Introduction: Malaria is one of the leading causes of morbidity and mortality in developing countries, with sub-Saharan Africa carrying the highest per capita burden of this disease in the world. In line with the World Health Organisation's Global Strategy for Malaria Control, which emphasises the empowerment of local communities in health decision making and positive health seeking behaviour, the KwaZulu-Natal Department of Health developed two malaria health education materials. These health education materials have since never been systematically evaluated in terms of their content, the target groups reached, and the appropriateness of the health education messages provided. The aim of this project was thus to evaluate these existing malaria health education printed materials, including their efficacy in communicating appropriate, understandable and relevant messages at community level in the malarias region of Jozini in northern KwaZulu-Natal. / Thesis (M.A.)-University of KwaZulu-Natal, Durban, 2007.

This study investigated aspects of the epidemiology of malaria in the Natal province of the Republic of South Africa. In this study the Collins English dictionary definition of epidemiology is used where it is defined as the branch of medical science concerned with the occurrence, transmission and control of an epidemic disease. Malaria has been a notifiable disease in the Republic of South Africa since 1958. Retrospective malaria case data from the Natal province as a whole was analyzed and the data from the KwaZulu and Natal areas of the province compared. Malaria cases were reported from 35 of the 65 magisterial districts in Natal province during the study period. In the Natal areas 91.5% of the cases were reported from eight districts and in the KwaZulu areas 96.4% of the cases came from three districts or as imports from Mozambique. The overall attack rate for both the Natal and KwaZulu areas using the total population figures for each area were very similar for the period 1986-1988 at 0.71 and 0.70 per 1000 head of population for the respective areas. The disease showed a distinct seasonal pattern in the KwaZulu areas with 86.9% of the cases being classified as indigenous and only 13.1% as imported. In the Natal areas, however, the seasonal pattern was not as marked and only 12.1% of the cases were recorded as indigenous and in excess of 82% as imported. Three species of the Anopheles gambiae complex were found to occur sympatrically in Natal province, namely: An. arabiensis, An. quadriannulatus and An. merus. Of these species An. arabiensis was found to occur at five localities during or after the notification of indigenous malaria cases from these areas. Due to the sympatric distribution of these species particular emphasis was placed on species identification and in particular the biting behaviour and control of An. arabiensis was investigated. The study found both morphological and behavioural differences between populations of An. arabiensis from those areas of the province with an intra-domiciliary residual insecticide vector control programme and those from the unsprayed areas. In the unsprayed areas the majority of the indoor resting An. arabiensis had fed on man whereas in the sprayed areas the majority of the indoor resting An. arabiensis were bovine fed. In the sprayed areas, however, the majority of the An. arabiensis caught leaving huts had fed on man. The percentage survival of bloodfed An. arabiensis caught leaving huts in the DDT sprayed area was in excess of 72%. The data strongly suggest that optimal control of An. arabiensis will not be achieved using the current control strategy of the annual application of intra-domiciliary DDT. / Thesis (Ph.D.)-University of Natal, 1990.

Background Recent malaria epidemics in KwaZulu-Natal indicate that effective anti-malarial therapy is essential for malaria control. Although artemether-lumefantrine has been used as firstline treatment for uncomplicated Plasmodium falciparum malaria in northern KwaZulu- Natal since 2001, its efficacy has not been assessed since 2002. The objectives of this study were to quantify the proportion of patients treated for uncomplicated P. falciparum malaria with artemether-lumefantrine who failed treatment after 28 days, and to determine the prevalence of molecular markers associated with artemether-lumefantrine and chloroquine resistance. Methods An observational cohort of 49 symptomatic patients, diagnosed with uncomplicated P. falciparum malaria by rapid diagnostic test, had blood taken for malaria blood films and P. falciparum DNA polymerase chain reaction (PCR). Following diagnosis, patients were treated with artemether-lumefantrine (Coartem®) and invited to return to the health facility after 28 days for repeat blood film and PCR. All PCR P. falciparum positive samples were analysed for molecular markers of lumefantrine and chloroquine resistance. Results Of 49 patients recruited on the basis of a positive rapid diagnostic test, only 16 were confirmed to have P. falciparum by PCR. At follow-up, 14 were PCR-negative for malaria, one was lost to follow-up and one blood specimen had insufficient blood for a PCR analysis. All 16 with PCR-confirmed malaria carried a single copy of the multi-drug resistant (mdr1) gene, and the wild type asparagine allele mdr1 codon 86 (mdr1 86N). Ten of the 16 samples carried the wild type haplotype (CVMNK) at codons 72-76 of the chloroquine resistance transporter gene (pfcrt); three samples carried the resistant CVIET allele; one carried both the resistant and wild type, and in two samples the allele could not be analysed. ii Conclusions The absence of mdr1 gene copy number variation detected in this study suggests lumefantrine resistance has yet to emerge in KwaZulu-Natal. In addition, data from this investigation implies the possible re-emergence of chloroquine-sensitive parasites. Results from this study must be viewed with caution, given the extremely small sample size. Recommendations A larger study is needed to accurately determine therapeutic efficacy of artemetherlumefantrine and resistance marker prevalence. The high proportion of rapid diagnostic test false-positive results requires further investigation. / Thesis (M.Med.Sc.)-University of KwaZulu-Natal, Durban, 2013.

