Last month the National Institute for Communicable Diseases (NICD) warned that they were seeing a significant increase in malaria cases in the endemic provinces and Gauteng, with many cases of severe malaria due to late presentation or late detection. “Any individual presenting with fever or flu-like illness, if they reside in a malaria-risk area in Limpopo, KwaZulu-Natal and Mpumalanga or have travelled to a malaria-risk area, in the past six weeks, must be tested for malaria by blood smear microscopy or malaria rapid diagnostic test. If they test positive for malaria, the patient must be started on malaria treatment, immediately,” they said in the alert.

The rise in cases seemed almost ironic given the NICD’s announcement came just two weeks after we observed World Malaria Day. With the Department of Health’s malaria elimination agenda announced in 2012, where is SA in the race to achieving malaria elimination by the targeted 2030?

Speaking at an event focused on unpacking malaria, hosted by South African Health Products Regulatory Authority (Sahpra), Dr Jaishree Raman (principal medical scientist at the NICD) took a closer look at malaria in SA.

“Because we lie on the southernmost limit of malaria distribution, malaria in SA is limited to the north and east parts of the country. So, unlike many countries in Africa where the whole country is in the malaria area, we only have certain regions that are exposed to malaria,” Dr Raman explained.

“Malaria is very seasonal in SA, and we have very high risk for outbreaks. We traditionally have our malaria runs from September to May, with peaks generally after Easter and Christmas, that's really associated with a lot of movement of people between higher endemic regions.”

THEN AND NOW

Comparing the area affected by malaria in the early 1930s, Dr Raman explained that while it was found all along the border, it also extended quite far into Gauteng and into parts of Pretoria. “If you look in KwaZulu-Natal it went right down into the area that was formerly Port Shepstone,” she said.

“But we put in sustained implementation of interventions which were primarily focused on the vector. We used indoor residual spraying (which was discovered in SA) from the 1940s. We've also added larviciding (a type of insecticide used to control mosquitoes). So, very much focusing on the vector.

“In terms of case management when treating the patient, we had very prompt diagnosis using microscopy initially, added rapid diagnostic tests (RDTs), and obviously we had effective treatment in place, or tried to have as effective treatment in place
as possible.” The interventions from the early 1900s, helped to push back the boundaries of malaria. “Now malaria is really limited to the borders we share with Botswana, Zimbabwe, Mozambique, and Eswatini, impacting three provinces – Mpumalanga, KwaZulu-Natal, and Limpopo. But we have a very low burden compared to other countries.

“The burden in these three provinces is not equal. Some have a much higher burden compared to others.
If I look at the malaria data for the three provinces from 1980 to 2020, it has changed between the provinces. Between 1980 and 2000 KwaZulu-Natal accounted for most of our cases, but after 2000 cases began to rise in Limpopo, and now Limpopo accounts for most of our cases,” said Dr Raman.

A closer look at SA’s burden shows we've had upsurges in cases over the years:

• 1987: Upsurge in cases in KwaZulu-Natal driven by parasite becoming resistant to chloroquine which forced a change to sulfadoxine-pyrimethamine.
• 2000: Major upsurge in cases across all provinces but particularly significant in KwaZulu-Natal. “The parasite became resistant to sulfadoxine-pyrimethamine (SP), but the mosquitos had also become resistant to the pyrethroids that were being used for insecticide resistance,” explained Dr Raman. “Added to that we had very heavy rains and floods in the KwaZulu-Natal and Mozambique area, so that really created the ideal breeding ground for mosquitoes, resulting in a real uptick in cases.”
• 2001: KwaZulu-Natal became the first area in Africa to put in an artemisinin-based combination therapy (ACT) introducing artemether-lumefantrine (AL). “DDT (dichlorodiphenyltrichloroethane) had to be reintroduced for better control in terms of indoor residual spraying (IRS),” Dr Raman said.
• 2002: “We started to see a decrease in cases across all three provinces which continued on a downward trajectory over the next few years.”
• 2007: With a major decrease in cases, SA started talking to the WHO about moving from controlling malaria (where the focus is only on controlling case burden) to elimination (trying to stop local transmission of malaria – stopping mosquitoes from being infected in country and then biting someone in country).
• 2012: SA officially planned an elimination agenda.
• 2017: A massive upsurge in cases. “It was the first time in a long time that we had an upsurge in cases that was not driven by resistance,” explained Dr Raman. “It was driven by climatic changes. Again, we had unexpected heavy rains and there were some system failures.”
• TO-DATE: “Since then cases have decreased again and it looks like we are progressing towards elimination, but we haven't quite achieved it as yet.”

SA’S ELIMINATION AGENDA

Currently in our second elimination strategy, which is due to end this year, we obviously won’t have reached the planned goal of stopping medical transmission. “The Covid pandemic played a major role in that, but we are making progress, which is something positive,” Dr Raman said. “We will be doing the next elimination strategy and hopefully we'll get much closer to being able to eliminate malaria.”

SA GUIDELINES AND THE HEALTHCARE PROFESSIONAL’S ROLE

“In SA, for malaria, you cannot do presumptive diagnosis,” cautioned Dr Raman. “Before you can treat anyone for malaria you should have a confirmed parasitological test and our guidelines recommend that it's done either by microscopy or rapid diagnostic test (RDT). We do not rule out PCR (polymerase chain reaction) testing, it's just not something that is recommended in our guidelines because primary healthcare facilities do not have access to PCR or any other molecular testing.

“Because most of the cases in SA are due to Plasmodium falciparum malaria, the RDT that is recommended in the public sector is a falciparum specific RDT. It targets the antigen that is produced by the falciparum parasite known as the histidine-rich protein two or HRP2 gene. “Currently the first response HRP2 falciparum specific RDT is used in the primary healthcare facilities across the endemic regions,” Dr Raman said.

“It's important to note that in SA, malaria is a category one notifiable medical conditions, which requires all medical practitioners that confirm a malaria case to notify the NICD within 24 hours.

It should be reported on the notifiable medical conditions form which can be done via the app.” Dr Raman explained that it's important to notify within 24 hours, particularly in the malaria endemic areas, as the case needs to be investigated to determine whether it is local or imported, as that informs the activities of the malaria control programme.

“It's important that when making a report, whether it's on the app or the form, you fill in as much information as possible, particularly on the signs and symptoms, the treatment and the travel, because the travel helps guide the way the case is going to be classified as local or imported. That is critical as we move towards elimination because when the WHO comes to certify us as having eliminated malaria, we need to be able to prove that we have stopped local transmission.”