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National Malaria Control Programme
Annual Report 2012-2013
The Kingdom of Swaziland
Ministry of Health
National Malaria Control Programme
2
Table of Contents
Table of Contents .................................................................................................................................... 2
Tables and Figures .................................................................................................................................. 3
Foreword ................................................................................................................................................. 4
Acronyms ................................................................................................................................................ 5
Executive Summary ................................................................................................................................. 6
1. Introduction ...................................................................................................................................... 8
2. Malaria Epidemiology in Swaziland .................................................................................................. 9
2.1 Malaria Morbidity ............................................................................................................... 9
2.2 Malaria Mortality .............................................................................................................. 12
3. Programme Management .............................................................................................................. 13
3.1 Human Resources ............................................................................................................. 13
3.2 Programme Review ........................................................................................................... 13
3.3 Programme Meetings ....................................................................................................... 13
3.4 Financial Management ...................................................................................................... 15
3.4 Interim Application ........................................................................................................... 16
4. Case Management .......................................................................................................................... 17
4.1 Capacity Building of Healthcare Workers ......................................................................... 17
4.2 Diagnosis ........................................................................................................................... 17
4.3 Treatment ......................................................................................................................... 18
4.4. Policy Changes .................................................................................................................. 19
4.5 Performance under Global Fund Grant ............................................................................ 19
5. Vector Management ...................................................................................................................... 21
5.1 Indoor Residual Spraying (IRS) .......................................................................................... 21
5.2 Long Lasting Insecticide-Treated Nets (LLINs) .................................................................. 23
5.3 Vector Surveillance ........................................................................................................... 23
5.4 Policy Changes .................................................................................................................. 24
5.5 Performance under Global Fund Grant ............................................................................ 24
6. Surveillance .................................................................................................................................... 25
6.1 Passive Surveillance .......................................................................................................... 25
6.2 Active Case Investigation .................................................................................................. 26
6.3 Active Case Detection ....................................................................................................... 31
6.4 Performance under Global Fund Grant ............................................................................ 32
7. Information, Education and Communication (IEC) ........................................................................ 33
7.1 Annual IEC Strategy ........................................................................................................... 33
7.2 Mass Media Campaigns .................................................................................................... 33
7.3 Community Mobilization and Outreach ........................................................................... 34
7.4 National Knowledge, Attitudes and Practices (KAP) Survey ............................................. 35
7.5 Performance under the Global Fund Grant ...................................................................... 35
8.1 Priorities for 2013-14...................................................................................................................... 36
3
Tables and Figures
Tables
No. Title Page
3.1 Government Budget and Expenditure for NMCP, 2012-13 15
3.2 Year 3 Financial absorption of GF Round 8 – Malaria Grant 16
4.1 Performance for Global Fund Indicators for Case Management 20
5.1 Structures Sprayed by Locality in 2012-13 22
5.2 Presence of P.Falciparum in adult An. Gambiaes.l mosquitoes, by Locality (2012) 23
5.3 Genotypes (kdr and ace-1R) of adult An. gambiaes.l mosquitoes, by Locality (2012) 24
6.1 Location of RDT Positive and LAMP Positive Cases Found through RACD, 2012-13 31
6.2 Performance for Global Fund Indicators for Surveillance 32
7.1 Mass Media Campaigns 33
Figures
No. Title Page
2.1 Malaria Cases (Confirmed and Presumed) Reported to HMIS by Region 10
2.2 Malaria Cases (Confirmed and Presumed) Reported to HMIS by Month/Region, 2012-13 10
2.3 Confirmed Malaria Cases Reported, 2012-13 11
2.4 Incidence by Inkhundla for All Confirmed Cases (Left) and Local Cases (Right), 2012-13 11
4.1 Confirmed and Unconfirmed Malaria Cases and Confirmation Rate, 2008-2013 17
4.2 Diagnosis Tool Used among Investigated Cases (n=323), 2012-13 18
4.3 Treatment Type among Investigated Cases (n=323), 2012-13 19
6.1 Confirmed Cases by Month, 2012-13 26
6.2 Case Investigation by Month, 2012-13 26
6.3 Proportion of Investigated Cases Classified as Local by Season 27
6.4 Distribution of Malaria Cases by Classification and Month, 2012-13 28
6.5 Local Cases by Locality, 2012-13 28
6.6 Household Locations of Local and Imported Cases, 2012-13 29
6.7 Location Travelled to in Mozambique of Select Imported Cases, 2012-13 30
4
Foreword
Swaziland is working to become the first mainland sub-Saharan African country to eliminate
malaria.As defined in the National Malaria Elimination Strategic Plan for 2008 to 2015, Swaziland’s
plan to transition from a control programme to an elimination programme focuses on four major
intervention areas: (1) effective case management through definitive diagnosis and proper case
management, (2) integrated vector management, particularly in combining the use of indoor
residual spraying, and long-lasting insecticide-treated nets, (3) a strong epidemiological and
entomological surveillance system, and (4) a comprehensive information, education, and
communication campaign. These activities began in July 2009 and are supported by funding
provided by the Swaziland government and a Global Fund Round 8 grant.
The implementation of these new strategies related to Swaziland’s malaria elimination campaign has
changed the understanding of malaria epidemiology in the country. Previously, the majority of
malaria cases were clinically diagnosed based on signs and symptoms of the disease. With the
introduction of rapid diagnostic tests at all health facilities in February 2010, lab confirmed cases
have increased marginally while the number of clinically diagnosed cases reported has decreased
significantly, indicating successful uptake of this new diagnostic tool. Additionally, an active
surveillance programme has been launched nationally that facilitates the investigation of all
confirmed malaria cases at household level to determine the source of each infection and case
detection activities with communities to help identify asymptomatic infections that contribute to
ongoing transmission. This has allowed the identification of high-risk groups and areas that can be
targeted with other interventions including vector control and health promotion.
This 2012-2013 Annual Report reflects progress made in the elimination campaign and challenges
experienced over this time period. Challenges include cancelled trainings for healthcare workers and
key community groups as part of a condition precedent to disbursement on the Global Fund grant.
This affected the NMCP’s ability to improve healthcare worker performance and likely the uptake of
personal protection measures among at-risk populations. In spite of these challenges, progress was
made on all major indicators including the overall case investigation rate and a reduction in the
proportion of confirmed cases attributed to local transmission compared to the previous
transmission seasons.
Remaining gaps that must beaddressed to achieve elimination addressed in the section on priorities
for 2013-14. TheNational Malaria Control Programme is confident that the continued refinement of
these intervention areas based on detailed evidence will lead to a malaria-free Swaziland in the
near-future.
_________________________
Simon Kunene
Programme Manager
National Malaria Control Programme
Ministry of Health, Swaziland
5
Acronyms
ACT artemisinin-based combination therapy
AL artemetherLumefantrine
CHAI Clinton Health Access Initiative
DBS dried blood spot
GPS global positioning system
HMIS Health Management Information System
IDNS Immediate Disease Notification System
IEC information, education, and communication
IRS indoor residual spraying
IVM Integrated Vector Management
KAP knowledge, attitudes, and practice
LLIN long-lasting insecticide-treated net
MPR Malaria Programme Review
MRC Medical Research Council
NERCHA National Emergency Response Council on HIV/AIDS
NMCP National Malaria Control Programme
PACD proactive case detection
RACD reactive case detection
RBM Roll Back Malaria
RDT rapid diagnostic test
SADC Southern African Development Community
SARN Southern Africa Roll Back Malaria Network
SMEAG Swaziland Malaria Elimination Advisory Group
SWADE Swaziland Water and Agricultural Development Enterprise
WHO World Health Organisation
6
Executive Summary
Introduction
This annual report refers to the period between July 2012 and June 2013. The report focuses on the
four major intervention areas of Swaziland’s elimination campaign: Case Management, Vector
Control, Surveillance, and Information, Communication, and Education (IEC). The majority of the
activities within these intervention areas have been led and executed by the National Malaria
Control Programme (NMCP), in conjunction with various implementing partners. This report also
includes a Programme Management section that covers financial and human resource issues, as well
as a section on priorities for the 2013-14 year.
