malaria strategies case study

A 30 year-old woman, HIV-positive, delivers by planned cesarean section an apparently normal female baby, weight 3.2 kg (7 lbs). At delivery AZT is administered IV for 7 hours. The mother is a native of the Democratic Republic of Congo who came to France 2 years ago and has not traveled outside France since then. The only abnormality found in the baby at delivery is an anemia (12.3 g/dL hemoglobin) attributed to antiretroviral drugs toxicity (ARV given to mother?)

At 6 weeks post-delivery, the infant is brought in for a fever of one-day duration. She is found to have a temperature of 38.5°C and both hepatomegaly (3 cm) and splenomegaly (3 cm). Serologic tests for HBs and HCV are negative, and PCR, DNA and RNA for HIV are negative. More routine laboratory exams show hemoglobin 6.4 g/dL, platelets 122,000/µL, LDH 1080 IU/mL, and blood smears showing the following:

Blood smear 1

Blood smear 2

Blood smear 3

Question 1: What is your diagnosis?

That is incorrect. Please, try another answer.

Plasmodium falciparum

Plasmodium vivax

Plasmodium ovale

Plasmodium malariae

That is correct.

The most likely diagnosis, based on microscopy and clinical history is P. malariae . Note the typical microscopic characteristics: all stages of parasites present; band-form trophozoite (image 1); round, rosette-shaped schizont (image 2); and round gametocyte (image 3, at right). The microscopic diagnosis of P. malariae was confirmed by PCR. The parasitemia is 1.8%, which is high for P. malariae (note that in image 3, four parasites are crowded in a relatively small field). The mild or absent symptoms of malaria in the mother is compatible with P. malariae, a parasite that can persist for years, even a lifetime, with minimal symptoms. Plasmodium malariae is known to occur in DR Congo, where it is second in prevalence (by far) to P. falciparum .

Mixed infection (several Plasmodium species)

A transfusion of 125 mLs of blood is given to the child.

Question 2. What antimalarial drug would you administer to the infant?

Chloroquine

Chloroquine is the drug of choice for the treatment of Plasmodium malariae. P. malariae is chloroquine-sensitive, and additionally chloroquine is one of the safest antimalarial drugs available.

Doxycycline is contraindicated in young children, and halofantrine can have cardiotoxic effects.

Primaquine is not necessary because there are no dormant liver stages in this parasite species. At the usual doses, primaquine would have no effect on the blood stage parasites (it targets mainly the liver stage parasites, and the gametocytes).

Even in congenital malaria caused by P. vivax and P. ovale , which have liver stage parasites, primaquine treatment of the infant is not necessary because no liver stages are transmitted from the mother to the child.

Quinine-doxycycline

Halofantrine

Following treatment with the orally administered antimalarial drug, parasitemia drops and the child becomes afebrile.

Question 3. What test(s) would you perform to confirm current infection of the mother?

Thin blood smear

All tests (with the exception maybe of serology) would be useful. The blood smears are the most practical tests for detecting an asymptomatic infection in the mother, with the thick smear being more sensitive. If both fail, and PCR is available, PCR would be even more sensitive than the thick smear. (When done correctly, PCR is the most sensitive and specific test for malaria detection and species identification.) Serology would not be useful in proving current infection.

Thick blood smear

PCR for malaria

A thick blood smear of the mother, taken 5 days after that of the infant, is indeed positive, while on the thin smear no parasites can be detected.

Main Points

Congenital malaria should be considered in febrile newborns and infants from women who could have been parasitemic during their pregnancy.

Malaria parasitemia during pregnancy can result because the mother became infected during her pregnancy, but it can also result from an infection acquired months or years before.

The woman in this case probably was infected in DR Congo more than 2 years before delivery. Untreated Plasmodium malariae infection can persist >40 years and remain relatively asymptomatic.

Plasmodium vivax and P. ovale can similarly cause malaria several months or years after the original infection, by reactivation of dormant liver stage parasites.

Diagnostic procedures for detecting active malaria infection are, in order of increasing sensitivity: thin blood smear, thick blood smear, and PCR. Serology does not detect active infection, but measures past exposure to malaria.

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Strategies and approaches to vector control in nine malaria-eliminating countries: a cross-case study analysis

Affiliations.

1 Malaria Elimination Initiative, Global Health Group, University of California, San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA, USA. [email protected].
2 Malaria Elimination Initiative, Global Health Group, University of California, San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA, USA. [email protected].
3 Malaria Elimination Initiative, Global Health Group, University of California, San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA, USA. [email protected].
4 Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, USA. [email protected].
5 London School of Tropical Medicine and Hygiene, Keppel Street, London, WC1E 7HT, UK. [email protected].
6 The University of Queensland School of Public Health, Herston, QLD, Australia. [email protected].
7 Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051, Basel, Switzerland. [email protected].
8 University of Basel, Basel, Switzerland. [email protected].
PMID: 26727923
PMCID: PMC4700736
DOI: 10.1186/s12936-015-1054-z

Background: There has been progress towards malaria elimination in the last decade. In response, WHO launched the Global Technical Strategy (GTS), in which vector surveillance and control play important roles. Country experiences in the Eliminating Malaria Case Study Series were reviewed to identify success factors on the road to elimination using a cross-case study analytic approach.

Methods: Reports were included in the analysis if final English language draft reports or publications were available at the time of analysis (Bhutan, Cape Verde, Malaysia, Mauritius, Namibia, Philippines, Sri Lanka, Turkey, Turkmenistan). A conceptual framework for vector control in malaria elimination was developed, reviewed, formatted as a matrix, and case study data was extracted and entered into the matrix. A workshop was convened during which participants conducted reviews of the case studies and matrices and arrived at a consensus on the evidence and lessons. The framework was revised and a second round of data extraction, synthesis and summary of the case study reports was conducted.

Results: Countries implemented a range of vector control interventions. Most countries aligned with integrated vector management, however its impact was not well articulated. All programmes conducted entomological surveillance, but the response (i.e., stratification and targeting of interventions, outbreak forecasting and strategy) was limited or not described. Indoor residual spraying (IRS) was commonly used by countries. There were several examples of severe reductions or halting of IRS coverage and subsequent resurgence of malaria. Funding and operational constraints and poor implementation had roles. Bed nets were commonly used by most programmes; coverage and effectiveness were either not measured or not articulated. Larval control was an important intervention for several countries, preventing re-introduction, however coverage and impact on incidence were not described. Across all interventions, coverage indicators were incomparable, and the rationale for which tools were used and which were not used appeared to be a function of the availability of funding, operational issues and cost instead of evidence of effectiveness to reduce incidence.

Conclusions: More work is required to fill gaps in programme guidance, clarify the best methods for choosing and targeting vector control interventions, and support to measure cost, cost-effectiveness and cost-benefit of vector surveillance and control interventions.

Publication types

Research Support, Non-U.S. Gov't
Research Support, U.S. Gov't, P.H.S.
Malaria / prevention & control*
Malaria / transmission
Mosquito Control / methods*
Philippines
Turkmenistan

Open Access
Published: 21 February 2022

Treatment-seeking and uptake of malaria prevention strategies among pregnant women and caregivers of children under-five years during COVID-19 pandemic in rural communities in South West Uganda: a qualitative study

Ivan Mugisha Taremwa 1 ,
Scholastic Ashaba 2 ,
Rose Kyarisiima 2 ,
Carlrona Ayebazibwe 1 ,
Ruth Ninsiima 3 &
Cristina Mattison 4

BMC Public Health volume 22 , Article number: 373 ( 2022 ) Cite this article

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Despite efforts to avert the negative effects of malaria, there remain barriers to the uptake of prevention measures, and these have hindered its eradication. This study explored the factors that influence uptake of malaria prevention strategies among pregnant women and children under-five years and the impact of COVID-19 in a malaria endemic rural district in Uganda.

This was a qualitative case study that used focus group discussions, in-depth interviews, and key informant interviews involving pregnant women, caregivers of children under-five years, traditional birth attendants, village health teams, local leaders, and healthcare providers to explore malaria prevention uptake among pregnant women and children under-five years. The interviews were audio-recorded, transcribed and data were analyzed using thematic content approach.

Seventy-two participants were enrolled in the Focus Group Discussions, 12 in the in-depth interviews, and 2 as key informants. Pregnant women and caregivers of children under-five years were able to recognize causes of malaria, transmission, and symptoms. All participants viewed malaria prevention as a high priority, and the use of insecticide-treated mosquito bed nets (ITNs) was upheld. Participants' own experiences indicated adverse effects of malaria to both pregnant women and children under-five. Home medication and the use of local herbs were a common practice. Some participants didn’t use any of the malaria prevention methods due to deliberate refusal, perceived negative effects of the ITNs, and family disparity. The Corona Virus Disease-2019 (COVID-19) control measures did not abate the risk of malaria infection but these were deleterious to healthcare access and the focus of malaria prevention.

Conclusions

Although pregnant women and caregivers of children under-five years recognized symptoms of malaria infection, healthcare-seeking was not apt as some respondents used alternative approaches and delayed seeking formal healthcare. It is imperative to focus on the promotion of malaria prevention strategies and address drawbacks associated with misconceptions about these interventions, and promotion of health-seeking behaviors. As COVID-19 exacerbated the effect of malaria prevention uptake and healthcare seeking, it’s critical to recommit and integrate COVID-19 prevention measures in normative living and restrict future barriers to healthcare access.

Peer Review reports

Infection with malaria possess a major public health challenge due to the associated morbidity, high cost of expenditure, and increased risk of mortality [ 1 ]. Its burden was reported at 229 million cases worldwide in 2019; of which sub-Saharan Africa accounted for over 90% of the cases [ 2 ]. Moreover, 11.6 million pregnant women in sub-Saharan Africa were infected with malaria [ 2 ]. In Uganda, malaria remains a perennial infection affecting an estimated 95% of the population [ 3 ], and it remains the primary cause of 15–20% of inpatient treatment, 30–50% outpatients’ care and up to 20% of all mortality [ 4 ].

Whereas global concerted efforts to control malaria have been intensified in the previous two-decades, limited success has been realized as its epidemiological burden has surpassed past incidences [ 2 ]. More, the United Nations Sustainable Development Goals (SDGs) report that focused on goal-3 asserts that interruption in service delivery due to high illnesses and deaths from communicable diseases may warrant a 100% increase in malaria deaths in sub Saharan Africa [ 5 ]. Further evidence by the global data affirms that response to malaria prevention has leveled off, and the disease burden had escalated in endemic settings [ 2 ]. This has necessitated a renewed focus on malaria prevention progress and end its catalyzed ‘high burden to high impact’ [ 2 , 6 ]. As a result, strategies to avert a worrying risk of malaria and portend global efforts towards attaining SDG-3 are a priority [ 5 , 7 ]. In this regard, the World Health Organization (WHO) Global Technical Strategy 2016–2030 initiative adopted novel strategies to fast-track malaria prevention and reduce the disease burden by at least 90% by 2030, and eventual elimination [ 7 ]. The new strategies involve primary vector control measures such as the use of insecticide-treated bed nets (ITNs), and where appropriate, in-door residual spray (IRS) with children under-five years and pregnant women as the focus [ 2 , 8 , 9 ].

Concurrently, a pandemic: the new corona virus disease-2019 (COVID-19) outbreak was declared by the WHO in March 2020 as a global pandemic. The seriousness of the pandemic necessitated an immediate response to curtail its spread and avert the associated effects. In Uganda, a series of vulnerability reduction and containment approaches including cessation of international passenger flights, closure of inland portals of entries for passengers with the exception of cargo drivers, closure of all learning institutions and other high congregation points, freezing of public and private means of transport, outlawing of all mass gatherings such as places of worship, institution of overnight curfew, and eventually a nationwide total lockdown was declared on 24 th March 2020 [ 10 ]. Further, a re-organization in the healthcare service delivery was needed diverting resources form other programs to direct them to COVID-19 control with limited consideration of their impact across other healthcare needs and services [ 11 ]. Presently, there is evidence of significant disruptions to essential healthcare services as a result of COVID-19 pandemic [ 11 , 12 , 13 ]. This has added to the malaria management burden. Malaria and COVID-19 infections have similar symptomatic presentation such as breathing difficulties, fever, acute headache, tiredness among others. Additionally, the outbreak of COVID-19 and use of restrictive measures to avert its spread limited access to healthcare, and instilled fear of visiting health facilities due to contagion. In addition, malaria prevention programs were disrupted due to the paradigm shift.

Despite the proven efficacy of prevention programs, the burden of malaria remains unacceptably high due to challenges related to new pyrethroid-resistant mosquito strains, and laxity in uptake of prevention measures [ 9 , 14 , 15 , 16 , 17 , 18 , 19 ]. A 2016 field survey in a rural district in Uganda [ 17 ], showed high malaria cases in the communities, despite the household possession of ITNs. As Uganda works towards malaria elimination, it is key to explore the specific local determinants that predict malaria prevention uptake. To the best of our knowledge, there is limited research that has explored the determinants of malaria prevention strategies among pregnant women and children under-five years during COVID-19 pandemic. This study explored the factors that are influencing the uptake of malaria prevention strategies among pregnant women and children under-five years in a rural district in south western Uganda during the COVID-19 pandemic.

Study design, site, and duration

This was a qualitative, explanatory single case study using focus group discussions, in-depth interviews and key informant interviews as the main sources of evidence. The case was defined as the common case conducted in Birere sub-county located in Isingiro district, southwestern Uganda between August to November 2020, to garner insights into the factors that influence the uptake of malaria prevention strategies among pregnant women and children under-five years [ 20 ]. Birere sub-county comprises 9 parishes and 76 villages, with a population of 26,000 people [ 2 ]. The study period overlapped with the second annual peak of the rainy season (September to November), and by this time, some of the instituted COVID-19 restrictions including in-country means of transport had been partially uplifted as of July 21 st 2020. Study activities were conducted in compliance with the COVID-19 guidelines.

Study participants and sampling strategy

The study purposively enrolled participants aged 18 years or above who were pregnant and/or provided care for pregnant women and newborns and had lived in Birere sub-county in Isingiro district for at least 6 months. These included pregnant women, caregivers of children under-five years, community health workers (village health teams) and tradition birth attendants and local leaders. For example, although the antenatal care (ANC)-based healthcare providers (HCPs) offer ANC services including malaria prevention and treatment; traditional birth attendants (TBAs) remain pivotal in the communities, partly due to persistent gaps in rural HCP availability and continued preferences for home-based deliveries. The auxiliary nurse midwives (ANMs) provide primary healthcare in community-level clinics and they support maternal-child health care provision. The village health teams (VHTs) act as community liaisons for the promotion of primary health care services, while the local council (LC) leaders supported community mobilization. Informed by previous qualitative studies, in which saturation is typically reached after interviewing 6–12 individuals with similar backgrounds [ 18 ], this study conducted 8 focus group discussions (FGDs), 13 in-depth interviews (IDIs), and 2 key informant interviews (KIIs)0.3. The details of the respondents are summarized in Table 1 .

The study participants were recruited from the 8-parishes in which, four parishes were selected for FGDs among pregnant women, and an equal number were considered for caregivers of children under-five years. Another parish was considered for each KII and IDI. The parishes were selected randomly to eliminate bias. The one parish that was not considered in either FGD for pregnant women or caregivers of children under-five years was prioritized for the in-depth interview respondents. Assisted by the local council-1 leaders, the VHTs compiled a list of households with a pregnant woman or a child under-five years. The list was used to randomly select households that participated in the FGD. Each FGD was clustered at the parish, with each village represented. Participants to the IDIs and KIIs were identified and contacted by the VHT coordinator, and the study team then followed up with those who were willing to participate.

Data instrument and collection

Guided by previous studies [ 21 , 22 , 23 , 24 , 25 ], data collection tools (supplementary files 1 and 2 ) were developed. FGD and KII questions focused on symptom recognition, healthcare seeking, knowledge, and behaviors towards malaria prevention. Also, the study assessed the impact of the COVID-19 pandemic on prevention uptake. The IDIs with pregnant women explored behavior to protect against malaria during pregnancy. On the other hand, IDIs with HCPs assessed the perceived behaviors of pregnant women and caregivers of children under-five towards malaria prevention uptake, and if malaria was emphasized during ANC. The interview guides were reviewed by two independent experts who were knowledgeable in the field of malaria. After the expert review, these were translated by 2-separate proficient persons who knew well both English and Runyankore-Rukiiga languages. Then, one of the research team members (CA) and the principal investigator (IMT) compared the translations, and compiled the final translated tools. These were then cross checked by two members of the team (RK and RN) for accuracy and comprehension in the Runyankore-Rukiiga language. The interview guides were pretested in communities within Mbarara City, Southwestern Uganda, and changes were made accordingly. Further, the interview guides were piloted in the first interview and edited during the data collection process in response to emerging themes. Additionally, participants’ socio-demographic information was captured.

Data collection was conducted by at least three members of the team supported by a research assistant who was conversant with the topic on malaria, and qualitative research methods. The research team liaised with the VHTs and LCs on the day of the appointment, and a convenient time as proposed by the participants was considered to convene. Each FGD was comprised of 8–10 participants in light of the COVID-19 guidelines. Individual introductions were done, and the research team sought individual written informed consent after explaining the purpose of the study. An interview guide in the local language (Runyankore-Rukiiga) was shared with the participants and guided the discussion with probing to pursue any emerging inquiry in major trends and cross-cutting themes. A member of the team led the discussion, and clarity to the question(s) was ensured by rephrasing where necessary. Participants were anonymized, and the discussion was guided by agreed rules to warrant appropriate communication. Field notes were recorded to contextualize the data and provide reflections on each interview, and the interviews were audio-recorded.

Data management and analysis

The audio recordings were transcribed and translated into English if conducted in the local language (Runyankore-Rukiiga language). Transcripts were carefully and independently studied by two dedicated members of the team, and reviewed by the lead author to assess translation quality and fidelity. Transcripts were read and re-read to allow familiarization with the text, and brief notes were taken to document the emerging themes. A codebook was developed based on the original and emerging themes. Content analysis was used to conduct the initial data analysis, and NVivo 10 (QRS International) was used to guide data analysis based on the emerging themes and patterns. Data from varied participants and sources (FGDs, IDIs, KIIs, and observations) were extracted and triangulated by three members of the team. The emerging concepts were categorized based on the study objective, coded, and subjected to conventional content analysis using a thematic approach with typical and atypical statements identified for sub-themes to illustrate key findings.

Ethical consideration

Ethical approval was obtained from the Mbarara University of Science and Technology Research and Ethics Committee (UG-REC-005) before the beginning of the study. Administrative permission was obtained from Isingiro district health office. The study obtained written informed consent, and permission to audio record the interviews from all participants. Legally authorized representatives (literate family member) of illiterate participants provided informed consent for the study. The anonymity of participants was ensured at all stages of data collection and analysis.

Eighty-six adult participants were recruited. Of these, 72 participants were enrolled in the FGDs, 12 in the IDIs, and 2 as key informants (KIs). Participants’ median age was 34 years (range: 18-57 years). About 98% percent of the participants (N = 84) were females and farming was the main source of livelihood ( N = 61). Most participants were married ( N = 66) with a median of 3 live-children, and the majority ( N = 49) of the pregnant women were in their second gestation trimester. Participants had attained various levels of education as summarized in Table 2 .

The key themes that emerged from the data were: (1) knowledge of malaria causes, transmission, and symptoms, (2) effect of COVID-19 pandemic on healthcare-seeking and the prevention of malaria behaviors, and (3) perceived effects of malaria, its treatment and uptake of prevention strategies. Each of these themes and subthemes are diagrammatically illustrated in Fig. 1 , and are discussed in detail below.

Showing illustration of the thematic analysis of the study. Key: ITNs: Insecticide Treated Nets, IPTp: Intermittent Presumptive Therapy during pregnancy

Knowledge of malaria causes, transmission, and symptoms

Knowledge of malaria, perceived cause and transmission of malaria.

Malaria was perceived as the major health problem, and a common life-threatening disease among pregnant women and children under-five years. In their own experiences, participants indicated that infection in malaria was high during the rainy season, and the onset of the disease was sudden. In a participant’s view; ‘Malaria is a life-time disease, and is transmitted by an infected a mosquito bite while feeding on humans’. (26 years old, pregnant woman).

Malaria was attributed to varied causes such as mosquito bites, poor sanitation, and hygiene, as well as harvest season of mangoes and maize.

