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Towards Malaria Elimination in the MOSASWA

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Towards Malaria Elimination in the MOSASWA Moonasar et al. Malar J (2016) 15:419 DOI 10.1186/s12936-016-1470-8 Malaria Journal COMMENTARY Open Access Towards malaria elimination in the MOSASWA (Mozambique, South Africa and Swaziland) region Devanand Moonasar1, Rajendra Maharaj2, Simon Kunene3, Baltazar Candrinho4, Francisco Saute5, Nyasatu Ntshalintshali6 and Natashia Morris2* Abstract The substantial impact of cross-border collaborative control efforts on the burden of malaria in southern Africa has previously been demonstrated through the successes of the Lubombo Spatial Development Initiative. Increases in malaria cases recorded in the three partner countries (Mozambique, South Africa, Swaziland) since termination of that programme in 2011 have provided impetus for the resuscitation of cooperation in the form of the MOSASWA malaria initiative. MOSASWA, launched in 2015, seeks to renew regional efforts to accelerate progress towards malaria elimina- tion goals already established in the region. National malaria programmes, together with developmental partners, academic institutions and the private sector seek to harmonize policy, strengthen capacity, share expertise, expand access to elimination interventions particularly amongst migrant and border population groups, mobilize resources and advocate for long-term funding to ultimately achieve and sustain malaria elimination in the MOSASWA region. Keywords: Malaria, Cross-border, Southern Africa, Elimination Background Maputo, Gaza and Inhambane, and the north-eastern Cross-border malaria control initiatives are important to districts of the South African provinces of KwaZulu- supporting malaria elimination efforts, especially when Natal, Mpumalanga and Limpopo (Fig. 1). The region low transmission countries share borders with higher constitutes approximately 14 % of the total land area of transmission countries. The World Health Organization the three countries of 2,039,991 sq km. All 27.2 million (WHO) Global Technical Strategy (GTS) 2016–2030 [1] of the inhabitants of Mozambique are at risk of malaria, and the Roll Back Malaria Action and Investment (AIM) compared with 28 % (356,077) in Swaziland and 10 % (5.4 Strategy 2016–2030 [2] advocate for cross-border collab- million) in South Africa [5]. The parasite responsible for oration to achieve successful malaria control and elimi- the majority of infection in the three countries is Plasmo- nation. In southern Africa, Swaziland and South Africa, dium falciparum, with Plasmodium malariae and Plas- both low transmission countries, are pursuing the goal modium ovale also occurring in Mozambique. Anopheles of malaria elimination by 2020 [3, 4]. South Africa and arabiensis and Anopheles funestus represent the primary Swaziland share borders with Mozambique, a country vectors in all three countries [6]. that has a considerably higher burden of malaria [5]. The Transmission in South Africa and Swaziland is sea- MOSASWA initiative aims to renew regional collabora- sonal, peaking between November and April, and is tion between Mozambique, South Africa and Swaziland. unstable and epidemic prone, but is stable and year- The MOSASWA region consists broadly of east- round in Mozambique. ern Swaziland, the southern Mozambican provinces of Baseline incidence rates of 2.64 cases per 1000 popu- lation at risk in South Africa, 2.34 in Swaziland and 219 in Mozambique were recorded in 2014 at the com- *Correspondence: [email protected] 2 Medical Research Council, Durban, South Africa mencement of the MOSASWA initiative [7]; however, Full list of author information is available at the end of the article incidence rates in Mozambique ranged between 0.01 and © 2016 The Author(s). This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Moonasar et al. Malar J (2016) 15:419 Page 2 of 5 Fig. 1 The MOSASWA region consists of: Swaziland; the southern Maputo, Gaza and Inhambane provinces of Mozambique; and the malaria endemic districts of KwaZulu-Natal, Limpopo and Mpumalanga provinces of South Africa 500 at sub-district level, higher rates concentrated in the The MOSASWA initiative is being built on the foun- northern provinces and with substantially lower rates dations of the Lubombo Spatial Development Initiative observed in the south [8]. Malaria is responsible for 29 % (LSDI), established in 1999 to address the issue of high of all deaths and 42 % of deaths in children aged under malaria transmission in an area targeted for accelerated 5 years in