Malaria Epidemiology in Swaziland
Reported malaria cases continue to decrease following the rollout of diagnostic tests at all health
facilities and implementationof reactive surveillance activities in receptive areas. In 2012-13,738
cases were reported to the Ministry of Health’s Health Management Information System (HMIS)
from inpatient and outpatient departments at health facilities in the country. This is a significant
decrease in reported cases compared to 2008-09 (7507 cases), 2009-10 (3622 cases), and 2010-11
(1181 cases), and a slight increase compared to 2011-12 (643 cases).Over this same period, the
country had a total of 379 confirmed malaria cases or 1.33laboratory-confirmed cases per 1000
population at-risk. Case mapping indicates that most local cases occur in the middleveld and lowveld
ecological zones toward the eastern part of the country near the Mozambique border. There were
2confirmed malaria deaths in 2012-13.
Programme Management
The Government of Swaziland provided a budget of SZL 6,856,953.00 to support the implementation
of malaria activities in 2012-13. Personnel costs accounted for 70% of government expenditure.
Global Fund expenditure for Year 4 of the grant (July 2012-June 2013) equaled 9,471,406.53 SZL,
which represented 70% of the disbursed funds for this period. Under expenditure was mainly due to
trainings that were planned but could not be carried out due to delays in approval by the Global
Fund. The country submitted an interim grant application to the Global Fund to extend necessary
activities currently funded under the Global Fund through December 2013.
Case Management
Although the Programme set out to train 400 healthcare workers during this period, no trainings
could be carried out except for the doctor’s training due to delayed approval of trainings by the
Global FundUnfortunately, this likely led to the decrease in the the case confirmation rate increased
to 51%, down from 57% in 2011-12.Out of the 323 cases investigated by the NMCP surveillance team
for this period, 267 were diagnosed by rapid diagnostic test, 3 by microscopy, and 53 by both.
Among the same cases, 261cases were treated with Artemether-Lumefantrine (AL), 32cases were
treated with Quinine, 28cases were treated with both AL and quinine, and 2 were treated by
another anti-malarial. Based on the results from the quality assurance program Artemether-
Lumefantrine remains the most efficacious first-line drug for treating uncomplicated malaria in
Swaziland; all 5 positive DNA PCR samples were sensitive to Artemether Lumefantrine.
7
Vector Management
Due to delays in tendering for insecticide, indoor residual spraying (IRS) and distribution of long-
lasting insecticide treated nets (LLINs) did not commence until December 2011. A total of53,960 out
of 59,404 structures were sprayed among households in the targeted areas, achieving coverage of
90%.No LLINs were distributed this year in accordance with the elimination work plan, as LLINS had
been distributed during the previous three seasons to cover the at-risk populations. Since the
inception the strategy to achieve universal coverage of LLINs in malaria at-risk areas of Swaziland,
total of 154,218 LLINs have been distributed, covering 208,443 persons in the malaria at-risk region.
No survey was conducted this year to validate IRS coverage or determine LLIN ownership and
utilization. Larval sampling and catches continued during this period as the Programme sought to
understand vector dynamics in areas targeted for vector control.
Surveillance
Of the 379 confirmed cases recorded, 333 (88%) of cases were reported through the Immediate
Disease Notification System (IDNS), 25 cases presented to the NMCP or were found through routine
health facility visits, 10 were found through the quality assurance program and 11 cases were
identified during case detection. Of the 379confirmed cases for this period, a total of 323 (85%)
cases were investigated. Of the cases investigated,84 (26%) cases were classified as local, 210 (65%)
were classified as imported, and 29 (8%) was not able to be determined.Of the 75cases which were
classified as local and had not travelled to any high risk areas within the country,25% emanated from
just 5localities including Mafucula, MaphobeniNkwene, Khuphuka, and Nkambeni. Reactive case
detection was conducted around115 index cases. A total of 2148people were screened during
reactive case detection yielding a total of 22 RDT positive cases and 45 LAMP positive cases.
Information, Education and Communication (IEC)
Mass media messages were developed and released via television, radio, and newspaper mediums
in the country educating the population on the signs and symptoms of malaria and promoting
treatment seeking behaviour and personal protection. Although Global Fund-supported trainings for
community mobilization could not be carried out due to delayed approval, the NMCP partnered with
other organizations to carry out trainings with farm workers, construction company workers, and
rural health motivators.
Priorities for 2013-14
Priorities for 2012-14 include government’s absorption of necessary staff positions currently funded
by the Global Fund, improved training for healthcare workers with emphasis on confirmed diagnosis
and reporting of malaria, expansion of vector surveillance activities in areas where local transmission
is reported, continued promotion of LLIN usage in the malaria at-risk region, increased coverage of
reactive case detection activities in at-risk areas by the NMCP surveillance team, timely return visits
to households where LAMP positives are found to treat asymptomatic infections, and continued
education on the utilization of personal protection measures, especially among travellers.
8
1. Introduction
The National Malaria Control Programme’s (NMCP) 2012-2013 Annual Report refers to the period
between July 2012 and June 2013 and reflects progress made in the implementation of the 2008-
2015Malaria Elimination Strategic Plan. It focuses on the four major intervention areas of
Swaziland’s elimination campaign: Case Management, Vector Control, Surveillance, and Information,
Education, and Communication (IEC). The majority of these activities have been led and executed by
the NMCP in conjunction with various implementing partners. This report includes data collected to
monitor the NMCP’s performance and the country’s progress toward elimination, including the
Global Fund Round 8 Performance Framework indicators. Based on remaining gaps, priorities for
2013-2014 have been included at the end of the report.
9
2. Malaria Epidemiology in Swaziland
In Swaziland, malaria transmission is most prevalent along the eastern border, particularly in the
Lubombo region. It is estimated that 30% of the population, or approximately 285,972 people live in
malaria at-risk areas. Transmission occurs primarily in the rainy season between November and May,
with a peak in February and March, and occurs mainly in the lowveld region of the country. Malaria
transmission is unstable and closely related to the level of rainfall and imported cases, which varies
considerably each year.Plasmodium falciparum is responsible for over 99% of malaria cases in
Swaziland. The main malaria vector in Swaziland is Anopheles arabiensis.
New strategies related to Swaziland’s malaria elimination campaign have changed the understanding
of malaria epidemiology in the country. Previous estimations of malaria incidence in Swaziland were
based on suspected cases reported in aggregate by health facilities on a monthly basis. In February
2010, rapid diagnostic tests (RDTs) were introduced at health facilities throughout the country,
allowing for definitive diagnosis of malaria through parasitological confirmation. Additionally in
August 2010, the country implemented a national immediate disease notification system for 15
notifiable diseases or conditions, of which confirmed malaria is included. Improved utilization of
diagnostic tools and reporting mechanisms has greatly reduced estimates of the country’s malaria
burden and provided a more clear understanding of the country’s malaria epidemiology.
2.1 Malaria Morbidity
In 2012-2013,738 cases were reported to the Ministry of Health’s Health Management Information
System (HMIS) from inpatient and outpatient departments at health facilities in the country.12 This is
a significant decrease in reported cases compared to 2008-09 (7507 cases), 2009-10 (3622 cases)3,
and2010-11 (1181 cases), and a slight increase compared to 2011-12 (643 cases). The monthly HMIS
system does not differentiate between confirmed and presumptively treated malaria cases, although
the parallel HMIS system and the immediate disease notification system (IDNS) allows for
comparison to determine case confirmation rate. The impact of increased availability of diagnostic
tools and enhanced case reporting methods is exhibited in the decrease in reported malaria cases, as
shown in Figure 2.1.
1 A total of 811 cases were reported to the HMIS during this period. 73 were removed from the official count
due to suspected data entry error (facilities report a high number of cases in low season after reporting none
at all for consecutive months). 2 A total of 647 cases were originally reported in the Global Fund Progress Update for Period 7 (July to
December 2012) and Period 8 (January to June 2013). These numbers were preliminary and have been
updated following completed data entry. 3 HMIS figures represent recent extraction from HMIS database in October 2011. In the NMCP’s 2009-2010
annual report, HMIS cases for 2008-2009 and 2009-2010 were reported as 6596 and 3470, respectively. This
discrepancy compared to the updated data reported here highlights larger systems issues.
10
Figure 2.1 Malaria Cases (Confirmed and Presumed) Reported to HMISby Region
During 2012-13, health facilities in the Manzini region reported the most cases to HMIS with 238,
followed by Lubombo reporting 211, Hhohhoreporting 186, and Shiselweni reporting 103. There was
an uptick in reported cases in January, primarily imported cases returning from travel to high
endemic areas during the festive season. Malaria cases reported by month and region for 2012-13
are exhibited in Figure 2.2 below.
