Area: 1,219,912 km²
Population: 37,400,000 inhabitants
Capital: Pretoria (1,200,000 habitants)
Bordering countries: Botswana, Lesotho, Mozambique, Namibia, Swaziland and Zimbabwe
Tourism: 3-4 million visitors a year
Climate: (source: South African Weather Bureau  http://www.gov.za ): These are based on average statistics taken from 1961 to 1990. Temperatures are in °C, rainfall in mm and hygrometry in% 

Johannesbourg

Cape Town

Durban

In the period from November 1931 until June 1932, KwaZulu Natal witnessed 22,132 malaria linked deaths (59). Following these findings, important vector control measures were taken with the result that even if the geographic distribution of malaria remains the same, that is to say the North east of the country that borders with Botswana, Zimbabwe and Mozambique (see map) the number of cases themselves have considerably diminished. From 1989 to 1995 the recorded number of malaria attributed deaths varied from 12 to 45 a year (59).

Malaria Distribution In South Africa

The provinces of the North and East Transvaal, north Natal and KwaZulu are considered as being malaria-infected regions. However, sporadic cases have been noted in other provinces such as the South Transvaal.
Within the malaria-infected region, one notes a very sharp gradient, the highest number of malaria cases (>3 p.1000) occurring in the areas that border with Zimbabwe and Mozambique with a serious problem of imported malaria. The lowest number of cases occur in the areas near Pretoria and Johannesburg. 

Conditions such as temperature and rainfall within the malaria-infected regions mean that the transmission of the disease is virtually permanent with, however, a very notable peak period from November to June.

In 1993, there were 13,258 recorded cases of malaria; in 1994 10,286 cases. This sudden increase in the number of malaria cases is concurrent with the start of Plasmodium falciparum ‘s   resistance to chloroquine and the agricultural development of malaria infected zones

In response to the development of Plasmodium falciparum’s  chloroquine resistance, the sulfadoxine-pyrimethamine combination (Fansidar®) was used as of 1988 as the first line drug to combat malaria attacks.

Even if Plasmodium falciparum is the most commonly occurring parasite, Plasmodium ovale  is also present:    in a 1987 study carried out on 4,184   malaria cases, JM Herbst found 54 cases of uniquely Plasmodium ovale  malaria and 113 cases of mixed malaria (32) . Plasmodium ovale  is  therefore present in almost 4% of cases.

The principal malaria vector in South Africa is Anopheles arabiensis  (51, 52, 54) but Anopheles merus  (39) is also found.

Anopheles funestus  once found on the coast has since been eradicated (59) and surveillance program has been implemented to prevent its reintroduction.

Jacques Brunhes et al. (Les anophèles de la région afro-tropicale, logiciel ORSTOM Ed., 1998)   registered   44 different anopheles species in the country:  

1.  Plasmodium falciparum’s  resistance to chloroquine

In vivo, the first case of chloroquine resistance was recorded in South Africa in January 1985, in a little girl aged 10 living in the Zimbabwe, Mozambique border region (23).  This chemoresistance was then confirmed in vitro (24).
The second case was also notified in 1985 in the north Transvaal in a 16 years old girl. (26).
A single report on in vivo resistance to chloroquine has been published (34) and was based in the North KwaZulu region on hospital patients treated with chloroquine (10 mg/kg)-pyrimethamine (1 mg/kg) (DARACLOR®, Lab. Wellcome), 1 tablet / day for 4 days, and asymptomatic carriers of Plasmodium  falciparum who received the same treatment. The trophozoite prevalence   7 days after this treatment went from 0% in 1983 to 21.2% for those suffering from the illness and 16.1% for asymptomatic carriers in 1987. In 1988, using FANSIDAR®,   these rates dropped to   6.9% and 0.4% respectively.

In vitro, few studies, and those often with little or no statistical value, have been published.

2.Plasmodium falciparum’s  resistance to other antimalarial drugs

sulfadoxine-pyrimethamine combination: a prophylaxis   failure was noted in 1996. The same case was also resistant to chloroquine (61) In 1999, JM Govere et al. published a study on 109 patients; they found 4 type RI resistances (3.7%) 1 of type RII ( 0.9% ) and 1 of type RIII ( 0.9% ) (93)
Quinine: a 1994 study showed that there was no resistance. (55)
Mefloquine: a 1994 study showed that was no resistance. (55)

The fight for vector control has been the cornerstone of the fight against malaria (55)

In 1928 Ingram and De Meillon compiled an inventory of vector sites and proposed measures to reduce these numbers. (INGRAM A., DE MEILLON B. - A mosquito survey of certain parts of South Africa, with special reference to the carriers of malaria and their control. Publ. SAIMR 1927 ; 4: 1-81).   

