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MALARIA ELIMINATION IN SWAZILAND

Sunday, 30th of October 2011

• MALARIA ELIMINATION IN SWAZILAND

 

Best viewed, with maps and graphic, at

http://www.malariajournal.com/content/pdf/1475-2875-10-313.pdf

 

Malaria Journal 2011, 10:313 doi:10.1186/1475-2875-10-313

Simon Kunene (manager@malaria.org.sz)

Allison A Phillips (PhillipsAA@globalhealth.ucsf.edu)

Roly D Gosling (GoslingR@globalhealth.ucsf.edu)

Deepika Kandula (dkandula@clintonhealthaccess.org)

Joseph M Novotny (jnovotny@clintonhealthaccess.org)

 

Article type Commentary

Submission date 10 September 2011

Acceptance date 21 October 2011

Publication date 21 October 2011

Article URL http://www.malariajournal.com/content/10/1/313

This peer-reviewed article was published immediately upon acceptance. It can be downloaded, printed and distributed freely for any purposes (see copyright notice below).

 

Malaria Journal

© 2011 Kunene et al. ; licensee BioMed Central Ltd.

This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

.

A national policy for malaria elimination in Swaziland: a first for sub-Saharan

Africa

Simon Kunene1, Allison A Phillips2*, Roly D Gosling2, Deepika Kandula3, Joseph M

Novotny4

1National Malaria Control Programme, Manzini, Swaziland.

2Global Health Group, University of California, San Francisco, UCSF Global Health

Sciences. 50 Beale Street, Suite 1200, San Francisco, CA 94105 USA

3Clinton Health Access Initiative and Global Health Group, University of California, San

Francisco, Harare, Zimbabwe.

4Clinton Health Access Initiative and Global Health Group, University of California, San

Francisco, Mbabane, Swaziland.

*Corresponding author

SK: manager@malaria.org.sz

AAP: PhillipsAA@globalhealth.ucsf.edu

RDG: GoslingR@globalhealth.ucsf.edu

DK: dkandula@clintonhealthaccess.org

JMN: jnovotny@clintonhealthaccess.org

.

Abstract

Swaziland is working to be the first country in mainland sub-Saharan Africa to eliminate

malaria. The highest level of Swaziland’s government recently approved a national

elimination policy, which endorses Swaziland’s robust national elimination strategic

plan. This commentary outlines Swaziland’s progress towards elimination as well as the

challenges that remain, primarily around securing long-term financial resources and

managing imported cases from neighbouring countries.

.

Background

In March 2011, Swaziland became the first country in sub-Saharan Africa to approve a

national malaria elimination policy. The technical and operational feasibility of

eliminating malaria in mainland sub-Saharan Africa has been questioned [1], however,

with recent declines in malaria transmission across the continent and especially in

southern Africa, calls for progressive elimination have been made [2].

Swaziland is a small landlocked country in southern Africa, bordering South Africa and

Mozambique (Figure 1). It has one of the world’s highest HIV and TB burdens and has

limited national resources for health. Yet, its progressive decline in malaria and the

strength of its malaria programme warrant Swaziland as the front-runner in the race to be

the first mainland sub-Saharan African country to achieve elimination.

Like other countries in the area, due to elevation and climate, the majority of Swaziland

has historically had low transmission. However, in the lowveld ecological zone,

transmission has been persistent and at times high, recording 114 cases per 1,000

population at risk in 1996 [3]. Swaziland greatly reduced the national burden of malaria;

between 1999 and 2009 laboratory confirmed cases declined from 3.9 to 0.07 cases per

1000 population, as shown in Figure 2 [4]. This decrease has been attributed to a scale up

of vector control activities in Swaziland’s at-risk region and bordering areas associated

with the cross-border collaboration with Mozambique and South Africa - the Lubombo

Spatial Development Initiative (LSDI) [5]. The LSDI was launched in 1999 with the goal

to improve economic development in the border areas in all three countries. As malaria .

was viewed as an impediment to economic development, malaria control was deemed a

core component of the regional partnership. The LSDI’s primary malaria intervention is

indoor residual spraying (IRS), specifically in high transmission areas in southern

Mozambique.

 

Cross-border initiatives like LSDI represent a contemporary elimination strategy intended

to reduce a country’s importation risk and in the case of LSDI, it has been shown to lead

to success towards elimination in both South Africa and Swaziland [5]. Presently, due to

a lack of secure long-term funding, the continuation of LSDI remains uncertain and its

potential end could threaten the progress made in all three participating countries.

