Decadal epidemiology of malaria in KwaZulu-Natal, a province in South Africa targeting elimination

A review of historical trends in Anopheles gambiae Giles (Diptera: Culicidae) complex composition, collection trends and environmental effects from 2009 to 2021 in Mpumalanga province, South Africa

South Africa is a frontline country for malaria elimination in the southern African region. It has three malaria-endemic provinces, each with its own transmission pattern. The elimination of malaria depends, in part, on controlling and/or eliminating vectors responsible for transmission. Sustained entomological surveillance is an important factor to consider when shifting from a control to elimination framework. The Ehlanzeni district in Mpumalanga province is a key entomological sentinel surveillance area. It is one of the malaria-endemic districts in South Africa with higher rates of malaria incidences. As such, entomological data about the Anopheles gambiae Giles (Diptera: Culicidae) complex have been collected in this province over a substantial period. These data are stored in a pre-existing institutional database. An analysis of the trends that can be observed from this database has not been performed before. This retrospective (longitudinal) analysis provides a summary of the An. gambiae complex vector composition in this region from 2009 to 2021. Routine surveillance data were correlated with climatic data (obtained from the NASA LaRC POWER project database) for the same period to assess the role of climatic factors in vector dynamics. This review also identifies a number of limitations in the data collection process across the sampling period and provides recommendations on how to strengthen the database going forward. The most abundant member of the An. gambiae complex since 2009 in the province was An. merus Dönitz followed by An. arabiensis Patton. Collection methods used showed that human landing catches were successful for collecting An. arabiensis, while pit traps were the most effective in collecting An. merus and An. quadriannulatus Theobald. The latter two species were mainly collected in spring, whereas An. arabiensis abundance was larger during autumn collections. Vector abundance was not significantly correlated with annual climatic data. The information gained from this database provides insights into the vector dynamics of the Ehlanzeni district of the Mpumalanga province.

Environmental and geographical factors influence malaria transmission in KwaZulu-Natal province, South Africa

The malaria burden remains largely concentrated in sub- Saharan Africa. South Africa, a country within this region, has made significant progress toward malaria elimination. However, malaria continues to be endemic in three of its nine provinces: Limpopo, Mpumalanga, and KwaZulu-Natal (KZN), which are located in the northern part of the country and share borders with Botswana, Zimbabwe, and Mozambique. This study focuses on KZN, where district municipalities report monthly malaria cases ranging from zero to 8,981. Fitting Bayesian zero-inflated models in the INLA R package, we assessed the effects of various climate and environmental variables on malaria prevalence and spatio-temporal transmission dynamics from 2005-2014. Specifically, we analyzed precipitation, day and night land surface temperature, the Normalized Difference Vegetation Index (NDVI), the Enhanced Vegetation Index (EVI) and elevation data for KZN local municipalities. Our findings indicate that the best model was the Zero- Inflated Negative Binomial (ZINB) and that at 95% Bayesian Credible Interval (CI), NDVI (0.74; CI (0.95, 3.87) is significantly related to malaria transmission in KZN, with the north-eastern part of the province exhibiting the highest risk of malaria transmission. Additionally, our model captured the reduction of malaria from 2005 to 2010 and the following resurgence. The modelling approach employed in this study represents a valuable tool for understanding and monitoring the influence of climate and environmental variables on the spatial heterogeneity of malaria. Also, this study reveals the need to strengthen the already existing crossborder collaborations to fortify KZN's malaria elimination goals.

Host Preferences and Impact of Climate on Blood Feeding in Anopheles funestus Group from South Africa

Anopheles vaneedeni and Anopheles parensis (members of the An. funestus group) are generally not considered malaria vectors. However, both species were recently identified as potential vectors in South Africa. A critical factor needed to determine their role in malaria transmission is their preference for human blood. The human blood index of An. vaneedeni and An. parensis and their potential role in the ongoing residual malaria transmission in South Africa is unknown. This study aimed to identify host blood meals from the wild-caught An. funestus group in a longitudinal study, and to establish the relationship between temperature, relative humidity, and precipitation on host feeding preferences. Anopheles leesoni, An. parensis, An. vaneedeni, and Anopheles rivulorum were collected, and females mainly fed on cattle. Climatic parameters did not influence the host feeding preferences of these four members of the An. funestus group, but impacted the proportion of females that took a blood meal. Significant changes in feeding proportions were driven by relative humidity, temperature, and precipitation. The role of these species in the ongoing residual malaria transmission in South Africa needs further investigation, as no human blood meals were identified. It is recommended that vector surveillance teams incorporate climatic monitoring and host blood meal identification into their routine activities. This information could provide the malaria vector control programmes with scientific evidence to evaluate the importance of the An. funestus group in residual malaria transmission.

