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The Kingdom of Swaziland is among 21 countries globally with the potential to interrupt indigenous malaria transmission by 2020 thereby achieving the goal of malaria elimination. Following a mid-term review process of the National Malaria Elimination Strategy 2015-2020, concluded recently, the country was found to be in a historical position to be a pioneer in malaria elimination in Sub Saharan Africa. The country has made great progress in reducing the incidence of malaria.
Since 2000, there has been a marked decline in malaria in southern Africa. In the E8 countries, malaria cases have decreased by nearly 50% over the past five years, declining from 14 million cases in 2007 to 8 million cases in 2012. Four frontline countries are projected to be on track to achieve a greater than 75% decrease in malaria incidence by 2015, when compared to 2000. Swaziland aimed for national elimination by 2015, while South Africa and Botswana are aiming to eliminate malaria by 2018 and Namibia by 2020; all four of these countries have achieved an incidence rate of <2.0 cases per 1,000 population.
Malaria transmission in Swaziland is unstable and heavily dependent on the level of rainfall and parasite importation, both of which vary considerably throughout the year. The bulk of confirmed cases occur between November and May coinciding with the rainy season, with a significant peak of imported cases in January/February. Local malaria transmission occurs primarily in the Lowveld climatic region, approximately 250 meters above sea level in the east of the country. The key drivers of local transmission are rainfall, temperature and relative humidity in these areas and, coupled with the occasional influx of parasites, leading to local transmission. Confirmed cases decreased from 4004 in the year 2000 to 317 in 2016. Although the goal of Swaziland is to have no (zero) people die of malaria, there have been five and three deaths in 2014/2015 and 2015/2016, respectively, with two deaths so far in 2016/2017 owing to late treatment seeking behaviour. IRS coverage has improved from 87% to 96% over the same time period. These measures suggest Swaziland is progressing towards malaria elimination.
Swaziland is pursuing a vision of a Kingdom free from malaria, elaborated in the National Malaria Elimination Strategic Plan 2015 – 2020. Four intervention areas underpin this pursuit:
(i) definitive diagnosis and standardized case management,
(ii) evidence-based vector control, particularly targeted indoor residual spraying,
(iii)epidemiological (including entomological) surveillance, and
(iv) behaviour change communications.
Malaria elimination is included and prioritised in the national health agenda as evidenced by the availability of domestic financing in addition to technical and financial support from partners including the World Health Organization (WHO). There is also political commitment at the highest level as His Majesty, King Mswati III, is the chairperson of the African Leaders Malaria Alliance (ALMA) for the next two years. The programme also has adequate and appropriate human resources.
Malaria is a notifiable disease in Swaziland hence all confirmed cases are reported through the Immediate Disease Notification System (IDNS). This is a strong system for immediate reporting of all notifiable diseases. The notification triggers intensive follow up done for all index cases, including case investigation, classification and reactive case detection. The main vector control intervention is targeted Indoor Residual Spraying (IRS) supplemented by long Lasting Insecticide treated Nets (LLINs).There is a good reporting system for spray activities feeding into database for IRS planning. These interventions are complimented by an innovative home improvement project where eaves of all houses in identified high risk areas are screened to prevent mosquito entry.
Joyful Hearts Organization as Malaria implementing partner of government has been contracted by the E8 Secretariat through ADPP to implement the Test Treat and Track (Surveillance) project for the reduction of cross-border malaria transmission through testing and treatment of mobile and migrant populations;
The malaria Test, Treat and Track activities will be focused along the border areas between Mozambique, South Africa and Swaziland. The program is focusing on Migrant and Mobile populations (MMPs) and underserved communities given the risk of infection importation to and from countries with varying risk transmission.
MMPs often face obstacles in accessing essential health care and malaria-control services, which result in undetected and untreated malaria. This increases their vulnerability to malaria-related morbidity and mortality. Communities along the border areas are therefore also at a risk, and resident populations that travel between areas of different transmission risks may import malaria into receptive areas.
The program has established malaria health posts for malaria Testing, Treatment and further provide surveillance units responsible for Tracking possible transmission communities (active foci). The TTT sites that have been established are the following:
JHO Team engagement in active foci and malaria At-Risk areas will be intensified coupled with an increase in malaria awareness to mobile populations.
Health workers are regularly trained on malaria diagnosis and case management. All malaria cases are parasitological confirmed before treatment with Artemisinin Based Combination Therapy according to national treatment guidelines. Malaria diagnosis and treatment is free of charge. Antimalarial drugs and laboratory commodities are available in JHO facilities and there is a system for commodities tracking.
There have been intensive mass community campaigns and border campaigns targeting travelers as well as community engagement and social mobilization.
Community based Malaria Elimination strategies were established in localities with active foci for enhancing community participation and ownership of malaria elimination interventions.
Demand creation for malaria testing and treatment is an important element of the program. This is carried out by locally recruited and trained Community Health Workers (CHWs) which we call linkages officers. Linkage officers were engaged to assist the nursing team and manage community demands through (i) a door-to-door approach; (ii) case investigation for relative presumptive cases, (Index cases); and (iii) malaria testing day (monthly event). CHWs are also been trained to conduct Malaria diagnosis and testing in the community. Additionally, the linkages officers build up a network of Peer Educators (volunteers) who participates in awareness raising and mobilization for malaria testing.