The start of summer generally marks the beginning of the high malaria transmission season in South Africa. Higher temperatures and increased rainfall provide ideal breeding conditions for Anopheles mosquitoes, increasing the risk of malaria transmission in the malaria-endemic regions of KwaZulu-Natal, Limpopo, and Mpumalanga.
To reduce the incidence and risk of malaria, affected communities and malaria control programmes should work closely to remove known mosquito breeding sites, if possible, and ensure optimal coverage of vector control strategies, including indoor-residual spraying and larviciding. Additionally, all residents and visitors in malaria risk areas should make every effort to reduce contact with mosquitoes by limiting outdoor activity after dark, covering up bare skin (not forgetting feet and ankles) when outdoors at night, using mosquito repellents containing at least 10% DEET, ensuring windows/mosquito screens on windows are closed at night, and using bed-nets, fans or air conditioning, if available.
Individuals traveling to high-risk areas within and outside South Africa should consider antimalarial prophylaxis. Doxycycline and atovaquone-proguanil are now available without a prescription from pharmacies and travel clinics. To increase access to malaria prophylactic treatment, doxycycline for malaria chemoprevention has been added to the Essential Medicines List, making it readily available in the public sector. Doxycycline is not recommended for children younger than eight years-of-age, so a healthcare provider should be consulted to determine the most appropriate prophylactic treatment for this age group. Currently, in South Africa, the recommended prophylaxis for pregnant women, mefloquine, is only available through a Section 21 approval process. Where possible, pregnant women should avoid visiting malaria-endemic areas, as they are more prone to serious complications of malaria.
It is important to note that while these pharmaceutical and non-pharmaceutical precautions will substantially reduce the chance of acquiring malaria, the risk is never completely removed. All travellers returning from malaria-transmission areas, including very low-risk ones, should immediately report any flu-like illness that occurs up to three weeks after potential exposure to a healthcare professional. Key symptoms include headache, fever, chills, fatigue, muscle, and joint pain. Children with malaria may present with non-specific symptoms such as fever, loss of appetite, and vomiting. Healthcare workers, particularly those in non-endemic areas, must remember to ask about travel to malaria-transmission areas in all patients who present with fever.
In rare instances, malaria is diagnosed in people with no recent travel history to endemic areas. This is known as odyssean malaria and is caused by infective mosquitoes which have accidentally been transported from malaria-endemic areas to non-malarious areas via various transport mechanisms (sea, air, rail, road). All healthcare practitioners are advised to consider malaria as a differential diagnosis in any patients presenting with a progressive febrile condition (>38°C), even in the absence of travel history to a malaria-endemic region, especially if there is unexplained thrombocytopenia.
Malaria is classified as a category one Notifiable Medical Condition (NMC) in South Africa, which requires immediate reporting via written or electronic notification within 24 hours of diagnosis. It is the responsibility of the healthcare practitioner who makes the diagnosis, following either a positive rapid diagnostic test (RDT) test for malaria and/or a positive result from a blood specimen submitted to a laboratory, to immediately notify the case. While the widely used histidine-rich-protein 2 (HRP2) based falciparum-specific RDTs are still effective in South Africa, falciparum parasites in several Central and Horn of African countries have mutated allowing them to avoid detection by these HRP2-based RDT. Travel history should be used to guide selection of a malaria diagnostic method.
Malaria risk map, FAQs and further information on malaria prevention are available here.