Mosquito as a cause of malaria: Most study participants recognized that the female anopheles mosquito lived in bushy areas, heaps of rubbish, stagnant water, broken pots, water tanks, and open tins near homesteads, and is the causative agent of malaria as given in the narrative: ‘…when it rains, the female Anopheles mosquito begins to lay eggs, and the life cycle is completed when it feeds on human blood. Subsequently, as one fails to close the house entrances (doors and windows) early, mosquitos’ gains access to the house and unaware, they bite and infect a person at night if not protected. Biting occurs from one person to another; as a result, malaria is spread if one is infected’. (29 years old, pregnant woman).

Poor sanitation and hygiene as a cause of malaria: Six of the participants from the different FGDs referred to malaria as a disease caused by ‘poor sanitation and hygiene’. One of the participants elaborated that; ‘…if one lives in a dirty environment, the bushy compounds, gardens near the homestead, garbage, and decomposing matter attracts many illnesses including malaria’. (24 years old, mother to 1 year old).

The harvest season of mangoes and maize as a cause of malaria: Two participants from different FGDs narrated; ‘….since my childhood, I have always seen people suffer from malaria during the harvest time particularly for mangoes and maize’ (34 years old, mother of 2 children & 26 years old, pregnant woman).

Symptoms of malaria infection

Participants locally recognized the symptoms of malaria infection as wounds on the lips, feeling cold, loss of appetite, yellowing of eyes, headache, general body weakness, shivering, and high body temperature. A pregnant woman described the symptoms of malaria infection as ‘a weird presentation’ and was associated with craving for good food as given in this narrative: ‘…malaria causes unease! You begin to shiver, vomit, and become weak similar to the early stages of pregnancy! This can stigmatize as it looks unusual in the public. Also, one develops a sour taste, and craves good foods! Sometimes you ask for rare foods like fish, and you are not yourself!’ (31 years old, pregnant woman) The symptoms of malaria during pregnancy were described to resemble those of early pregnancy.

The caregivers of children under-five years considered the symptoms of malaria as ‘sudden changes to their wellbeing’ manifesting as diarrhea, unending crying, vomiting, and failure to feed as narrated; ‘…when a child suffers from malaria, s/he looks bad! S/he begins to vomit, cries endlessly, rejects all the foods and the as a mother you feel peaceless.’ (26 years old, mother to 3 years old) . Further, the onset of malaria among children under-five was sudden, and affected their emotions and behavior. The symptoms were not obvious, and one relied on the change to predict the dire state of their health. A caregiver specified the difficulty to recognize these symptoms among younger children, as described: ‘…symptoms of malaria are challenging among children! From nowhere, a child starts to cry a lot, the body temperature rises suddenly, they develop diarrhea, and they pass yellow smelly urine. The child rejects foods, feels a burning sensation while breastfeeding, and often rejects the breast. They occasionally vomit yellow kinds of stuff’. (41 years old, mother of five) More, malaria was associated with a change in behavior. There occurs a noticeably reduced activity such as playing among children, and a child would often fall sleep. The unending cry and high body temperatures associated with malaria among children under-five stirred swelling of the blood veins and led to the yellowing of eyes. These changes were considered to manifest later, and they would depict a late-stage of malaria infection which necessitated to seek for healthcare. Profoundly, parents who spent time away from their children didn’t recognize malaria symptoms in time, as reported; ‘…I had gone to work, and on my return, I found my 11-months baby very sick, and she had developed rigors, and if I had delayed to take her to the hospital, maybe the worst would have occurred’ (33 years old, pregnant woman). These narratives showed a good recognition of malaria symptoms, however, to some, these required a caregivers’ critical attention.

Effects of malaria, its treatment, and uptake of prevention strategies

Perceived effects of malaria infection.

The participants stressed the effects of malaria as life-threatening to both pregnant women and children under-five years due to the risk of mortality, and its sudden onset that necessitates urgent attention as narrated by one of the participants: ‘…my child developed high temperatures. …I gave him a fraction of panadol, but the night was too long and worrying! Very early the next morning, I took him to a hospital where he was put on a drip (intravenous treatment) and he got well’. (28 years old, mother to 4 years old).

On the sad note, a participant reportedly lost a child to severe malaria as narrated in the following quote: ‘…my child presented with signs of malaria, and in a short time, his condition worsened! He became very unconscious, and I anticipated many possibilities including death! Unfortunately, he didn’t make it even when we struggled to get to the hospital’. (38 years old, mother of four).

Among pregnant women, participants were cognizant of the negative effects of malaria such as spontaneous abortions and stillbirths. Some pregnant women reportedly experienced peri-vaginal bleeding and resulted in pregnancy complications such as spontaneous abortion as a result of malaria. Resultantly, pregnant women greatly considered malaria prevention uptake, as narrated:

‘…pregnant women do it to protect their unborn babies, not even for themselves! Because one knows that if she gets affected by malaria she could be treated and gets healed but what about the unborn child? if you lose it, you have lost it…’. (22 years old, pregnant woman).

Economic challenges of malaria

Infection with malaria posed an economic challenge as it negated productivity. The reported effects were unfavorable as they negatively affected both the caregivers of children under-five years and pregnant women. Participants reported many days lost, and often led to huge expenditure on treatment bills, and this may lead to many debts.

Initial care and treatment for malaria

Most participants ( N = 41) attested that usually when a child or pregnant woman becomes badly off, they used home-remedies and then rushed to the health facility for treatment. From there, they would get well or were referred to a higher health care facility. A participant narrated: ‘…I returned from the market and found my 2-year child unwell. Her elder sister whom I had left to baby-sit her informed me that she had vomited, and she had high temperatures. I then remembered that I had panadol in the house, and I gave her a small’ fraction of the tablet and I proceeded to the health center’. (35 years old, mother of three) Also, a non-medicinal approach was used to subvert the high temperatures as narrated: ‘…I got a clean cloth and soaked it in cold water, after which, I massaged the child as I prepared to go to a clinic’. (23 years old, mother to 2 years old) The use of home remedies was confirmed by the VHT who indicated that they are used to subdue the symptoms of malaria while still in the community before they seek healthcare. She elaborated that whenever a child or pregnant woman got sick, home remedies (tablets leftover from a previous dose, or one would buy them from a clinic) were used first. Also, it emerged that local herbs are used as narrated: ‘…there was when you find that you don’t have any tablet of panadol, and you don’t have any money with you! …so I went to the farm and searched for local herbs (‘eshabiko’), I boiled it and used it to massage, and gave some to drink. I then started looking for ways to go to the hospital when the child was somehow stable’. (37 years old, mother to 8 months old). To explore further the use of herbal remedies, another participant narrated that: ‘…I went to the hospital, and they could not detect the disease my child was suffering from. I requested for referral, however, on my way, I felt like even where I will go, they won’t get the disease. So, I went to the elderly woman who gave me herbs for the baby to drink and she became better’. (31 years old, mother of three).

Malaria prevention strategies

Participants knew and used varied malaria prevention approaches such as ITNs, insecticide home sprays, intermittent presumptive therapy during pregnancy (IPT) and emphasized homestead hygiene practices such as drainage of stagnant water, covering of water tanks, clearing of bushes around homesteads, destruction of broken pots and empty tins, as narrated: ‘…we practice varied malaria prevention methods, for example, most of us close our windows and doors early (by 7 pm), and ensure that our compounds are free from any water’. (36 years old, pregnant woman).

As the most available and widely used preventive method, the availability and effectiveness of ITNs was rated high. Participants expressed positive attributes and indicated that distribution and sensitization efforts had yielded positively as narrated: ‘…. there is strong evidence that ITNS work for us. Even when you go for antenatal care visit, they emphasize malaria prevention, and they also give us an ITN. At immunization, young children are given a free ITN, and their use is welcomed by all of us’. (34 years old, pregnant women). The ITNs were perceived to have reduced on the burden of malaria among the vulnerable groups, and majority of the participants expressed positive attributes towards their regular and correct use as narrated: ‘Ever since I started sleeping under an ITN, I have spent about four years without suffering from malaria. When people noticed that use of ITNs reduced malaria infection, they understood the importance of these nets, and loved using them’. (25 years old, pregnant woman).

Despite this, ITNs were not 100% effective since it only offered protection while one is asleep. The methods of spraying with an insecticide were not common as narrated: ‘….sometimes you can’t afford to buy that mosquito spray, others fear using the spray because it causes severe headaches, and others are allergic, so you may use it and you start breathing badly or get a skin rash’ (27 years old, pregnant woman) . Often, participants considered the use of ITNs as the only available method considering its (ITNs) availability and ease of use. Consequently, participants recognized the good attributes of ITN use, and they expressed an irresistible willingness to buy and use an ITN as narrated: ‘….ITNs were freely distributed by the government, and even if I was to buy one, it costs less than the treatment charge for malaria. While an ITN would cost about 10,000 Uganda Shillings (an equivalent of 2.78 United States Dollars), most of the private health facilities would charge an average fee of 68,000 Ugandan Shillings (an equivalent 18.89 United States Dollars); which is not affordable by the majority of the households, and it is more expensive if more than one individual in the household fell sick’ (43 years old, mother of six). To this, HCPs and VHTs asserted the positive attributes of ITN use and affirmed the positive perception and improved practices among communities as narrated; ‘…when they would announce that they are distributing ITNs, people would leave all they were doing to make sure that they also get. During the distribution, they don’t mention bad things about them (ITNs) (38 years old, mother of five/midwife) . The local leaders affirmed the positive attitude as given in the narrative: ‘…people have seriously taken up the call to malaria prevention. We usually monitor homes to find out whether the malaria prevention and control measures are practiced, and we are impressed by the majority’ (59 years old, father of eight/local council chairperson of P_cell). Participants reported a positive attitude as given in the verbatim: ‘…malaria infection has reduced in our communities. Most of the people now suffer from cough and flu’ (47 years old, VHT) . This was further affirmed by the healthcare provider who reported that: ‘…the cases of malaria have declined, and most of the patients we see at the health centre are due to respiratory tract infections’ (44 years old, mother of four/midwife).

Utilization and challenges of malaria prevention methods

The use of ITNs was preferred as people freely acquired them from the universal rollout programs. Besides, ITNs are quite easy to use. The use of insecticide sprays was not common as the spray is costly for a rural population, and the chemical caused adverse effects if inhaled. Despite the varied strategies and positive attributes of malaria prevention, some participants didn’t utilize such measures. These were ascribed to deliberate refusal, being careless with their health, others felt suffocated under ITNs, uncomfortable on hot nights, while health conditions like asthma portended consistent use of ITNs. Other participants considered ITNs as highly flammable, which would put the house at risk, as narrated: ‘Some people are scared of using ITNs because they can easily catch fire and burn the whole house down, as it has been reported in most fire outbreaks in school dormitories’. (29 years old, mother of 3 months). Also, family disparity as a wife may prefer sleeping under an ITN while the husband is uncomfortable was another reported factor for ITN non-use. More, some participants didn’t receive sufficient ITNs for all the members in their households as explained by the local council leader: ‘…usually, we distribute one ITN to two people in a household, so in the end, households that have many members sleeping in separate beds will have a problem of inadequate ITNs’. (40 years old, father of six/local council leader n_cell).

Effect of COVID-19 pandemic on healthcare-seeking and prevention methods

Effects of covid-19 towards healthcare access for malaria infection.

There were unprecedented challenges that affected healthcare access as narrated: ‘…at the start of the lockdown, public transport means were stopped and the curfew was put in place. These halted people accessing healthcare facilities’. (38 years old, mother of six) . Further, two participants expressed dismay as reported: ‘… that even when the lockdown was eased, the private cars were allowed to carry a limited capacity, and even then, it was expensive to hire someone’s car to access the healthcare facility’. (28 years old, pregnant woman) ‘…in the subsequent easing of the transport restrictions, public transport was allowed, but to carry half the capacity of the passengers. […] this led to exorbitant transport charges’ (21 years old, mother to 2 years old). To the greatest extent, COVID-19 negatively affected healthcare access. This was affirmed by local council authority as narrated: ‘…. when COVID-19 broke out, the world changed! The president stopped the movement of both motorcycles and cars. Whenever a child or even a pregnant woman fell sick, it was difficult to go to the hospital. Sometimes the motorcyclists would risk transporting you, but they would be badly beaten by the law enforcers. Also, the motorcyclists would charge much more money, and this discouraged people from accessing healthcare facilities’. (33 years old, father of three/local council leader q_cell).

Effect of COVID-19 pandemic on malaria prevention methods

As the most available and commonly utilized malaria prevention method, the use of ITNs was negatively affected by the COVID-19 pandemic. For example, COVID-19 increased family conflicts, and these affected the availability and use of malaria prevention as narrated; ‘…the outbreak of Corona (COVID-19) increased family conflicts! When such happened, it made it hard to share a bed with ITN! So a woman and her baby would go and sleep somewhere else! As we received limited ITNs, when you shift from the main bed, then you sleep on a mattress that is put down on the floor without an ITN’ (29 years old, mother to 11 months old).

Also, the sudden closure of schools with no clear understanding of when these would re-open for the learners posed great challenges in regard to ITN utilization. It emerged that most school supplies like ITNs were left behind, and as learners went back to their homes, resulting in a scarcity of ITNs there. For parents who did not want their children’s lives risked to mosquito bites, they gave in theirs to protect the children as narrated: ‘Due to COVID-19, schools closed abruptly and children left their ITNs at school. As a parent, it hurts to have an ITN when your three children who share a bed are not protected. So, I gave mine to protect my children, but now it is six months and schools haven’t opened. I think I will get another during my antenatal visit’. (31 years old, mother of three).

Further, the COVID-19 pandemic shifted the focus of priorities as reported: ‘…some government programs including ITN distribution were halted, and people spent several months without ITNs. […] also, malaria-related training reduced due to COVID-19 as a gathering is discouraged’ (37 years old, mother of four/VHT).

Furthermore, COVID-19 negatively affected household income, and this hampered malaria prevention as narrated: ‘…COVID-19 has reduced the utilization of malaria prevention using insecticide sprays as the standards of living were greatly impoverished as people lost jobs. …the major focus is on survival, and priorities have left households compromised with malaria prevention’ (23 years old, pregnant woman).

On the contrary, the curfews put in place ensured early return to home (from 07:00PM to 06:00AM), and this allowed people to be indoors much earlier than before, and this reduced the risk of mosquito bites as given in the verbatim: ‘…. everyone now returns so early because of the curfew, so we ensure that we cook in time and go to bed. This protects us from mosquitoes that bites us late in the night’. (36 years old, pregnant women).

The results of this study affirmed that the majority of participants knew that the causes and transmission of malaria were associated with mosquito bites, and further asserted that malaria was transmitted from person-to-person through a mosquito bite. This finding agrees with previous studies [ 26 , 27 , 28 ] and is indicative of ample community knowledge on malaria, which is key to its prevention. The observed malaria-related knowledge is ascribed to the awareness campaigns, and this is hoped to foster prevention uptake [ 29 ]. On the other hand, some participants did not correctly understand the causes, transmission, and symptoms of malaria which may impede prevention uptake, and risk community malaria infections. Also, the early signs of pregnancy overlapping symptoms of malaria have been reported [ 30 , 31 ], and may negatively affect healthcare seeking [ 32 , 33 , 34 ].

Misconceptions about malaria prevention still exist and may portend malaria prevention uptake. For example, studies conducted in Nigeria reported that misconceptions related to malaria prevention methods affected their uptake [ 35 , 36 ]. Mathania et al.[ 37 ] further assert that uptake of malaria prevention requires strategies that address misinformation on the various methods. Similar findings from Zimbabwe and Burkina Faso have affirmed this [ 36 , 38 ]. Misconceptions related to malaria causation have indicated spurious prevention strategies, which risks the lives of the vulnerable populations [ 39 , 40 ]. To this, overlapping knowledge on malaria causes, symptoms, and prevention has been observed between pregnant women and the caregivers of children under-five [ 41 ]. In Uganda, numerous studies have shown a knowledge gap in both malaria causes and prevention measures [ 17 , 40 ]. In our experience of exploring the knowledge, attitude, and behavioral practices towards the use of ITNs among pregnant women and children under-five years in Isingiro district, there was optimal knowledge of malaria prevention, however, major barriers existed related to texture, color, and chemical composition impeded their utilization [ 17 ]. The low uptake of malaria prevention among vulnerable groups raises critical health concerns.

Participants were cognizant of the negative effects of malaria, and these are key towards malaria prevention uptake [ 23 , 42 ]. Further, the reported effects were detrimental as they negatively affected both the caregivers of children under-five years and pregnant women [ 27 , 31 ]. These corroborate with previous reports [ 43 , 44 ], and these demonstrate the threat posed by malaria infection. Consequently, this shows the need to urgently seek healthcare to avert the fatal consequences of the disease. Further, although the majority of the participants who reported fever had sought formal healthcare, some had initially considered home-remedies in form of paracetamol, herbs, and tepid sponging before seeking formal health care. The alternative remedies were agitated by frequent drug stock-outs in public health facilities and exorbitant charges in private health facilities. This pattern of healthcare-seeking affected delivery as some pregnant women reportedly opted to deliver from their villages due to long distances, and transport barriers. This affirms a previous report [ 45 ], and further highlights the gap in timely healthcare-seeking [ 46 ]. COVID-19 control requirements made seeking outside medications more difficulty of finding and cost of transport and the decrease in income. This finding contravenes recommendations that oblige timely healthcare seeking [ 47 ]. Similar to our study, previous research reported participants adopting a thriving private market and caregivers practiced over-the-counter remedies [ 48 ]. This suggests that home treatment may provide a more attractive option than formal healthcare [ 49 , 50 ], since access to shop‐bought medicines can be easier, with less time spent traveling or waiting, longer opening hours, and customer‐orientated staff [ 50 ]. Additionally, as malaria infection occurs most during the rainy season when farming is at its peak, the use of home remedies may be preferred. From this study, paracetamol (also known as panadol) as an antipyretic monotherapy was reportedly used to ameliorate fever as an initial home remedy. This practice is inapt and is attributed to the negative influence of media advertisement of various antipyretics that acclaim for home treatment of fever with the addendum that ‘the doctor’ should be consulted if symptoms persist. Resultantly, healthcare seeking is delayed with the hope of getting better, a risky practice that aggravates unnecessary drug side effects, severe life-threatening complications, and preventable deaths [ 51 , 52 ]. Home and local remedies, as per opinions by participants were as a result of healthcare challenges, similar to previous studies [ 53 , 54 ].

Participants knew and reportedly utilized more than one malaria prevention method. Human vector control through the use of ITNs was the most available and participants expressed irresistible willingness to its use; consistent with a previous report [ 55 ]. Despite this, some participants did not use them due to perceived negative sentiments linked to the adverse risks of the insecticide, which corroborates well with previous reports [ 17 , 56 ]. On the other hand, insecticide spray presented severe adverse challenges only exacerbated by COVID-19’s negative impact on income and decrease in educational reminders because group gatherings to discuss health topics were curtailed. These health-impacting outcomes have been recognized, and previous studies have emphasized the need to limit children, and women's exposure to in-door insecticide use [ 57 , 58 ]. Again, some participants didn’t uptake malaria prevention measures, and this was ascribed to the consideration of ITNs as highly flammable, deliberate refusal, being careless with their health, others felt suffocated under ITNs, uncomforted night as it would be too hot, while conditions like allergy and asthma affected consistent use of ITNs. Also, family disparity as a wife may like sleeping under an ITN while the husband is uncomfortable, and conflicts in homes. Previous research has shown similar findings [ 17 , 59 , 60 ], and these affirm a previous report [ 61 ] that the malaria prevention uptake is not effectively used. It is plausible that when the government is going to distribute ITNs, a single ITN-to- a person in a home is ideal. Also, they government ought to consider tough punishments for people who misuse the ITNs.

