Malaria in Eswatini, 2012-2019: A Case Study of the Elimination Effort.

Abstract Eswatini was the first country in sub-Saharan Africa to pass a National Malaria Elimination Policy in 2011 and later set a target for elimination by the year 2020. This case study aimed to review Eswatini’s progress towards malaria elimination by 2020. Coverage of indoor residual spraying (IRS) for vector control and data on malaria cases were provided by the National Malaria Programme (NMP) of Eswatini. The data included all cases treated for malaria in all health facilities. The data was analysed descriptively. Over the eight-year period, a total of 5,511 patients reported to the health facilities with malaria symptoms. Case investigation rate through the routine surveillance system increased from 50% in 2012 to 84% in 2019. Incidence per 1000 population at risk fluctuated between the years but in general increased from 0.70 in 2012 to 1.65 in 2019 with highest incidence of 3.19 reported in 2017. IRS data showed inconsistency in spraying over the eight-year period. Eswatini has fallen short of achieving malaria elimination by 2020. Malaria cases are still consistently reported, albeit at low rates, with occasional localised outbreaks. To achieve elimination, it is critical to optimise timely and well-targeted IRS and to consider rational expansion of tools for an integrated malaria control approach in Eswatini by including tools such as larval source management, long-lasting insecticidal nets (LLINs), screening of mosquito house entry points and chemoprophylaxis. The establishment of rigorous routine entomological surveillance should be among the priorities in order to determine the local malaria vectors’ ecology, potential species diversity and the role of secondary vectors and insecticide resistance.