Phytochemical evaluation of Ziziphus mucronata and Xysmalobium undulutum towards the discovery and development of anti-malarial drugs

BACKGROUND

The development of resistance by Plasmodium falciparum is a burdening hazard that continues to undermine the strides made to alleviate malaria. As such, there is an increasing need to find new alternative strategies. This study evaluated and validated 2 medicinal plants used in traditional medicine to treat malaria.

METHODS

Inspired by their ethnobotanical reputation of being effective against malaria, Ziziphus mucronata and Xysmalobium undulutum were collected and sequentially extracted using hexane (HEX), ethyl acetate (ETA), Dichloromethane (DCM) and methanol (MTL). The resulting crude extracts were screened for their anti-malarial and cytotoxic potential using the parasite lactate dehydrogenase (pLDH) and 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay, respectively. This was followed by isolating the active compounds from the DCM extract of Z. mucronata using silica gel chromatography and structural elucidation using spectroscopic techniques (NMR: 1H, 12C, and DEPT). The active compounds were then targeted against P. falciparum heat shock protein 70-1 (PfHsp70-1) using Autodock Vina, followed by in vitro validation assays using ultraviolet-visible (UV-VIS) spectroscopy and the malate dehydrogenase (MDH) chaperone activity assay.

RESULTS

The extracts except those of methanol displayed anti-malarial potential with varying IC50 values, Z. mucronata HEX (11.69 ± 3.84 µg/mL), ETA (7.25 ± 1.41 µg/mL), DCM (5.49 ± 0.03 µg/mL), and X. undulutum HEX (4.9 ± 0.037 µg/mL), ETA (17.46 ± 0.024 µg/mL) and DCM (19.27 ± 0.492 µg/mL). The extracts exhibited minimal cytotoxicity except for the ETA and DCM of Z. mucronata with CC50 values of 10.96 and 10.01 µg/mL, respectively. Isolation and structural characterization of the active compounds from the DCM extracts revealed that betulinic acid (19.95 ± 1.53 µg/mL) and lupeol (7.56 ± 2.03 µg/mL) were responsible for the anti-malarial activity and had no considerable cytotoxicity (CC50 > µg/mL). Molecular docking suggested strong binding between PfHsp70-1, betulinic acid (- 6.8 kcal/mol), and lupeol (- 6.9 kcal/mol). Meanwhile, the in vitro validation assays revealed the disruption of the protein structural elements and chaperone function.

CONCLUSION

This study proves that X undulutum and Z. mucronata have anti-malarial potential and that betulinic acid and lupeol are responsible for the activity seen on Z. mucronata. They also make a case for guided purification of new phytochemicals in the other extracts and support the notion of considering medicinal plants to discover new anti-malarials.

Evaluation of the malaria case surveillance system in KwaZulu-Natal Province, South Africa, 2022: a focus on DHIS2

BACKGROUND

South Africa set a target to eliminate malaria by 2023, with KwaZulu-Natal (KZN) Province the malaria-endemic province closest to achieving this goal. Objective two of the National Malaria Elimination Strategic Plan (NMESP) focused on strengthening surveillance systems to support the country's elimination efforts. Regular evaluations of the malaria surveillance systems against the targets of the NMESP objective are crucial in improving their performance and impact. This study aimed to assess whether the malaria surveillance system in KwaZulu-Natal Province meets the NMESP surveillance objective and goals.

METHODS

A mixed-methods cross-sectional study design was used to evaluate the malaria surveillance system, focusing on the District Health Information System 2 (DHIS2). The study assessed the data quality, timeliness, simplicity, and acceptability of the system. Key personnel from KZN's Provincial malaria control programme were interviewed using self-administered questionnaires to evaluate their perception of the system's simplicity and acceptability. Malaria case data from January 2016 to December 2020 were extracted from the DHIS2 and evaluated for data quality and timeliness.

RESULTS

The survey respondents generally found the DHIS2-based surveillance system acceptable (79%, 11/14) and easy to use (71%, 10/14), stating that they could readily find, extract, and share data (64%, 9/14). Overall data quality was good (88.9%), although some variables needed for case classification had low completeness and data availability. However, case notifications were not timely, with only 61% (2 622/4 329) of cases notified within 24 h of diagnosis. During the 5-year study period, the DHIS2 captured 4 333 malaria cases. The majority of cases (81%, 3 489/4 330) were categorized as imported, and predominately in males (67%, 2 914/4 333).

CONCLUSION

While the malaria surveillance system in KZN Province largely met the NMESP surveillance strategic goals, it failed to achieve the overarching surveillance objective of 100% notification of cases within 24 h of diagnosis. The majority of reported cases in KZN Province were classified as imported, emphasizing the importance of complete data for accurate case classification. Engaging with healthcare professionals responsible for case notification and disseminating aggregated data back to them is needed to encourage and improve notification timeliness.