The outbreak of the COVID-19 pandemic presented an unprecedented challenge towards malaria prevention uptake. For example, some malaria prevention interventions like ITN distribution and malaria-related training were halted because of discouraging gatherings. The observed pattern has been reported elsewhere [ 62 , 63 ]. Educational gatherings are helpful in supporting behaviors to prevent and control malaria. Also, movement restrictions reduced the mobility of healthcare workers in-country, limited the capacity of staff, community outreach activities, and logistical supplies that were supporting malaria prevention [ 64 ]. Furthermore, COVID-19 reduced functional health care facilities as healthcare workers were repurposed to support the COVID-19 control response [ 65 ]. Even when public transport resumed, there remained significant barriers particularly exorbitant transport fees as a result of a reduced carriage capacity, and less income to pay which hindered malaria prevention uptake particularly access to artemisinin combination therapies [ 64 ]. Further, increased time together increased family conflicts which negatively affected the consolidated use of malaria prevention. The findings of this study furthers affirms to the social and health impacts concluded in a commentary drawn on sub-Saharan African health researchers’ accounts of their countries’ responses to control the spread of COVID-19 [ 66 ]. These findings further underline the worrying negative effects experienced by the majority of the vulnerable population in rural southwestern Uganda. The findings of this study ought to be interpreted in light of the following: 1) the study interviewed caregivers to children under-five as the proxy to obtain data on presumed malaria cases at the household level, and 2) data presented is based on participants’ self-reports, which may be associated with socially desirable bias.

Our findings highlight that there is a need to reignite awareness promotion regarding malaria prevention, address misconceptions about malaria symptoms and early signs of pregnancy, and support interventions that promote formal and timely seeking of healthcare. Finally, response to COVID-19 ought to be integrated with malaria efforts by recommitting and integrating COVID-19 measures in the normative living and restrict future barriers to healthcare access.

The majority of the participants recognized the symptom of malaria, its transmission, and prevention measures. Their malaria prevention experience was highly influenced by the perceived causes and severe adverse effects of malaria infection. Furthermore, the use of home-remedies and non-formal approaches was a common practice. There were reported major negative effects of malaria prevention uptake due to the COVID-19 pandemic.

Availability of data and materials

All relevant data are within the paper. The interview guides are included as supplementary materials .

Abbreviations

Focus Group Discussion

In-depth Interview

Insecticide-Treated mosquito Net

Key Informant Interview

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Acknowledgements

We are grateful to the study participants, VHTs, and local council authorities. We acknowledge Nuwagaba Gabriel, Ssenyonga Pius, and Muhangi Steven who supported the data collection process. We are grateful to Robert Bortolussi and Noni E. MacDonald for critically reviewing this manuscript.

This study was supported by a MicroResearch ( www.microresearch.ca ) grant MR 19 N MUS 01. The funders had no role in study design, data collection, and analysis, or decision to publish.

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IMT and RN conceived the study idea, participated in study design; data acquisition, analysis, and interpretation; and manuscript drafting and revision. RK, CA participated in drafting data collection tools, data acquisition, analysis, and interpretation; manuscript drafting and revision. SA and CM oversaw the research design, cross-checked data collection tools, manuscript drafting and critically reviewed the manuscript. All authors read and approved the final manuscript.

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Taremwa, I.M., Ashaba, S., Kyarisiima, R. et al. Treatment-seeking and uptake of malaria prevention strategies among pregnant women and caregivers of children under-five years during COVID-19 pandemic in rural communities in South West Uganda: a qualitative study. BMC Public Health 22 , 373 (2022). https://doi.org/10.1186/s12889-022-12771-3

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Published: 13 May 2022

Malaria in 2022: Increasing challenges, cautious optimism

Prasanna Jagannathan ORCID: orcid.org/0000-0001-6305-758X 1 , 2 &
Abel Kakuru 3

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Malaria cases and deaths remain unacceptably high and are resurgent in several settings, though recent developments inspire optimism. This includes the approval of the world’s first malaria vaccine and results from novel vaccine candidates and trials testing innovative combinatorial interventions.

Despite gains over the first 15 years of this millennium, malaria control has stagnated in the last several years, with resurgence and rising morbidity in several highly endemic countries exacerbated by service disruptions due to the COVID-19 pandemic 1 . In 2020, malaria was estimated to have resulted in 627,000 deaths and 241 million cases, with 77% of deaths in children <5 years of age 1 . Overall, 90% of malaria cases and deaths are reported in Africa, and six countries—Nigeria, DRC, Uganda, Mozambique, Angola, and Burkina Faso—account for 55% of all cases globally.

The main interventions used for prevention of malaria include vector control with long lasting insecticidal bednets (LLINs) and indoor residual spraying of insecticides (IRS). However, Anopheles vector resistance to pyrethroids, the main insecticide used in LLINs, has become widespread, and insecticide resistance also increasingly threatens the utility of IRS. In addition to vector controls, prompt treatment of malaria with artemisinin-based combination therapy (ACTs) is recommended in all settings where falciparum malaria is endemic. ACTs have played a crucial role in controlling malaria over the past 20 years 2 , with artemether-lumefantrine being the most widely used ACT in Africa. However, artemisinin-resistant Plasmodium falciparum parasites have spread in Southeast Asia 3 , resulting in reduced treatment efficacy of some ACTs 4 . More alarmingly, recent reports from Rwanda 5 , 6 and Northern Uganda 7 , 8 suggest the emergence of artemisinin-resistant parasites in Africa. Loss of artemesinin activity would threaten the activity of partner drugs such as lumefantrine; loss of both components of ACTs could have devastating consequences across the continent 9 .

To combat the emergence of artemisinin-resistant parasites, identification of novel therapeutic approaches has become critically important. Although new antimalarial drugs are being identified, they are still in various stages of clinical development ( www.mmv.org ). One such drug, KAF-156, was found to be active against artemisinin-resistant parasites in a small trial of adults 10 , and is currently being tested in Phase 2 trials in children when given with the partner drug lumefantrine (NCT 04546633). Another emerging therapeutic strategy is the use of artemisinins along with two long-acting partner drugs instead of one, similar to the therapeutic approach to HIV and tuberculosis (e.g., triple ACTs.). Triple ACTs have been found to be effective in clinical trials conducted in the setting of artemisinin-resistant parasites 11 , 12 , and may be useful as a “stop-gap” therapy for drug-resistant malaria until new antimalarials become available, or to prevent and/or delay the development of resistance to antimalarials in settings where resistance has not yet emerged 13 . Given potential safety and tolerability concerns, questions remain about which agents to use, and how and when to deploy such a strategy.

One of the most elusive interventions to aid malaria control has been an effective malaria vaccine that can prevent severe malaria and deaths. The WHO and partners set a strategic goal of achieving a malaria vaccine with >75% efficacy by 2030 14 . However, this goal has been a major challenge, and very few candidate vaccines have demonstrated significant efficacy 15 . The malaria vaccine RTS,S/AS01 is the only vaccine tested to reach Phase 3 trials with reproducible efficacy in different populations. This recombinant protein vaccine targets the circumsporozoite protein (CSP) of P. falciparum , which is expressed at the pre-erythrocytic stage of infection. Although RTS,S has been found to be efficacious, overall efficacy in the Phase 3 trial was low, with 36% protective efficacy against clinical malaria, and 32% against severe malaria, in the 4 years after vaccination among children who began the vaccination series between 5 and 17 months of age and received a booster 21 months later 16 . RTS,S efficacy was highest (~60–70%) in the first 6 months following vaccination, but rapidly decayed, and was limited or non-significant by 18 months 17 . This waning of vaccine efficacy was broadly mirrored by a decline in antibody responses against CSP 18 , although definitive correlates of protection remain unclear. Identification of correlates and mechanisms that contribute to malaria vaccine performance in endemic settings remains an active area of research.

Given results from the Phase 3 trial, the WHO launched pilot implementation studies of RTS,S in Malawi, Kenya and Ghana beginning in 2019 19 . These implementation studies showed that delivery of the vaccine was feasible, with high uptake of the vaccine, confirming demand. Importantly, these studies also reaffirmed vaccine safety and efficacy, observing that vaccination was associated with a 30% reduction in severe malaria 1 . Given these results, in October of 2021, after 30 years of development, the WHO-approved RTS,S for use in children living in regions with moderate to high transmission of malaria caused by P. falciparum .

Although RTS,S is now WHO-approved, its availability will be limited in the short term. GlaxoSmithKline (GSK), which produces the vaccine, is committed to donate up to 10 million vaccine doses to the pilot implementation regions of Ghana, Kenya, and Malawi through 2023, and to supply up to 15 million doses of vaccine per year to the end of 2028 if it is recommended for wider use, pending financing. However, this represents only ~10–15% of the annual doses required if provided to all children living in highly endemic settings 20 . GSK has committed to transfer the technology to manufacture RTS,S to Bharat Biotech (BBIL), and, by 2029, BBIL is expected to be the sole supplier of the vaccine, with increased production capacity expected. Given the relatively low efficacy of RTS,S, and its limited short-term availability, new vaccines are needed to reach the WHO target of malaria vaccines with >75% efficacy by 2030. One such candidate is R21, another CSP-based subunit vaccine with a similar construct to RTS,S but with more CSP antigen in the virus-like particle. In a phase 2 trial, R21 was recently shown to have 71–77% protective efficacy against a first episode of clinical malaria in the year following vaccination among children living in an area with seasonal malaria transmission 21 . However, this study only reported protection across one malaria transmission season; the durability of this protection, and whether R21 would be efficacious in areas with year-round malaria transmission, remains unclear. Phase 3 trials in 4 countries, with longer follow-up, are underway. In addition, several other vaccines for both P. falciparum and Plasmodium vivax are under development, targeting each of the life cycle stages of Plasmodium, including sporozoite/pre-erythrocytic, asexual/erythrocytic, and sexual/mosquito 22 .

Another promising intervention for malaria control is intermittent preventive therapy (IPT)—the provision of full treatment doses of antimalarial drugs to at risk populations to clear existing infections and prevent new infections. IPT with sulfadoxine-pyrimethamine (SP) given at the time of routine vaccination in infants (IPTi) has been shown to be safe and modestly effective against malaria in the first year of life 23 , but is only recommended in areas with low levels of SP resistance. Uptake of IPTi has therefore been very low, with only one country (Sierra Leone) recently adopting this strategy. Seasonal malaria chemoprevention (SMC) using monthly SP plus amodiaquine during the transmission season is a proven strategy to decrease morbidity and mortality in young children 24 , and is currently deployed in parts of West and Central Africa where annual malaria transmission is confined to a few months. However, neither IPTi nor SMC are recommended in areas with high level SP resistance and/or year-round malaria transmission as in much of Central and East Africa 25 . In these settings, the ACT dihydroartemisinin-piperaquine (DP) has emerged as an excellent candidate for use as IPT in children 26 , including as perennial malaria chemoprevention in areas with year-round malaria transmission 27 . IPT during pregnancy (IPTp) with DP has also been shown to be more effective than IPTp with SP for prevention of malaria in pregnancy in areas with high level SP resistance 28 , 29 , although IPTp with SP may result in improved birth outcomes independent of SP’s antimalarial activity 30 . As above, there are important concerns about selection of drug-resistance through IPT, though modeling suggests that this could be limited via prevention of infections and/or optimization of target drug concentrations 31 . IPT studies should therefore be accompanied by close monitoring for emergence of genotyping and phenotypic evidence of antimalarial drug resistance. An added concern is that preventing malaria in children may delay acquisition of antimalarial immunity, increasing the risk of malaria after IPT has stopped (rebound malaria). Though some studies have reported rebound following cessation of IPT 32 , 33 , other studies have reported either no increase 23 or evidence of sustained protection 27 , 34 following cessation. How IPT impacts the acquisition of immunity to malaria remains an important area of investigation.

Finally, exciting new data suggest that combinations of malaria control interventions might be more efficacious than individual interventions. Vaccination of malaria-naïve adults with P. falciparum sporozoites under prophylactic cover with either chloroquine or pyrimethamine induced durable sterile protection against controlled challenge with either a homologous or heterologous P. falciparum strain 35 . A follow-up study conducted in malaria-exposed Malian adults has recently been completed (NCT03952650), with results eagerly anticipated. However, studies of this strategy in malaria-exposed children will be needed, given prior vaccination studies showing limited efficacy in children despite higher vaccine efficacy in adults 36 . In another recent randomized controlled trial conducted in West Africa, investigators found that the combination of seasonal malaria chemoprevention (SMC) in children with amodiaquine + sulfadoxine-pyrimethamine (AQ + SP) along with RTS,S vaccination was superior to either intervention alone 37 . This promising dual intervention deserves additional study in settings where malaria transmission is seasonal. However, in settings with year-round malaria transmission and/or high SP resistance, alternative IPT + vaccine regimens require urgent evaluation.

In conclusion, despite earlier gains, malaria cases and deaths remain unacceptably high and are resurgent in several settings, and our ability to prevent and control malaria with current tools is challenged by the specter of insecticide-resistant vectors and drug-resistant Plasmodium parasites. Clearly, renewed focus—and new interventions—are needed to achieve the goals highlighted by the WHO “high burden to high impact” campaign to reduce cases and deaths in countries hardest hit by malaria. There are reasons for cautious optimism, including approval of the world’s first malaria vaccine and results from novel vaccine candidates and trials testing innovative combinatorial interventions. However, critical research gaps remain, and there is an urgent need to prioritize and fund development of novel therapeutic, prophylactic, and vaccine strategies against malaria.

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Policy brief article, achievements, gaps, and emerging challenges in controlling malaria in ethiopia.

Controlling malaria is one of the top health sector priorities in Ethiopia. The concrete prevention, control, and treatment interventions undertaken in the past two decades have substantially reduced the morbidity and mortality attributable to malaria. Emboldened by these past achievements, Ethiopia envisages to eliminate malaria by 2030. Realizing this ambition, however, needs to further strengthen the financial, technical, and institutional capacities to address the current as well as emerging challenges. It particularly needs to step up measures pertaining to diagnosis, domestic resource mobilization, vector surveillance, and seasonal weather forecasting.

● Ethiopia has made a remarkable progress in terms of controlling malaria, especially, since 2004.

● It is further campaigning towards a “malaria free Ethiopia”.

● This requires building strong cross-sectoral and cross-border coordination capacity.

● It also needs to scale up research and surveillance on emerging malaria vectors.

● The implications of irrigation and hydropower dams on malaria transmission should not be undermined.

Introduction

Malaria is one of the major infectious tropical diseases with substantial socio-economic repercussions in the sub-Saharan Africa region. In 2019, WHO’s African Region accounted for about 94% of malaria cases while only six African countries (Nigeria, Democratic Republic of the Congo, Tanzania, Mozambique, Niger, and Burkina Faso) accounted for about 51% of all malaria deaths globally ( 1 ). The number of estimated malaria cases in Africa in 2019 were 215 million ( 1 ).

Currently, more than 50% of the population in Ethiopia is exposed to the risk of malaria infection ( 3 – 5 ). Despite the range of prevention measures undertaken in the last two decades, malaria remains to be one of the top ten causes of morbidity and mortality in Ethiopia ( 6 ) with substantial repercussions for the macroeconomy ( 7 , 8 ). The effects of malaria propel into the macroeconomy through two main channels. The first is through agricultural labor productivity changes as the malaria transmission seasons (September to December, and April to May) coincide with the main agriculture harvest seasons ( 5 , 7 , 8 ). Agriculture is the main source of employment (≈ 75%) and merchandise export earnings (≈ 80%) in Ethiopia ( 9 ). The second way is through government budget allocation and fiscal balance as government is the main health service provider ( 4 ). Seen against the forgoing conditions in Ethiopia, even a marginal increase in the risk of malaria has profound socio-economic implications making malaria disease public health as well as economic problem ( 8 ).

It is therefore important to assess the status of malaria risk, and to continuously evaluate the prevention and control measures in the country. It is equally important to identify the existing policy and implementation gaps, and emerging challenges that may undermine (or even reverse) the progress made so far. This paper aims to contribute its part in this regard. It briefly discusses the status of malaria risk, the past achievements, gaps, and emerging challenges in fighting malaria in Ethiopia. The study is a narrative overview that aims to briefly synthesize the existing knowledge, and to draw implications for future research and policy makers ( 10 – 12 ).

The remainder of the paper is structured as follows. Section 2 gives a brief overview of the malaria risk in Ethiopia. Section 3 succinctly presents the malaria prevention and control measures followed by the past achievements, the current gaps, and emerging issues related to malaria control measures in Section 4. This is followed by some recommendations in Section 5, and conclusions in Section 6.

Overview of Malaria Risk

Malaria transmission in Ethiopia is seasonal, unstable, and often characterized by highly focal and large-scale cyclic epidemics ( 1 , 7 ). Areas lying at altitudes between 1600 and 2000 meters above sea level (masl) are in general epidemic prone hypo-endemic zones of malaria ( 4 ) although some studies could also detected malaria in areas higher than 2000 masl ( 5 , 7 ). Altitude, climate, environmental changes (e.g., due to dams, roads construction, agricultural projects), and housing conditions are important determinants of malaria risk and transmission in Ethiopia ( 3 , 7 ). Overall, more than 50% of the total population in Ethiopia is exposed to the risk of malaria infection ( 3 – 5 ). Every year, four to five million people are affected by malaria ( 3 , 13 ) while a major epidemic occurs every five to eight years ( 7 ).

The reported malaria cases remain higher than one million cases per annum. On an average, about 1.6 million malaria cases (more than 60% is related to the P. falciparum species) are reported between 2010 and 2019 ( 1 , 5 ). The rate of the P. falciparum species is especially higher in the lowland regions ( 7 ).

There are five distinct malaria risk strata classified based on annual parasite incidence (API) per 1,000 population, elevation, and expert opinions ( 7 ). According to the latest malaria risk classification, about 18% of the population lives in high (API ≥ 50) and moderate (10 ≤ API < 50) risk strata. Such classifications are important as they facilitate the design and implementation of most appropriate interventions per strata ( 5 , 7 , 14 ). It worth noting here that the latest stratification ( 7 ) and percentage distribution of population living under each risk stratum is different from the previous stratifications and percentage distributions such as, for example, the one in 2014 ( 14 ). Figure 1 collates the two stratification maps together. See also that the latest stratification adds one more stratum which is very low risk.

Figure 1 Malaria risk stratification in Ethiopia, 2014 (A) , and 2020 (B) .

Policy Responses to Malaria

Ethiopia has been fighting malaria through formal institutions for more than five decades ( 5 , 13 ). Today, malaria is one of its top national health and economic development priorities ( 7 ). In line with this, especially since 2004, the Government of Ethiopia together with its international partners has implemented a series of malaria prevention, control, and elimination programs ( 7 ) including preparing malaria guidelines ( 15 , 16 ) and strategies ( 7 , 17 – 19 ), and conducting surveys ( 14 , 20 , 21 ). The guidelines present detailed procedures on implementing and reporting various malaria vector control, diagnosis and treatment, and surveillance and response activities ( 15 , 16 ). The periodic surveys produce evidence needed to formulate as well as evaluate different policy measures. All in all, policy wise, Ethiopia is stepping up its efforts to move from controlling ( 17 ) to eliminating ( 7 ) malaria.

Ethiopia started scaling up prevention and control measures in 2004 ( 5 ). Notable large-scale interventions include distribution of long-lasting insecticidal nets (LLINs), and indoor residual spraying (IRS), and introduction of additional diagnosis and treatment mechanisms such as artemisinin-based combination therapy (ACT), artemether lumefantrine (AL), and rapid diagnostic test (RDT) ( 5 , 7 , 13 ). Furthermore, in 2010 it started implementing test-treat policy, i.e., administration of antimalarial drugs based on test results ( 5 ). Figure 2 , which is adapted from ( 5 ), depicts the timeline for major interventions between 1995 and 2016.

Figure 2 Timeline of major malaria control, diagnosis, and treatment interventions in Ethiopia, 1995-2016.

Remarkable progress has been made afterwards. The share of households in malarious areas (≤ 2000 masl) that possess at least one LLINs and received IRS have, respectively, reached 85% and 93% in 2019 ( 22 ). The introduction of RDTs in 2004 was a significant step forward in terms of case detection and management ( 3 ) since RDTs are easy to use and to deploy in rural areas ( 23 ) where 80% of Ethiopians live. These mass scale deployment of malaria specific inputs were also accompanied by the deployment of health extension workers (HEW) in rural areas which conduct home-to-home outreach activities, and provide basic curative, promotive, and preventive services at health posts ( 24 ).

The malaria-specific interventions are also complemented with the overall increase in the number of health infrastructure (e.g., public health facilities and professionals) which profoundly improved malaria case management ( 13 , 24 ). Notwithstanding the limitations, currently, about 68% of the facilities in the country offers malaria diagnosis or treatment ( 4 ). Table 1 presents the key trends in public health services, in malaria control measures, and in malaria disease in the past two decades.

Table 1 Public health services, malaria interventions, and malaria disease in Ethiopia, 2000-2019.