With malaria control achieved through national and cross-border efforts, Swaziland has

exceeded Roll Back Malaria’s Abuja targets [6] and the Millennium Development Goal

on malaria [7]. Recognizing Swaziland’s success, the Southern African Development

Community (SADC) and the African Union earmarked Swaziland for elimination by

2015 [2,8]. With the financial support of the Global Fund to Fight Aids, Tuberculosis and

Malaria, technical support from the World Health Organization [9], support from SADC

[10] and the Southern Africa Malaria Elimination Support Team [11], the National

Strategic Plan for Elimination of Malaria in Swaziland was born.

Swaziland’s strategic plan for elimination includes a robust surveillance program that

identifies local and imported cases and tests all people living within a one kilometer

radius of a confirmed malaria case. The Strategic Plan led to the revision of the diagnosis

and treatment guidelines tailored for a low-transmission setting, scale-up of vector

control interventions including distribution of long-lasting insecticide-treated nets to

cover the entire malaria at-risk population, and implementation of a comprehensive

health education campaign aimed to improve personal protection and treatment-seeking

behaviour [4]. Since the implementation of the strategic plan in 2009, Swaziland’s

reported malaria incidence has decreased by 76% [12]. The reduction is mostly due to

increased malaria testing, correct classification of febrile illness, and adherence to

malaria test results, an important lesson for all malaria endemic countries.

Beyond a national elimination strategy, the adoption of a national malaria elimination

policy is a significant step forward and a confirmation of Swaziland’s commitment to the

goal of being malaria free. The policy establishes clear procedures, roles and systems for

all malaria stakeholders within Swaziland to contribute to the central elimination goal and

ensures that the highest levels of Government remain dedicated to the elimination

agenda. Support for implementation of the policy is provided by the Swaziland Malaria

Elimination Advisory Group, an independent council of national malaria advisors and

partners that represent 29 different constituencies and meet on a regular basis to evaluate

the effectiveness of the malaria policy, monitor progress towards elimination, and revise

the policy and/or strategy as appropriate. The government’s commitment to elimination

and preventing reintroduction fosters the necessary environment and political will for

continued progress towards Swaziland’s goal of becoming malaria-free by 2015.

.

Swaziland’s substantial progress towards elimination is significant. Swaziland currently

has the national and political will, operational and technical capacity, and is rapidly

strengthening the systems and procedures necessary to achieve elimination. However,

with the persistent risk of importation from nearby endemic countries, long-term

resources for preventing reintroduction will need to be secured. Donor-funded malaria

programmes, such as Swaziland’s, that are progressively reducing malaria may

potentially be victims of their own success. The threat of donors moving resources into

other high-endemic countries could leave low-endemic countries with the risk of

resurgence as seen in Madagascar [13] and Zanzibar [14]. Additional guidance to lowendemic

countries on securing sustainable financing for elimination will be critical to

Swaziland and other malaria-eliminating countries. With a strong collaborative effort,

Swaziland is well poised to set a leading example for the rest of the sub-Saharan African

region.

.

Competing interests

SK is the programme manager for Swaziland’s National Malaria Control Programme. DK

and JMK work at the Clinton Health Access Initiative, which is in part funded by the

UCSF Global Health Group. AAP and RG work at the UCSF Global Health Group. The

Global Health Group exists in part to support countries that are on an evidence-based

pathway towards elimination. SK, RG and AAP are members of the Malaria Elimination

Group. The views and conclusions in this comment are those of the authors and do not

necessarily represent the views of their employing organizations nor of the sources of

funding.

Author’s contributions

All authors contributed by guiding and shaping the messages and ideas contained in this

commentary. SK shaped the key messages. The text was drafted by JMN, AAP, RG and

DK, with contributions and guidance from SK. All authors took part in the review,

preparation and final approval of the commentary.

 

Acknowledgements and Funding

The work of the UCSF Global Health Group Malaria Elimination Initiative is supported

by grants from the Bill & Melinda Gates Foundation and ExxonMobil. The Clinton

Health Access Initiative acknowledges support from the UCSF Global Health Group for

their work on malaria elimination. We appreciate the support of Sabelo Dlamini in the

creation of Swaziland’s incidence maps. We are grateful for helpful comments from

Chris Cotter, Cara Smith Gueye and Bruno Moonen.

.

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