A Comparative Study of Genetic Diversity and Multiplicity of Infection in Uncomplicated Plasmodium falciparum Infections in Selected Regions of Pre-Elimination and High Transmission Settings Using MSP1 and MSP2 Genes

BACKGROUND

Understanding the genetic structure of P. falciparum population in different regions is pivotal to malaria elimination. Genetic diversity and the multiplicity of infection are indicators used for measuring malaria endemicity across different transmission settings. Therefore, this study characterized P. falciparum infections from selected areas constituting pre-elimination and high transmission settings in South Africa and Nigeria, respectively.

METHODS

Parasite genomic DNA was extracted from 129 participants with uncomplicated P. falciparum infections. Isolates were collected from 78 participants in South Africa (southern Africa) and 51 in Nigeria (western Africa). Allelic typing of the msp1 and msp2 genes was carried out using nested PCR.

RESULTS

In msp1, the K1 allele (39.7%) was the most common allele among the South African isolates, while the RO33 allele (90.2%) was the most common allele among the Nigerian isolates. In the msp2 gene, FC27 and IC3D7 showed almost the same percentage distribution (44.9% and 43.6%) in the South African isolates, whereas FC27 had the highest percentage distribution (60.8%) in the Nigerian isolates. The msp2 gene showed highly distinctive genotypes, indicating high genetic diversity in the South African isolates, whereas msp1 showed high genetic diversity in the Nigerian isolates. The RO33 allelic family displayed an inverse relationship with participants' age in the Nigerian isolates. The overall multiplicity of infection (MOI) was significantly higher in Nigeria (2.87) than in South Africa (2.44) (p < 0.000 *). In addition, heterozygosity was moderately higher in South Africa (1.46) than in Nigeria (1.13).

CONCLUSIONS

The high genetic diversity and MOI in P. falciparum that were observed in this study could provide surveillance data, on the basis of which appropriate control strategies should be adopted.

Geo-epidemiology of malaria incidence in the Vhembe District to guide targeted elimination strategies, South-Africa, 2015-2018: a local resurgence

In South Africa, the population at risk of malaria is 10% (around six million inhabitants) and concern only three provinces of which Limpopo Province is the most affected, particularly in Vhembe District. As the elimination approaches, a finer scale analysis is needed to accelerate the results. Therefore, in the process of refining local malaria control and elimination strategies, the aim of this study was to identify and describe malaria incidence patterns at the locality scale in the Vhembe District, Limpopo Province, South Africa. The study area comprised 474 localities in Vhembe District for which smoothed malaria incidence curve were fitted with functional data method based on their weekly observed malaria incidence from July 2015 to June 2018. Then, hierarchical clustering algorithm was carried out considering different distances to classify the 474 smoothed malaria incidence curves. Thereafter, validity indices were used to determine the number of malaria incidence patterns. The cumulative malaria incidence of the study area was 4.1 cases/1000 person-years. Four distinct patterns of malaria incidence were identified: high, intermediate, low and very low with varying characteristics. Malaria incidence increased across transmission seasons and patterns. The localities in the two highest incidence patterns were mainly located around farms, and along the rivers. Some unusual malaria phenomena in Vhembe District were also highlighted as resurgence. Four distinct malaria incidence patterns were found in Vhembe District with varying characteristics. Findings show also unusual malaria phenomena in Vhembe District that hinder malaria elimination in South Africa. Assessing the factors associated with these unusual malaria phenome would be helpful on building innovative strategies that lead South Africa on malaria elimination.

The effect of the COVID-19 lockdown on malaria transmission in South Africa

BACKGROUND

For a country such as South Africa which is targeting malaria elimination, mobile and migrant populations pose a substantial risk to importation of malaria parasites. It has been hypothesized that halting cross-border movement of mobile and migrant populations will decrease the importation of malaria, however this option is not a politically, operationally, and financially viable prospect. It has social impacts as well, since families live on either side of the border and preventing travel will challenge family ties. Due to the COVID-19 pandemic and closure of ports of entry (land and air) for non-essential travel into South Africa, a unique opportunity arose to test the hypothesis.

METHODOLOGY

An interrupted time series analysis was done to assess whether the post-lockdown trends (April-December 2020) in monthly reported imported and local cases differed from the pre-lockdown trends (January 2015-March 2020). The analysis was conducted separately for KwaZulu-Natal, Mpumalanga, and Limpopo provinces.

RESULTS

On average, imported cases were lower in the post-intervention period in all three provinces, and local cases were lower in Mpumalanga and Limpopo, though no results were statistically significant.