Mozambique, rendering it the most significant agricultural and economic development [6]. The pri- public health threat nationally [9]. Following the relative mary emphasis of the LSDI malaria programme was to decline in national malaria incidence rates in Mozam- extend malaria control to southern Mozambique. There bique between 2007 and 2012, significant increases were was increasing consensus that even if malaria control recorded subsequently, rising from just over three million measures were optimal in South Africa and Swaziland in 2013 to 5.5 million by 2014 (Fig. 2). (with effective treatment and insecticides in place), Mozambique has traditionally not implemented wide- the disease burden could only be further reduced by a spread indoor residual spraying (IRS) due to financial and regional approach to control. The objectives of the LSDI logistical challenges, and has also prioritized its resources were to: reduce malaria incidence in the border areas for the higher transmission and more populous north. of South Africa and Swaziland from 250/1000 to fewer Conversely, South Africa and Swaziland have invested than 20/1000; reduce malaria infections from 625/1000 heavily in the scale-up of IRS towards the goal of zero to fewer than 200/1000 within three years of commence- local transmission [10, 11]. However, the lack of coordi- ment of IRS in Maputo Province; develop a regional nated regional efforts in this regard results in continued malaria control programme to cover 200,000 sq km; importation into the elimination areas. The MOSASWA develop a regional geographic information system (GIS)- initiative will jointly support the expanded coverage of a based malaria information system (MIS) in the three robust, efficiently executed IRS programme in Maputo countries; and, establish effective treatment and defini- Province, strengthen entomological surveillance and tive diagnosis through the roll-out of rapid diagnostic scale-up drug-based parasite clearance strategies towards tests (RDTs) and artemisinin-based combination therapy transitioning the south to elimination. (ACT) at all public health facilities. The objectives of the Moonasar et al. Malar J (2016) 15:419 Page 3 of 5 Fig. 2 Number of confirmed malaria cases reported in South Africa, Swaziland and Mozambique, 1982–2014 LSDI malaria control initiative were realised within five The MOSASWA malaria initiative has received politi- years of initial implementation [12]. The initiative termi- cal support from each of the participating countries nated in 2011 as the result of financing constraints. The through the signing of a declaration committing them substantial decline in the malaria burden realised dur- to tackling malaria, particularly in the shared border ing that period greatly improved the health quality of the areas of each country [17]. The goal of the initiative is to targeted populations, and as a result, contributed to eco- accelerate the transition from pre-elimination to elimi- nomic productivity in the region [13]. nation of malaria in Swaziland and South Africa, and An increase in the burden of malaria in all three coun- from control to pre-elimination in southern Mozam- tries has been noted since the closure of the LSDI in bique, so as to achieve zero local transmission in Swazi- 2011, despite sustained in-country implementation of land, South Africa and Maputo Province (Mozambique) malaria interventions in South Africa and Swaziland. by 2020 and achieve pre-elimination status in Gaza and Comparison of case counts recorded at baseline prior Inhambane provinces (Mozambique) by 2025 [18]. Key to the implementation of the LSDI (1999) with those objectives are to: (1) harmonize policies, strengthen observed at project termination in 2011 and again in sub-national capacities and share expertise; (2) expand 2014 just prior to the establishment of MOSASWA, access to malaria elimination interventions with particu- reveals that gains achieved by the LSDI have been lar focus on mobile and migrant populations, malaria risk eroded subsequent to project termination in 2011 [5]. localities and residents to reduce and interrupt malaria Consequently, resuscitation of cross-border collabora- transmission; (3) strengthen capacity for surveillance, tion is essential to return the malaria trend in the region operational research and monitoring and evaluation; and, to a downward trajectory. (4) mobilize resources and advocate for increased long- Following the successes recorded by the LSDI, the term financing to achieve and sustain malaria elimination impact of cross-border collaboration
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