An anti-larvae program was run from 1928 to 1946 with Paris green and oil but was abandoned in 1956.

The first campaign against adult insects was conducted in 1932 in Natal. Pyagra was used, a mixture of kerosene and pyrethrum. In light of the excellent results achieved, large scale program of domestic spraying with long lasting insecticides was decided upon. DTT was used as of 1946. 1958 saw the first ever complete spraying of malaria-infected regions.

In the 70’s the program combined home spraying of DTT once a year with treatment of cases following evidence of the illness by parasitological diagnosis. (NGXONGO S.M. - The epidemiology of malaria in KwaZulu 1980-1991. M. Sc. Thesis, University of Natal, Pietermaritzburg, 1994).

The insects started showing resistance to DTT in the 80’s (Anopheles arabiensis, punaises), meanwhile the population started to reject the use of the insecticide whose cost was becoming too much of a heavy burden for the program and, in addition, more and more papers on DTT and it’s toxic nature, harmful to humans, were   being published. ( 35, 37, 41 , 42 , 43 , 53)

At this point the Medical Research Institute took up the task of evaluating replacement insecticides. (51, 52) The pyrethrinoides caused much interest due to their long lasting nature, still active 6 months later; that is to say, superior to the period of high risk malaria transmission . Nevertheless, it costs almost double the price of DDT. A large scale trial is being run in KwaZulu- Natal.

The research into malaria is also run by the National Malaria Research Program, Medical Research Council, 17120 Congella, Durban, South Africa.   

Its work is based upon: 

        1- Research into long lasting insecticides adapted to South Africa (cf supra)

        2- The creation of a Malaria Risk Atlas of Africa. This is the initiative of “Mapping Malaria Risk in Africa”/  “Atlas du Risque de la Malaria en Afrique” (MARA/ARMA). The program is now 4 years old and its first results can be viewed on their website:  http://www.mara.org.za

The National Anti Malaria Program also organized the MIM African Malaria Conference in Durban from the 14^th to the 19^th march 1999. ( MIM stands for the   Multilateral Initiative on Malaria. For more information please visit: http://www.malaria.org).

It is common to divide South Africa in two sections and to advise a chemoprophylaxis for people wishing to visit the north and nothing for those who will be staying in the south. In fact, it would be more logical to advise this treatment for those travelling to the east of Durban, which in practical terms means to all those who wish to visit Kruger Park.  

The South African health authorities advise the combination of chloroquine-proguanil (SAVARINE®) or mefloquine (LARIAM®). However, a 1999 study on 7397 visitors of the park showed that on average only 1 in 2 tourists follow these recommendations. (84) 

      19%         didn’t take any form of chemoprophylaxis
      36.1%      took the combination of chloroquine-proguanil 
      18.4 %     took   mefloquine  
      17.1%      took chloroquine only  
      3.5%        took proguanil only  
      0.9 %       took doxycycline  
      0.6 %       took the combination pyriméthamine-dapsone  
      0.6 %       took homeopathic treatments 
      0.5 %       took the chloroquine-pyrimethamine combination 
      0.4 %       took the chloroquine-mefloquine combination 
      2.9 %       were unable to say what treatment they were following. 

According to the B.E.H. n°24-25 of the 14th June 2005, South Africa is classified in chloroquine-resistance group III. This signifies that a traveler spending less than 3 months in the country should take the Mefloquine or the Atovaquone-Proguanil combined treatment.

G Lonergan estimates that the risk of contracting a Plasmodium falciparum caused malaria attack, to be at 4.5 per 10 000 visitors and at 14 per 10 000 visitors for those not taking a chemoprophylaxis which leads to the recommendation of a prophylaxis with mefloquine.   (92) 

S. Warner recommends a chemoprophylaxis (mefloquine or the chloroquine-proguanil combination)   only from October to May. He judges that for the rest of the year, methods of vector control are largely sufficient. 

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