CONCLUSION

Since population movement continued after the travel restrictions were lifted, border screening with testing and treating should be considered for reducing parasite movement. Another option is reducing malaria cases at the source in neighbouring countries by implementing proven, effective vector and parasite control strategies and through a downstream effect reduce malaria entering South Africa.

Perceived Health System Challenges of Implementing Cross-Border Malaria Preventive Measures at Ports of Entry in KwaZulu-Natal

Background

Cross-border movements, especially from a malaria-endemic neighbour, contribute to importation of malaria, as they provide favourable conditions for malaria transmission in the receiving country. In the KwaZulu-Natal (KZN) province of South Africa (SA), the uMkhanyakude district is one of the endemic malaria areas where the borders are characterised by frequent cross-border movements of travellers coming into the province, mostly from Mozambique. Many studies have suggested that regional efforts through the implementation of cross-border measures are needed in both the high- and low-endemic countries to effectively address imported malaria. The implementation of cross-border measures to prevent imported malaria has led to a significant decline in malaria cases in KZN and SA; however, those measures are subjected to various challenges.

Objective

This study sought to determine the health system challenges of implementing cross-border preventive measures for imported malaria at the Kosi Bay, Kwaphuza and Golela ports of entry in KZN.

Methods

This inquiry consisted of a mixed methods approach, of which the qualitative component is reported here. In-depth interviews were conducted with four purposively selected health officers working at the legal and illegal ports of entry of the KZN province. Data were coded manually and then analysed using thematic data and descriptive analyses.

Results

This study identified operational and prevention challenges. The related operational challenges included travellers' non-disclosure and refusal, uncontrolled cross-border movements and poor coverage as well as shortage of staff. The prevention challenges included lack of novelty in the existing cross-border preventive measures, insecurity and illegal migration. Concerning travellers' non-disclosure and refusal to cooperate, these issues occur at the legal ports of entry of Kosi Bay and Golela, where travellers were less cooperative in disclosing their health-related information to health border officers. They were more eager to cross and attend to their business. The findings revealed a lack of new ideas in the existing cross-border measures for the prevention of imported malaria, which some scientists considered as the reason for the failure of the elimination efforts in SA. Because of the porous borders and the shortage of staff to cover all the uncontrolled entries, travellers constantly crossed without any hindrances. Porous borders exposed the people living at the border areas and travellers to insecurity, promoted criminal activities and encouraged illegal migration.

Conclusion

Cross-border malaria preventive measures are meant to contribute to decreased travel-related disease. Failure to attain this purpose must be carefully examined and mitigation strategies implemented. The study revealed the challenges of implementing cross-border measures at the KZN ports of entry of Kosi Bay, Kwaphuza and Golela. The challenges occurred at the operational and prevention levels, which, if not effectively addressed, could impede the decrease of imported malaria in the malaria-endemic district of KZN and SA in general.

Organochlorine pesticide contamination in sediments from Richards Bay, South Africa: spatial trends and ecotoxicological risks

The occurrence and distribution of organochlorine pesticides (OCPs) in aquatic systems is a matter of global concern and poses significant toxicological threats to both organisms and human health. Despite the extensive use of OCPs for pest and disease control in southern Africa, relatively few studies have examined the occurrence and toxicological risks of OCP residues in the region. This study investigates the composition, distribution, and potential sources of OCP contamination in sediments from Richards Bay, a rapidly developing industrial port on the northeast coast of South Africa. Surface sediments collected from Richards Bay Harbour and surrounding areas indicate that OCP contamination in the region is widespread. Total concentrations (∑OCP) in surface samples ranged from 135 to 1020 ng g-1, with hexachlorocyclohexanes (∑HCH; 35-230 ng g-1) and dichlorodiphenyltrichloroethanes (∑DDT; 12-350 ng g-1) the dominant contaminant groups detected. Metabolite isomeric compositions indicate that the presence of aldrin and endosulfan likely result from historical agricultural usage, while recent input of γ-HCH, heptachlor, and endrin may be linked to the illegal use of old pesticide stockpiles. Total DDT concentrations were dominated by p,p'-DDT (80 ± 64 ng g-1), which was attributed to its ongoing use in malaria vector control in the region. A 210Pb-dated sediment core revealed that OCP input to the local environment increased dramatically from relatively low concentrations in the mid-1940s (∑OCP, 355 ng g-1) to peak levels (∑OCP, 781 ng g-1) in the 1980s/1990s. An overall decrease in ∑OCP concentration from the mid-2000s is likely related to restrictions on use following the Stockholm Convention in 2004. Despite current restrictions on use, OCP concentrations exceeded sediment quality guidelines in the vast majority of cases, raising concerns for protected estuarine and mangrove habitats in the area, as well as for local fishing and farming communities.

