Accelerating Towards Malaria Elimination: Evidence from the Magude Project

Magude, a district of Maputo province in southern Mozambique, is much like any other inland rural area of the country: an arid landscape where children play while women wash their laundry in the river; homes made of straw, reeds and adobe, organised in communities led by elders; and a town with a square, a market, schools, shops and bars—the hub of the district’s economic and social activity.

As in many parts of Mozambique—and Africa generally—the nearly 50,000 inhabitants of Magude do not have easy access to the public health system. This is especially true for those who live a long distance—in some cases, more than 40 km—from any of the district’s 10 health centres. Just a handful of these centres have electricity and running water; only one, located in the town centre, has a doctor on staff and the capacity to admit patients rather than referring them to the nearest hospital, which is about 30 minutes away by car. These considerations are especially important for a population mainly affected by infectious diseases such as HIV, tuberculosis and malaria, which require a strong prevention and treatment infrastructure.

In places like Magude, the key question posed by national malaria control programmes, the World Health Organisation (WHO), funding agencies and academic institutions —Can we eliminate malaria in endemic rural areas of sub-Saharan Africa?—is a matter of the utmost importance.

Can we eliminate malaria in endemic rural areas of sub-Saharan Africa? This was the aim of the Magude Project

In 2013, under the leadership of Dr. Pedro Alonso and with the support of the Bill & Melinda Gates Foundation and the ”la Caixa” Foundation, we set out to answer this question through the Mozambican Alliance Towards Elimination of Malaria (MALTEM). Thus was born the Magude Project, led and implemented by the Manhiça Health Research Centre (CISM) and its collaborators. Following WHO guidelines, we designed a two-phase, five-year project that could subsequently be replicated by Mozambique’s national malaria control programme. The project had to strike a balance between scientific rigour and reproducibility, two key aspects of “operationalising” science that are not always easy to reconcile.

In the first phase of the project, our goal was to show that malaria transmission could be reduced in a short period of time (two years). We began by taking a census of the population, encouraging the use of mosquito nets, measuring the prevalence of malaria in the community and strengthening the malaria surveillance system. As the rainy season approached, we sprayed about 80% of homes in the district with insecticides. After the rains began, we made the rounds twice more. During these visits, we gave most of the population antimalarial drugs to clear asymptomatic infections and provide protection against future infections for two to three months. After repeating this combination of interventions two years in a row, we were not disappointed by what we observed.

Given the large number of factors that must be considered a posteriori, epidemiologists who work in the field do not usually put much faith in preliminary results. But this case was different. As soon as we finished our first year of activity, the number of malaria cases seen by the health centres started to fall sharply. At the same time, we found almost no cases of malaria in the community, despite a significant increase in the number of people testing for the disease. After the arduous process of cleaning and analysing the data, we were able to translate this anecdotal evidence of our impact into hard numbers: in just two years, we had reduced the number of infections in the community by 71% and the number of clinical cases by 62%.

As soon as we finished our first year of activity, the number of malaria cases seen by the health centres started to fall sharply

On the heels of these encouraging results, we embarked on the second phase of the project, in which we worked to maintain the progress achieved during the first two years and bring the number of locally acquired cases down to zero. We decided to continue spraying homes with insecticides each year and providing mosquito nets to the entire population. We also adopted a strategy for detecting and reacting to any malaria cases that continued to turn up in the health centres. Our response to these cases was to administer antimalarial drugs to everyone who shared a home with the infected person, thus controlling potential transmission hotspots.

In the first year of the second phase of the project (2017-2018), our interventions had the desired effect: the gains achieved in the first phase were maintained and the number of cases dropped further. By the end of the 2018 rainy season, we had reduced the prevalence of malaria by 85% and prevented approximately 39,000 cases. Even so, we continued to see cases of malaria in Magude, which meant we had not been able to interrupt transmission completely.

We had reduced the prevalence of malaria by 85% and prevented approximately 39,000 cases. Even so, we continued to see cases of malaria in Magude, which meant we had not been able to interrupt transmission completely.

Why did malaria transmission continue despite our intense efforts in Magude? For several reasons:

1. It is difficult to reach a large percentage of the population with all community interventions.
2. Cases can be imported from other areas of the country.
3. Transmission can occur outside of homes, where people are not protected by insecticides, mosquito nets or walls.

To address any of these three challenges, we need new implementation strategies and new tools capable of offsetting the shortcomings of our current tools.

In any case, the Magude project has shown that it is possible, using the tools available today, to bring malaria transmission down to very low levels that can be sustained over time in a cost-effective manner. In doing so, we prevented thousands of cases—which might have led to death—and accelerated the process towards malaria elimination. This is particularly important now, as the number of cases plateaus in the world’s most endemic countries, including Mozambique. Our results in Magude provide much-needed hope that should encourage endemic countries, funding agencies and field workers to redouble their efforts to eliminate, once and for all, this disease that affects the world’s most vulnerable populations.