Figure 2.2Malaria Cases (Confirmed and Presumed) Reported to HMIS by Month/Region, 2012-13
The NCMP utilizes the immediate disease notification system to track and investigate confirmed
malaria cases reported. Of the 379 confirmed cases recorded betweenJuly 2011 and June 2012, as
shown in Figure 2.3,333 (88%) of cases were reported through the Immediate Disease Notification
System (IDNS), 25 cases presented to the NMCP or were found routine health facility visits, 10 were
found through the quality assurance program and 11 cases were identified during case detection.
For laboratory-confirmed malaria cases seen in health facilities, the intended target for Year 4 of the
Global Fund-Round 8 grant was 1caseper 1000 population at risk. The country
achieved1.33laboratory-confirmed cases per 1000 population at-risk.
0
2000
4000
6000
8000
2008-09 2009-10 2010-11 2011-12 2012-13
Cases Reported to HMIS by Region
2008-09 to 2012-13
SHISELWENI
MANZINI
LUBOMBO
HHOHHO
0
10
20
30
40
50
60
July
Au
gu
st
Se
pte
mb
er
Oct
ob
er
No
vem
be
r
De
cem
be
r
Jan
ua
ry
Fe
bru
ary
Ma
rch
Ap
ril
Ma
y
Jun
e
2012-13
HHOHHO
LUBOMBO
MANZINI
SHISELWENI
11
Figure 2.3 Confirmed Malaria Cases Reported, 2012-13
Of the 323cases investigated via the NMCP’s active surveillance programme during 2012-13, 84cases
were determined to be locally transmitted. Case mapping indicates that most local cases occur in the
middleveld and lowveld ecological zones toward the eastern part of the country near the
Mozambique border (see Local Case Map in Figure 2.4). A total of 210 cases were determined to be
imported from outside of Swaziland, of which 195 were determined to originate from Mozambique.
A total of 29were investigated and were unable to be classified.
Figure 2.4.Incidence byInkhundla for All Confirmed Cases (Left) and Local Cases (Right), 2012-13
0
20
40
60
80
100
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May June
Confirmed Malaria Cases by Month, 2012-13 (n=379)
12
2.2 Malaria Mortality
HMIS recorded 4 malaria deaths from health facilities in the country during the period July 2012
June 2013. Ofthe 2 deaths that were timely reported and could be investigated, 2 were confirmed as
malaria deaths. The deaths were the result of late treatment seeking behaviour by the patient and
delayed suspicion of malaria at the health facility leading to delayed treatment. For laboratory
confirmed malaria deaths seen in health facilities, the intended target for Year 4 of the Global Fund-
Round 8 grant was 0.25 deaths per 1000 cases. The country recorded.007 deaths per 1000
population at-risk, achieving this target.
13
3. Programme Management
3.1 Human Resources
Staff Changes
In the year under review, the National Malaria ControlProgramme lost 3 technical team members
who resigned. The GIS Analyst and Foci Investigator resigned to pursue further education, while the
Information Education Communication (IEC) officer resigned to pursue new opportunities
Following the departure of these officers, the programme recruited and appointed new officers to
the vacant positions. A surveillance agent was recruited and appointed to the vacant Foci
Investigator/Entomologist position, while two candidates were recruited and appointedto the GIS
Analyst and IEC positions. All these positions report to the Programme Manager.Furthermore, two
surveillance agent positions that became vacant when an officer resigned and the other was
appointed Foci Investigator were filled during this period. Recruitment to fill these surveillance
positions will be conducted prior to the 2013-2014 surveillance team training.
3.2 Programme Review
Malaria Programme Review
The NMCP with support from the World Health Organization (WHO) conducted the Annual Malaria
Programme Review from the 3rd to 5th of April 2013 where the objectives of this meeting were to
present, review and revise the 2011-2012 annual and programmatic report, finalize, complete and
adopt the 2008-2015 Revised Malaria Strategic Plan as well as draft the malaria M&E Plan to align
with the this plan. The Programme managed to complete the annual report as well as the revised
2008 – 2015 Strategic Plan. Working in close collaboration the Programme is yet to complete the
M&E Plan and plan of action.
3.3 Programme Meetings
Quarterly Meetings
To ensure effective implementation of planned activities under the Global Fund grant, quarterly
implementation meetings were held with all implementing partners and the country’s Global Fund
Principal Recipient. The purpose of these meetings was to review progress made in implementation
of planned activities, identify bottlenecks and solutions to implementation challenges; review and
update work plans for the upcoming quarter. Implementing partners held 2 quarterly implementers
meeting during the period under review, on July 18th, 2012,and on May 31st, 2013.
Meetings of Swaziland Malaria Elimination Advisory Group (SMEAG)
Terms of reference for the SMEAG outlines that the general committee should meettwice annually
to review progress toward implementation of the national elimination strategic plan and elimination
policy guidelines. SMEAG subcommittees(Case Management, Vector Control, Surveillance and
Epidemic Preparedness and Response, and Health Promotion) are to meet as necessary to review
strategies to improve service delivery and overall impact of interventions.
14
SMEAG General Committee
During the year under review, the SMEAG General Committee did not meet during the year under
review due to Global Fund restrictions on expenditures related to trainings and workshops. SMEAG
Subcommittees by Thematic Area
For the period under review the following SMEAG subcommittee meetings were held in January
2013:
The Case Management SMEAG Subcommittee reviewed and revised the Diagnosis and
Treatment Guidelinesand agreed to include artesunate as the first line treatment for severe
malaria. The subcommittee also discussed the use of primaquine as supplemental treatment
for malaria to reduce transmission. The subcommittee advocated for further study on the
safety of low-dose primaquine for elimination as well as an evaluation ofthe prevalence of
glucose 6 phosphate dehydrogenase (G6PD) deficiency in Swaziland.
The Vector Control SMEAG Subcommittee met to discuss the use of DDT and consideration
for alternative insecticides due to their future limited as prohibited under the Stockholm
Convention. The subcommittee also discussed the timing and geographical targeting
oflarviciding andcommunication strategiesto sensitize communities to the use of larvicides.
The Surveillance and Epidemic Preparedness and Response SMEAG Subcommittee received
preliminary results from reactive active case detection operational research study. The
subcommittee discussed strategies for increasing screening coverage during reactive case
detection, including reducing the radius for screening around an index case from 1 km to
500 meters.
The Health Promotion SMEAG Subcommittee to review the 2012 KAP survey results. The
subcommittee discussed strategies for improving LLIN utilization in at-risk areas and
personal protection among travelers.
Meetings and Workshops Attended
Nationally
During the year under review, Programme staff participated in numerous meetings and workshops
organized within the Ministry of Health and partners. The NMCP Programme Manager and technical
officers also served in a number of technical committees in the Ministry of Health and other
government departments.
Regionally
The NMCP Programme Manager met with regional constituencies as leader of the Southern African
Development Community (SADC) Malaria Sub-committee and member of the Southern African Roll
Back Malaria Network (SARN).
The NMCP Grant Manager and Information Technology - Database Manager attended the
Harmonization Working Group (HWG) Gap Analysis workshopfrom February 13th-15th, 2013, in
Nairobi, Kenya. The workshop’s objectives weretocomplete countries’ 2013-2016 comprehensive
programmatic gap analyses, synthesize country gap information into global demand for investment;
and share information from donors on current and future funding opportunities (including the
Global Fund’s new funding modality).
15
Globally
The NMCP Molecular Technologist attended aworkshop on the LAMP diagnostic methodhosted by
the Foundation for Innovative New Diagnostics (FIND)from June 19th-20th, 2013,in St. Ives, England.
Workshopparticipants reviewedcurrent protocols for sample preparation and workflow for the high
throughput LAMP Assay.
The Surveillance Supervisor attended an Advanced International Training Course on Malaria
Surveillance, Monitoring and Evaluation in Moscow Russian Federation from the June 5th-26th, 2013.
3.4 Financial Management
The National Malaria Control Programme has two major sources of funding to support
implementation of the National Malaria Elimination Strategy: (1) the Government of Swaziland and
(2) the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria.
Government of Swaziland – Budget and Expenditure
The Government of Swaziland provided a budget of SZL 6,856,953.00 to support the implementation
of malaria activities in 2012-13. Budget line items supported by the Government include funding for
transportation and vehicle maintenance, some employee salaries and allowances, communication,
drugs and other medical supplies, professional services and consumable supplies, insecticides.