The mosquito vectors that sustained malaria transmission during the Magude project despite the combined deployment of indoor residual spraying, insecticide-treated nets and mass-drug administration

The "Magude project" aimed but failed to interrupt local malaria transmission in Magude district, southern Mozambique, by using a comprehensive package of interventions, including indoor residual spraying (IRS), pyrethroid-only long-lasting insecticide treated nets (LLINs) and mass-drug administration (MDA). Here we present detailed information on the vector species that sustained malaria transmission, their association with malaria incidence and behaviors, and their amenability to the implemented control interventions. Mosquitoes were collected monthly between May 2015 and October 2017 in six sentinel sites in Magude district, using CDC light traps both indoors and outdoors. Anopheles arabiensis was the main vector during the project, while An. funestus s.s., An. merus, An. parensis and An. squamosus likely played a secondary role. The latter two species have never previously been found positive for Plasmodium falciparum in southern Mozambique. The intervention package successfully reduced vector sporozoite rates in all species throughout the project. IRS was effective in controlling An. funestus s.s. and An. parensis, which virtually disappeared after its first implementation, but less effective at controlling An. arabiensis. Despite suboptimal use, LLINs likely provided significant protection against An. arabiensis and An. merus that sought their host largely indoors when people where in bed. Adding IRS on top of LLINs and MDA likely added value to the control of malaria vectors during the Magude project. Future malaria elimination attempts in the area could benefit from i) increasing the use of LLINs, ii) using longer-lasting IRS products to counteract the increase in vector densities observed towards the end of the high transmission season, and iii) a higher coverage with MDA to reduce the likelihood of human infection. However, additional interventions targeting vectors that survive IRS and LLINs by biting outdoors or indoors before people go to bed, will be likely needed to achieve local malaria elimination.

Seasonal variations in air concentrations of 27 organochlorine pesticides (OCPs) and 25 current-use pesticides (CUPs) across three agricultural areas of South Africa

For decades pesticides have been used in agriculture, however, the occurrence of legacy organochlorine pesticides (OCPs) and current-use pesticides (CUPs) is poorly understood in Africa. This study investigates air concentrations of OCPs and CUPs in three South African agricultural areas, their spatial/seasonal variations and mixture profiles. Between 2017 and 2018, 54 polyurethane foam-disks passive air-samplers (PUF-PAS) were positioned in three agricultural areas of the Western Cape, producing mainly apples, table grapes and wheat. Within areas, 25 CUPs were measured at two sites (farm and village), and 27 OCPs at one site (farm). Kruskal-Wallis tests investigated area differences in OCPs concentrations, and linear mixed-effect models studied differences in CUPs concentrations between areas, sites and sampling rounds. In total, 20 OCPs and 16 CUPs were detected. A median of 16 OCPs and 10 CUPs were detected per sample, making a total of 11 OCPs and 24 CUPs combinations. Eight OCPs (trans-chlordane, o,p'-/p,p'-dichlorodiphenyldichloroethylene (DDE)/dichlorodiphenyltrichloroethane (DDT), endosulfan sulfate, γ-hexachlorocyclohexane and mirex) and two CUPs (carbaryl and chlorpyrifos) were quantified in all samples. p,p'-DDE (median 0.14 ng/m³) and chlorpyrifos (median 0.70 ng/m³) showed the highest concentrations throughout the study. Several OCPs and CUPs showed different concentrations between areas and seasons, although CUPs concentrations did not differ between sites. OCPs ratios suggest ongoing chlordane use in the region, while DDT and endosulfan contamination result from past-use. Our study revealed spatial and seasonal variations of different OCPs and CUPs combinations detected in air. Further studies are needed to investigate the potential cumulative or synergistic risks of the detected pesticides.

Exploring public awareness of the current and future malaria risk zones in South Africa under climate change: a pilot study

Although only a small proportion of the landmass of South Africa is classified as high risk for malaria, the country experiences on-going challenges relating to malaria outbreaks. Climate change poses a growing threat to this already dire situation. While considerable effort has been placed in public health campaigns in the highest-risk regions, and national malaria maps are updated to account for changing climate, malaria cases have increased. This pilot study considers the sub-population of South Africans who reside outside of the malaria area, yet have the means to travel into this high-risk region for vacation. Through the lens of the governmental "ABC of malaria prevention", we explore this sub-population's awareness of the current boundaries to the malaria area, perceptions of the future boundary under climate change, and their risk-taking behaviours relating to malaria transmission. Findings reveal that although respondents self-report a high level of awareness regarding malaria, and their boundary maps reveal the broad pattern of risk distribution, their specifics on details are lacking. This includes over-estimating both the current and future boundaries, beyond the realms of climate-topographic possibility. Despite over-estimating the region of malaria risk, the respondents reveal an alarming lack of caution when travelling to malaria areas. Despite being indicated for high-risk malaria areas, the majority of respondents did not use chemoprophylaxis, and many relied on far less-effective measures. This may in part be due to respondents relying on information from friends and family, rather than medical or governmental advice.

