In recent years, South Africa has made significant progress in its efforts to eradicate malaria. The World Health Organization (WHO) lists it as one of the countries with the potential to eliminate the disease in the near future.
In 2021, the World Health Organization also praised South Africa for breaking a bleak trend. It was one of the few malaria-endemic countries in Africa that did not see a significant increase in malaria cases from COVID-related disorders.
But it’s not all good news. For the second time in a decade, South Africa is set to fail its malaria eradication goal. The country committed to eliminating malaria by 2018, but this did not happen. In 2019, the government set a goal of eliminating malaria by 2023. Despite implementing a number of new interventions that have reduced the malaria burden in the country, South Africa has failed to stop malaria transmission within its borders.
The number of malaria cases in the country has also begun to rise since travel restrictions were lifted in early 2022. This follows a significant decrease in malaria cases during 2020 and 2021 – as a result of reduced cross-border movements due to coronavirus regulations, as well as proactive and innovative measures by some Malaria control programs in the provinces of South Africa.
It is critical that South Africa’s malaria control program regroup and refocus. This will enable the country to put malaria eradication efforts back on track.
There are many complex reasons for South Africa’s failure to achieve its goal of eradicating the disease. COVID is one of them and has played a pivotal role in restarting malaria control efforts in the country.
Before the pandemic, South Africa was on the way to declaring some malaria-endemic areas free of malaria. This is one of the main objectives of the current eradication strategy. Then the resources were diverted to deal with COVID; Travel and movement restrictions were imposed and staff absences increased.
The situation was further complicated by the fact that people with fever or flu-like symptoms had delayed visits to health care facilities. People are afraid of contracting COVID or are worried that they have contracted COVID and may pass it on to others.
Ozer Patel / World Health Organization
The delivery of essential disposal interventions, particularly those associated with vector control and surveillance, has also been seriously compromised over the past two years.
The testing and treatment activities of mobile border control units for malaria control have been particularly hampered. These units have played a major role in reducing malaria in border communities and highly mobile immigrant populations. It is critical that these units become fully operational again as soon as possible.
So what can South Africa do to repair the damage done to malaria efforts by COVID?
room for improvement
Some work is already underway. The National Malaria Control Program is working to expand access to basic services during the current malaria season. This initiative will continue until South Africa is declared malaria-free. Certified malaria environmental health practitioners will conduct community testing using rapid diagnostic tests. They will also be able to treat any individual with uncomplicated malaria with artemisinin combination therapies (ACTs).
This is a good plan. But for this method to be successful, it is essential that rapid and effective diagnostic tests and artemisinin-based combination therapies are available. Reports that African parasites are able to evade detection by these tests or survive ACT treatment are becoming more frequent.
South Africa was one of the first African countries to establish a program to routinely evaluate drug and diagnostic efficacy. Unfortunately, the program is not used by provincial malaria control programs. Samples from the Limpopo province in South Africa, which is hardest hit by malaria, are rarely evaluated by this programme.
If South Africa is serious about its eradication goals and wants to prevent outbreaks of drug-resistant and insecticide-resistant malaria as occurred during the 1999/2000 malaria season, the effectiveness of rapid tests, artemisinin-based treatments and insecticides used to control vectors should be regularly evaluated.
The country has a long history of using indoor residual spraying with insecticides to successfully control malaria. But in recent years it has struggled to adequately protect communities using this intervention. This is due to delays in the purchase or delivery of insecticides and spray pumps. People are also increasingly refusing to expose their homes to indoor residual spraying because they feel that malaria is no longer a problem in South Africa.
More to do
Processes and procedures must be urgently put in place to improve procurement and delivery. Community awareness campaigns demonstrating the benefits of IRS are also important. They should be developed and presented, as a matter of urgency, to improve uptake of this critical intervention. Failure to address these issues will lead to a resurgence of vector numbers – and most likely to lead to an increase in malaria cases.
Improving real-time case reporting is also imperative. This allows health authorities to respond quickly to each confirmed case to prevent any possibility of transmission. Communication challenges in many endemic areas, staff overburdened with multiple diseases, and competing reports are just two of the reasons for the delay in reporting. This issue must be addressed by improving communication within rural malaria endemic areas and by allocating staff to report malaria and other cases that must be reported.
South Africa is close to eliminating malaria. But the country needs to do more. Business as usual is no longer enough – eliminating malaria requires extra effort from all stakeholders. There must be sustainable funding to support the effective implementation of malaria elimination interventions, with all cadres of the malaria workforce prepared to go further if South Africa is to achieve malaria elimination.
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