Climatic, environmental and socio-economic factors for malaria transmission modelling in KwaZulu-Natal, South Africa.

Doctoral Degree. University of KwaZulu-Natal, Durban.Sub-Saharan Africa (SSA) largely bears the burden of the global malaria disease, with the transmission and intensity influenced by the interaction of a variety of climatic, environmental, socio-economic, and human factors. Other factors include parasitic and vectoral factors. In South Africa (SA) in general and KwaZulu-Natal (KZN) in particular, the change of the malaria control intervention policy in 2000, may be responsible for the significant progress over the past two decades in reducing malaria case report to near zero. Currently, malaria incidence in KZN is less than 1 case per 1000 persons at risk placing the province in the malaria elimination stage. To meeting the elimination target, it is necessary to study the dynamics of malaria transmission in KZN employing various analytical/statistical models. Thus, the aim of this study was to explore the factors that influence malaria transmission by employing different analytical models and approaches in a setting with low malaria endemicity and transmission. This involves a sound appraisal of the existing literature on the contribution of remote sensing technology in understanding malaria transmission, evaluation of existing malaria control intervention; delineation of empirical map of malaria risk; provide information on the climatic, environmental and socio-economic factors that influences malaria risk and transmission; and formulation of a relevant malaria forecast and surveillance models. The investigator started with a systemic review of studies in chapter two. The studies were aimed at identifying significant remotely-sensed climatic and environmental determinants of malaria transmission for modelling malaria transmission and risk in SSA via a variety of statistical approaches. Normalised difference vegetation index (NDVI) was identified as the most significant remotely-sensed climatic/environmental determinants of malaria transmission in SSA. Majority of the studies employed the generalised linear modelling approach compared to the Bayesian modelling approach. In the third chapter, malaria cases from the endemic areas of KZN with remotely-sensed climatic and environmental data were used to model the climatic and environmental determinants of malaria transmission and develop a malaria risk map in KZN. The spatiotemporal zero inflated Poisson model formulated indicates that at 95% Bayesian credible interval (BCI) NDVI (0.91; 95% BCI = 0.71, -1.12), precipitation (0.11; 95% BCI = 0.08, 0.14), elevation (0.05; 95% BCI = 0.032, 0.07) and night temperature (0.04; 95% BCI = 0.03, 0.04) are significantly related to malaria transmission in KZN, SA. The area with the highest risk of malaria morbidity in KZN was identified as the north-eastern part of the province. The fourth chapter was to establish the socio-economic status (SES) that influence malaria transmission in the endemic areas of KZN, by employing a Bayesian inference approach. The obtained posterior samples revealed that, significant association existed between malaria disease and low SES such as illiteracy, unemployment, no toilet facilities and no electricity at 95% BCI Lack of toilet facilities (odds ration (OR) =12.54; 95% BCI = 0.63, 24.38) exhibited the strongest association with malaria and highest risk of malaria disease. This was followed by no education (OR =11.83; 95% BCI = 0.54, 24.27) and lack of electricity supply (OR =10.56; 95% BCI = 0.43, 23.92) respectively. In the fifth chapter, the seasonal autoregressive integrated moving average (SARIMA) intervention time series analysis (ITSA) was employed to model the effect of the malaria control intervention, dichlorodiphenyltrichloroethane (DDT) on confirmed monthly malaria cases. The result is an abrupt and permanent decline of monthly malaria cases (w0= −1174.781, p-value = 0.003) following the implementation of the intervention policy. Finally, the sixth chapter employed a SARIMA modelling approach to predict malaria cases in the endemic areas of KZN. Three plausible models were identified, and based on the goodness of fit statistics and parameter estimation, the SARIMA (0,1,1) (0,1,1)12 model was identified as the best fit model. The SARIMA (0,1,1)(0,1,1)12 model was used to forecast malaria cases during 2014, and it was observed to fit closely with the reported malaria cases during January to December 2014. The models generated in this study demonstrated the need for the KZN malaria program, relevant policy makers and stakeholders to further strengthen the KZN malaria elimination efforts. The required malaria elimination fortification are not limited to the implementation of additional sustainable developmental approach that combines both improved malaria intervention resources and socio-economic conditions, strengthening of existing community health workers, and strengthening of the already existing cross-border collaborations. However, more studies in the area of statistical modelling as well as practical applications of the generated models are encouraged. These can be accomplished by exploring new avenues via cross-sectional survey to understand the impact of community and social related structures in malaria burden; strengthening of existing community health workers; knowledge, attitude and practices in malaria control and intervention; and the likely effects of temporal/seasonal and spatial variations of malaria incidence in neighbouring endemic countries should be explored