Investment case for malaria elimination in South Africa: a financing model for resource mobilization to accelerate regional malaria elimination

BACKGROUND

Malaria continues to be a public health problem in South Africa. While the disease is mainly confined to three of the nine provinces, most local transmissions occur because of importation of cases from neighbouring countries. The government of South Africa has reiterated its commitment to eliminate malaria within its borders. To support the achievement of this goal, this study presents a cost-benefit analysis of malaria elimination in South Africa through simulating different scenarios aimed at achieving malaria elimination within a 10-year period.

METHODS

A dynamic mathematical transmission model was developed to estimate the costs and benefits of malaria elimination in South Africa between 2018 and 2030. The model simulated a range of malaria interventions and estimated their impact on the transmission of Plasmodium falciparum malaria between 2018 and 2030 in the three endemic provinces of Limpopo, Mpumalanga and KwaZulu-Natal. Local financial, economic, and epidemiological data were used to calibrate the transmission model.

RESULTS

Based on the three primary simulated scenarios: Business as Usual, Accelerate and Source Reduction, the total economic burden was estimated as follows: for the Business as Usual scenario, the total economic burden of malaria in South Africa was R 3.69 billion (USD 223.3 million) over an 11-year period (2018-2029). The economic burden of malaria was estimated at R4.88 billion (USD 295.5 million) and R6.34 billion (~ USD 384 million) for the Accelerate and Source Reduction scenarios, respectively. Costs and benefits are presented in midyear 2020 values. Malaria elimination was predicted to occur in all three provinces if the Source Reduction strategy was adopted to help reduce malaria rates in southern Mozambique. This could be achieved by limiting annual local incidence in South Africa to less than 1 indigenous case with a prediction of this goal being achieved by the year 2026.

CONCLUSIONS

Malaria elimination in South Africa is feasible and economically worthwhile with a guaranteed positive return on investment (ROI). Findings of this study show that through securing funding for the proposed malaria interventions in the endemic areas of South Africa and neighbouring Mozambique, national elimination could be within reach in an 8-year period.

Incidence of Plasmodium falciparum malaria infection in 6-month to 45-year-olds on selected areas of Bioko Island, Equatorial Guinea

Background

Extensive malaria control measures have been implemented on Bioko Island, Equatorial Guinea over the past 16 years, reducing parasite prevalence and malaria-related morbidity and mortality, but without achieving elimination. Malaria vaccines offer hope for reducing the burden to zero. Three phase 1/2 studies have been conducted successfully on Bioko Island to evaluate the safety and efficacy of whole Plasmodium falciparum (Pf) sporozoite (SPZ) malaria vaccines. A large, pivotal trial of the safety and efficacy of the radiation-attenuated Sanaria^® PfSPZ Vaccine against P. falciparum is planned for 2022. This study assessed the incidence of malaria at the phase 3 study site and characterized the influence of socio-demographic factors on the burden of malaria to guide trial design.

Methods

A cohort of 240 randomly selected individuals aged 6 months to 45 years from selected areas of North Bioko Province, Bioko Island, was followed for 24 weeks after clearance of parasitaemia. Assessment of clinical presentation consistent with malaria and thick blood smears were performed every 2 weeks. Incidence of first and multiple malaria infections per person-time of follow-up was estimated, compared between age groups, and examined for associated socio-demographic risk factors.

Results

There were 58 malaria infection episodes observed during the follow up period, including 47 first and 11 repeat infections. The incidence of malaria was 0.25 [95% CI (0.19, 0.32)] and of first malaria was 0.23 [95% CI (0.17, 0.30)] per person per 24 weeks (0.22 in 6–59-month-olds, 0.26 in 5–17-year-olds, 0.20 in 18–45-year-olds). Incidence of first malaria with symptoms was 0.13 [95% CI (0.09, 0.19)] per person per 24 weeks (0.16 in 6–59-month-olds, 0.10 in 5–17-year-olds, 0.11 in 18–45-year-olds). Multivariate assessment showed that study area, gender, malaria positivity at screening, and household socioeconomic status independently predicted the observed incidence of malaria.

Conclusion

Despite intensive malaria control efforts on Bioko Island, local transmission remains and is spread evenly throughout age groups. These incidence rates indicate moderate malaria transmission which may be sufficient to support future larger trials of PfSPZ Vaccine. The long-term goal is to conduct mass vaccination programmes to halt transmission and eliminate P. falciparum malaria.