Achievements, Gaps, and Emerging Issues

Achievements.

The range of malaria prevention and control measures discussed in the preceding section are paying off. Mortality and morbidity attributable to malaria have significantly declined ( 7 , 30 ). The number of deaths due to malaria declined by 54% between 2000 and 2016 ( 31 ) while the age-standardized mortality rate of malaria has declined by 96.5% between 1990 and 2015 ( 32 ). Ethiopia is also on a good track in terms of meeting its Global Technical Strategy for Malaria (2016-2030) ( 1 , 7 ).

These past achievements encouraged the country to set more ambitious future goals. It envisages to reduce malaria morbidity and mortality, relative to 2020, by 50% in 2025 and to eliminate malaria by 2030 ( 7 ). More specifically, it aims to reduce malaria deaths per 100,000 population at risk (from 0.36 to 0.1), and the number of reported cases (from 1.7 million to 0.7 million) between 2019/20 and 2025/26 ( 7 ). Seen against these past achievements and the ongoing efforts, Ethiopia’s aim to eliminate malaria by 2030 seems ambitious but attainable. ( 13 ). There are however outstanding gaps and emerging challenges that should be addressed to keep this momentum of fighting malaria. Some of them are highlighted below.

Diagnosis is one of the key factors in controlling and eliminating malaria. In Ethiopia, 63% of the health facilities provide malaria diagnosis testing ( 4 ). Of the alternative methods of malaria diagnosis ( 33 ), a microscopic diagnosis allows for the identification of parasitemia percentage, parasitic morphology, and speciation ( 23 ). The microscopic diagnosis in Ethiopia is limited. Health facilities that offered malaria diagnosis by microscopy (17%) was much lower than health facilities that offered diagnosis by clinical symptoms (42%) and RDT (54%) ( 4 ). Diagnosis by microscopy is available only in 7% of the rural health facilities ( 4 ). This represents a major diagnosis capacity gap seen against the fact that about 80% of the population lives in rural areas ( 7 ) with poor housing conditions, and thus at higher risk of infection ( 3 ). A recent review on the relative advantages and limitations of different malaria diagnostic methods can be found in ( 23 ). The readiness for malaria diagnostic capacity is 55% in private health facilities compared to 80% in government health facilities ( 4 ).

On the other hand, sufficient and sustained amount of funding is required to keep the momentum of fighting malaria ( 24 ). The generous funding from external sources has been one of the major reasons behind the past success ( 5 , 13 ). Development assistance, for instance, contributes about 57% of an estimated US$ 81.2 million total spending on malaria in 2016 ( 34 ). See also Figure 3 which is based on ( 34 ). The Global Fund and the US Presidents’ Malaria Initiative (PMI) are the two main sources of external funds ( 7 ). Ethiopia received close to US$ 0.5 billion between 2008 and 2021 from the PMI funds ( 35 ). The biggest share of the external funds is spent on fixed costs and commodities such as LLINs, ACTs, and RDTs ( 7 , 35 ). As such, it is fair to argue that the prospects of malaria elimination goals partly hinges on the financial commitments by the international donors. The amount of external funds are however expected to decline, and thus domestic sources should fill the gap. For example, the Government of Ethiopia anticipates financing about 56% of the total spending required to implement the malaria elimination plan by 2025/26 ( 7 ). In spite of this increased budgetary commitment from the government, however, implementing the current Ethiopia Malaria Elimination Strategic Plan (2021/22-2025/26) will still face about US$ 167.9 million financial gap ( 7 ). Diversifying the sources of funds is particularly important in light of unforeseen global and domestic challenges such as the COVID-19 pandemics that may affect the priority areas of the government as well as international partners ( 7 ).

Figure 3 Malaria spending in Ethiopia by source, 2016.

Emerging Challenges

The past progress in fighting malaria is threatened by a set of emerging challenges due to such as mosquito resistance to insecticides, the emergence of new vectors, the potential side effects of irrigation and hydropower reservoirs, and climate change and variability ( 7 ). Recent evidence shows that local vectors are generally resistant to dichloro-diphenyl-trichloroethane (DDT) and pyrethroids ( 35 ), and the LLINs ( 36 ). The use of DDT for IRS was of course discontinued in 2007 ( 5 ). The emergence of new vectors such as the A.stephensi , which were not previously widely known, poses yet another challenge ( 1 , 7 ). Anopheles stephensi mosquitoes breed predominately in urban settings preferably in man-made water containers and poses risk for increased transmission of P. falciparum and P. vivax ( 37 ). Currently, the A. stephensi vector is widely distributed and established in the eastern parts of Ethiopia ( 38 ). On the other hand, Ethiopia is expanding irrigation and hydropower dams that were found intensifying malaria transmission ( 39 ). For instance, malaria incidence was about 32% among households in villages with irrigation micro-dams compared to 19% in villages with no micro-dams in northern Ethiopia ( 40 ). The side effects are much more pronounced in the lowland and midland ecological settings ( 41 ) where the country is recently eyeing to expand its large-scale irrigated agriculture. On top of this, temperature suitability for malaria is climbing into the highlands of Ethiopia ( 42 , 43 ) because of which the prevalence of malaria is projected to increase ( 44 ). A case study in northern Ethiopia shows that climate change may increase area suitable for malaria transmission by 94 to 114% by 2050 ( 45 ). Overall, countrywide, up to 130 million people may be at risk of malaria by 2070 ( 46 ) that could induce substantial economic costs ( 8 , 42 ).

Actionable Recommendations

Therefore, in order to maintain the momentum of fighting malaria, it needs to scale up measures related to funding, climate services, and vector control. More specifically, it needs to:

● Raise the domestic resource mobilization capacity ( 7 ).

● Enhance climate information processing capacity ( 47 ).

● Consider dam reservoir management as one of malaria vector control tools ( 48 ).

● Scale up research ( 38 ), and surveillance ( 37 ) capacity particularly with regard to the emerging vectors.

● Pursue regional cooperation to control cross-border malaria transmission through migration ( 24 ), and to surveille the emerging vectors ( 38 ).

Conclusions

Ethiopia has been undertaking a wide range of policy measures to control malaria, especially, after 2004. Consequently, mortality and morbidity attributable to malaria have declined significantly. To keep the momentum of fighting malaria, however, Ethiopia needs to strengthen its institutional capacity pertaining to domestic resource mobilization, diagnosis by microscopy, vector surveillance, and climate information processing and seasonal weather forecasting. These actions need, among others, to layout and enhance cross-sectoral coordination (e.g., with irrigation, hydropower, and climate change), and cross-border cooperation (e.g., for better surveillance of vectors) mechanisms. Future public budget allocation to fight malaria should factor in these and other emerging challenges.

Author Contributions

The author confirms being the sole contributor of this work and has approved it for publication.

Conflict of Interest

The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: malaria risk, malaria control, malaria funding, health policy, Ethiopia

Citation: Yalew AW (2022) Achievements, Gaps, and Emerging Challenges in Controlling Malaria in Ethiopia. Front. Trop. Dis 2:771030. doi: 10.3389/fitd.2021.771030

Received: 05 September 2021; Accepted: 09 December 2021; Published: 25 January 2022.

Reviewed by:

Copyright © 2022 Yalew. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Amsalu Woldie Yalew, [email protected]

This article is part of the Research Topic

Highlights in Disease Ecology, Prevention and Control

Open Access
Published: 20 March 2021

Malaria in Eswatini, 2012–2019: a case study of the elimination effort

Theresia Estomih Nkya ORCID: orcid.org/0000-0003-3015-1363 1 , 5 ,
Ulrike Fillinger 1 ,
Makhoselive Dlamini 2 ,
Onyango P. Sangoro 1 ,
Rose Marubu 1 ,
Zulisile Zulu 3 ,
Emmanuel Chanda 4 ,
Clifford Maina Mutero 1 , 6 &
Quinton Dlamini 3

Malaria Journal volume 20 , Article number: 159 ( 2021 ) Cite this article

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Eswatini was the first country in sub-Saharan Africa to pass a National Malaria Elimination Policy in 2011, and later set a target for elimination by the year 2020. This case study aimed to review the malaria surveillance data of Eswatini collected over 8 years between 2012 and 2019 to evaluate the country’s efforts that targeted malaria elimination by 2020. Coverage of indoor residual spraying (IRS) for vector control and data on malaria cases were provided by the National Malaria Programme (NMP) of Eswatini. The data included all cases treated for malaria in all health facilities. The data was analysed descriptively. Over the 8 years, a total of 5511 patients reported to the health facilities with malaria symptoms. The case investigation rate through the routine surveillance system increased from 50% in 2012 to 84% in 2019. Incidence per 1000 population at risk fluctuated over the years, but in general increased from 0.70 in 2012 to 1.65 in 2019, with the highest incidence of 3.19 reported in 2017. IRS data showed inconsistency in spraying over the 8 years. Most of the cases were diagnosed by rapid diagnostic test (RDT) kits in government (87.6%), mission (89.1%), private (87%) and company/industry-owned facilities (84.3%), either singly or in combination with microscopy. Eswatini has fallen short of achieving malaria elimination by 2020. Malaria cases are still consistently reported, albeit at low rates, with occasional localized outbreaks. To achieve elimination, it is critical to optimize timely and well-targeted IRS and to consider rational expansion of tools for an integrated malaria control approach in Eswatini by including tools such as larval source management, long-lasting insecticidal nets (LLINs), screening of mosquito house entry points, and chemoprophylaxis. The establishment of rigorous routine entomological surveillance should also be prioritized to determine the local malaria vectors’ ecology, potential species diversity, the role of secondary vectors and insecticide resistance.

Globally, more countries are moving towards zero indigenous malaria cases. In 2018, 49 countries reported fewer than 10,000 malaria cases [ 1 ]. The number of countries with fewer than 100 indigenous cases increased from 17 in 2010 to 25 in 2017 and 27 in 2018 [ 1 ]. In 2016, the World Health Organization (WHO) identified 21 countries with the potential to eliminate malaria by 2020, the E-2020 initiative, and resolved to work with their governments to support their elimination goals [ 2 ]. Eswatini is among the E-2020 countries and part of the Elimination 8 (E-8), a regional initiative established in 2009 by the Southern African Development Community (SADC). The E-8 initiative is coordinating a collaborative effort, led by the ministers of health in eight countries (Botswana, Namibia, South Africa, Eswatini, Angola, Mozambique, Zambia, and Zimbabwe) to jointly plan and execute a regional malaria elimination strategy. The E-8 aims to mitigate cross-border transmission, which presents a major threat to the re-establishment of infection [ 3 ].

In Eswatini, malaria transmission is seasonal and highly influenced by variations in altitude through the corresponding effects of rainfall and temperature levels. The country is divided into four ecological regions distinguished by elevation, climate, soil quality and vegetation: highveld (altitude above 1500 m); middleveld (average altitude 700 m); and, lowveld (average elevation 400 m) [ 4 ] (Fig. 1 a). Historically, malaria transmission has been confined in the lowveld and lower areas of middleveld regions, where malaria vector breeding is favoured by a range of environmental factors, including warm and wet autumn and summer seasons, and availability of suitable mosquito breeding habitats. Before the commencement of vector control measures in 1949, malaria was a major health problem in Eswatini, with epidemics reported during the summer and autumn months from December to May [ 4 ]. Malaria control measures were extremely limited and prejudicial, whereby the Europeans living in the lowveld regions were advised to put screens on their windows and to avoid walking outdoors in the evenings, while no similar health instructions were given to the native Swazi. In 1946, during the first epidemic, where extensive malaria surveys were carried out, it was estimated that 50,000 cases occurred, which corresponded to 26% of the total population of Eswatini at the time [ 5 ]. These epidemics were attributed to heavy rainfall which led to an increase in vector breeding sites and colonial economic policies, which prevented many Swazi families from producing enough food to meet their subsistence needs [ 4 ]. Following the successful control of malaria with indoor residual spraying (IRS) using dichloro-diphenyl-trichloroethane (DDT) in the 1950s and early 1960s in the lowveld, agricultural activities could now be intensified in these regions. This led to the construction of major irrigation schemes for sugar plantations which, unfortunately, resulted in a resurgence of malaria in the areas in which sugar was grown, undermining the effectiveness of the malaria control measures that had been put in place. Autochthonous cases of malaria occurred around the sugar estates in 1960 and larger outbreaks followed in 1967 and 1972 [ 5 ]. The number of recorded cases continued to rise during the late 1970s and began to spread out from the sugar estates to other areas of the lowveld and into the lower parts of the middleveld. Ineffective malaria control measures within the sugar estates, and more widely in the lowveld, led to the creation of ideal breeding sites for malaria vectors within the irrigation projects. Demographic shifts, with more non-immune populations living near malaria vectors and carriers, further contributed to the re-establishment of malaria as a serious health problem in Eswatini in the late 1970s.

Map of Eswatini is a landlocked country surrounded by South Africa and Mozambique. a Ecological regions; highveld, middleveld, and lowveld. b Eswatini showing regions, constituencies, and international borders

However, between 1999 and 2009, Eswatini scaled up vector control, largely using IRS in the at-risk regions and border areas and established a cross-border collaboration with Mozambique and South Africa for malaria control [ 6 ]. As a result, Eswatini greatly reduced the national burden of malaria from 3.9 laboratory-confirmed cases to 0.07 cases per 1000 population [ 7 ]. The successful control of malaria through national and cross-border efforts positioned Eswatini to be earmarked for elimination by 2015 by the SADC and the African Union [ 8 , 9 ] and the National Strategic Plan for Elimination (NMESP) of Malaria in Eswatini was initiated [ 7 ]. The NMESP for 2008–2015 set the country on a malaria elimination path. In March 2011, Eswatini became the first country in sub-Saharan Africa to approve a National Malaria Elimination Policy [ 7 ]. As defined in the NMESP 2015–2020, Eswatini’s plan to eliminate malaria focused on four major intervention areas: case management; vector control with IRS; surveillance; and information, education, and communication on malaria [ 10 ]. With the introduction of rapid diagnostic test (RDT) kits at all health facilities in February 2010, laboratory-confirmed cases increased marginally while the number of clinically diagnosed cases decreased significantly, indicating successful uptake of RDT use [ 11 ]. Additionally, a surveillance programme has been operationalized nationally to facilitate the investigation of confirmed malaria cases at the household level to determine the source of each infection. Community-based case detection was established to help identify asymptomatic infections that contribute to ongoing local transmission. This has allowed the identification of high-risk groups and areas that can be targeted with additional interventions, including vector control using IRS and health promotion messages [ 10 , 11 ]. At the core of Eswatini’s National Malaria Programme (NMP) vector control strategy is IRS targeted at areas of high malaria transmission/burden. IRS guidelines direct that the entire populations living in those areas have all rooms of their houses sprayed once a year prior to the malaria season. Furthermore, in response to each confirmed local case, and in the event of local malaria epidemic, additional spatially targeted IRS campaigns are to be implemented alongside vector surveillance. However, in recent years, IRS activities have been scaled down to a more targeted approach (as opposed to blanket spraying) in malaria hotspots [ 10 ].

This case study aimed to review the malaria surveillance data of Eswatini collected over 8 years between 2012 and 2019 to evaluate the country’s efforts that targeted malaria elimination by 2020.

Study setting

Eswatini is a landlocked country in the southern part of Africa bordered by South Africa and Mozambique (Fig. 1 b). Malaria transmission is seasonal in Eswatini, due to the country’s subtropical climate, and occurs during the warmer and wetter months of November to April. From May to October, it is cooler and drier (winter) and malaria transmission normally ceases, except for a few malaria hotspots in the riverine areas of the lowlands [ 12 ]. Of the 1,172,433 population, an estimated 30% live in communities that are prone to malaria transmission (Table 1 ) [ 13 ]. Plasmodium falciparum , is responsible for > 99% of malaria cases, while the main vector is reported as Anopheles arabiensis [ 14 ], even though there is a scarcity of up-to-date entomological data to support this assertion [ 3 ]. Eswatini’s mobile population and labour force contribute to sustaining the malaria risk in the country, especially across the border with Mozambique, where malaria remains a major public health issue. According to the Service Availability and Readiness Assessment (SARA) of 2017, Eswatini had 327 health facilities [ 15 ] providing services to most households within an 8 km radius. Facility ownership was distributed between government-owned facilities (39%), facilities privately owned by doctors or nurses (29%), mission-owned facilities (13%), industry-owned facilities (10%), and non-governmental-organization-owned facilities (9%).

The NMESP for 2008–2015 led to the revision of the country's diagnostic and treatment guidelines and the adoption of the WHO guidelines for low-transmission settings [ 16 , 17 ]. The revised guidelines required that all cases of fever be confirmed for malaria infection by RDT or microscopy before treatment was initiated. Artemether–lumefantrine (AL) was the drug of choice for uncomplicated cases, and quinine for severe cases and as first-line treatment for pregnant women in their first trimester of pregnancy [ 18 ]. The guidelines underwent revision in 2014 and 2017. The latest National Malaria Diagnosis and Treatment Guidelines replaced parenteral quinine with parenteral artesunate as the first-line treatment for severe and complicated malaria and single, low-dose primaquine (0.25 mg/kg) in addition to AL are used for the treatment of uncomplicated P. falciparum malaria [ 19 ].

Eswatini’s malaria case surveillance

Case notification is through the Instant Disease Notification System (IDNS) hosted by Emergency Preparedness and Response (EPR) for notification of diseases reported from health facilities by call and the IDNS sends SMS to the NMP surveillance for a response. This system allows the health care worker to capture demographic details about the patient that assist in patient follow-up. The NMP carries out active surveillance which involves; active case investigation in the household of the index case, triggered by parasitological confirmation of a malaria case at a health facility; reactive case detection (RACD), triggered by the location of a confirmed malaria case in Eswatini’s receptive area; and, pro-active case detection, triggered by a strong suspicion of malaria transmission within a defined detection area and on high-risk populations. The index case, whether it is identified by RDT and/or by microscopy, is investigated at the patient’s home within 48 h of the patient’s presentation date, subject to consent by the patient or guardian. The case investigation’s primary purpose is to establish the case origin (imported or autochthonous) and collect other relevant demographic data such as global positioning system (GPS) coordinates, treatment received, age, gender, nationality, and occupation of the patient. If the confirmed malaria case lives in a receptive area, every person residing within a radius of either 1 km or 500 m from the residence of the index case is tested for malaria. A RACD event remains open for up to 5 weeks, where the NMP additionally conducts fever screening and where individuals near the index case report a recent fever, enabling identification of additional secondary cases. Any identified positive case is referred to the nearest health facility for treatment and followed up. The active surveillance programme is implemented in all regions of the country, however; RACD only takes place in receptive areas, determined by mapping the locations of historic cases and vector surveillance data (Fig. 2 ).

Eswatini’s national malaria program surveillance structure

Review of data

This was a descriptive retrospective study utilizing data routinely collected using IDNS from the health facilities and reported to the Eswatini NMP between 2012 and 2019. The data included cases treated for malaria in all health facilities of Eswatini reported to NMP and entered in the active case investigation database; including confirmed cases (RDT and/or microscopy), investigated cases (followed up at household level), case origin (autochthonous and imported cases), and demographic data (nationality, age, and gender). The terminology used is as per WHO definitions (Table 2 ).

The IRS data for the same period was also reviewed. According to national guidelines, IRS is supposed to be carried out annually in October (one spray cycle) in malaria-endemic areas. Over the study period, insecticides used for IRS were DDT, lambda-cyhalothrin and pirimiphos-methyl. DDT was sprayed in mud structures and lambda-cyhalothrin in modern/cement structures. Spray coverage was obtained from the NMP records and was based on the number of structures reported to have been sprayed between 2014 and 2019. Lack of data for 2012–2013, as reported by NMP, was due to a technical malfunction of their servers that led to the loss of data records.

Data analysis

The study variables included case status (investigated or not investigated), case origin (autochthonous, imported), demographics of patients (age, gender, and nationality), IRS coverage (coordinates of sprayed structures), health facility (government, mission/NGO and private) and method of diagnosis (RDT and microscopy) as well as treatment. Data were entered into Microsoft Office Excel 2010 (Microsoft Corp., Redmond, WA) and SPSS 19.0 software (IBM) for analysis. The incidence rate was calculated from the confirmed number of cases per 1000 population at risk for each year (Table 1 ).