Personnel costs accounted for 70% of expenditure; over expenditure under this budget area
occurred because salaries for seasonal spray operators are not accounted for in the budget as these
positions are not inthe government establishment register, but their payment is accounted for in
actual expenditure. Over expenditure was recorded for the procurement of insecticides due to the
rising costs ofDDT and Icon 10cs. Under expenditure was reported for CTA vehicles charges due to
the low number of vehicles receiving maintenance from CTA during this period.
Table 3.1 Government Budget and Expenditure for NMCP, 2012-13
Control Item Estimated
(SZL)
Released
(SZL)
Actual
(SZL)
Variance
(against budget)
CTA Vehicle Charges 1,083,687.00 1,083,687.00 451,925.00 631,762.00
Personnel Costs 4,184,434.00 4,213,434.00 4,691,403.84 -506,969.84
Communication 93,366.00 93,366.00 41,321.63 52,044.37
Drugs and Medical Supplies 248,976.00 248,976.00 129,719.40 119,256.60
Professional/ Contract Services 25,935.00 40,935.00 24,733.18 1,201.82
Materials and Supplies 62,243.00 62,243.00 36,320.57 25,922.43
Office Furniture and Fittings 39,900.00 39,900.00 28,956.00 10,944.00
Utilities (Water and Electricity) 11,411.00 36,411.00 14,447.31 -3,036.31
Seed, Feed, Fertilizer and
Chemicals (insecticides)
591,318.00 891,318.00 908,935.09 -317,617.09
Protective Clothing 25,935.00 125,935.00 99,542.60 -73,607.60
Construction Material 20,748.00 20,748.00 0.00 20,748.00
TOTAL 6,387,953.00 6,856,953.00 6,427,304.62 -39,351.62
Global Fund Round 8 Malaria Grant – Budget and Expenditure
The Global Fund Round 8 Malaria Grant complements domestic resources to strengthen key malaria
interventions as outlined in the National Malaria Elimination Strategic Plan. In 2012-13, the fourth
year of the five-year grant, implementing partners revised key activities and the related budget
items to ensure maximum impact of intervention under the grant. Expenditure under the grant and
implementation of a number of activities has improved during this perioddue to the approval of the
16
Revised Training Plan which constitutes a considerable share of the grant. Although the planned
construction of the insectary building for vector management was suspended, the programme is
lobbying the Global Fund to approve activity as all paperwork required is in order. Financial
expenditure of the Year 4 grant disbursement is shown in Table 3.2.
Table 3.2 Year 3 Financial absorption of GF Round 8 – Malaria Grant
Activity Budget Expenditure Variance
Burn Rate (SZL) (SZL) (SZL)
Case Management 2 865 495.67 987 091.83 1 878 403.84 34.45%
Vector Control 5 061 346.08 4 826 445.20 234 900.88 95.36%
Surveillance 2 949 032.20 2 046 091.38 902 940.82 69.38%
IEC 1 517 124.56 670 744.61 846 379.95 44.21%
Grant Management 1 167 367.50 941 033.51 226 333.99 80.61%
TOTAL 13 560 366.01 9 471 406.53 4 088 959.48 69.85%
3.4 Interim Application
The Global Fund has designed a new funding model (NFM) to enable strategic investment and
maximum impact. The full implementation of this NFM will begin late 2013 once the level of
available funding for the 2014-2016 cycle is established; therefore the Global Fund is prepared to
provide additional funding to applicants throughout this transition period. Activities related to
malaria in Swaziland are eligible for $300,000 under the new funding model’s transition phase for
interim applications. As Swaziland’s Round 8 Malaria Grant (SWZ-809-G06-M) is not eligible for
renewal and re-programming toward a specific once-off activity is not viewed as critical, this interim
application serves as an extension of the essential services of the current grant.
The NMCP supported by the Clinton Health Access Initiative drafted and submitted on the 21st
August 2013 an application on the extension of essential personnel and purchase of necessary
consumable diagnostic commodities through December 2014.
17
4. Case Management
Case management is a critical component of the Swaziland’s malaria elimination campaign. Prompt
and accurate diagnosis leads to effective treatment, which in turn eliminates the parasite from
malaria patients and prevents forward transmission within the communities. This section covers
aspects that relate to the case management of malaria cases within the country’s health system for
the period July 2012 to June 2013.
4.1 Capacity Building of Healthcare Workers
Trainings for healthcare workers on malaria case management are funded in partnership with the
Global Fund and the government of Swaziland. However, trainings were suspended in November
2011 across all of Swaziland grants due to potential misappropriation of funds. Trainings were again
permitted in October 2012 following conditions met regarding financial cash management systems
by the Principal Recipient. Trainings for nurses and pharmacists that were scheduled to be carried
out between July and December 2012 were cancelled due the timing of this decision and the lack of
time available time required to plan and implement these trainings. Therefore, the Programme only
managed to train doctors during this period in May 2013. A total of 23 doctors were trained.
Doctor’s training focused on discussions of major issues in case management of malaria at health
facilities and potential changes to the country’s diagnosis and treatment guidelines to align with
WHO recommendations.
4.2 Diagnosis
Confirmation of every single malaria case by a parasitological test becomes very critical as Swaziland
progresses towards elimination. For this period, a total of 738 malaria cases were reported to HMIS,
of which only 379 were confirmed by RDT and/ or microscopy.As the country progresses towards
elimination, the malaria confirmation rate, a measurement of the number of cases confirmed using a
parasitilogical test out of all cases treated as malaria, becomes an important indicator to measure
the uptake of new diagnosis and treatment protocols. During the period under review, 379 of the
738 malaria cases for this period were confirmed by RDT and/or microscopy, a confirmation rate of
51%. This represents a decrease from 2011-12, when 57% of all malaria cases were confirmed by a
parasitilogical diagnostic test. Since the introduction of RDTs at all health facilities in February 2010,
there has been an increasing trend in case confirmation, when from 1% in 2008-09 to 51% in 2012-
13, as shown in Figure 4.1
Figure 4.1 Confirmed and Unconfirmed Malaria Cases and Confirmation Rate, 2008-2013
0%
10%
20%
30%
40%
50%
60%
0
1000
2000
3000
4000
5000
6000
7000
8000
2008-09 2009-10 2010-11 2011-12 2012-13
Co
nfirm
atio
n R
ateM
ala
ria
Ca
ses
Confirmation of malaria cases pre- and post-RDT roll-out, 2008-09 to 2012-13
Unconfirmed cases Confirmed cases Confirmation rate
18
For this reporting period, the surveillance team investigated 323 cases and out of the 379 confirmed
cases. Of these cases, 3 were confirmed using microscopy only, 267 (82%) by RDT and 53 (16%) were
confirmed using both diagnostic tools, as illustrated by Figure 4.2.
Figure 4.2 Diagnosis Tool Used among Investigated Cases (n=323), 2012-13
Diagnosis Quality Assurance Program
The diagnosis quality assurance program which was launched in February 2010 when RDTs were
rolled out is still ongoing in health facilities in the Lubombo region. The Program sent all quality
assurance samples (DBS and RDTs) to the Medical Research Council (MRC) for a DNA PCR analysis
until September 2012. After which in country capacity to run a molecular laboratory for malaria was
established in January 2013. During the period under review, a total of 40 samples were sent to
MRC for DNA PCR analysis, the remaining samples are currently waiting processing at the national
laboratory. The introduction of DBS collection during case detection increased the number of
samples for analysis which resulted in a backlog of samples. From 40 samples, 8 were RDT positive
(health facility) and of these, 5 were true positive by DNA PCR. Three (3) were false positive by DNA
PCR and 32 of the samples were true negative.There were 48 false positive malaria cases4, though
RDTs passed WHO Lot testing.
Drug Resistance Testing
Drug resistance testing was conducted on all PCR positive samples. Samples were tested for SP
Sulfadoxine-pyrimethamine (SP)/Fansidar resistance and sensitivity to Lumefantrine. Of the 5 PCR
positive samples, 3 carried SP resistance markers, while all the 5 were sensitive to Lumefantrine.
These results indicate that Artemether-Lumefantrine remains the most efficacious first-line drug for
treating uncomplicated malaria in Swaziland.