Background The years 1985 to 1988 and 1997 to 2001, were periods of high morbidity and mortality due to malaria in KwaZulu-Natal, South Africa. One reason for the increased burden of disease was the emergence of drug resistant Plasmodium falciparum. The parasite was resistant initially to chloroquine and then to sulphadoxine-pyramethamine, the medication of choice for the treatment and prevention of malaria in different periods of time. The changing epidemiology of malaria in Mrica was exacerbated by policy makers not making timely and rational change to the failing malaria drug regimens to newer and effective ones. Purpose ofthe study This study was conducted to determine the impact of delayed introduction of sulphadoxine-pyramethamine (Fansidar®) and artemether-lumefantrine (Coartem®) as a first-line drugs for malaria in KwaZulu-Natal from 1985 to 1988 and 1997 to 2001 respectivel y, Study Design Observational, Analytic, Ecological Method The incidence of malaria in KwaZulu-Natal was compared during different phases of the period when chloroquine was the first line treatment. The baseline phase (1982 to 1984) was taken when chloroquine correctly should have been used and this was compared with the delayed phase (1985 to 1988), when it should have been replaced by of sulphadoxinepyramethamine. During the second period sulphadoxine-pyramethamine was the first line treatment of malaria, the baseline phase (1993 to 1996) when it correctly should have been used was compared to the delayed phase (1997 to 2001) of introduction of the alternate treatment of malaria with artemether-Iumefantrine. Ethical approval for this study was obtained from the Biomedical Research Ethics Committee, of the University of KwaZulu-Natal. Statistical Methods The relative association of malaria infection during the chloroquine baseline and change phases and the sulphadoxine-pyrametharnine baseline and change phases were compared with statistical significance at 0.05. Results The risk of malaria infection was 4.5 times (Incidence Risk Ratio = 4.5; 95% Confidence Interval: 4.1 to 5.0; P < 0.0001) higher in chloroquine change phase relative to the baseline phase. During the sulphadoxine-pyrametharnine period, the malaria risk was 3.5 times greater (Incidence Risk Ratio = 3.50; 95% Confidence Interval: 3.40- 3.60; p < 0.0001) in the change phase. In the chloroquine period, the malaria mortality risk was 9.1 times higher (95% Confidence Interval: 2.1 to 38.5; p=0.0003) and the case fatality rate was increased 1.3 times more (95% Confidence Interval: 1.0 to 1.7; p< 0.001) in the change period. The risk of death during the sulphadoxine-pyramethamine change phase was 4.8 times (95% Confidence Interval: 3.3 to 7.0; p<O.OOl) and case fatality rate of2 times (95% Confidence Interval: 1.5 to 2.7; p <0.001) relative to the baseline phase. Conclusions The dramatic change in the malaria epidemiology in Africa in recent times was exacerbated by delay in replacing first line failing antimalarial drugs. The establishment of sentinel sites for assessing drug resistance or failure and the application of World Health Organisation standards in drug resistance studies will go a long way to achieving the Roll Back Malaria target by 2010. / Thesis (MMed.)-University of KwaZulu-Natal, Durban, 2007.