A total of 5511 patients reported to health facilities between 2012 and 2019 with malaria symptoms. The case investigation rate increased from 50% in 2012 to 84% in 2019, with a record high of 92% in 2017 (Fig. 3 a). The number of cases fluctuated in these 8 years, with an upward trend, from a total of 460 cases in 2012 to 693 in 2019 and a peak of 1198 cases in 2017. As the cases increased, so did the malaria incidence per 1000 population at risk, from 0.70 in 2012 to 1.65 in 2019 (Fig. 3 b). The highest malaria incidence of 3.19 was recorded in 2017.

Malaria case numbers and incidence in Eswatini, 2012–2019. a Investigated cases, uninvestigated cases, and investigation rate. b Incidence per 1000 population at risk of contracting malaria

Malaria remains a major public health problem in Eswatini, with significant transmission occurring in the local communities as shown by the number of autochthonous cases over the years. Most of the investigated cases were Swazi (n = 2895) and Mozambican (n = 1315), with a few from other nationalities (n = 67) (Fig. 4 ). Whilst in 2012 only 13% (58 out of 460 cases) of the cases were autochthonous, in 2019 over 33% (234 out of 693 cases) were autochthonous (Fig. 5 a). Furthermore, as malaria transmission in Eswatini is seasonal, annual data showed a peak in malaria cases in January due to imported rather than autochthonous cases, whilst the local cases peaked later and especially in years with the higher transmission (2014 and 2017), with peak transmission being observed from September to December. In 2017, a year with an exceptionally high number of cases, over 57% of the cases were autochthonous (686 out of 1198 cases). Most autochthonous malaria cases were located along the borders with Mozambique and South Africa and in the Hhohho (middleveld) and Lubombo (lowveld) regions (Fig. 6 ). Imported malaria cases were found in naturally low malaria risk areas like the central region of Manzini, but also the southern part of the Hhohho region and along the borders with Mozambique and South Africa (Fig. 6 ). The geographical distribution of cases indicates that local cases occurred in areas supporting transmission (lowveld and lower middleveld), whilst the imported cases to a large extent were seen to occur in the highland areas (highveld and upper middleveld).

Distribution of malaria cases by nationality in Eswatini, 2012–2019

Epidemic curve and demographic features of malaria in Eswatini. a Epidemic curve of autochthonous and imported malaria (n = 4173) in Eswatini, 2012–2019. b Age of autochthonous male (n = 1194) and female cases (n = 677) in 2012–2019. c Age of imported male (n = 1662) and female cases (n = 640) in 2012–2019

Geographic distribution of malaria cases origin (autochthonous, imported, and unknown), and indoor residua spraying (IRS) in Eswatini, 2012–2019. There was lack of data for 2012 and 2014 even though IRS was done

There was no IRS data for 2012 and 2013, while in 2014 the data indicates the limited application of IRS and a high number of malaria cases with an increased proportion of autochthonous cases (Fig. 6 ). In 2015, IRS was very focal, targeting primarily areas that had local transmission in 2014. In 2016, IRS efforts were even more reduced and targeted at the few local transmission hotspots, while in 2017, the year with the highest case incidence rate over the observation period, hardly any IRS was done. In response to the increase in malaria incidence, the areas targeted with IRS in 2018 significantly increased, and focussed especially on Eswatini’s border with South Africa. In 2019, targeted IRS was maintained, keeping cases controlled, with 693 cases reported compared to 847 the previous year (Fig. 6 ).

Looking at the role of various health facilities in the detection of malaria, most of the cases were diagnosed by RDT in government (86.6%), mission (89.2%), private (87.1%) and company/industry-owned facilities (83.3%), either singly or in combination with microscopy. Mission-owned facilities were more likely to use both RDT and microscopy testing (21.9%) than the other facilities (Table 3 ).

Malaria case surveillance checks if the type of drug prescribed as per national malaria diagnosis and treatment guidelines. The results show that only 58.4% of all uncomplicated cases were treated with AL and single dose primaquine, while only 46.9% of all complicated cases were treated with Artesunate per national guidelines (Table 4 ).

Eswatini has made major investments in improving malaria control and surveillance, including significant policy changes enabling the NMP to rapidly respond to cases. Despite all the efforts to make Eswatini malaria-free by 2020, there has been little change over the past decade and the overall elimination strategy has fallen short of its target. Eswatini has managed to keep malaria controlled, with relatively low annual incidence rates compared to its neighbour Mozambique and other E-2020 countries in the region [ 1 , 22 ]. However, outbreaks could still not be prevented within the case study’s observation period. The reviewed data suggests that higher case numbers are associated with decreased vector control efforts. This is especially well illustrated in 2017 when hardly any structures were sprayed, and local malaria transmission increased rapidly, reaching an unprecedented high over the study observation period. Whilst a surveillance system has been established in the country, the epidemiological case investigation rate is only 84%, with around a fifth of the reported cases remaining uninvestigated. Case classification is based on 3 categories (autochthonous, imported, and unknown), leaving out introduced cases, which are an important marker of local transmission. This must be improved if elimination is to be achieved. Reviewing the NMP databases highlighted significant missing demographic data (GPS coordinates, case origin data) that limited the mapping of malaria cases and IRS coverage. This missing information is pertinent for a country that is aiming for elimination, as all cases need to be identified and mapped for proper and effective deployment of vector control interventions [ 20 ].

IRS remains one of the most powerful vector control interventions for reducing/interrupting malaria transmission in terms of its immediate impact. Its use in the last seven decades has played a major role in the elimination of malaria from southern Europe, the Mediterranean region, Russia, large parts of Asia and Latin America, as well as many parts of South Africa [ 23 ]. In Eswatini, IRS is supposed to be implemented annually in October, marking one spray cycle before the start of the major local malaria season. This strategy is based on malaria transmission occurring during the warmer and wetter months of November to April. Also, this strategy targets the local cases that seem to peak later in the year as observed in this case study, marking the duration of the transmission season of November–April. The frequency of IRS application depends on, among other factors, the insecticide used and the structure types. Eswatini sprayed DDT in mud structures and pyrethroids in modern/cement structures due to a difference in the residual effect of each insecticide on different wall types. In 2016, the IRS effort was reduced and targeted at the few local transmission hotspots observed in the previous year when IRS was more widely applied. In 2017, hardly any IRS was done. This reduced vector control effort correlated with major outbreaks of local cases in an expanded area of lowveld and lower middleveld regions. The exploration of the data suggests that IRS applications were frequently targeted in areas seen to be persistent malaria hotspots in the previous year. However, this targeted approach might have not considered that the higher coverage with IRS in the previous year prevented most of the cases that would have been seen without intervention. The increase of the IRS efforts in 2018 was associated with reductions in malaria incidence.

The mapped locations receiving IRS from the data provided by the NMP surveillance highlights significant gaps in the strategic deployment of this vector control tool to targeted malaria hotspots in part of the studied period (years). Studies have shown IRS to be an effective strategy for preventing malaria infection and mortality across a range of transmission settings [ 24 , 25 , 26 , 27 , 28 , 29 ]. However, low coverage and poor quality of IRS can limit the impact on malaria transmission [ 29 ]. Eswatini’s low coverage in 2017 was attributed to challenges in the procurement of insecticide, hence only limited amounts of insecticide (lambda-cyhalothrin) that remained from the previous season were used and targeted at outbreaks rather than prior transmission season hotspots. In 2018, IRS coverage maps show much more spraying. However, the challenges in procurement extended to 2018 and hence whilst there was increased coverage, the timing of IRS was not adhered to and was done late in many targeted regions [ 14 ]. In summary, the challenges experienced by the NMP are due to procurement and resource allocation, which led to poor planning and execution of IRS and thus, insufficient coverage. Since IRS is at the core of Eswatini’s vector control strategy, this delay had a major impact on malaria control. To get on track with the elimination effort, the NMP must identify and address the challenges in the implementation of IRS to sustain vector control. Clearly, in Eswatini, logistics is the main challenge in implementing a timely and effective IRS.

Many factors have been shown to contribute to malaria outbreaks in various settings in Eswatini, including rainfall, temperature, population movement, and the lack of sufficient or appropriate control tools or timings of vector control strategies [ 18 ]. Control of malaria transmission in border areas, together with the importation of cases, presents a major threat to successfully eliminating malaria in Eswatini. Population movement, especially from the malaria-endemic neighbouring Mozambique, has been previously recorded as an important factor contributing to the persistence of malaria cases in Eswatini [ 30 ]. The reviewed data supported these international border movements contributing to malaria cases.

Eswatini can be described as a low-transmission and high-importation case, similar to what was described in a study of Ethiopia, where the local transmission risk was very low, but many cases likely originated from other countries [ 31 ]. The high numbers of imported cases that were observed in this Eswatini study during the first few months of the year were likely caused by workers from Mozambique returning to Eswatini in January following the Christmas and New Year holidays [ 30 ]. A study conducted in 2016 on travel patterns and demographic characteristics of malaria cases in Eswatini attributed high malaria case importation rates to sugar plantation workers, whose travel patterns are well known between these two countries [ 30 ]. Furthermore, the study reported that, since international travellers tend to spend more time away than domestic travellers, they are at a higher risk of getting malaria, especially those travelling to malaria-endemic areas. This length of stay increases the risks of acquiring and returning with parasites. Also, adolescents and employed males were showed to be frequent travellers [ 30 ].

Currently, Eswatini’s NMP carries out malaria screening at the Eswatini/Mozambique border, where they do not treat the positive cases but rather refer them to the nearest health facility. The data in this study indicate that outbreaks are due to local transmission, which calls for two different responses: for cases imported to areas where transmission is unlikely, it is more a medical treatment case, so there should be border checks and treatment; whilst for local cases, there needs to be more emphasis on vector control. Elsewhere, it has been previously demonstrated in Eastern Myanmar that early diagnosis and prompt onsite treatment of confirmed cases is effective in achieving malaria elimination [ 32 ]. Also, it has been observed in southern Iran that the presence of foreign immigrants could cause malaria outbreaks [ 33 ]. Cross-border malaria control initiatives are important in supporting malaria elimination efforts, especially when low-transmission countries share borders with higher-transmission countries. Therefore, there is a need for Eswatini to strengthen its cross-border surveillance, form collaborations with its neighbouring countries, and learn from past lessons such as the cross-border initiative Lubombo Spatial Development Initiative (LSDI) [ 6 ]. This initiative represented collaborative efforts between Eswatini, Mozambique and South Africa to reduce each country’s malaria importation risk and achieve elimination. LSDI led to success towards malaria elimination in both South Africa and Eswatini, with IRS as the core intervention [ 6 , 7 ]. However, the termination of LSDI resulted in an upsurge of malaria cases in these countries, mainly as a result of migration from high-transmission areas to low-transmission ones [ 6 ]. The LSDI focus on vector control with IRS further demonstrates the important role of vector control in elimination efforts, and in particular, IRS.

In recent years, Eswatini has engaged in cross-border collaborations with the neighbouring countries of Mozambique and South Africa [ 14 ] and regional collaborations via the E-8 initiative [ 3 ] as well as partnering with development partners in efforts to tackle cross-border malaria transmission and to augment national efforts towards elimination. The E-8’s mandate has a particular focus on Migrants and Mobile Populations (MMPs) where Eswatini is a recipient of funds through the Initiative to establish malaria border health facilities for Testing, Treating and Tracking (T3). The Mozambique South Africa Swaziland (MOSASWA) cross-border initiative focuses on helping countries to set up mobile clinics along the borders of these three countries [ 3 ], however, since Eswatini is a recipient of E-8 funds for the same purpose, the country reprogrammed its budget to focus on IRS, Entomological Surveillance, and Information Education Communication (IEC) [ 14 ]. Despite the presence of these mobile clinics along the border, Eswatini still had cases along the border, both autochthonous as well as imported in the study period.

Indeed, community involvement plays an important role in efforts to achieve malaria elimination as the success of interventions, including indoor residual spraying (IRS) and community case management, are effective only if they are accessible, acceptable, and properly used within communities. Many of the challenges to malaria elimination are site-specific and require a more tailored approach to effectively target the remaining malaria foci of transmission and populations at higher risk [ 34 ]. Eswatini’s NMP used community engagement platforms, stakeholder meetings, community radio stations, song and dance, roadshows, community drama, as well as home visits to involve communities in information-sharing and collaborative capacity building that sensitized communities on the elimination agenda [ 35 ].

Accurate laboratory diagnosis is essential, especially with the adoption of the T3 initiative. False-negative results can lead to untreated malaria and potentially severe consequences, including death. Surveillance systems need to capture true malaria cases for informed interventions. The WHO ‘A Framework for Malaria Elimination’ recommends in the monitoring and evaluation that a percentage of microscopy results be cross-checked by a national reference laboratory for 100% of positive results and 10% of negative results [ 22 ]. This study observed that most malaria cases were confirmed using RDT in all health care facilities, while mission/NGO-owned facilities had a higher proportion of cases confirmed by microscope. Even though Eswatini has National Quality Assurance Guidelines for Malaria Diagnosis [ 34 ] in place, the NMP has not been routinely implemented, and data was not updated in the ACD database for the samples that were checked for quality assurance. The NMP further stated that it was understaffed and lacked the capacity for routine implementation. Eswatini needs to emphasize the implementation of its guidelines by assessing the epidemiological, operational and financial situation of the malaria programme as recommended by the WHO [ 22 ] if it is to attain elimination in the future.

Adherence to the National Malaria Diagnosis and Treatment Guidelines is critical if malaria elimination is to be achieved. Almost all (85%) of the confirmed malaria cases in Eswatini were uncomplicated. However, only a little over a half (58.4%) were treated with AL + primaquine, while only 46.9% of severe malaria cases were treated with artesunate. In contradiction with recommendations in the national diagnosis and treatment guidelines, some cases of uncomplicated malaria were treated with quinine and artesunate, while some patients with severe malaria were treated with AL. Mistreatment of malaria cases could result in worsening of the patient's health status or even death. Non-adherence to national guidelines for malaria treatment has been reported in other African countries such as Uganda [ 36 ], Nigeria [ 36 ], and Tanzania [ 37 ], but none of these countries is at the frontline of malaria elimination, unlike Eswatini. Several factors have been cited for the flouting of national guidelines by clinic staff, including delay in producing laboratory results [ 36 , 38 ], inadequate supplies of the recommended drugs, and inadequate training of the prescribers [ 39 ]. It is therefore crucial for Eswatini to conduct an in-depth evaluation of the possible factors for the non-adherence of national guidelines to generate information to improve case management to achieve malaria elimination.

There are limitations in this study considering this was a retrospective study using secondary data for analysis. Since this data was already entered in the database, there was a possibility of missing data and/or wrong entry in some of the records. Health facility data has the potential for under-reporting malaria cases as a considerable proportion of people may not have presented at the health facilities due to factors such as accessibility. Furthermore, unavailable (missing) data on the mobile population and labour force such as case demographics, reasons for travelling and length of stay when travelled, made it impossible to present data on mobile populations and labour force. Also, other factors may have confounded the observed results, such as the impact of malaria control activities as well as host- and mosquito-related ecological and environmental factors. This study also looked at vector control with IRS; however, for the years 2012 and 2013, there was no IRS data. The NMP explained that the missing/lost information resulted from the Programme modifying its database during the study years.

This case study has programmatic implications. IRS has in the past been successfully proven to work in Eswatini to manage cross-border transmission via the LSDI regional malaria control collaboration [ 6 ] and has for over 70 years contributed to eliminating malaria from various countries when integrated with other measures [ 23 ]. Integrated vector management (IVM) is the rational decision-making process to maximize the impact of resources allocated for vector control for long-term sustainability [ 40 ]. It might be time for Eswatini to consider an integrated approach for malaria control by adding tools such as long-lasting insecticidal nets (LLINs) [ 41 ], screening of house entry points [ 42 ] and targeted larviciding [ 43 ] along with chemoprophylaxis to their malaria control toolbox. Operational research should support such efforts towards IVM [ 44 ], which has been demonstrated in other countries including Zambia [ 45 ] and Tanzania [ 46 , 47 ]. In Zambia, the interventions include IRS, LLINs, larviciding and environmental management implemented in eligible urban and rural areas [ 45 ]. In Tanzania, integrated control of urban mosquitoes in Dar es Salaam using community sanitation supplemented by larviciding was successful in managing mosquitoes [ 46 , 47 ].

Furthermore, there is a need to improve entomological surveillance in Eswatini to identify and monitor malaria vectors. Despite the country’s emphasis on vector control, surprisingly little is known about the local vector species and population dynamics, the role of secondary vectors in malaria transmission and the status of insecticide resistance. Monitoring and evaluation indicators for interventions in an elimination programme for vector control calls for independent vector surveys targeting local vectors [ 19 ]. This is a challenge Eswatini still faces because its core intervention is IRS and yet there is a lack of crucial ecological data on local malaria vectors, making the emphasis of such intervention lack factual justification. Equally, implementation of resistance management strategies and alternative approaches, including natural-based interventions, will be pivotal for effective IVM and attainment of the objectives of the Stockholm Convention [ 40 ]. A review of procedures and challenges at the programme level might help to improve vector control implementation, including routine entomological surveillance in sentinel sites in the different ecological zones. Overall, the review of the malaria control effort over the past 8 years highlights the need to invest in strengthening human resources and infrastructural capacity. These include training and retaining personnel with the necessary skills, establishing laboratories, an insectary, systems for timely procurement and appropriate storage, and adherence to standard operating procedures.

The achievement of malaria elimination requires the involvement of stakeholders in strategic planning and solicitation of funds as well as implementing strategies to achieve the desired goal of malaria elimination. Through Eswatini’s continental partnerships with the African Leaders Malaria Alliance; ALMA [ 35 ], and international stakeholders such as WHO-AFRO and Roll Back Malaria (RBM) [ 35 ], the country can and must leverage on vast capital and human resource networking. For instance, through ALMA’s scorecard for accountability and action, countries track malaria data to spur action and drive progress towards the goal of ending malaria mortality and morbidity [ 35 ]. Furthermore, through a partnership with WHO-AFRO, Eswatini benefits from financial and technical support [ 14 ] as well as the opportunity to collaborate with international organizations, such as the International Centre of Insect Physiology and Ecology ( icipe ) [ 14 ] which provides technical support to the programme. It is, therefore, important for Eswatini to utilize such partnerships and collaborations to address challenges the challenges that hindered the country from achieving elimination.

This case study has presented a descriptive analysis of Eswatini’s malaria elimination effort over the past 8 years. Whilst overall malaria incidence rates have remained low, sporadic outbreaks could not be prevented, and they set back Eswatini’s malaria elimination goal of eliminating malaria by 2020. The country needs to review the malaria elimination strategic plan and set a more realistic goal for achieving a malaria-free Eswatini. An integrated vector management approach with a more diverse set of tools and strong community engagement and participation is recommended for higher impact and sustainability.

Availability of data and materials

Relevant data included in the manuscript.

Abbreviations

Active case detection

Artemether–lumefantrine

African Leaders Malaria Alliance

Dichloro-diphenyl-trichloroethane

Emergency Preparedness and Response

Global Positioning System

Global Technical Strategy for Malaria 2016–2030

Instant Disease Notification System

Information Education Communication

Indoor residual spraying

Integrated vector management

Long-lasting Insecticidal Nets

Lubombo Spatial Development Initiative

Mozambique South Africa Swaziland

Non-governmental Organization

Migrants and Mobile Populations

National Malaria Elimination Strategic Plan

National Malaria Programme

Reactive case detection

Roll Back Malaria

Rapid diagnostic test

Southern African Development Community

Service Availability and Readiness Assessment

Testing, Treating and Tracking

World Health Organization

World Health Organization Regional Office for Africa

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Acknowledgements

The authors thank Emily Kimathi for preparing the maps for the manuscript.

Funding support is acknowledged from the AFRO-II Project under the auspices of the Global Environment Facility/United Nations Environment Programme (GEF/UNEP) through the World Health Organization Regional Office for Africa (WHO-AFRO). We also gratefully acknowledge the financial support by icipe’s core donors, Foreign, Commonwealth & Development Office (FCDO) of the UK Government; Swedish International Development Cooperation Agency (Sida); the Swiss Agency for Development and Cooperation (SDC); Federal Democratic Republic of Ethiopia; and the Kenyan Government. The views expressed herein do not necessarily reflect the official opinion of the donors.

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TEN, CM and UF conceived the idea for this manuscript. TEN conducted the literature review and wrote the first draft. UF helped with writing. ZZ, QD and MD provided data. CM, POS, RM and EC critically reviewed the manuscript. All authors read and approved the final manuscript.