An SEIR model with infected immigrants and recovered emigrants

We present a deterministic SEIR model of the said form. The population in point can be considered as consisting of a local population together with a migrant subpopulation. The migrants come into the local population for a short stay. In particular, the model allows for a constant inflow of individuals into different classes and constant outflow of individuals from the R-class. The system of ordinary differential equations has positive solutions and the infected classes remain above specified threshold levels. The equilibrium points are shown to be asymptotically stable. The utility of the model is demonstrated by way of an application to measles.

Organochlorine pesticide accumulation in fish and catchment sediments of Lake St Lucia: Risks for Africa's largest estuary

Although use of organochlorine pesticides (OCPs) has been banned or severely limited on a global basis, concerning concentrations continue to be reported in many tropical and subtropical regions of the world. These habitats often support high levels of unique biodiversity and vulnerable communities that depend on the environment for their survival. We investigated threats associated with OCP contamination at Lake St Lucia, a global hotspot for biodiversity and a UNESCO World Heritage Site in South Africa. Lake St Lucia is sustained largely by surface runoff from catchment areas where significant quantities of OCPs have historically been used in agriculture and where DDT continues to be used for disease control. Sediments (n = 40) collected from the two largest fluvial inputs to Lake St Lucia showed that these rivers represent important sources of contaminants, with ∑OCP concentrations ranging between 74 and 510 ng g^-1. Measured HCH, dieldrin, ∑DDT and ∑chlor concentrations exceeded NOAA sediment toxicity guidelines in the majority of samples analysed. Bioaccumulation was assessed by examining residue concentrations in muscle tissues from two abundant fish species from Lake St Lucia. OCPs were detected in all samples analysed, with total concentrations ranging 860-5000 ng g^-1 lw and 390-3200 ng g^-1 lw for Oreochromis mossambicus (n = 17) and Clarias gariepinus (n = 41), respectively. A health risk assessment indicated potential dietary risk associated with exposure to aldrin, dieldrin and heptachlor, although the cumulative effect of OCPs on human health, ecosystem biodiversity and long-term ecotourism sustainability remains unknown.

Multilevel modelling of the risk of malaria among children aged under five years in Nigeria

BACKGROUND

Malaria is still a major cause of morbidity and mortality among children aged <5 y (U5s). This study assessed individual, household and community risk factors for malaria in Nigerian U5s.

METHODS

Data from the Nigerian Malaria Health Indicator Survey 2015 were pooled for analyses. This comprised a national survey of 329 clusters. Children aged 6-59 mo who were tested for malaria using microscopy were retained. Multilevel logit model accounting for sampling design was used to assess individual, household and community factors associated with malaria parasitaemia.

RESULTS

A total of 5742 children were assessed for malaria parasitaemia with an overall prevalence of 27% (95% CI 26 to 28%). Plasmodium falciparum constituted 98% of the Plasmodium species. There was no significant difference in parasitaemia between older children and those aged ≤12 mo. In adjusted analyses, rural living, northwest region, a household size of >7, dependence on river and rainwater as primary water source were associated with higher odds of parasitaemia, while higher wealth index, all U5s who slept under a bed net and dependence on packaged water were associated with lower odds of parasitaemia.

CONCLUSION

Despite sustained investment in malaria control and prevention, a quarter of the overall study population of U5s have malaria. Across the six geopolitical zones, the highest burden was in children living in the poorest rural households.

Widespread zoophagy and detection of Plasmodium spp. in Anopheles mosquitoes in southeastern Madagascar

BACKGROUND

Malaria is a top cause of mortality on the island nation of Madagascar, where many rural communities rely on subsistence agriculture and livestock production. Understanding feeding behaviours of Anopheles in this landscape is crucial for optimizing malaria control and prevention strategies. Previous studies in southeastern Madagascar have shown that Anopheles mosquitoes are more frequently captured within 50 m of livestock. However, it remains unknown whether these mosquitoes preferentially feed on livestock. Here, mosquito blood meal sources and Plasmodium sporozoite rates were determined to evaluate patterns of feeding behaviour in Anopheles spp. and malaria transmission in southeastern Madagascar.

METHODS

Across a habitat gradient in southeastern Madagascar 7762 female Anopheles spp. mosquitoes were collected. Of the captured mosquitoes, 492 were visibly blood fed and morphologically identifiable, and a direct enzyme-linked immunosorbent assay (ELISA) was used to test for swine, cattle, chicken, human, and dog blood among these specimens. Host species identification was confirmed for multiple blood meals using PCR along with Sanger sequencing. Additionally, 1,607 Anopheles spp. were screened for the presence of Plasmodium falciparum, P. vivax-210, and P. vivax 247 circumsporozoites (cs) by ELISA.

