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Swaziland Leads Sub-Saharan Africa in Ending Malaria; Aims to Eliminate by 2015

November 8, 2012

In 2011, Swaziland took a bold step, declaring a national malaria elimination policy, with the goal of eliminating malaria by 2015. Despite longstanding skepticism that malaria elimination is possible in sub-Saharan Africa, a new report gives credence to Swaziland's optimism: the just-published Roll Back Malaria Partnership (RBM) Progress & Impact Series Report: Focus on Swaziland documents that Swaziland achieved a 74% reduction in malaria cases between 2000 and 2012 – including a 42% decline just from 2011 to 2012 – leaving only a few hundred cases between its current state, and its 2015 goal.

Being within sight of the finish line for malaria elimination is not something that Swaziland takes for granted. Nearly 70 years ago, the country experienced as many as 45,000 malaria cases annually, and 60% of children aged 1 to 12 years were infected with malaria parasites. However in 2011, a nationally representative survey found the overall prevalence of malaria parasites in Swaziland had fallen to just 0.2%. Much of this remarkable progress has been attributed to Swaziland's evidence-based and strategic scale-up of malaria control interventions, including insecticide-treated nets and indoor residual spraying for at-risk populations; consistent use of malaria diagnostics and first-line drugs for all confirmed cases; harmonization of interventions with Mozambique and South Africa through the Lubombo Spatial Development Initiative (LSDI); and effective communications campaigns about optimal behaviors to prevent malaria transmission. As a result, according to the RBM report, an estimated 33,000 malaria cases were successfully averted between 2000 and 2012.

"Swaziland is a compelling example of a country driving down malaria through aggressive and flexible application of control measures and modern technology," says Sir Richard Feachem, Director of the Global Health Group at the University of California, San Francisco. "As long as financial and political commitments to malaria elimination are sustained, I am confident that Swaziland will achieve its goals and be free of malaria by 2015. We applaud the commitment of all those in Swaziland who are leading and implementing this excellent work, and we will continue our support to them until this task is complete."

The Global Health Group and colleagues have worked closely with Swaziland's National Malaria Control Program since 2008, supporting the country's technical and human resource capacities to help make Swaziland's malaria mission possible. For instance, the Southern Africa Malaria Elimination Support Team (SAMEST), a partnership between the Global Health Group and the Clinton Health Access Initiative (CHAI), placed analysts within Swaziland's malaria program to assist with a range of programmatic activities, which include conducting operational and technical gap analyses; drafting community education and cross border screening strategies; helping write Swaziland's successful Round 8 grant proposal from the Global Fund to Fight AIDs, Tuberculosis and Malaria; and supporting operational research to track remaining malaria cases. In addition, Global Health Group researchers are helping Swaziland hone its surveillance by analyzing geospatial data on areas at higher risk for malaria - or malaria 'hot spots' - and developing cost-effective tools to optimally identify and confirm asymptomatic cases of malaria.

Swaziland's malaria program has been widely recognized as a global leader in controlling malaria, with its program manager, Simon Kunene, receiving the prestigious "Healthcare Engagement Strategy 2012 Life Changer" award in February 2012. Kunene was formally presented with this honor at the Swaziland Health and Research Conference on November 8, 2012, at which Swaziland's Minister of Health, the Honorable Benedict Xaba, and RBM Goodwill Ambassador Yvonne Chaka Chaka, a world-renowned singer and malaria advocate, formally launched the RBM Focus on Swaziland report.

Beyond documenting Swaziland's malaria success story, the RBM report also highlights key activities for Swaziland to reach zero malaria, including integrated vector management, effective case management (i.e., prompt diagnosis and treatment), ongoing program coordination with Mozambique along shared borders, communications campaigns, and perhaps most importantly, a highly responsive surveillance system that can rapidly detect and react to malaria cases. Strong surveillance systems are viewed as "the crux of a strong elimination program," and Swaziland's program is regarded as a model for the region. With its highly functioning surveillance system, Swaziland's malaria program can very quickly identify cases of malaria throughout the country, determine whether the malaria case was acquired locally or if it originated from a neighboring country, and subsequently enact an appropriate response (e.g., treatment, preventative interventions for homes and individuals near the detected case).

Figure 1. Actions triggered when the Swaziland malaria program detects a case of malaria.
Source: Roll Back Malaria Progress & Impact Series Report: Focus on Swaziland

Despite its success to date, Swaziland faces the substantial challenge of ensuring that the country crosses the elimination finish line – especially as malaria is perceived as a less threatening public health problem and program funding becomes more difficult to acquire. Swaziland's Round 8 Global Fund grant for malaria elimination ends in 2014, a year before the country hopes to reach zero malaria. In addition, the proposed restructuring of the Global Fund's distribution mechanisms may exclude lower burden countries like Swaziland from continued malaria program funding.

"This paradox, whereby malaria-eliminating countries become ineligible for international funding because of their success in ending malaria, just when they need sustained funding to finish the job and prevent reintroduction of malaria, is unacceptable," cautions Feachem. Funding and coordination for a regional initiative to control malaria in neighboring regions of Swaziland, South Africa and Mozambique - known as LSDI - also expired in 2011, raising the specter of increased imported malaria into Swaziland from Mozambique if replacement interventions fail.

Swaziland is no stranger to what can happen when malaria program funding disappears. In 1969, after years of vigorous malaria control, Swaziland documented only 46 malaria cases, and determined that 36 of these had been imported from outside the country's borders. By 1970, with the risk of malaria viewed as nearly nonexistent, funding for interventions and program staffing were cut back. Without critical funding to maintain control, the disease rebounded, and in 1977, Swaziland experienced a widespread epidemic, with 87 deaths and 1,473 cases. This relationship between funding trends and malaria outbreaks is not limited to Swaziland or even sub-Saharan Africa: in a study published earlier this year, Global Health Group researchers and colleagues found that 91% of all historical malaria resurgences worldwide followed the weakening of malaria programs, of which reduced program funding was a major cause.

Despite these challenges, Swaziland remains steadfastly committed to its goal to reach zero malaria by 2015 – and the country is fully on track to achieve it. The Global Health Group continues to conduct research to help Swaziland map and pinpoint cases, and to determine the most appropriate, cost- effective approaches to diagnose low-grade malaria infections that are largely asymptomatic but can nonetheless contribute to onward transmission. Such new tools and strategies are critically needed today by the countries that seek to eliminate malaria in the next few years, and they will serve as the vital foundation for elimination programs throughout the world in the future.

The Global Health Group is an "action tank" dedicated to translating new approaches into large-scale action to improve the lives of millions of people. Its Malaria Elimination Initiative provides intellectual and practical support to the 34 countries around the world that are pursuing malaria elimination. Since 2008, the Global Health Group has partnered with the Clinton Health Access Initiative (CHAI) to lead and support SAMEST, the Southern Africa Malaria Elimination Support Team, which provides management and technical support to countries that have declared a goal of malaria elimination, and is currently engaged in Namibia, South Africa and Swaziland.