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Nkya, T.E., Fillinger, U., Dlamini, M. et al. Malaria in Eswatini, 2012–2019: a case study of the elimination effort. Malar J 20 , 159 (2021). https://doi.org/10.1186/s12936-021-03699-x

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Received : 09 December 2020

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DOI : https://doi.org/10.1186/s12936-021-03699-x

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Strategies for case management of malaria are usually an integral part of the national malaria control program in countries where malaria is endemic (WHO 2015). Malaria can quickly escalate in severity and, if untreated, lead to severe anemia and death. Early diagnosis should be followed by prompt, effective treatment within 24–48 hours of the onset of symptoms. For the malaria species Plasmodium falciparum , the recommended first line treatment for uncomplicated malaria is a fixed-dose artemisinin-base combination therapy, although pregnant women in the first trimester and other special risk groups may require different treatments or dosing regimens. Treatment of complicated malaria should start with intravenous or intramuscular injections of artesunate until the patient can tolerate oral therapy with artemisinin-base combination therapy.

Infection by other species may require different treatments, depending on antimalarial resistance in the area 1 . Antimalarial drug resistance—a growing concern—has led to increases in malaria cases and treatment failures in Asia (Tilley et al. 2016).

Measurement and data sources

Population-based surveys typically report the percentage of children under age 5 who have experienced fever in the two weeks preceding data collection. For those children, the survey collects information on the percentage for whom advice or treatment was sought, who had blood taken from a finger or heel for testing, and who took any artemisinin-base combination therapy.

Surveys that collect information related to coverage of malaria case management include—

Demographic and Health Surveys
Malaria Indicator Surveys
Multiple Indicator Cluster Surveys
Knowledge, Practice, and Coverage Surveys
other research or evaluation activities.

Information related to malaria treatment is sometimes available through the country’s health monitoring information system. Consider the usage of health care services in your context when interpreting findings, because not all people suffering from malaria will seek services at the facility. However, in Africa, careseeking for fever is generally high for children under 5 years of age.

Methodological issues

Always consider seasonality when interpreting malaria data, especially for population-based surveys. Generally, survey reports indicate when the survey was conducted so that data are interpreted appropriately. Malaria transmission rates —( and the resulting stock flows) at the time of data collection — will affect the comparability of these estimates over time and across studies. For instance, Demographic and Health Surveys often avoid the rainy season, given the difficulties inherent with data collection at this time, while Malaria Indicator Surveys are deliberately scheduled during the rainy season to capture indicators during a season of high malaria transmission.

1 Primaquine is used to treat the relapsing stage of Plasmodium vivax or Plasmodium ovale , but care must be taken to avoid hemolytic toxicity in subjects who are glucose-6-phosphate dehydrogenase (G6PD) deficient (Baird 2015).

Roberts, David J. 2016. “Hematologic Changes Associated with Specific Infections in the Tropics.” Hematology/Oncology Clinics of North America 30 (2): 395–415. doi:10.1016/j.hoc.2015.11.007.

Tilley, Leann, Judith Straimer, Nina F. Gnädig, Stuart A. Ralph, and David A. Fidock. 2016. “Artemisinin Action and Resistance in Plasmodium Falciparum.” Trends in Parasitology 32 (9): 682–96. doi:10.1016/j.pt.2016.05.010.

Ukpe, I. S., D. Moonasar, J. Raman, K. I. Barnes, L. Baker, and L. Blumberg. 2013. “Case Management of Malaria: Treatment and Chemoprophylaxis.” South African Medical Journal 103 (10): 793. doi:10.7196/SAMJ.7443.

WHO (World Health Organization). 2009. “Malaria Case Management Operations Manual.” Geneva, Switzerland: WHO.

———. 2015. “Guidelines for the Treatment of Malaria.” Geneva, Switzerland: WHO.

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Strategies and approaches to vector control in nine malaria-eliminating countries: a cross-case study analysis.

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Smith Gueye C 1
Gosling RD 1
Whittaker MA 2
Chandramohan D 3
Slutsker L 4

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Whittaker MA | 0000-0002-1677-2991

Malaria Journal , 04 Jan 2016 , 15: 2 DOI: 10.1186/s12936-015-1054-z PMID: 26727923 PMCID: PMC4700736

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Strategies and approaches to vector control in nine malaria-eliminating countries: a cross-case study analysis

Cara smith gueye.

Malaria Elimination Initiative, Global Health Group, University of California, San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA USA

Gretchen Newby

Roland d. gosling, maxine a. whittaker.

Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA USA

Daniel Chandramohan

London School of Tropical Medicine and Hygiene, Keppel Street, London, WC1E 7HT UK

Laurence Slutsker

The University of Queensland School of Public Health, Herston, QLD Australia

Marcel Tanner

Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Switzerland

University of Basel, Basel, Switzerland

There has been progress towards malaria elimination in the last decade. In response, WHO launched the Global Technical Strategy (GTS), in which vector surveillance and control play important roles. Country experiences in the Eliminating Malaria Case Study Series were reviewed to identify success factors on the road to elimination using a cross-case study analytic approach.

Reports were included in the analysis if final English language draft reports or publications were available at the time of analysis (Bhutan, Cape Verde, Malaysia, Mauritius, Namibia, Philippines, Sri Lanka, Turkey, Turkmenistan). A conceptual framework for vector control in malaria elimination was developed, reviewed, formatted as a matrix, and case study data was extracted and entered into the matrix. A workshop was convened during which participants conducted reviews of the case studies and matrices and arrived at a consensus on the evidence and lessons. The framework was revised and a second round of data extraction, synthesis and summary of the case study reports was conducted.

Countries implemented a range of vector control interventions. Most countries aligned with integrated vector management, however its impact was not well articulated. All programmes conducted entomological surveillance, but the response (i.e., stratification and targeting of interventions, outbreak forecasting and strategy) was limited or not described. Indoor residual spraying (IRS) was commonly used by countries. There were several examples of severe reductions or halting of IRS coverage and subsequent resurgence of malaria. Funding and operational constraints and poor implementation had roles. Bed nets were commonly used by most programmes; coverage and effectiveness were either not measured or not articulated. Larval control was an important intervention for several countries, preventing re-introduction, however coverage and impact on incidence were not described. Across all interventions, coverage indicators were incomparable, and the rationale for which tools were used and which were not used appeared to be a function of the availability of funding, operational issues and cost instead of evidence of effectiveness to reduce incidence.

More work is required to fill gaps in programme guidance, clarify the best methods for choosing and targeting vector control interventions, and support to measure cost, cost-effectiveness and cost-benefit of vector surveillance and control interventions.

Tremendous progress has been made over the last decade in reducing morbidity and mortality from malaria. At present, 55 countries are on track for or have already achieved a 75 % reduction in morbidity from 2000 to 2015 [ 1 ]. This progress has prompted a review of the current global malaria strategy and goals, set forth in the Global Technical Strategy for Malaria 2016 – 2030 (GTS) by the Global Malaria Programme of the World Health Organization (WHO) and its implementation and action framework, Action and Investment to Defeat Malaria (AIM) by Roll Back Malaria (RBM). GTS was approved by the World Health Assembly in May 2015 and AIM by the RBM Advisory Board in the same month [ 2 , 3 ]. Out of the three pillars laid out in the GTS to ensure continued progress towards and achievement of malaria elimination, two emphasize the role of entomological surveillance and vector control response.

Vector control encompasses the measures that are directed against a vector of disease, intended to limit its ability to transmit the disease by protecting areas that are known to be receptive to transmission [ 4 ]. Receptivity to malaria depends on the vectorial capacity of local vector populations, as in not just the presence of the vector but its population size, human biting habits and longevity in relation to the period of sporogony. Each of these parameters is strongly influenced by the climate, local ecology and behaviour of both humans and vectors. In an elimination phase, the objective of vector control is the reduction of the vectorial capacity of the local vector populations below the critical threshold needed to maintain transmission [ 5 ].

The GTS outlines the need for high-quality implementation of core vector control tools of indoor residual spraying (IRS) and long-lasting insecticide-treated bed nets (LLINs), as well as the role of larval source management as a supplementary tool. Integrated vector management (IVM) should be the overarching vector control strategy for all countries, and includes the components described in Fig. 1 [ 6 , 7 ].

IVM framework and distinguishing characteristics. Source: Beier et al. [ 7 ]

Routine entomological surveillance (e.g., vector mapping and bionomics) and insecticide resistance monitoring data should be combined with epidemiological data to identify new vectors or shifts in vector composition, understand receptivity in a country setting, inform choice of vector control interventions, coverage, timing, and to evaluate the quality and impact of interventions. When malaria burden is reduced to low levels, a shift from universal to targeted vector control activities is needed for those programmes that are ready for this transition. Plans must be in place for the management of insecticide resistance, operational research to develop and validate new tools, as well as strategies to improve upon microstratification and delivery of interventions.

As vector control is an important component in the overall strategy to control and ultimately eliminate malaria, there may be factors in its implementation that influence the likelihood of attaining malaria elimination. Vector control intervention choice and how it matches the context of vector habitat and behaviours, targeting and coverage of at-risk populations, and evaluation and modification of programme interventions may influence the success or failure of malaria elimination programmes. The Eliminating Malaria Case Study Series by the WHO Global Malaria Programme and University of California, San Francisco (UCSF) Global Health Group provides detailed examples of national malaria programmes that are currently eliminating or have eliminated malaria, offering an opportunity to review synthetically key components of these programmes. In this paper a review of vector control activities across nine countries was undertaken to identify success factors along the road to elimination using a cross-case study, analytic approach. The analysis focuses on vector control tools, approaches, coverage and, when information was available, impact in elimination settings.

This cross-case study review included nine case studies from the Eliminating Malaria Case Study Series, produced through a collaboration between the WHO Global Malaria Programme and UCSF Global Health Group. Each case study details the programme strategies and interventions from the early 1900s to the current period, with epidemiological and intervention data coverage and an analysis of the main factors behind their successful handling of outbreaks or epidemics and programmatic challenges. Countries were selected for the case study series if they: (a) demonstrated successful transition towards or achievement of elimination; (b) committed to the case study research and analysis process; and, (c) were able to provide access to sufficient data. Countries were also chosen to represent a range in malaria epidemiology, stage of elimination (from low endemic control to prevention of re-introduction), geography (island vs continental), and strength of their health system. Countries selected were Bhutan, Cape Verde, Malaysia, Mauritius, Namibia, Philippines, La Reunion, Sri Lanka, Tunisia, Turkey, and Turkmenistan [ 8 – 16 ]. Table 1 shows the different stages and goals of the nine countries that were included in this review. Prevention of re-introduction (POR) countries were those considered to have reached zero locally acquired cases and are actively preventing re-introduction of malaria [ 4 ].

Table 1

Elimination history and goals of the nine case study countries

Case studies were included in the cross-case analysis if they were part of the WHO Global Malaria Programme/UCSF Global Health Group case study report series, all of which used the same type of quantitative and qualitative approaches and methods. Reports or publications that were in final English language draft at the time of analysis (November 2014) were included. Case studies included in this cross-case analysis are Bhutan, Cape Verde, Malaysia, Mauritius, Namibia, Philippines, Sri Lanka, Turkey, and Turkmenistan. Case studies from La Reunion and Tunisia were not included in the cross-case study review because the report from La Reunion was not finalized nor translated into English at the time of analysis, and a draft of Tunisia was not yet available by the time the analysis was underway.

A conceptual framework for vector control in malaria elimination was developed to provide structure for the cross-case analysis. To develop this framework, a document review was conducted of malaria elimination vector control guidelines, reports, consultations, and manuals to identify historical and current policy and research on vector control strategies, entomological surveillance, operational research, and costs. Search terms included ‘vector control’ and ‘malaria elimination’ or ‘malaria’; or ‘indoor residual spraying’, ‘insecticide-treated nets’, ‘long-lasting insecticide treated nets’, ‘entomology’, ‘entomological surveillance’, ‘larval control’, and ‘larval source management’ in the following search engines and databases: The Cochrane Library, PubMed, Google Scholar, and WHOSIS. Using this literature, a conceptual framework of vector control strategies and interventions was developed based on the topic areas of vector species and behaviour, approach to vector control, tools and coverage, combination interventions, stratification, outbreak response, implementing organizations, and cost of activities. The framework was reviewed by malaria elimination and vector control experts and formatted in Excel as a matrix. A first round of data extraction from the case study reports occurred as a result of a thorough review of the nine reports by two researchers (CSG, GN). CSG and GN then extracted challenges and weaknesses of the vector control programme for each case study and reviewed each other’s summaries. This analysis focused on the vector control strategies and tools used after the Global Malaria Eradication Programme (GMEP, 1955-1970), in order to reflect current tools (e.g., LLINs) and research.

Once the matrices with data and summaries were assembled, a two-day workshop of malaria elimination researchers and experts was convened to review the case studies, matrix summaries and findings to ensure that the data captured in the matrix were comprehensive and to debate the different learning across the country experiences. Workshop participants revisited the principles of vector control (aims, objectives, what implemented, how implemented, by whom) and identified examples from each case study report for each of the elements of the framework, arriving at a consensus on the evidence and lessons learned from the case study series. A second round of data extraction and summary was undertaken to ensure that data was extracted for each portion of the framework. The results of the cross-case analysis were then compared with the strategies laid out in the GTS.

The review of case studies showed that all countries implemented a range of vector control interventions, whether they had eliminated (Mauritius, Turkey, Turkmenistan) or were moving towards elimination (Bhutan, Cape Verde, Malaysia, Namibia, Philippines, Sri Lanka). The types of intervention used were likely determined by many factors, including operational constraints, cost, vector density and behaviour, insecticide resistance levels and epidemiological trends, among others. The vector control tools used by each country can be found in Table 2 .

Table 2

Vector control intervention mix across the nine case study countries

GTS Global Technical Strategy

1 Primary vector control intervention during most recent elimination strategy

2 A vector control intervention implemented during recent elimination programme, but not considered primary

C Strategy used during consolidation phase (after having achieved elimination)

b Locally produced bed nets

The IVM strategy document was disseminated by WHO in 2004 [ 17 ]. Most countries that were eliminating or had eliminated had strategies in place that used components of IVM, in particular the combination of interventions. IRS, insecticide-treated nets (ITNs) and LLINs were used commonly by most programmes to collectively increase population coverage, along with larval control. Some countries supplemented these interventions with environmental management, personal protection and insecticide fogging. Implementation most typically occurred at the district level, with guidance and strategy development provided at the national level. Some reports showed outsourcing of vector control activities to community volunteers or the private sector. There was little explicit description of the other four components of IVM, such as collaboration in health and with other sectors; advocacy, social mobilization and legislation; capacity building; nor development and use of evidence-based decision-making.

The rationale for which tools were used and which were not used was not well-articulated in the case studies. Moreover, there did not appear to be a clear linkage between entomological surveillance data, including insecticide resistance data, and parasitological data, nor was there evidence that either types of data informed intervention choice. Instead, the availability of funding and cost of interventions appeared to have played an important role in decision making for vector control interventions. The coverage and targeting of interventions was also poorly reported in the case studies. Some case studies included detailed stratification strategies, but not all. Even for those with a stratification strategy, most case studies did not consistently report on intervention coverage, and the ways in which coverage was described varied enormously, making comparisons across time periods and countries difficult. There was little evidence of reported quality assessment of interventions.

Measurement or evidence of impact of vector control interventions was scant or practically absent. Many case studies indicated that activities were effective in reducing receptivity in risk areas, but did not provide evidence or indicators, instead using anecdotal evidence that was likely based on programme experience.

In the analysis, the targeting, coverage and impact of all vector control measures were compared across the case study countries and similarities and differences highlighted. The results are described below for each vector control approach and tool.

Integrated vector management

IVM was adopted by four of nine programmes in the cross-case study analysis, but the meaning and utility of IVM varied across case studies (Table 3 ). The strategy of IVM was introduced in 2004 by WHO to increase cost effectiveness of vector control and to reduce the spread of drug and insecticide resistance [ 17 ]. The strategy focused on using a combination of interventions to attack the vector at different stages of its life cycle. It also requires decisions on which tools to use to be made based on evidence and that the type of vector control deployed will change as one approaches elimination and post-elimination (Fig. 1 ). For some countries (e.g., Turkmenistan) it was used as a way to combine vector control interventions. In other countries it ensured intersectoral collaboration, community engagement and integration of services, such as entomological surveillance, with other diseases (e.g., dengue). In Sri Lanka, IVM combined all of these elements, and engaged other sectors and communities in developing vector control strategies. It also ensured the use of a mix of interventions, as well as insecticide rotation for IRS, in which different types of insecticides were used in bordering districts with rotation of insecticides across districts over time, in order to lessen the risk of the development of insecticide resistance.

Table 3

Integrated vector management adoption and definition

The impact of IVM was not articulated in the reports, except for Sri Lanka, where the use of the approach in agricultural areas was thought to have contributed to a reduction in malaria incidence. Further research would be valuable to understand the impact of implementation of IVM as a broad strategy on reducing malaria transmission.

Entomological surveillance

Most countries in the case study series began conducting entomological surveillance during the GMEP. Entomological surveillance is typically comprised of monitoring of larval habitats, surveying for adult mosquitoes, conducting insecticide susceptibility tests, and assessing changes in environmental parameters [ 4 ], with the objectives of identifying the level of change in receptivity, and of designing and monitoring effectiveness of programme vector control strategy and interventions. The case studies did not outline specific activities that were maintained in the current elimination periods, instead only providing details and time frame when a new effort or initiative was undertaken. Even for countries that had more consistent entomological surveillance, the response component was not articulated in the case studies; it appears that, for most countries, entomological surveillance data were not analysed and used for outbreak forecasting or programme strategy, including better targeting of vector control interventions.

There was variation in the quality and consistency of entomological surveillance across the case studies. Countries that have reached elimination generally had a more detailed description of their surveillance programmes. For example, in the years leading up to elimination in Turkmenistan (2004–10), the programme maintained ‘passports’ for each water body, and district officials systematically updated a database on vector bionomics and densities. Entomological officers were recruited to serve on epidemic response mobile teams. In Turkey, surveillance included mapping of larval habitats in addition to data collection in sentinel sites. The continuation of this type of surveillance through the years of POR and post-elimination certification was only described in detail in the Mauritius report, where the programme maintained weekly surveillance of breeding areas since elimination in 2008.

The Malaysia and Sri Lanka case studies likewise described strong entomological surveillance programmes. In both countries, consistent entomological surveillance was one of several approaches credited by the malaria programmes for the national progress in reducing incidence, as it was used to guide planning of vector control. Malaysia’s diversity of vectors was a reason for continual monitoring, and district-level surveillance tracked larval habitats (conducted by district entomologists and assistant environmental health officers). Mapping with GPS units captured housing locations and larval habitats. Sri Lanka’s national and district health offices conducted entomological surveillance on a monthly basis. In later years, Sri Lanka had a large increase in funding to support entomological surveillance (from a Global Fund grant), which was conducted by a private sector organization in some areas. In Bhutan, surveillance was conducted monthly.

In other countries, entomological surveillance was more limited, such as in Cape Verde, where there was not a consistent programme of monitoring. Surveillance in the Philippines was limited to semi-annual or annual monitoring in the sporadic and malaria-prone transmission provinces.

In all case study countries, data collected during surveillance were not consistently used by programmes. Most case studies did not describe the use of entomological surveillance data to assess impact of interventions or to inform programme strategy. For example, because Turkey did not conduct entomological evaluations pre- and post-epidemic (after 1993), the programme was unable to assess effectiveness of the response interventions. There are some examples of programmes using their entomological data to guide decision-making. In the Philippines, surveillance data were reviewed during sub-national, provincial elimination certification, a process that was formalized in 2011. In addition, prior to the national programme’s devolution, all new strategies were tested through field research and entomological and parasitological surveys before becoming policy, such as the shift from IRS alone to combined IRS with ITNs. Bioassay and susceptibility test results guided changes in insecticide usage. In Malaysia and Mauritius, maps of larval habitats were used to target vector control interventions. Also in Malaysia, research was undertaken by district and state officers to measure effectiveness of management of the larval stage of the vector in reducing receptivity, although the outcomes of this research were not described in the report.

As entomological surveillance data should be the basis for all response interventions and programme strategies, consistent and high-quality data are needed. Further action is required to ensure that entomological surveillance is a priority for elimination programmes and that data are analysed and inform robust response, including forecasting, targeting and programme strategy.