RESULTS

Cattle and swine accounted, respectively, for 51% and 41% of all blood meals, with the remaining 8% split between domesticated animals and humans. Of the 1,607 Anopheles spp. screened for Plasmodium falciparum, Plasmodium vivax 210, and Plasmodium vivax 247 cs-protein, 45 tested positive, the most prevalent being P. vivax 247, followed by P. vivax 210 and P. falciparum. Both variants of P. vivax were observed in secondary vectors, including Anopheles squamosus/cydippis, Anopheles coustani, and unknown Anopheles spp. Furthermore, evidence of coinfection of P. falciparum and P. vivax 210 in Anopheles gambiae sensu lato (s.l.) was found.

CONCLUSIONS

Here, feeding behaviour of Anopheles spp. mosquitoes in southeastern Madagascar was evaluated, in a livestock rich landscape. These findings suggest largely zoophagic feeding behaviors of Anopheles spp., including An. gambiae s.l. and presence of both P. vivax and P. falciparum sporozoites in Anopheles spp. A discordance between P. vivax reports in mosquitoes and humans exists, suggesting high prevalence of P. vivax circulating in vectors in the ecosystem despite low reports of clinical vivax malaria in humans in Madagascar. Vector surveillance of P. vivax may be relevant to malaria control and elimination efforts in Madagascar. At present, the high proportion of livestock blood meals in Madagascar may play a role in buffering (zooprophylaxis) or amplifying (zoopotentiation) the impacts of malaria. With malaria vector control efforts focused on indoor feeding behaviours, complementary approaches, such as endectocide-aided vector control in livestock may be an effective strategy for malaria reduction in Madagascar.

Agrochemicals in freshwater systems and their potential as endocrine disrupting chemicals: A South African context

South Africa is the largest agrochemical user in sub-Saharan Africa, with over 3000 registered pesticide products. Although they reduce crop losses, these chemicals reach non-target aquatic environments via leaching, spray drift or run-off. In this review, attention is paid to legacy and current-use pesticides reported in literature for the freshwater environment of South Africa and to the extent these are linked to endocrine disruption. Although banned, residues of many legacy organochlorine pesticides (endosulfan and dichlorodiphenyltrichloroethane (DDT)) are still detected in South African watercourses and wildlife. Several current-use pesticides (triazine herbicides, glyphosate-based herbicides, 2,4-dichlorophenoxyacetic acid (2,4-D) and chlorpyrifos) have also been reported. Agrochemicals can interfere with normal hormone function of non-target organism leading to various endocrine disrupting (ED) effects: intersex, reduced spermatogenesis, asymmetric urogenital papillae, testicular lesions and infertile eggs. Although studies investigating the occurrence of agrochemicals and/or ED effects in freshwater aquatic environments in South Africa have increased, few studies determined both the levels of agricultural pesticides present and associated ED effects. The majority of studies conducted are either laboratory-based employing in vitro or in vivo bioassays to determine ED effects of agrochemicals or studies that investigate environmental concentrations of pesticides. However, a combined approach of bioassays and chemical screening will provide a more comprehensive overview of agrochemical pollution of water systems in South Africa and the risks associated with long-term chronic exposure.

Changing Patterns in Epidemiology of Malaria Between 2006 and 2018 in the South of Fars Province, Southern Iran: The Fall and Rise of Malaria

Background

Malaria is one of the major human health problems that have become increasingly important in recent decades.

Objective

The present study aimed to identify the epidemiological status of malaria in the years 2006-2018 in the southern region of Fars province in southern Iran.

Methods

This is a cross-sectional descriptive-analytical study. The study population consisted of all persons with malaria referred to the Center for Disease Control in the four cities of Larestan, Gerash, Evaz and Khonj in the south of Fars province, Southern Iran, between 2006 and 2018. Frequency (%) was used to report descriptive statistics and mean and standard deviation for quantitative variables. The trend of malaria incidence during these years was analyzed using the Cochran Armitage Test. The significance level was considered 5%.

Findings

A total of 190 cases of malaria in the period of 2006 to 2018 occurred in the southern region of Fars province; 77.9% were men, more than 95% were Afghans, and most of them were workers. The incidence of malaria in one hundred thousand people per month showed that most of the new malaria cases were in the months of July to October. The peak incidence was in August, with 19.88 cases per 100,000 people. Cochran-Armitage test results showed that this trend was not statistically significant (P = 0.399), despite an almost upward trend in malaria incidence in the south of Fars province.

Conclusion

The results of this study showed that the trend of malaria in the south of Fars province was ascending; therefore, increasing surveillance activities to prevent and control malaria in such area is of utmost importance.