This study investigated the effects of temperature and relative humidity (both controlled and natural) on the lifecyle and morphology of adults of members of the Anopheles gambiae complex in northern KwaZulu-Natal, South Africa. Laboratory investigations into the effects of simulated temperature and relative humidity regimes concentrated on seasonal differences in longevity, egg hatchability, reproductive potential and adult survivorship of An. arabiensis. Differences were found in the life table parameters when these mosquitoes were reared under conditions of seasonal temperature and relative humidity. During the cool season the lifespan and adult survivorship of mosquitoes were greater than those reared during the warm season. In summer, the egg hatchability and reproductive potential were greatest whereas in winter An. arabiensis underwent gonotrophic dissociation although these females were found to take blood meals readily. The influence of seasonal temperature and relative humidity on the body size of An. arabiensis was investigated, both in the laboratory and under field conditions. In both environments, these factors were found to significantly influence body size. In winter, there was a 13% increase in wing size compared to summer bred mosquitoes. A comparison of body size of An. arabiensis, An. merus and An. gambiae reared under laboratory conditions of seasonal temperature and relative humidity showed that the wing size of An. arabiensis was greater than that of An. merus and An. gambiae. The effect of temperature and relative humidity on morphological criteria used in species separation was also investigated. Seasonal differences in wing spot size were compared for An. arabiensis, An. merus and An. gambiae. From this investigation it was concluded that the pale and dark spots on the wing of Anopheles mosquitoes could not be used in species identification due to the large degree of inter-species overlap in the wing spot measurements. The measurement of the pale band at the junction of the 3rd and 4th tarsomere on the hind leg was also investigated for its use in species separation and were found to be useful within the An. gambiae complex. The implications of this study on the transmission and control of malaria are discussed with reference to the late season transmission during March to May that is characteristic of the region. / Thesis (Ph.D)-University of Natal, Pietermaritzburg, 1996.

The irrigation farming methods on the Makhathini Flats are thought to be responsible for recent increase in malaria cases in the Mamfene area of northern KwaZulu-Natal despite ongoing malaria control activities. Their coincidence with the period of intensive fanning is an interesting one. This study was therefore carried out to determine the relationship between larval habitats and adult mosquito population in malaria transmission using Geographic Information System (GIS). Four types of breeding sites were utilised by malaria vectors in Mamfene, viz; types 1, II, III and IV. Habitat type I was tap pools, type II was irrigation spillage in agricultural land, type III was spillage outside but adjacent to the agricultural land and type IV was depression pools located both in the Balamhlanga swamp and inland. The cumulative larval density in all habitats peaked in March 1995 (20/man-hr), with irrigation spillage (type III) recording the highest density index (33/man-hr) as compared to tap pools (type I) which recorded 32.8/man-hr while other waterbodies recorded I3 .4/man-hr (type II) and O.5/man-hr (type IV) respectively. Subsamples of both larvae and adults of An. gambiae group were identified by the Polymerase Chain Reaction (PCR) technique. Of the larvae identified, 94.1 % and 5.9% (n=289) were An. arabiensis and An. quadriannulatus respectively while in the adult component, the composition was 98.7% and 1.3% (n=303) for An. arabiensis and An. quadriannulatus respectively. This confirmed An. arabiensis as the dominant malaria vector in Mamfene area while the exophilic behaviour of An. quadriannulatus was portrayed. Of the An. gambiae group dissected for parity, 51 .5%) were found parous. This is an indication that the population was old and was able to maintain transmission locally despite ongoing vector control measures. The Global Positioning System (GPS) was used to position larval and adult mosquito sampling sites. The spatial distribution of adult mosquitoes from the breeding sites were plotted using GIS soft ware (Map Info ) and the distance between the breeding sites and study houses were measured using a utility distance tool. With the aid of GIS, the adult mosquito density in houses could be used as an indicator to locate the breeding sites in the vicinity. The importance of these findings in terms of application in cost-effective malaria control cannot be over-emphasized. / Thesis (M.Sc.)-University of Natal, Pietermaritzburg, 1995.

