance Data in Mutale Municipality, Limpopo Province, 2005 to 2010. Malaria Journal. Vol. 12:7. 1-8 Maharaj, R, Raman, J, Morris, N et al. (2013). Epidemiology of Malaria in South Africa: From Control to Elimination. South African Medical Journal. Vol. 103(10 Suppl 2):779-783 Maharaj, R, Morris, N, Seocharan, I, Kruger, P, Moonasar, D, Mabuza, A, Raswiswi, E and Raman, J. (2012). The Feasibility of Malaria Elimination in South Africa. Malaria Journal. Vol. 11 (423): 1-10 Matthews, G. (2011). Integrated Vector Management: Controlling Vectors of Malaria and other Insect Vector Borne Diseases. Chichester: Wiley-Blackwell Moonasar, D, Nuthulaganti, T, Mabuza, A and Maharaj, R. (2012). Malaria Control in South Africa 2000–2010: Beyond MDG6. Malaria Journal. Vol. 11:294 1-7 Morri, N, Frean, J, Baker, L, Ukpe, I, Kruger, P, Raswiswi, E and Maharaj, R. (2013). Re- defining the Extent of Malaria Transmission in South Africa: Implications for Chemoprophylaxis. South African Medical Journal. Vol. 103(11):861-864 Radcliffe, E, Hutchison, W and Cancelado, R. (2008). Integrated Pest Management. Cambridge: Cambridge University Press White, N, Pukrittayakamee, S, Faiz, M, Mokuolu, A and Dondorp, A. (2014). Malaria. Lancet. Vol. 383: 723–35 Whittaker, M, Dean, A and Chancellor, A. (2014). Advocating for Malaria elimination - Learning from the Successes of Other Infectious Disease Elimination Programmes. Malaria Journal. Vol. 13 (1): 221 World Health Organization. (2015). World Malaria Report 2014. Geneva: World Health Organization Read More