4.3 Treatment
Artmether-lumefantrine (AL), an artemisinin-based combination therapy, (ACT), continues to be the
recommended first-line treatment for uncomplicated malaria cases in Swaziland.Intravenous and
intramuscular quinine is the first-line treatment for severe malaria cases. During this period, the
NMCP successfully lobbied to include a treatment field on the IDNS tool, which is expected to roll-
out to all health facilities by September 2013. This will facilitate the collection of treatment data on
all confirmed malaria cases.For this period,treatment information on malaria cases is only available
on cases investigated by the NMCP surveillance team.
4 A false positive malaria case is RDT positive and slide negative
267
3 53
RDT
Microscopy
RDT and Microscopy
19
For the period 2012-2013, out of the 323 investigated cases, 261malaria cases received AL for
treatment, 32 cases received quinine,28 cases were treated with both AL and quinine, and 2 cases
were treated with a different treatment regimen (likely chloroquine or sulfadoxine-pyrimethamine),
as shown in Figure 4.3.
Figure 4.3 Treatment Type among Investigated Cases (n=323), 2012-13
Malaria Chemoprophylaxis
The country recommends the use of chemoprophylaxis by people travelling to malaria endemic
areas outside the country. The knowledge, attitudes and practices (KAP) Survey which is conducted
at the end of the peak season for malaria to inform the NMCP on the use of chemoprophylaxis for
personal protection was not conducted this period under review. Health facilities currently do not
report on chemoprophylaxis distribution to the Central Medical Stores or the National Malaria
Control Programme; therefore, it is difficult to quantify its use in the population.During this period,
the country did experience a shortage of chemoprophylaxis, although this may have been limited to
high volume facilities that see a large number of travellers. For this reporting period, the Central
Medical Stores distributed1328 packets of mefloquineto selected facilities in the country, indicating
the drug’s ongoing consumption.
4.4. Policy Changes
During the period under review, the Swaziland Malaria Elimination Advisory Group – Case
Management Subcommittee met to review the diagnosis and treatment guidelines. Subcommittee
recommendations were reviewed at the Doctor’s training in May 2013. New policy changes include
the adoption of intravenous (IV) and intramuscular (IM)artesunate as the first line treatment for
severe malaria, in alignment with WHO recommendations. IV and IM artesunate will be procured
and distributed to all health centres and hospitals once the country has consumed all non-expired IV
and IM quinine in stock.Also, low-dose primaquine, a gametocidal drug to be administered in
addition to recommended treatment regimens for uncomplicated malaria according to new WHO
case management guidelines, was approved for research purposes to ensure safety prior to national
distribution and use.
4.5 Performance under Global Fund Grant
There are two indicators in the Global Fund grant’s performance framework to measure progress on
the implementation of case management interventions. For the indicator measuring the number of
malaria cases confirmed by RDT and/or microscopy, progress has stalled from 2011-12 to 2012-13,
with decrease in the confirmation rate from 57% to 51%. The Programme also fell short of the
261
32
282
Artemether-lemfantrine (AL)
Quinine
AL+Quinine
Other
20
intended target of 100% for this period. For the percentage of confirmed uncomplicated malaria
cases treated with ACTs, the Programme achieved the target of 95%, recording 99% of all
uncomplicated cases receiving treatment with an ACT. This was a small improvement from 2011-12
when 96% of uncomplicated cases were treated with an ACT, as shown in Table 4.1.
Table 4.1 Performance for Global Fund Indicators for Case Management
Indicator 2011-12
Actual
2012-13
Target
2012-2013
Actual
% of malaria cases confirmed by RDT and/or
microscopy
57% 100% 51%
% of all RDT and/or microscopy diagnosed
uncomplicated malaria cases treated with
ACTs
96% 95% 99%
21
5. Vector Management
The principal objective of vector management is to decrease malaria morbidity and mortality by
suppressing vector activity and interrupting malaria transmission. The Programme utilizes the WHO-
recommended Integrated Vector Management (IVM) strategy, a systematic approach to controlling
vector-borne diseases wherein all control measures are incorporated and the local health
infrastructure and resources are taken into account. The key interventions of IVM in Swaziland
include utilization of indoor residual spraying (IRS),long lasting insecticide-treated nets (LLINs), and
larvaciding at potential vector breeding sites. In line with country’s Malaria Elimination Strategic
Plan2008-2015, the Programme targetsuniversal coverage of vector control interventions among all
households in the malaria at-risk region through a combined campaign of IRS and distribution of
LLINs.
5.1 Indoor Residual Spraying (IRS)
Preparation and Planning
In preparation for the 2012-13 indoor residual spraying operation, 34 seasonal spray operators were
recruited in October 2012 for a 6 month period. Recruitment occurred three months later than
planned due to delayed authorization from the civil service commission. An additional 12 vector
control staff members were employed under the Global Fund grant to support IRS operations. All 46
seasonal staffa 2 week training workshop on implementation of the country’s IVM strategy,
including the safe and effective application of insecticides, compliance with conventions governing
the use of insecticides, and promotion of the utilization of LLINs in communities that have previously
received bed nets.
An analysis of existing surveillance case data was conducted to inform the location and timing of IRS
operations.Selection of localities to receive IRS in 2012-13 was based on location of locally
transmitted cases during2011-12 malaria transmission season. The list of localities to be sprayed was
shared with the Programme’shealth promotion unit to ensure that communities were aware and
acceptingof indoor residual spraying prior to their deployment.
IRS Coverage
During the 2012-13 transmission season, a total of 54,005of 59,497 household structureswere
sprayed in the targeted areas, achieving coverage of 90%. The number of structures sprayed in 2012-
13 was much lower compared to 2010-11 and 2011-12 when 101,030and 73,217 structures were
sprayed, respectively. The decrease in structures sprayed was the result of delayed delivery of
insecticides.The number of households sprayed by locality is listed in Table 5.1 below.
Under the integrated vector management policy, all traditional structures made of mud are sprayed
with DDT 75% WP and all modern structures made of cement or other materials are sprayed with
the pyrethroid lambda-cyhalothrin (ICON). During this malaria season, 38,748structures were
sprayed with DDT and 15,257 structures sprayed with ICON.
22
Table 5.1 Structures Sprayed by Locality in 2012-13
Locality Structures Sprayed Total Structures Coverage
Emasini 644 732 87.98%
Game 5 116 122 95.08%
Gamula 473 514 92.02%
Hlane 1878 2006 93.62%
Ka-Mngometulu 145 165 87.88%
Ka-Shoba 2243 2603 86.17%
Lomahasha 6112 6816 89.67%
Lubhuku 1237 1431 86.44%
Lukhetseni 1227 1404 87.39%
Lukhula 9 12 75.00%
Mafucula 2888 3051 94.66%
Mahlabaneni 422 432 97.69%
Malibeni 2207 2353 93.80%
Mambane 2183 2541 85.91%
Mandlenya 106 122 86.89%
Manzana 1895 2067 91.68%
Maphilongo 619 727 85.14%
Maphiveni 416 453 91.83%
Maphungwane 3094 3433 90.13%
Mchele 73 71 102.82%
Mhlume 4 9 44.44%
Mhlumeni 704 733 96.04%
Mlawula 250 254 98.43%
Mndobandoba 635 694 91.50%
Mnjoli 836 916 91.27%
Mpaka 40 40 100.00%
Mpolonjeni 1171 1347 86.93%
Ndzangu 1410 1623 86.88%
Ndzevane 71 79 89.87%
Ngcamphalala 2425 2705 89.65%
Ngcina 1362 1592 85.55%
Ntfonjeni 1232 1330 92.63%
Nyakatfo 3184 3390 93.92%
Shewula 5354 5788 92.50%
Shoka 98 104 94.23%
Sidvwashini 676 717 94.28%
Sinceni 19 21 90.48%
Siphofaneni 729 860 84.77%
Sitsatsaweni 1206 1282 94.07%
Tikhuba 1769 1949 90.76%
Tsambokhulu 200 213 93.90%
Tshaneni 18 22 81.82%
Unknown 45 45 100.00%
Vuvulane 1432 1510 94.83%
Zandondo 1148 1219 94.18%
Total 54005 59497 90.77%
23
5.2 Long Lasting Insecticide-Treated Nets (LLINs)
No LLINs were distributed in 2012-13 in accordance with the National Strategic Plan and work plan.