Tourism is the world's largest earner of foreign currency. It brings an estimated R20 billion a year into the South African economy, second only to the manufacturing and mining industry in its contribution to the Gross Domestic Product (GDP). An estimated 1.7 million overseas and African tourists visited South Africa in 1999. Of the 1.7 million approximately 500 000 or 30% of these tourists visited KwazuluNatal. Forty seven percent of the foreign tourists visited the Zululand and Maputaland area, which falls within a malaria transmission zone. An estimated 8 million domestic tourists from outside or within this province travelled to one or more destinations within KwaZulu-Natal on an annual basis. The Lubombo Spatial Development Initiative is a tri-Iateral initiative between the governments of Swaziland, Mozambique and South Africa to develop the Lubombo region into a globally competitive economic zone. The geographical area targeted by this initiative is broadly defined as eastem Swaziland, southem Mozambique and north-eastem KwaZulu-Natal. Accelerated development with regards to agriculture and tourism is the main objective of the Lubombo Spatial Development Initiative (LSD!). The Lubombo corridor has the potential to develop into an intemational tourist destination but malaria is hampering the growth and development of the region. Perceived malaria risk by tourists is believed to be an important factor that has a negative influence on the tourism industry in the study area. The risk factor, as defined in this study, is the possibility of contracting malaria whilst visiting a tourism facility in the area. It is therefore essential to understand perceptions relating to malaria and malaria risk in the LSDI area. Malaria control plays a pivotal role in the Lubombo Spatial Development Initiative (LSD!). The objective of the malaria control component of the LSDI is to put in place a malaria control programme that will protect the economic interest of the Lubombo Spatial Development Initiative (LSD!) and stimulate development. Malaria control activities have been taking place in the three countries since 1999. Residual house spraying is the method used to control malaria in the Lubombo corridor. Major reductions in both malaria cases and parasite prevalence have been recorded. Swaziland's malaria incidence reduced by 64%, South Africa's malaria incidence plummeted by a staggering 76% and Mozambique saw a parasite prevalence reduction of40% in the first year of residual house spraying in 1999. This study focuses on the scientific study of malaria incidence and distribution as well as on both tourists and tourism operator's perceptions of malaria risk. It considers the factors that drive people's perceptions of risk and investigates how tourists and tourism operators respond to malaria risk. It draws conclusions about how malaria impacts on tourism in the LSDI and recommends how malaria control can play a positive role in tourism development in the area. / Thesis (M.Sc.)-University of Natal, Durban, 2003.

Malaria incidence in the province of KwaZulu-Natal is influenced by seasonal climatic variations, drug and insecticide resistance, and population mobility within the region. Current control methods are directed at the malaria vector, the Anopheles arabiensis mosquito, through indoor residual spraying. Control of the dominant malaria parasite, Plasmodium falciparum, is done by treatmenting the symptomatic and asymptomatic parasite carriers with prophylactic medications of. A ceiling of effectiveness with current control efforts have been reached, necessitating the search for supplementary methods. The study area is located in the Ingwavuma District of northern of KwaZulu-Natal which adjoins the Mozambique border to the north, and includes the malaria areas of Ndumu and Makanisdrift. Homestead location coordinates were obtained with Global Positioning System (GPS) receivers and linked to malaria case records through homestead numbers which have been allocated to all homes in the area. The study includes the cases reported during 1993 and 1994 as this was the only data available when the project commenced in 1995. A geographic information system was used to undertake the spatial analysis to test the hypothesis that the malaria vector, Anopheles arabiensis, is localised to certain breeding sites during the winter months in northern KwaZulu-Natal. Identification of these winter 'seed point' breeding sites from which the onset of transmission spreads during the following malaria season, will allow them to be targeted for winter larval control measures. This will contribute to limiting the distribution and lowering the levels of malaria intensity in the region as a whole. The analysis also provided evidence of the maximum likely flight distance of the female mosquito given an adequate host supply in close proximity, thereby identifying those areas requiring additional prevention and control activities. Understanding the local epidemiology of the disease was necessary to determine which monthly malaria cases to include in order to identify the winter breeding sites, due to seasonal variations in the length of the mosquitoes life cycle. Medical geography, as a sub-discipline of geography, combines investigating spatial patterns with the epidemiological principles of medicine and zoology through scientific methods. It is traditionally divided into two approaches, the first being the geography of disease, under which this research falls, and the second being the geography of health care. The integration of the two disciplines allowed the results of the analysis to be presented in maps, graphs and tables in order to describe, interpret, test and explain possible associations between the location of the potential breeding sites and the homesteads at which the malaria cases were reported. The potential breeding sites consisted of the perennial pans, non-perennial pans and dams. Zones were created in the GIS at one kilometre intervals from these sites up to a distance of four kilometres, and the number of cases within each zone determined and corrected for the population at risk per 1000 people for comparative purposes. This spatial analysis was followed by the statistical analysis of the results to verify the findings. The results of the spatial and statistical analysis indicated that the perennial pans were used as the winter 'seed point' breeding sites, and that the maximum likely flight distance of the female mosquito, given an adequate host supply in close proximity, is 4 kilometres. The results will be made available to the local malaria research and control community who will assess the feasibility of implementing supplementary control measures. / Thesis (M.Sc.)-University of Natal, Durban, 2001.