Indoor residual spraying

Each of the nine programmes employed IRS, and most countries continued IRS after its introduction during the GMEP era because IRS historically was found to be effective in reducing receptivity. IRS targeting strategies varied across the countries, but generally by the 1990s most countries had transitioned to focal IRS instead of universal coverage, or blanket spray, operations. This transition may have been in response to the introduction of the WHO Global Strategy for Malaria Control [ 18 ]. As all countries (both eliminating and POR) approached elimination, their programmes transitioned to targeting IRS for active foci or active transmission areas.

In the case studies there were several instances of premature reduction of coverage or disbanding of IRS, some of which were linked to subsequent resurgences of malaria (e.g., Cape Verde, Sri Lanka, Turkey). The reported reasons for reducing IRS operations varied, but the trend was that scale-down occurred when countries were very close to eliminating malaria or were firmly in the POR stage. In Sri Lanka, IRS was halted in eliminated areas, which is thought to have contributed to the epidemic of 1957. In more recent times, Sri Lanka has shown a decline in IRS coverage as it moved from full coverage of risk areas to focal IRS (conducted in areas with malaria cases) and outbreak response, moving from 23 % coverage of total population in 2005 to 6 % in 2010. Even without continued IRS coverage, however, to date Sri Lanka has been able to maintain low caseload and has not experienced a resurgence, perhaps related to the continued distribution of LLINs and use of larval control in addition to a strong surveillance system. In Cape Verde, in contrast, twice in recent history, foci on Santiago Island were re-activated within 3 years after relaxation of aggressive, bi-annual IRS operations. IRS was not replaced by another vector control intervention; larval control (temephos and larvivorous fish) was used after the 1960s in Cape Verde, but there is no evidence in the case study that it was scaled up when IRS declined, and coverage data were not available. Cape Verde has since continued its small-scale IRS operations, mainly outbreak response activities that covered about 5–10 % of Santiago Island.

Turkey scaled down IRS to residual foci only when it did not achieve elimination during the GMEP, and in the 1970s and 1990s fell short of coverage of active foci that was achieved in 1961 (86–88 %) and 1968 (nearly 100 %). In both the 1970s and 1990s, reductions in IRS coverage were linked to the availability of funding; the malaria service was under pressure to reduce expenses when it did not reach elimination. Other challenges included operational constraints, lower quality of implementation, a high rate of refusals in the target population, and insufficient and inexperienced staff. IRS was not replaced by another method of vector control at that time, although larviciding had been used as a complementary measure since the late 1950s. In its latest strategy, the country reserved IRS for areas with residual or active transmission. Likewise, Mauritius did not have enough funding to conduct IRS island-wide during its second elimination attempt, so it was restricted to areas with ongoing transmission. Mauritius used a combination of interventions (IRS, fogging, larval control, and entomological surveillance) for areas with transmission that reported more than three cases. Areas with fewer than three cases did not receive IRS. Coverage was described as 65–80 % of foci in 1986, although it was not clear in the case study if this was considered sufficient. In recent years, Mauritius used IRS to prevent establishment of transmission within a residence of a confirmed case, of which all are imported.

Some countries, particularly those in the early stages of elimination, indicated that operational constraints, instead of a stratification strategy, led to the scale-down of IRS. Worker shortages and an inability to mobilize spray teams, inadequate training, and low morale were all factors described in the case studies. In the 1990s, the Philippines reduced IRS coverage to 20 % of targeted areas as a result of operational disruptions during the process of programme decentralization. Even when an increase in funding boosted coverage to two spray cycles per year with 76 % of target achieved, quality was considered poor due to delays, lack of training, and an insufficient number of spraymen. In part because of the operational challenges and in part due to Global Fund influence, the country focused instead on LLIN distribution. In 2011, ITN and LLIN coverage in the 40 target provinces was 73 % of the total target population. In Namibia, rainy conditions, poor roads and worker shortages have prevented completion of IRS activities. IRS national coverage of at-risk populations ranged from 16 to 41 % from 2001 to 2011, and the country revised its goal to a target of 95 % coverage in areas of moderate endemicity and 100 % focal coverage in low-endemic regions, prioritizing the highest burden villages in the event that the spray season was cut short due to staffing or logistics problems. In Bhutan, political instability in the southern region in the early 1990s led to difficulties in completing IRS spray campaigns and by 1994 cases were increasing. IRS was halted in 1998 when the programme switched to ITNs as a primary vector control measure. Focal IRS was re-instated in 2004 and by 2012 the Bhutan programme reported achieving 100 % coverage of its target population (14 % of the population at risk).

Some countries appear to have maintained a consistent level of coverage. Turkmenistan employed IRS as an outbreak response measure, covering 91–100 % of targeted areas during the 1998–2000 period. The programme did not conduct IRS from 2005 because there were no malaria infections to ‘trigger’ the focal IRS response. The case study on Malaysia did not report any decline in IRS activities, but it was challenging to understand the coverage because it was measured as the number of households sprayed of those targeted, and not by proportion of risk population protected.

Some programmes relied on communities or volunteers for IRS campaigns, such as in the Philippines. Bhutan also trained community volunteers to conduct IRS, however the quality and coverage declined so volunteer teams were disbanded. In some private sector plantations in Sabah State (Borneo) of Malaysia, IRS was implemented (and paid for) by the plantations, with oversight by the Sabah Malaria Control Programme.

Effectiveness of IRS to reduce receptivity was assumed in the reports, evidenced by declines in malaria incidence in the 1950s and 1960s that were linked with increases in IRS coverage. But the picture became more complicated in recent years, as multiple interventions were employed at the same time. This was the case in Malaysia, where IRS with ITN distribution (ITN distributed began in 1995) was credited for a decrease in annual parasite index (API), the number of reported cases per 1000 population per year, from 3.0 (1995) to 0.5 (2000), in addition to the benefits of replacing DDT with pyrethroids in 1998. Turkey and Mauritius also attributed malaria case declines to IRS activities along with active surveillance measures.

Most case study reports did not contain adequate information on recent insecticide resistance monitoring activities or description of evidence of resistance. Malaysia and the Philippines described the sentinel sites for monitoring insecticide resistance. Malaysia, Namibia, and the Philippines reported conducting bioassay and susceptibility tests on insecticides. In the Philippines, Laguna Province shifted insecticides reportedly due to a drop in effectiveness after 10 years, and more recently there was pyrethroid resistance possibly detected in Isabela Province. Sri Lanka implemented insecticide rotation in 1998, part of IVM, in order to prolong the life and utility of the insecticides and optimize vector control.

Given the experience of several countries that halted or scaled down IRS and suffered serious epidemics and resurgences of malaria, further research is needed on the transmission dynamics in various types of contexts, and the alternative methods, such as larval source management, that can be put into place to avoid resurgence. Information should also be shared on the monitoring for insecticide resistance and the programmatic response to the data collected. For some countries, typically higher endemic areas, logistical issues or decreases in funding have led to poor quality implementation or disruption of IRS. Less resource intensive, sustainable methods for vector control must be explored for some countries.

Space spray

Outdoor space spray with insecticide was reported in the case studies of three programmes: Mauritius, Sri Lanka and Turkey.

Mauritius used space spray as an epidemic response measure starting in 1975, but by 1981 it was discontinued. Implementation was viewed as costly and ineffective because it was conducted in the morning when the temperature was too warm. The thermal clines made the insecticide rise and in addition the mosquitos were not flying at that time. It was re-instated in 1982 as a response to the outdoor-biting behaviour of Anopheles gambiae s.l. , this time conducted in the evening. At that time, coverage was limited to the Port Louis areas in response to outbreaks only. In Sri Lanka, space spray has been used during festivals and other large gatherings, but coverage and effectiveness was not articulated in the case study. Turkey conducted space spray as an outbreak containment strategy. While the report indicated that epidemics were controlled through a combination of interventions that included space spray, there are no data on the effectiveness of space spray alone. More research specifically on the impact on malaria transmission of space spray in countries that use it would help in developing an evidence base.

Long-lasting insecticidal nets/insecticide-treated nets

Most malaria programmes in the case study series employed ITNs, followed by LLINs as they became available, as a supplementary vector control measure to IRS. However, the countries in POR (Mauritius, Turkey, Turkmenistan) never used ITNs or LLINs, as they had achieved elimination before they were available. One exception is Turkmenistan, where locally made bed nets were in use since the 1930s and were reportedly widely used (coverage rates not given) in the 2004–2010 elimination campaign.

Of the six eliminating countries, Cape Verde never employed LLINs or ITNs, although information on the reasons behind this was not reported. ITNs/LLINs became a primary vector control tool in the Philippines and Namibia, and replaced IRS for 6 years in Bhutan (1998–2004), until cases doubled from 1998 to 1999, sparking a programme review and the introduction of several activities, including focal IRS to supplement ITNs. The programme had struggled to re-treat ITNs in a timely manner, which may have contributed to the increase in cases. Malaysia never switched from ITNs to LLINs because the programme believed that ITNs were sufficient. Malaysia also did not have external funding, such as a Global Fund grant, which may have contributed to the decision to continue ITN use. LLINs have been used to protect populations living or working in hard-to-reach or remote areas, such as parts of Bhutan and in the former conflict zone of Sri Lanka. NGOs in Sri Lanka that were familiar with the conflict-affected communities in the east and north distributed LLINs.

Similar to reporting on IRS coverage, comparison of coverage and its definition for ITNs/LLINs across case studies was challenging. Countries used different estimates, most based on net ownership rather than any measure of use, including the number of nets distributed as a proportion of the national total population or national population at risk. Only the Philippines case study report detailed the assumptions behind the LLIN coverage indicator. In the Philippines, coverage was defined as two people having an LLIN for an assumed net lifespan of 3 years. In Sabah, one of the most endemic areas of Malaysia, 55 % of the high-risk areas were considered covered by ITNs in 2009. The distribution of ITNs then increased, from 56,000 in 2009 to nearly 80,000 in 2011, while continuing re-treatment of older ITNs. In Sri Lanka, LLINs were introduced in 2004 and by 2005 15 % of the population at risk, approximately 440,000 persons, was considered to be covered (protected) by a LLIN, climbing to 35 % by 2010. It was believed that the combination of IRS and LLINs in the country helped to lower receptivity. The Philippines programme first distributed ITNs in 1990, then LLINs were introduced in 2005, and by 2011, ITN and LLIN coverage in the 40 provinces that received funding from the Global Fund was 73 % of the target. In Namibia, ITNs were first distributed in 1993 and then replaced by LLINs in the mid-2000s. By 2005, coverage ranged from 5 to 10 % of the population at risk, increasing to 50 % in 2009 and 2010, but dropped down to 30 % in 2011. Mass distribution of nearly 500,000 LLINs in the northern regions was conducted in 2013.

Other alternatives have also been tested. The Philippines experimented with hammock-type LLINs for their military but they found the available design to be too difficult to climb out of so they were not scaled up. Hammock LLINs were found to be an effective tool for preventing malaria in forested areas of Cambodia, but this may be related to cultural factors, as villagers and forest workers in the area were used to using hammocks in the early evening hours [ 19 ]. In Sri Lanka, efficacy of insecticide-treated curtains was studied in the late 1990s but no scale up was reported.

ITNs/LLINs have been a core vector control tool for many countries, in particular for populations that are harder to reach with IRS. However, coverage estimates are difficult to compare across countries, and actual use has been difficult to estimate, thus it has been difficult to estimate the impact of ITNs/LLINs. Routine monitoring of coverage and impact of LLINs must be enhanced to better estimate their programmatic impact, especially on a more regular basis, to support locally relevant use of the nets.

Larval control

Larval control is defined as the use of substances that kill or inhibit the development of mosquito larvae or the introduction of fish or invertebrates that feed on larvae [ 20 ], and has been employed by all countries in the analysis. Larval control can include either larvivorous fish or larviciding (which includes both chemical and biological agents in water bodies to kill mosquito larvae).

Most countries started using larval control in the early years of their control programmes (1930s or 1940s) or during the GMEP campaign. Several of the case studies highlighted larval control as a strategy for outbreak or epidemic response (e.g., Bhutan, Malaysia, Mauritius, Turkey, Turkmenistan). In some countries larval control was used as a supplement to IRS, to cover areas that had low or phased-out IRS coverage (e.g., Cape Verde, Mauritius, Sri Lanka), or when zero cases had been reached and IRS was discontinued (Turkey, Turkmenistan). Coverage was typically measured by the number of persons estimated to be protected by this method but this was not detailed in most of the case study reports. When coverage was reported, it was measured in a variety of ways.

In the countries that have eliminated malaria (Mauritius, Turkey, Turkmenistan), larval control has been a continuous and important vector control method and is part of their POR strategic plans. In Mauritius, use of larvivorous fish was perceived to be useful when implemented in proximity to the airport (to lower receptivity in an area that may have imported cases) as well as in deeper rooftop pools and irrigation ponds where vectors were breeding. For the eliminating countries, there were differences in when and why larval control was used. In Malaysia, for example, it was used in low-risk areas throughout the year to keep receptivity at low levels; in contrast, in Namibia it was used primarily in the dry season, when there were fewer water bodies to treat. Sri Lanka used chemical larviciding in abandoned gem pits and wells. Difficulties in implementing larval control were noted throughout the case studies. In Namibia, perceived risk of poisoning animals impeded its widespread use, as did the cost. Inconsistent use of larval control (Philippines and Namibia), lack of intervention data reported to the central level (Cape Verde), lack of breeding site maps (Mauritius), and lack of entomological surveillance in intervention areas (Mauritius) made it difficult to assess the impact of larval control on reducing receptivity or malaria incidence.

Effectiveness of larval control has been measured in Mauritius and Turkey. However, it was conducted in combination with other interventions (in Mauritius alongside IRS and fogging; in Turkey alongside IRS and environmental management) so it was not possible to identify the impact of larval control alone. Research on larval control undertaken in Sri Lanka showed reductions in vector density in the laboratory and in field sites, such as dams, gem pits, brick-making fields, and cement water tanks [ 21 , 22 ], but the study did not measure impact on malaria transmission.

Similar to IRS and LLINs, coverage of larval control has been measured in different ways across programmes. Countries measured larval control by coverage of larval habitats, hectares, reservoirs, or by the number of people protected, all of which are challenging to compare or understand the scale, much less the impact of this intervention. In Turkmenistan, 136 larval habitats and labour camps (in the early 2000s) were covered by larval control, and (in 2009) six hectares were treated with oil-based larvicides and 1828 hectares were treated with fish. In Mauritius (1985), nearly 16,000 potential larval habitats were treated with temephos. In Sri Lanka in 2001 approximately one million people were estimated to be protected through the distribution of larvivorous fish, but by 2002 only 40,000 were considered to be protected.

As there are some countries that may rely heavily on larval control in the prevention of re-introduction stages, such as Sri Lanka, more rigorous monitoring, including stronger indicators, and measurement of impact is needed to understand the best settings for its implementation.

Environmental management

Environmental management activities aim to reduce the size of the immature vector population through habitat modification [ 20 ]. Environmental modification activities ranged across the case studies, depending on the Anopheles species and their preferred larval habitats: cleaning and drainage projects (Bhutan, some parts of Malaysia, Mauritius), marsh draining (Turkey), cleaning or flushing of stream or irrigation canals (Philippines, Sri Lanka, Turkey), infilling of unused reservoirs (Turkmenistan), intermittent drying of reservoirs (Cape Verde), protection of water tanks (Cape Verde), and filling of unused gem pits (Sri Lanka). Namibia did not list any of these activities.

Environmental management was used as a major intervention for five programmes (Turkey, Turkmenistan, Malaysia, Philippines, Sri Lanka) since the early 1900s. In Malaysia it was mainly used in West Malaysia. It was continued as a supplementary measure to IRS in Turkey and Malaysia, as an outbreak response measure in Turkmenistan, and part of the POR strategy in Mauritius. Coverage was not reported in the case studies.

In Mauritius, the large-scale draining/cleaning projects, in addition to other factors such as improvements to housing structures and urbanization, is credited with decreasing the level of malaria transmission before the initial malaria elimination campaign and helped to sustain lower transmission levels during the rest of the 20th Century. In the Philippines, stream clearing was used as a supplementary vector control measure, but had limited overall impact on case incidence, which may be in part due to its inconsistent use.

Similar to larval control, environmental management has been used by many countries as an ongoing vector control tool, and may become more important in the end stages towards malaria elimination. However, as with larval control, methods to monitor its impact on transmission need to be improved.

Personal protection

Four of the case studies reported having a strategy that included use of personal protection approaches, such as promotion of protective clothing, or insecticide-treated products and some without a strong evidence base, such as ingesting traditional herbal medicines. For example, in the Philippines, use of personal protective measures during evening activities was a recommended strategy, but the specific activities were not described. Namibia promoted awareness in the community of wearing protective clothing, and in one region the population traditionally used herbs as personal protection.

Personal protection methods may become more important in settings where outdoor-biting anophelines play or will begin to play a larger role in transmission, owing partly to vector replacement dynamics. Additional evidence is needed on the effectiveness of these tools on transmission reduction at the community level.

Economic development and development projects

Economic development was noted as a main contributor to declining receptivity across many countries as it catalyzed changes that impeded the breeding, feeding or resting behaviour of major malaria vectors. Economic development may have led to changes at individual household level (e.g., housing materials) or larger community level (e.g., large-scale construction projects, urbanization, increased access to medical care and services). Improvements in housing made indoor feeding more difficult, as anophelines were less able to enter and exit homes pre- and post-feeding. These improvements, including use of air conditioning by about 50 % of households and villages, were likely contributors to a reduction in receptivity in Turkmenistan. Similarly, in Bhutan, electrification of homes and subsequent use of electric fans may have reduced transmission. Urbanization is another factor, in that it reduced the number and surface area of anopheline breeding habitats. Water bodies became dry or polluted in some provinces in the Philippines, leading to a decline in larval habitats, since the primary vectors require clear, clean, slow flowing water. For many case study countries, in particular in the Asia Pacific, primary vectors were forest dwelling. Increasing deforestation reduced vector-breeding habitats, such as in Sabah State of Malaysia, where the decline in forest habitat was believed to have reduced vector abundance of Anopheles balabacensis . Economic development in Mauritius in the 1950s and 1960s reduced malaria transmission, leading to the first malaria elimination campaign (1969) and helped to sustain lower transmission levels for the rest of the Century. Although receptivity may have declined in some countries, these transitions were also accompanied by increases in population movement or immigration into receptive areas, elevating the potential risk of transmission. This increased vulnerability due to risk of importation has affected Bhutan and Malaysia even while receptivity is declining.

While changes in economic or infrastructure development in some countries led to a decrease in receptivity, in some areas changes led instead to an increase in receptivity. Irrigation schemes increased levels of receptivity in several countries, such as in Turkey and Mauritius. Dam construction was thought to have increased receptivity in Sri Lanka, Turkmenistan and Bhutan. For example, in Sri Lanka, the 1987 epidemic was linked to a major dam construction project on the Mahaweli River, in the malaria-endemic eastern part of the country, which included forest clearing for rice cultivation. This change in land use resulted in an increase in receptivity, which increased risk of malaria for the one million settlers who moved there from non-endemic areas.

Cape Verde and the Philippines provide examples of the increase in receptivity due to human behaviour. In Mauritius, flat rooftops became popular after the 1960s but because of the pooling of water may have led to an increase in receptivity, as they provided good larval habitats for Anopheles gambiae . In the Philippines, the benefits of electrification in reducing transmission may have been offset in remote areas as more people stayed up later in the evening hours when vector exposure is greatest.

Some changes in development have accelerated malaria transmission or, in contrast, progress toward elimination. In either case, continuous measurement of receptivity will alert malaria programmes to changes in transmission dynamics. This measurement relies upon ongoing, robust entomological surveillance.

Combining vector control strategies

Most programmes rely on a combination of interventions, which together are believed to have reduced vectorial capacities and receptivity of the risk areas.

IRS was a primary tool for most programmes, along with ITN/LLIN to increase coverage of vector control and some type of larval control. Some countries credited the combination of interventions with reducing incidence or receptivity in their countries. In Mauritius, IRS, space spray and larviciding were used in combination with surveillance in active foci; non-active foci receive all interventions except for IRS. The programme attributed success to the control of larval habitats above all other interventions. In the Philippines, the combination of IRS and LLINs was credited for the significant drop in cases since the 1990s. In Turkey, the impact of vector control methods was used as a justification for the setting of a national elimination goal, with the plan to use IRS, larvivorous fish and ITNs to reduce receptivity and achieve elimination.