Distribution was previously carried out in 2009-10, 2010-11, and 2011-12 to reach targeted
coverage. Since the inception the strategy to achieve universal coverage of LLINs in malaria at-risk
areas of Swaziland, total of 154,218 LLINs have been distributed, covering 208,443 persons in the
malaria at-risk region. A total of 91,175 LLINs were ordered for distribution in 2013-14 to cover
newly identified risk areas and areas that may require replacement LLINs after 3 years of use.
5.3 Vector Surveillance
Vector surveillance was routinely carried out in at-risk areas and at times, in response to suspected
local transmission in certain localities. Wild samplescollected from the field were morphologically
identified, preserved, and tested by PCR. Further analysis was made in respect of knock down
resistance sensitivity, and other variables. However, expiration of WHO test kits and delayed
construction of the insectory limited other capacity for other analyes including bio-assays and
susceptibility tests.
Pyrethrum spray catches were carried out 13 at risk localities in 2012. A total of 1335 An. Gambiaes.l
samples were collected; samples from Macocweni, Manyovu and Manyonyaneni were raised from
larvae to F1. All test results were negative, as shown in Table 5.2.
Table 5.2.Presence of the P.falciparumin adult An. gambiaes.lmosquitoes, by Locality (2012)
These 1335 samples were tested by PCR for genetic mutations (kdr and ace-1R)that confer resistance
to insecticides, including pyrethroids and DDT. All samples were positive for both genotypes, as
shown in Table 5.3. Although no resistance tests were carried out, these results indicate a need to
continually monitor vector susceptibility to deployed insecticides and the exploration of alternative
insecticides, if necessary.
Locality No tested Plasmodium falciparum detection
(Negative)
Dvokolwako 1 1
Luvatsi 7 7
Macocweni 168 168
Mahlabaneni 2 2
Malayini 1 1
Manyovu 952 952
Manyonyaneni 161 161
Mabhensane 3 3
Meleti 1 1
Manzana 1 1
Ndlalambi 4 4
Ntsatsama 12 12
Phumlamcansi 22 22
24
Table 5.3.Genotypes (kdr and ace-1R) of adult An. gambiaes.lmosquitoes, by Locality(2012)
Larval Control
Larval collections were continuously made the 1st week of each month from November 2012 to
March 2013 from previously reported selected sites to determine vector species, distribution, and
larval density. Collected larvae were raised to F1 adults, fed, morphologically identified and
preserved in Iso propanol in eppendorf tubes and preserved for PCR analysis so as to inform planned
interventions.
Mosquito Window Traps
Sentinel sites for window traps remain at Mhlumeni, Mngometulu, Maphungwane, Malindza,
Mabhesane and Masini. No surveillance was carried out during this period due to lack of
procurement of new window traps. Procurement has been halted due to procedural issues at the
Principal Recipient, hindering surveillance of vector dynamics.
5.4 Policy Changes
Swaziland is a participant in theUnited Nations Environmental Programme (UNEP)projectto
implementan inter country DDT regulatory framework to monitor the use of Organic Pollutant
Pesticides, with particular emphasis on DDT. Under this project, the University of Swaziland is tasked
with looking at the alternatives on the use of DDT and the feasibility and/or efficacy of larviciding as
a vector control strategy in the country.
5.5 Performance under Global Fund Grant
Vector control indicators under the Global Fund grant’s performance framework are focused on LLIN
distribution and ownership, specifically the total number of LLINs distributed and the number of
households in at-risk areas reporting LLIN ownership through the annual KAP survey. As no LLINs
were distributed, there was no reporting on these indicators during the period under review.
Locality No
tested kdr genotype ace-1R genotype
S/SEast S/SWest S/S
Dvokolwako 1 1 1 1
Luvatsi 7 7 7 7
Macocweni 168 168 168 168
Mahlabaneni 2 2 2 2
Malayini 1 1 1 1
Manyovu 952 952 952 952
Manyonyaneni 161 161 161 161
Mabhensane 3 3 3 3
Meleti 1 1 1 1
Manzana 1 1 1 1
Ndlalambi 4 4 4 4
Ntsatsama 12 12 12 12
Phumlamcansi 22 22 22 22
25
6. Surveillance
Malaria elimination requires robust passive and active surveillance systems that are able to capture
information about each and every case. Passive surveillance refers to cases systematically identified
and reported at health facilities. Active surveillance refers to the system of proactively investigating
passively identified cases and searching for and identifying new cases.
National guidelines require the confirmation of all malaria cases at health facility level by RDT and/or
microscopy. All confirmed malaria cases are to be reported using the immediate disease notification
system tool (977) which is available at all health facilities. This system allows the health care worker
to capture key details about the patient that assists in patient follow-up. Once a case has been
notified through the passive surveillance system, the NMCP surveillance team contacts the patient
and attempts to conduct a case investigation within 48 hours, of which the primary purpose is to
determine whether that case was imported or locally transmitted.
In addition to case investigation, the NMCP surveillance team carries out case detection, a process in
which malaria infections are identified within the communities through screening using RDTs. There
are two types of case detection: 1) Proactive case detection (PACD), triggered by strong suspicion of
malaria transmission within a defined detection area or population and 2) Reactive case detection
(RACD), triggered by the identification of a confirmed malaria case at a health facility and conducted
within 1 km of the confirmed cases’ household.
To explore ways to improve reactive case detection in the identification of asymptomatic infections
with the community, the NMCP partnered with the University of California, San Francisco, the
Clinton Health Access Initiative, and the Foundation for Innovative New Diagnostics (FIND),on an
operational research project using of loop mediated isothermal amplification (LAMP), a molecular
diagnostic method similar to PCR, to determine if more sensitive diagnostic methods are required to
identify asymptomatic cases with low parasitemia.DBS cards are now collected during RACD,
transported to the National Reference Laboratory, and tested using LAMP. In addition to using
LAMP, surveys administered for case investigation and case detection have been expanded to better
understand risk factors associated with infection.
The data captured from the passive and active surveillance systems and the implications of that data
are presented below.
6.1 Passive Surveillance
In 2012-13, a total of 379 confirmed cases were recorded by the NMCP. Of the 379 confirmed cases
were identified, 333 (88%) of cases were reported through the Immediate Disease Notification
System (IDNS), 25 cases presented to the NMCP or were found routine health facility visits, 10 were
found through the quality assurance program and 11 cases were identified during case detection.
Compared to 2011-12 when 369 confirmed cases were recorded, there was a slight increase in the
number of recorded cases.
The highest number of confirmed cases was recorded in January (95), often associated with the high
travel period of the festive season. The following months of February through May saw a consistent
and high number of cases recorded (average cases: 41.5 per month), as shown in Figure 6.1; this
time period is associated the country’s high transmission season due to the hot and wet climate.
26
Figure 6.1. Confirmed Cases by Month, 2012-13
6.2 Active Case Investigation
Active Case Investigation
Of the 379 confirmed cases, 323 (85%) cases were investigated. Of the investigated cases, 204 (63%)
were investigated within 7 days of notification while 91 (28%) cases were investigated within 48
hours of notification. The proportion of cases investigated is shown by month in Figure 6.1. Reasons
for cases not being investigated include patients returning to their country of origin, incorrect or
incomplete contact information and non-reporting of cases.
Figure 6.2.Case Investigation by Month, 2012-13
1320
14 1125
17
95
44 42 4436
19
0
10
20
30
40
50
60
70
80
90
100
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
Confirmed Cases 2012-2013 by Month (n=379)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
10
20
30
40
50
60
70
80
90
100
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May June
Case Investigation, 2012-13 (n=379)
Investigated Not Investigated Case Investigation Rate
27
Demographics
A total of 229 investigated cases (71%) identified as Swazis, 85 cases as Mozambicans (26%), and 9
cases (2%) were of other nationalities(e.g., South African, Zimbabwean, Malawian). Of the cases
investigated, 235 cases (73%) were males and 92 (29%) were under the age of 18. Two (2) of
investigated cases (0.01%) were pregnant women and were considered a vulnerable population.
Case Classification
During case investigation, surveillance agents collect detailed travel history from malaria cases. The
agent then weighs variables like time between travel and presentation of symptoms to determine
the origin of the case. During the 2012-13 season, 84 (26%) of the cases were classified as local, of
which 9 cases (2.3%) were intraported from another part of Swaziland. A total of 210 (65%) cases
were classified as imported, and 29 (9%) being undetermined.The proportion of cases classified as
local has steadily declined from 2009-10 to date, which is encouraging for the country’s elimination
prospects.