This study aimed at investigating the knowledge, perceptions and attitudes of both the community and traditional healers with regard to the diagnosis and treatment of malaria in KwaZulu Natal with special reference to Ndumu in the magisterial district of Ingwavuma. Ingwavuma is one of the two northern magisterial district of KwaZulu Natal Province which is regarded as the highest malaria risk district in South Africa as a whole. The area has a warm temperature, 27-32°C, which is favourable for the development of the Anopheles mosquito. The factors predisposing the community to malaria infections were the socio-economic status of the area which is characterised by poverty. unemployment, poor housing and illiteracy, cross border migration, drug resistance, the agricultural development and irrigation scheme. Efficient control measures like house spraying a residual insecticide to control malaria vector mosquitoes, passive surveillance and active case detection with definitive diagnosis and treatment in place to prevent and control the upsurge of the disease The objectives of the study were to ascertain the knowledge. attitudes and perceptions of traditional healers in regard to malaria diagnosis and treatment and that of the community in relation to malaria treatment and diagnosis by traditional healers. The ultimate objective was to identify possible forms of collaboration between the traditional and the modern health services. The study was conducted from sections 2 - 10 of Ndumu where the population was 13 047 and 1300 households. A random sample of 173 respondents from the community and 70 traditional healers were selected for interview. Qualitative and quantitative methodologies were used in order to collect numerical and descriptive information. Data was collected using semi- structured questions and two sets were made: for traditional healers and the community. The study showed that the community was well aware of the signs of malaria but their knowledge was not supported by definitive testing and diagnosis of the condition. It came out that there are forms of health services available at grass root levels for example. self - help. where an individual tried on his own to combat he offending symptoms of the disease, family support systems, where family members especially the elder member gave support and assisted during the times of ill-health, the use of traditional healers, the malaria control camp, clinics and the hospital. The community supported the idea of collaboration between healers and the malaria control team and expressed their willingness to attend the services of a trained healer. Traditional healers confirmed the fact that some community members utilize traditional healers services and also expressed their wish to see the two forms of health services working together to control malaria. / Thesis (M.Sc.)-University of Natal, Durban, 2000.

This study investigated aspects of the breeding biology, ecophysiology, morphology, over-wintering and population dynamics of the pre-imaginal stages of members of the Anopheles gambiae complex in northern Natal, South Africa, Investigation of the breeding biology, concentrated on breeding site utilisation by the different members of the Anopheles gambiae complex. Surveillance personnel were unable to locate the breeding sites of Anopheles arabiensis and postulated that location and description of these would offer a unique opportunity for control. The difficulty in locating the breeding sites of An. arabiensis at certain localities was found to be a product of their low density, presumably as a result of the intra-domiciliary, residual insecticide spray programme. The effect of temperature on larval physiology and adult morphology was investigated. terms of their implications Anopheles gambiae complex. The findings are discussed in for anopheline taxonomy and the The effect of temperature on larval growth rates was investigated in both the field and laboratory. The finding of this part of the study indicate that the larval stages play an important role in the over-wintering of populations within the region. The control implications of these findings and winter breeding site localisation are discussed. A theory for the so called 'late season transmission i.e. Apri-May, within the province and southern Africa is proposed. The population dynamics of An. merus were investigated, together with the effect of abiotic factors such as temperature, salinity and rainfall. The effect of sampling bias due to factors such as behavioural avoidance were studied. / Thesis (Ph.D.)-University of Natal, Pietermaritzburg, 1991.