SWAZILAND: Winning the fight against malaria

01 Dec 2008
A decline in the incidence of malaria in Swaziland is being attributed to a devastating drought in the country's malaria belt.

In recent years the government and international donors have embarked on a coordinated response to the mosquito-borne disease and there now is confident talk of making Swaziland malaria-free. Malarial eradication is defined as no new clinically confirmed cases.

The Global Fund to Fight AIDS, Tuberculosis and Malaria, a US-sponsored international public/private partnership, the UN World Health Organisation (WHO), the UN children's fund, UNICEF, have all assisted in the country's malaria eradication programmes.

"There has been good progress in bringing down the number of new malaria cases as well as mortalities, and now our goal is eradication," Simon Kunene, director of the health ministry's Malaria Control Unit, told IRIN. "The gains of the past few years have given us confidence that eradication is within reach."

The unit is based in Swaziland's commercial hub of Manzini, which used to be the capital city before British colonial administrators relocated it to Mbabane to escape the malaria.

The number of confirmed malaria cases has dropped 75 percent since 2000, when 4,000 new patients were diagnosed with the disease, to 1,000 confirmed cases in 2008. Malaria fatalities have also dropped from 50 deaths in 2000 to between 10 and 15 deaths annually in the past three years.

Effects of drought

The strides made against malaria infections have coincided with a period of severe drought in the malaria belt, located primarily in the eastern Lubombo region bordering Mozambique - Swaziland's "crescent of drought" - although malaria breeding grounds are found throughout the country's other three regions.

"No one thought that drought had a silver lining, but that's apparently the case with malaria. Small bodies of water and vegetation where mosquitoes breed dried up," said Arnold Simelane, a health worker in Lubombo's regional capital, Siteki.

The drought's trade-off of lowering malaria infection rates has come at the cost of a prolonged humanitarian crisis, killing crops and putting hundreds of thousands of the country's one million people at risk of malnutrition, as the good rains that have fallen so far this year have bypassed the Lubombo region.

The battle against malaria has been long in this small, poor country, and the good news of a decrease in reported cases is welcome. "There are a lot of contributing factors, including government's commitment of resources, which allowed for one of the more successful interventions, the Indoor Residual House Spraying programme," Zandi Dlamini, the Malaria Programme Officer for the Malaria Control Unit, told IRIN.

The malaria season starts in October and carries through to May, the end of the southern hemisphere summer, when systematic spraying with DDT - said to afford protection to 90 percent of the population at risk of malaria - is carried out across Swaziland.

"This has worked splendidly, and from a pilot programme in 2003, when the World Health Organisation [WHO] supplied the [insecticide-treated] sleeping nets, we have increased coverage with nets purchased in South Africa with Global Fund sponsorship," Dlamini said.

Distribution of the nets was initially targeted at people considered most at risk - children under five years of age and pregnant women - but the expanded goal is to put at least two treated sleeping nets in every household in malaria-risk zones.

Health officials last week were conducting meetings and workshops in preparation for a proposal for a US$13.8 million Global Fund grant to the Malaria Control Unit, with assistance from the Clinton Foundation and Swaziland's National Emergency Response Council on HIV and AIDS (NERCHA).

It is hoped that the final push to eradicate malaria will be made with the Rapid Diagnostic Test (RDT), which will allow patients exhibiting malaria-like symptoms to be tested at local clinics and to know immediately whether they are infected.

Malaria testing

"It works like a pregnancy test or an HIV test; the results are available in 15 minutes. The clinics don't have labs, and now they won't have to rely on central labs," Dlamini said. It is envisaged that RDT will be introduced early in 2009 after clinical workers have been trained how to use the malaria testing kits.

Currently, blood samples are collected from clinics around the country by the Malaria Control Unit and then taken to laboratories in government hospitals in provincial capitals, where blood smears are microscopically examined for evidence of parasites.

"It takes a long time - more than a week from when we pick up the slides from the clinics and send back the results. It's for this reason all patients are now treated for malaria at the first sign of symptoms, even before there is confirmation of the disease," Dlamini said.

Immediate but possibly unnecessary treatment is preferable to the risk of doing nothing. After someone has been infected with malaria, it takes between 10 and 14 days before the onset of symptoms; if another week passes and the patient has not received treatment, death can result.

"Improved knowledge by individuals and increased knowledge of health-seeking behaviour by whole communities - where people know to seek treatment within 48 hours of the onset of symptoms - has also contributed to the drop in malaria," Dlamini said.

However, the lower incidence of malaria has also exposed Swazis to making the unpalatable admission that a loved one has died of an AIDS-related illness. Swaziland has the world's highest HIV/AIDS infection rate - 26.1 percent of people between the ages of 15 and 49 - and malaria is an opportunistic disease to which people with an immune system compromised by HIV/AIDS are more susceptible.

"The 10 to 15 people a year who die of malaria are not from the groups most at risk: the children under five and pregnant women. The people who die are adults; this means they probably have AIDS," said a health worker who asked not to be identified.

In Swazi society, having AIDS is a delicate, almost taboo admission for an infected person to make. "Malaria is even used as a cover-up," the health worker said. "I know one AIDS patient who contracted malaria, and at his funeral his family was relieved to say he died of malaria and not of AIDS."