Figure 6.3. Proportion of Investigated Cases Classified as Local by Season
There was a large increase in the number of cases classified as undetermined during the period
under review. Cases are classified as undetermined when the person does not report travel to an
endemic region and/or does not reside in an area considered receptive.5To better classify these
cases, the duration of travel history collected may need to be expanded; entomological
investigations in areas previously thought to be non-receptive will also be explored. Strengthening of
the country’s diagnosis quality assurance system will also ensure that all cases investigated are true
cases and therefore, survey results from case investigation reflect the situation of those infected
with malaria.
The distribution of confirmed cases by month varied with the month of January seeing the highest
number of imported cases. The increase in imported cases in January is directly related to the
volume of travel to neighboring Mozambique during the festive season. There was a 48% increase in
the number of casesreported in 2012-13during the months of March, April, May and June (127
cases) compared to 2011-12 (66 cases). The increase might be attributed tolocal cases occurring
5 Undetermined cases are often suspected to be false positive, but no slide or DBS is available for secondary
confirmation so these cases are treated as true infections.
69%52%
32%26%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2009-10 2010-11 2011-12 2012-13
Proportion of Investigated Cases Classified as Local by Season
Undetermined
Local
Imported
28
localities that were not well covered by the IRS campaign. Figure 6.4 below depicts the distribution
of cases by classification and month for the period under review.
Figure 6.4. Distribution of Malaria Cases by Classification and Month, 2012-13
Geographical Distribution
Of the 75 cases which were classified as local and had not travelled to any high risk areas within the
country, the highest number of cases in any one locality was 5, which were in theMafucula and
Maphobeni area. Additionally, Nkwene recorded 4 cases, Khuphuka 3 cases, and Nkambeni 3 cases.
Areas like Bhalekane, Game 5, Lomahasha, Mafusini, Makhewu and Maphungwane each saw 2
cases. There was no observed larger cluster of locally transmitted cases made up of multiple
localities. The 9 intraported cases that resided in non-receptive areas reported travel to the
following localities Lubuli, Maloma, Phuzamoya and Tabankhulu.
Figure 6.5. Local Cases by Locality, 2012-13
0
10
20
30
40
50
60
70
80
90
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr
Cases by Classification and Month, 2012-2013 (n=323)
Undetermined
Local
Intraported
Imported
0
1
2
3
4
5
6
Ma
fucu
la
Ma
ph
ob
en
i
Nkw
en
e
Kh
up
hu
ka
Nka
mb
en
i
Bh
ale
kan
e
Ga
me
5
Lom
ah
ash
a
Ma
fusi
ni
Ma
khe
wu
Ma
ph
un
gw
an
e
Mp
aka
Nd
um
a
St
Ph
illi
ps
Zin
ya
ne
Zo
mb
od
ze
Bu
hle
bu
yeza
Bu
sele
ni
Ga
rag
e
Hla
thik
hu
lu
Lom
shiy
o
Lub
uli
Ma
dle
nya
Ma
dza
lan
e
Ma
futs
en
i
Ma
lin
dza
Ma
ng
we
ni
Ma
nzi
ni
Ma
tsa
nje
ni
Ma
yiw
an
e
Md
um
ezu
lu
Mh
lum
e
Mku
zwe
ni
Msh
ing
ish
ing
ini
Ng
culw
ini
Ng
we
mp
isi
Ntf
on
jen
i
Pig
g's
Pe
ak
Sa
nd
len
i
Sh
ew
ula
Sid
vwa
shin
i
Sim
un
ye
Sip
ho
fan
en
iLocal Cases by Locality, 2012-13 (n=84)
29
Of the 210 imported cases, 37 (25%) resided in Manzini. Other localities that included a large
number of imported cases included Logoba (12cases), Mafutseni (8 cases), Matsapha (7 cases), and
Mbabane (6 cases). The household location of local and imported cases is shown in Figure 6.5.
Figure 6.6. Household Locations of Local and Imported Cases, 2012-13
30
Of the 210 cases classified as imported, 199 (95%) reported to have travelled to Mozambique. Of the
cases reported to have visited Mozambique between August 2012 and June 20136 (185 cases), 42.7%
reported travel to Maputo, 38.6% reported travel to Inhambane, and 14.3% reported travel to Gaza
Province.
Figure 6.7. Location Travelled to in Mozambique of Select Imported Cases, 2012-13
Utilization of Prevention Methods among Investigated Cases
Of the local cases who reported no travel outside of their communities, only 17 (23%) reported that
their houses were sprayed during the most recent IRS campaign, with 55 (73%) reporting that their
houses had not been sprayed, and 3 cases were unsure if their home had been sprayed or not. A
total of 27(36%) local cases reportedly owned a LLIN; of the cases that owned a LLIN, only 10(13%)
reportedly slept under the net the night preceding the investigation. The coverage of IRS was higher
among local cases in 2011-12 when 35% of local cases resided in sprayed structures. LLIN ownership
however, was lower in 2011-12 at 24%.
Of the population that travelled to and were infected inendemic areas, be it outside the country or
within the country, only 2 cases reportedly used preventative measures: 1 caseused a LLIN while the
other used chemoprophylaxis.
6 As part of the operational research study, active case investigation tools were changed in August 2012 to
collect a travel history up to 4 weeks and more precise travel locations.
31
6.3 Active Case Detection
Reactive Case Detection
Of the323 cases investigated, 116 cases resided in receptive areas requiring RACD.Of these cases,
RACD was conducted around93 index cases. A total of2148 out of 3350 people identified in these
areas 64.11% were screened, with an average of 23 people screened per RACD event. Of the people
eligible within the 1 km radius around an index case, a total of 1202 people were missed during this
exercise; they were not at home when the surveillance team visited the household. Twenty-two (22)
RDT positives were found during the activity. All RDT positive cases were referred to the nearest
health facility for treatment.
As part of a larger operational research study, DBS cards were collected on all consenting individuals
regularly screened during NMCP RACD operations. These DBS cards were sent to the National
Reference Laboratory and testing use the LAMP method. Of the 2148 tested during RACD, a DBS was
collected on 2110 individuals and tested by LAMP. There were a total of 45 LAMP positives for this
period; all werep. falciparum. Of the 22 RDT positives from RACD, 17 were true positive by LAMP. All
LAMP results from this operational research project will be cross-checked by individual PCR at a
partner laboratory outside of Swaziland.
Table 6.1Location of RDT Positive and LAMP Positive Cases Found through RACD, 2012-13
Locality Number of LAMP Positives
Game 5 4
Gangakhulu 1
Herefords 1
Khuphuka 1
Mafucula 4
Mafusini 3
Makhewu 1
Mambane 1
Manzana 1
Manzini 3
Maphobeni 2
Maphungwane 8
Mbutfu 1
Moyeni 1
Ncandweni 4
Nduma 2
Nkambeni 2
Simunye 2
Sinyamantulu 1
St Phillips 1
Zinyane 1
32
Proactive Case Detection
The NMCP seeks to identify and test high-risk groups who may be infected with malaria in an effort
to prevent transmission before it can occur. A total of 389 people were screened during the boarder
screening campaign which was held in January to raise awareness for travelers utilizing
theMhlumeni and Lomahasha boarder gates that border Mozambique. Of the people screened, 2
people tested positive on RDT and were referred to nearest health facility for treatment.
6.4 Performance under Global Fund Grant
There are two indicators for Surveillance that appear in the Global Fund grant’s performance
framework, as shown below in Table 6.1. The percentage of cases investigated with 7 days
decreased from 70% in 2011-12 to 66% in 2012-13; however, the overall case investigation rate for
the period did increase from 60% to 85% compared to the previous year. This indicator fell short of
the target of 95% of cases investigated within 7 days. The proportion of cases attributed to local
transmission decreased from 32% in 2011-12 to 26% in 2012-13. The ultimate goal for this indicator
is 0% of cases being attributed to local transmission.
Table 6.2 Performance for Global Fund Indicators for Surveillance
Indicator 2011-12 Actual 2012-13 Target 2012-13 Actual
Percentage of confirmed cases
investigated within 7 days of diagnosis
70% 95% 66%
Percentage of cases classified as local
(Inverse Indicator)
32% 15% 26%
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7. Information, Education and Communication (IEC)
In support of the elimination campaign, the NMCP Health Promotion Office disseminated IEC
messages and materials through various activities in two mediums: mass media and community
outreach.