In the elimination case study series, the scope of data collection was broad and not focused exclusively on vector control, which in some cases translated to a limitation in the comparability of results in the cross-case study analysis. Quality and coverage of vector control interventions was difficult to understand and to compare across case studies, limiting the lessons drawn across all the countries’ experiences. Furthermore, assessment of the impact of vector control interventions was either not available or not fully explored in any of the case studies, most attribution of impact was anecdotal. Moreover, there was no possibility to explore counterfactuals to compare interventions, or lack of, when analysing what may have helped or hindered the programme. However, even with these limitations, the case studies were used as the primary data source as they were comprehensive and extracted information from national malaria programme data, reports, and publications; WHO reports; malaria programme reviews; and WHO and other historical documents.

Some common themes and lessons have emerged. The cross-case study analysis showed that most countries, both eliminating and POR, employed a similar range of vector control tools in the latest period of elimination. IRS was a primary vector control tool throughout the case studies, as most countries have continued this intervention since the GMEP era, when it was proven effective at reducing receptivity. However, there were several examples of programmes that rapidly scaled down IRS without evidence of any strategic planning or stratification process. It is possible that reductions in IRS were linked with a foci- and case-based (focal) strategy, where cases declined and then IRS was phased out. However, this was not clearly described. Instead, the declines in IRS documented in the case studies appear to be more related to a reduction in funding, personnel, programme capacity, or due to ongoing operational constraints. Several countries slowed or halted IRS and subsequently had outbreaks or epidemics. More information is needed on how and when countries should consider decreasing or halting of their primary vector control interventions, and how to maintain capacity to respond to outbreaks. ‘Stopping’ or ‘slowing’ rules for vector control, or guidelines on when programmes should scale down IRS or LLIN distribution or halt them completely, would be helpful to countries pursuing and reaching elimination.

Other tools used by most countries included LLINs, in particular to provide prevention for hard-to-reach populations (e.g., in remote or unstable and insecure areas, or areas with a high number of mobile populations). In some case studies, LLIN use was directly linked with access to external funding, such as from the Global Fund.

Larval control and environmental management were implemented by many programmes, however, coverage and effectiveness were not well described in the case studies nor was the articulation of rationale supporting their use. There was a lack of evidence of effectiveness of these tools in reducing receptivity or malaria transmission by programmes, likely because it was challenging to measure or studies where it did not show impact were not reported. There was also scant research undertaken to measure effectiveness of environmental management schemes. Larval source management (not including larvivorous fish), in selected circumstances, has been found to contribute to a reduction in malaria incidence [ 23 ]. There was only “low quality” evidence reported in the Cochrane Review on larvivorous fish, where there was variable evidence of the effect of larvivorous fish on the density of larvae or reduction in breeding sites with immature vector breeding, and no studies measured the impact of larvivorous fish on malaria incidence [ 20 ]. Notwithstanding, if countries choose to rely upon larval control instead of IRS and/or LLIN implementation as they approach elimination, more country-level and setting-specific evidence, based on rigorous evaluation, is still required for more consolidated conclusions [ 24 ].

The objective of implementing IVM was not well articulated by the malaria programmes, and the meaning of this strategy varied across programmes. While it means a combination of five components, most programmes assumed that intervention combination was the main IVM strategy.

Countries in the case study series that have successfully eliminated malaria and are now in the POR phase had similar approaches. All POR countries used IRS and larval control as primary vector control measures. Two of the three countries that successfully reached elimination combined IRS with other interventions with the intention of reducing receptivity. POR countries had a more detailed description of the entomological surveillance activities undertaken, which appeared to be consistently implemented over time.

As entomological surveillance data should be the basis for all response interventions and programme strategies, consistent and high-quality data are needed [ 25 ]. Entomological surveillance was prioritized by some programmes, in particular in countries that are either close to or have achieved elimination. However, the response component of this surveillance, which could be used for outbreak forecasting, stratification leading to targeting of interventions, and longer term malaria programme strategy, was either not a programme intervention or was poorly articulated in the case studies. Information on insecticide resistance monitoring was scarce, with only a few reports of insecticide resistance and the programme response. There were limited data on how entomological surveillance was conducted or the workforce needs, and no description of collaboration with reference or other research laboratories or training institutions. Linkage between the entomological and epidemiological data was not described, except in Malaysia, where one database combines both types of data. It is likely that most programmes were not taking advantage of these data to inform their intervention responses, coverage, timing or tools.

The choice of vector control tools in the case studies was not strongly linked to evidence. Although biologically plausible, the empirical evidence base on the effectiveness and cost effectiveness of vector control tools implemented, such as larviciding, environmental management and space spraying or fogging, remains weak. WHO does not recommend space spray [ 26 ]. Given that these interventions are implemented as part of integrated vector control strategy, it is difficult to conduct trials. However, countries embarking on introducing these interventions should consider incorporating rigorous operational research to gather evidence on the effectiveness and cost-effectiveness of these interventions.

Choice of vector control tools was not described as a response to the receptivity profile of the country. In fact the factors behind intervention choice were generally opaque across the case studies, leading to the assumption that there must be other background factors at play that are not articulated in the case studies. Global guidance, such as the 1993 WHO Global Malaria Strategy, likely informed some of these choices. Intervention cost, funding availability, and programme capacity required for distribution and operation of interventions were all likely factors at play, as well as cultural and historical factors.

Scaling up or down of vector control, in particular IRS, was not linked clearly with changes in stratification, epidemiology or operational information. In most cases declines appeared to be decided based on funding constraints rather than strategy. The scaling down of IRS contributed towards malaria resurgence in several countries, wiping out years of effort and progress. Countries must be able to make a case to policy and decision makers for continued investments in vector control in order to ‘go the last mile’ and attain and sustain elimination. Programmes must be able to link together quality entomological surveillance data, evidence-based real-time vector control response strategies, evidence on impact of vector control, and comparable coverage and quality indicators to make this case. The linkage between epidemiological surveillance data and vector control as part of the surveillance and response intervention is critical as countries move towards elimination and seek to prevent resurgence. This entails a much closer link between the eco-systemic and public health approaches in malaria control and elimination. An evidence-based stratification system, using risk and receptivity maps, would help programmes make the case for maintaining coverage of risk areas with expensive and time-consuming vector control interventions [ 27 ].

The GTS provides a strategy of the action needed to accelerate progress towards elimination and AIM when placed in the context of a given country, and provides the framework for policy and advocacy. The international malaria community can take forward these strategies and play an important role in filling in the gaps that are outlined in this analysis of country experience. More work needs to be done to fill gaps in programme guidance, providing clarity on the best methods for choosing and targeting vector control interventions, and then supporting countries in the next steps, which are measuring cost, cost-effectiveness and cost-benefit of vector surveillance and control interventions.

Authors’ contributions

CSG, GN, RG, and MT developed the research topic. CSG, GN, RG, DC, and MW developed the framework for analysis. CSG and GN conducted the first analysis of the reports. CSG designed the workshop. All authors reviewed and analysed the case study reports and participated in discussions during and after the case study workshop. CSG conducted additional analysis and drafted the manuscript. GN, RG, LS, DC, MW, and MT provided feedback and direction on the manuscript. All authors read and approved the final manuscript.

Acknowledgements

The authors acknowledge Sir Richard Feachem and Dr. Robert Newman for their vision which led to the development of the joint Eliminating Malaria Case Study Series. The authors acknowledge the efforts of the case study workshop participants (Richard Cibulskis, Jimee Hwang, Catherine Smith, and Jim Tulloch) who reviewed the case studies and matrices, and contributed to the results of this publication in addition to the co-authors, and Rabindra Abeyasinghe, Moh Seng Chang, Rossitza Mintcheva for reviewing the vector control analysis framework.

CSG, GN and RG are supported by the Malaria Elimination Initiative of the Global Health Group at the University of California, San Francisco, and whose funding for this work and publication comes from a grant from the Bill & Melinda Gates Foundation. LS is supported by the Centers for Disease Control and Prevention, which is funded by the US Government. DC is funded by the London School of Hygiene and Tropical Medicine. MW is supported by the University of Queensland and the Department of Foreign Affairs and Trade (Australia) for malaria activities in Solomon Islands and Vanuatu. MT is supported by the Swiss Tropical and Public Health Institute and receives funding from the local and national Swiss Government.

Competing interests

The authors declare that they have no competing interests.

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Monitoring and Evaluation for Social and Behavior Change Communication

Guidance tailored to malaria case management interventions, what is the purpose of this i-kit.

This how-to guide was developed to support professionals from National Malaria Control Programs (NMCPs), health promotion units, technical working groups, and implementing partners to monitor and evaluate SBCC activities that support case management. This guide will take the reader through five steps in developing and executing a plan for monitoring and evaluating SBCC components of malaria case management interventions , and then provide three examples based on actual SBCC programs.

Step-By-Step Guide

This guide was developed to walk users through the process of designing and executing a monitoring and evaluation plan for malaria case management SBCC programs.

Illustrative Examples

Three examples have been included in this guidance. Each example gives a common scenario, steps for monitoring or evaluating in that specific situation, and an example of an actual program that faced those specific challenges.

Introduction

Only half of febrile children under five were taken to a trained provider between 2013 and 2015. Of the febrile children whose caretakers did visit public facilities three-fourths received a parasitological test. Only 14% of children under five with evidence of recent or current Plasmodium falciparum infection and a history of fever were treated with artemisinin-based combination therapy (ACT). There is clearly room for improvement of malaria case management behaviors at both the community and service provider levels.

This guidance is aligned with World Health Organization (WHO) Test, Treat, Track (T3) guidance on malaria case management:

Every suspected malaria case should be tested.
Every confirmed case should be treated with a quality-assured antimalarial medicine.
Every malaria case should be tracked in a surveillance system.

Sought Care

Properly diagnosed, received act.

World Health Organization. World Malaria Report. 2016.

S ocial and behavioral change communication (SBCC) seeks to increase knowledge, change attitudes, and promote the adoption of a set of health behaviors among individuals and communities through shifting social norms. In recent years malaria SBCC campaigns have focused on influencing the knowledge, attitudes, and behaviors of not only individuals, but their social networks as well. 1 Standard indicators 2 that measure attitudinal factors like perceived fear, self-efficacy, and perception of social acceptability are improving the rigor with which SBCC activities are measured.

Case management of malaria has changed a great deal since the introduction and widespread use of rapid diagnostic tests (RDTs) and artemisinin-based combination therapy (ACT). These changes demand shifts in the way individuals, households, communities, and service providers think about malaria case management. Prompt care seeking for fever continues to be emphasized by SBCC campaigns, but families are now being asked to demand for a test before seeking medication. Service providers are being asked to replace clinical diagnosis of febrile patients with blood testing. While supply-side factors such as RDT and ACT availability play a definite role in uptake and use of these essential commodities, efforts to eliminate stock-outs should be paired with activities that establish trust in RDT reliability (response efficacy) among providers and in communities.

Rigorous monitoring and evaluation of SBCC that addresses these new case management approaches must be applied to ensure that resources are allocated to evidence-based programming. While case management SBCC interventions have changed and the standard indicators to measure their effect have only been recently adopted, the tools used to successfully measure and evaluate SBCC programs remain the same. Household questionnaires at the national and sub-national level, focus groups discussions, client exit-interviews, etc. continue to be an effective means of measuring knowledge, attitudes, practices, and social norms. However, practitioners must know where, when, and how to correctly use these measurement tools.

With this in mind, this guidance document was developed to support professionals from National Malaria Control Programs (NMCPs), health promotion units, technical working groups and implementing partners to monitor and evaluate their malaria case management SBCC activities. This reference tool highlights key considerations when developing and implementing monitoring and evaluation (M&E) strategies and activities. It also includes practical examples from three core malaria case management interventions to help troubleshoot frequently faced problems. These core interventions include:

Recognition of malaria signs and symptoms and prompt care seeking at the community level for febrile children under 5

Prompt care seeking at the community level remains the cornerstone of malaria case management. Guidance on measuring this intervention's impact is most likely to serve the greatest number of SBCC practitioners.

Demand generation for testing before treatment among parents and guardians of children under 5

The increased emphasis on testing before treatment requires SBCC programs to improve the communities’ desire for and acceptance of RDTs, so that demand matches supply and available RDTs. The second focus of this guide will describe how to measure increased demand for proper diagnosis before treatment.

Provider adherence to national diagnosis guidelines (regarding treatment according to test results)

In the Examples section of this I-Kit, three interventions are paired an appropriate monitoring or evaluation approach corresponding to the three interventions listed above. Each example will use a common scenario to frame instructions on how to monitor or evaluate SBCC activities in that context. Examples will end with a program example that employed the approach described. While the examples are designed to illustrate practical, evidence-based approaches for specifically monitoring and evaluating malaria case management, the general lessons can be applied to a number of other SBCC interventions. These interventions are not included to suggest prioritization, but because they illustrate both community and service provider issues.

SBCC for Malaria Case Management Desk Review . HC3. 2014
RBM Malaria BCC Indicator Reference Guide . 2014.

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COMMENTS

Prospects and strategies for malaria elimination in the ...
Results: All respondents described current malaria control and elimination strategies, such as case detection and management, prevention and strengthening of surveillance systems as critical and of equal priority. Aware of the emergence of multi-drug resistance in the GMS, researchers and policy makers outlined the need for additional ...
Malaria in Eswatini, 2012-2019: a case study of the elimination effort
However, in recent years, IRS activities have been scaled down to a more targeted approach (as opposed to blanket spraying) in malaria hotspots . This case study aimed to review the malaria surveillance data of Eswatini collected over 8 years between 2012 and 2019 to evaluate the country's efforts that targeted malaria elimination by 2020.
PDF A Case Study
The main strategic pursuits were promoting multiple prevention approaches; improving malaria case management at all levels; encouraging evidence-based research ... Case Study AGA Malaria and Public-Private Partnerships in Ghana's Health Sector 9 AGA, the world's third largest gold producer, has operations in 11 countries with over 70% ...
Malaria
It is intended to guide and support regional and country programmes as they work towards malaria control and elimination. The strategy sets ambitious but achievable global targets, including: reducing malaria case incidence by at least 90% by 2030; reducing malaria mortality rates by at least 90% by 2030
Case Study: Strengthening National Malaria Control Programs
Case Study: Strengthening National Malaria Control Programs. "Malaria affects many people in my community, especially children. It is worse in the rainy season. Many people can't afford treatment in the hospitals," says Abdoulaye Bakary, a health provider at the Bogo health center in Balaza, the Far North region of Cameroon.
Namibia's path toward malaria elimination: a case study of malaria
Low malaria transmission in Namibia suggests that elimination is possible, but the risk of imported malaria from Angola remains a challenge. This case study reviews the early transition of a program shift from malaria control to elimination in three northern ...
Clinical Case Study 1: Fever 6 months after a visit to Pakistan
Clinical Case Study 1: Fever 6 months after a visit to Pakistan. A 44-year-old man is seen at a physician's office in the United States, during a week-end, for suspected malaria. The patient was born in Pakistan but has lived in the United States for the past 12 years. He travels frequently back to Pakistan to visit friends and relatives.
Clinical Case Study 2: 6-Week-Old Infant With Fever
The microscopic diagnosis of P. malariae was confirmed by PCR. The parasitemia is 1.8%, which is high for P. malariae (note that in image 3, four parasites are crowded in a relatively small field). The mild or absent symptoms of malaria in the mother is compatible with P. malariae, a parasite that can persist for years, even a lifetime, with ...
Malaria Journal
Criteria. Malaria Journal welcomes well-described Case studies. These will usually present a major programme intervention or policy option relevant to the journal field. Manuscripts that include a rigorous assessment of the processes and the impact of the study, as well as recommendations for the future, will generally be considered favourably.
Strategies and approaches to vector control in nine malaria-eliminating
In response, WHO launched the Global Technical Strategy (GTS), in which vector surveillance and control play important roles. Country experiences in the Eliminating Malaria Case Study Series were reviewed to identify success factors on the road to elimination using a cross-case study analytic approach.
Treatment-seeking and uptake of malaria prevention strategies among
Background Despite efforts to avert the negative effects of malaria, there remain barriers to the uptake of prevention measures, and these have hindered its eradication. This study explored the factors that influence uptake of malaria prevention strategies among pregnant women and children under-five years and the impact of COVID-19 in a malaria endemic rural district in Uganda. Methods This ...
Malaria in 2022: Increasing challenges, cautious optimism
In 2020, malaria was estimated to have resulted in 627,000 deaths and 241 million cases, with 77% of deaths in children <5 years of age 1. Overall, 90% of malaria cases and deaths are reported in ...
Achievements, Gaps, and Emerging Challenges in Controlling Malaria in
A case study in northern Ethiopia shows that climate change may increase area suitable for malaria transmission by 94 to 114% by 2050 . Overall, countrywide, up to 130 million people may be at risk of malaria by 2070 ( 46 ) that could induce substantial economic costs ( 8 , 42 ).
Strategies and approaches to vector control in nine malaria-eliminating
There has been progress towards malaria elimination in the last decade. In response, WHO launched the Global Technical Strategy (GTS), in which vector surveillance and control play important roles. Country experiences in the Eliminating Malaria Case Study Series were reviewed to identify success factors on the road to elimination using a cross-case study analytic approach.
Malaria in Eswatini, 2012-2019: a case study of the elimination effort
Eswatini was the first country in sub-Saharan Africa to pass a National Malaria Elimination Policy in 2011, and later set a target for elimination by the year 2020. This case study aimed to review the malaria surveillance data of Eswatini collected over 8 years between 2012 and 2019 to evaluate the country's efforts that targeted malaria elimination by 2020.
Case Management of Malaria
Strategies for case management are usually an integral part of the national malaria control program in countries where malaria is endemic (WHO 2015b). Malaria case management entails prompt and appropriate treatment to reduce the risk of severe disease or death and to minimize transmission (Roberts 2016).
Strategies and approaches to vector control in nine malaria-eliminating
Country experiences in the Eliminating Malaria Case Study Series were reviewed to identify success factors on the road to elimination using a cross-case study analytic approach. ... Uusiku P, Liu J. Namibia's path toward malaria elimination: a case study of malaria strategies and costs along the northern border. BMC Publ Health. 2014; 14:1190 ...
Malaria Case Management SBCC
I n 2015 there were approximately 212 million malaria cases and 429,000 related deaths globally, the majority of both occurring in sub-Saharan Africa (SSA). 1 While surveys show that people in SSA have knowledge of the cause, signs and symptoms of malaria, as well as awareness of how to prevent it, uptake of key malaria case management behaviors remains suboptimal.
4 strategies to make electric utilities' water usage more resilient and
This case study synthesizes strategies that electric power utilities can implement to reduce surface water risks to infrastructure, operations, and regulatory compliance as climate change impacts hydrologic regimes over the next century. The strategies range from the reach scale to watershed scale. A reach-scale example would be evaluating ...
Case Study: Oshkosh Uses A Future Fit Tech Strategy To...
Forrester's research shows that companies with a future fit technology strategy outperform their peers by 1.8x. But what does a future fit technology strategy look like in practice? Oshkosh Corporation, which won Forrester's inaugural Technology Strategy Impact Award for North America, can serve as a guide.

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Clinical Case Study 2: 6-Week-Old Infant With Fever

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Strategies and approaches to vector control in nine malaria-eliminating countries: a cross-case study analysis

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Treatment-seeking and uptake of malaria prevention strategies among pregnant women and caregivers of children under-five years during COVID-19 pandemic in rural communities in South West Uganda: a qualitative study

Conclusions

Study design, site, and duration

Study participants and sampling strategy

Data instrument and collection

Data management and analysis

Ethical consideration

Knowledge of malaria causes, transmission, and symptoms

Symptoms of malaria infection

Effects of malaria, its treatment, and uptake of prevention strategies

Economic challenges of malaria

Initial care and treatment for malaria

Malaria prevention strategies

Utilization and challenges of malaria prevention methods

Effect of COVID-19 pandemic on healthcare-seeking and prevention methods

Effect of COVID-19 pandemic on malaria prevention methods

Availability of data and materials

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Malaria in Eswatini, 2012–2019: a case study of the elimination effort

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Data analysis

Availability of data and materials

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Corresponding author

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Strategies and approaches to vector control in nine malaria-eliminating countries: a cross-case study analysis