7.1 Annual IEC Strategy
The Programme could not implement the annual communication strategy development workshop as
outlined in the work plan due a condition precedent from the Global Fund grant prohibiting all
trainings and workshops. As a result, no new IEC materials were produced and the Programme
instead utilized IEC materials that had been produced from previous seasons’ campaigns.
Adverts selected from previous campaigns included those for radio, television and printed media
focusing on prevention, particularly the use of LLINs and personal protection measures when
traveling to malaria-affected areas. Adverts also focused on educating the public on the
identification of malaria signs and symptoms to encourage treatment seeking behavior.
7.2 Mass Media Campaigns
Television, Radio, Newspaper, and Magazine Campaign
Previously developed adverts ran from December 2012 to April 2013 in the local media as illustrated
in the Table 7.1 below.
Table 7.1. Mass Media Campaigns
Media Channel Duration Time Slot/Page Media Channel
Television 16 days Evening Prime Time Swazi TV; Channel S
Radio 34 days Morning /Evening Prime Time SBIS 1; VOC
Newspaper
Magazine
7 days
2 issues
Half Page Full Colour
Full page Full Colour
Times of Swaziland; Swazi Observer
The Nation
Border Post Campaign
In 2012-13, the twelve billboards requested for a period of three months could not be setup due to
procurement challenges at the Principal Recipient. The Programme is advocating utilizing this
funding in 2013-14 so that 12 billboards will appear over a period of six months.
In December 2012 and January 2013, theProgramme ran border post campaigns at the two border
posts with Mozambique, Lomahasha and Mhlumeni. In December, messages focused on prevention
towards travelers departing for Mozambique. In January, the Surveillance Department and
volunteers from the University of Swaziland established an information desk and a testing station for
travelers returning from Mozambique. Messages focused on the identification of malaria signs and
symptoms and early treatment seeking behavior.
Adverts in Transportation Vehicles
The Programmewas approached by an established marketing company who are introducing
television screens inside kombis for running adverts. The Programmeidentified this is a potential
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medium fordisseminating messages on malaria prevention and early treatment seeking behavior
among travelers. The Programme has requested funds that were initially earmarked in the Global
Fund grant for the rental of TV screens at the border posts to be reprogrammed for utilization of
adverts in public transportation vehicles.
7.3 Community Mobilization and Outreach
A number of trainings and workshops to mobilize communities in affected or at-risk for malaria were
scheduled for the 2012-13 season. The target groups included media personnel, immigration
officers, school support teams, community leaders, rural health motivators, farmers and traditional
healers. These trainings could not be conducted due to a condition precedent on the Global Fund
grant prohibiting trainings until financial structures could guarantee transparency and compliance.
Additionally, the training of traditional healers has been permanently cancelled due to challenges
engaging and mobilizing this group since 2009-10. The Programme has requested that the funds
from this activity be reprogrammed to train Environmental Health Officers (EHOs) who conduct
home visits and could be an asset to the promotion of LLIN use and other personal protection
measures.
Despite restrictions on trainings, some workshops were carried out in collaboration with other
health programmes and organizations as highlighted below.
Farmers Training
In October 2012, the Programme collaborated with Swaziland Water and Agricultural Development
Enterprise (SWADE) in Siphofaneni to train farm workers on malaria and malaria prevention. The
training was organized and funded by SWADE. Approximately 60 farmers were reached during this
training. IEC materials such as brochures and calendars were distributed to all participants
Rural Health Motivator Training
The Programme was invited to train caregivers who were being promoted to rural health motivators
(RHMs) in various Tinkhundla. The Programme trained RHMs from the Siphofaneni, Manzini North,
Mbabane East, and West Tinkundla on basic information on malaria, the country’s elimination
campaign, and their role in the communities.
Exhibitions
The Programme was able to disseminate information through exhibitions during the World Health
Day, World TB day, and Sigcineni Community Family Day. The Programme also provided education to
the Dvokolwako community focusing on malaria prevention following several suspected deaths.
Massages included identification of signs and symptoms and early treatment seeking behavior.
Private Sector Engagement
The Programme conducted malaria health education forInyatsi Construction Company at all their
sites as the company has many workers from outside the country who travel frequently to endemic
areas and their company has many construction sites situated in malaria at-risk areas. The
Programme also trained lay counselors that were mobilized by the Swaziland Business Coalition on
HIV/AIDS at the Matsapha HealthCare Centre. Lay counselors were trained on promoting malaria
health seeking behavior amongst their clients.
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7.4 National Knowledge, Attitudes and Practices (KAP) Survey
The 2013 KAP Survey, intended to evaluate the Programme’s communication and education
strategy,was cancelled due to delayed approval of the Global Fund grant’s training plan. Also, as no
LLINs were distributed this year, it was not absolutely necessary to conduct a KAP survey after
carrying out the survey each of the last three years. To ensure value for money, it was then decided
that the 2013 survey would be cancelled. The 2014 KAP Survey will be carried out as planned as the
Global Fund grant will be coming to an end.
7.5 Performance under the Global Fund Grant
There is one indicator that NMCP reports to Global Fund in relation to information, education and
communication (IEC) which is percentage of the population that can identify four or more malaria
signs and symptoms. Due to the cancellation of the 2013 KAP Survey, this indicator was not
measured this year and the Programme did not report on it.
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8.1 Priorities for 2013-14
Progress has been made toward many targets outlined in the Malaria Elimination Strategic Plan;
however, gaps still remain. To ensure that these gaps are addressed and the targeted goals are
achieved, the Programme has identified several priorities for the 2012-13 season to improve overall
performance.
Programme Management
To ensure continued resources for malaria elimination, the NMCP will work with the MOH and the
Principal Recipient to develop and submit an interim application to extend necessary activities
currently funded by the Global Fund through December 2014. The Programme will also advocate
with the Ministry of Finance and the Ministry of Public Service for the absorption of key human
resource positions currently covered under the Global Fund grant. In preparation for the Global
Fund’s New Funding Model, the NMCP will meet with stakeholders to develop and cost a strategy
for 2015-2020 to complete elimination and achieve WHO certification.
Case Management
To ensure that case management targets are met, the NMCP through the Ministry of Health will
continue to engage with both public and private health facilities to ensure there is maximum
compliance to the diagnosis and treatment guidelines and reporting requirements. The Programme
will seek to increase the number of monitoring and mentoring visits at health facilities to reinforce
these guidelines on a regular basis. As a way to maximize resources, the Programme will work
closely with partners and educational institutions to ensure that all new nurses receive full training
on malaria case management prior to graduation. The Programme will also strengthen, through
trainings, the reporting of malaria cases, especially to HMIS to reduce the potential for error.
Furthermore, to prevent onward transmission of the disease, the Programme will implement a study
to determine the safety of primaquine among the population, especially those who may have G6PD
deficiency, which can complicate interactions with the drug.
Vector Control
The NMCP will work to ensure all areas that have reported cases in the previous two seasons are
adequately covered by IRS and LLINs.To improve the efficiency of these operations, the NMCP will
carry out entomological investigations in localities reporting clusters of local cases or where local
transmission is suspected but has not been previously recorded. This would improve available data
on each focus in the country, including species and environmental profiles of each area. This will
include further research on Anopheles merus as a vector potentiallydriving transmission in the
country.
Surveillance
The NMCP will continue to strive to achieve a 100% investigation rate of all confirmed malaria cases
by working with healthcare workers to improve the accuracy of contact details collected and the
timeliness of follow-up with reported cases. The Programme will also seek to work with healthcare
workers to ensure that all confirmed cases have samples for secondary confirmation, including a
blood smear and/or DBS card. The Programme will aim to increase the testing rate and coverage
amongst communities receiving RACD. The Programmewill also seek to respond to LAMP positive
37
cases immediately after receiving results to ensure that all infections are treated and transmission is
halted.
Information, Education, and Communication
The NMCP will seek to carry out trainings with key groups as part of its larger community
mobilization campaign after trainings were cancelled in 2012-13. The Programme will also carry out
the 2014 KAP Survey to understand the impact of its mass media and community mobilization
activities and how they might be improved in the future. New mediums will be explored to reach
those traveling to malaria endemic areas, including multi-media messages within public transport
vehicles.
