Tackling the “Last Mile” to Interrupt Malaria Transmission in Southern Mozambique

[Post published jointly with CaixaCiencia on the occasion of World Malaria Day 2018, celebrated on April 25]

A CISM worker talks with a couple during a Mass Drug Administration in Magude, Mozambique.

The past ten years have observed an exciting shift of gears in the race against malariaThe past ten years have observed an exciting shift of gears in the race against malaria, from a control to an elimination-oriented vision. The World Health Organization’s (WHO) Global Technical Strategy for Malaria has established very ambitious goals: to reduce malaria incidence and mortality by 90% and eliminate malaria in at least 35 countries by 2030. All endemic countries in the world are now challenged to meet these goals without a “silver bullet” to do the job, and each one of them will need to identify how to accelerate elimination depending on the malaria transmission profiles within their own borders.

According to the WHO, Mozambique is one of the countries with the highest malaria burden in the world, with more than eight million cases and 14,000 deaths reported every year. In this context, in 2014 the ”la Caixa” Foundation and the Bill & Melinda Gates Foundation joined forces with the Barcelona Institute for Global Health (ISGlobal) and the Centro de Investigação em Saúde de Manhiça (CISM) to design and implement, in collaboration with the Mozambican National Malaria Control Programme (NMCP), a five-year programme to contribute to the development of a malaria elimination strategy for the three Southern provinces of Mozambique (Mozambican Alliance Towards Elimination of Malaria, MALTEM).

Logistics coordination and preparation of materials at the beginning of a Mass Drug Administration (MDA) against malaria, in Magude, Mozambique.

This two-year malaria elimination package was associated with a 71% reductionThe first three years of the initiative (2014 –2017) have mainly focused on piloting a malaria elimination strategy in the district of Magude aimed at assessing the impact, feasibility and acceptability of two rounds of Mass Drug Administrations (MDA) per year for two consecutive years. During each round, the whole population of Magude was targeted to receive treatment with a long-lasting prophylactic antimalarial drug (Dihydroartemisinin-Piperaquine, DHAp) in the context of high vector control coverage and standard case management. Overall, this two-year malaria elimination package was associated with a 71% reduction in all-age community-based malaria infection prevalence from 9% to 2.6% and a decrease in the incidence of clinical malaria cases from 221 cases per 1,000 in 2014 to 73 per 1,000 in 2017. However, malaria transmission was not interrupted.

MDAs in combination with vector control tools can sharply drop transmission at an unprecedented speedSimilar results have been observed in Zambia, where a similar package of interventions was associated with a sharp drop in prevalence and incidence, but transmission still persisted. In this context, the question remains: Are we able to eliminate malaria in low-to-moderate transmission areas in Africa with the tools available today? We have observed that MDAs in combination with vector control tools can sharply drop transmission at an unprecedented speed, but how do we finish the job once transmission is low and the probability of resurgence is still high?

Administration of antimalarial drugs during an MDA, in Magude, Mozambique.

In an attempt to answer this question, a Reactive Case Detection (RCD) system was established in March of 2017 in Magude in order to tackle the remaining and new infections after the MDA. All confirmed malaria cases, or index cases, detected passively trigger a response in the community. Each index case is visited at his/her household by a malaria officer within 48 to 72 hours after detection. All eligible residents of the index case household are treated with the long-lasting prophylactic antimalarial DHAp, regardless of their infection status, what is known as a “targeted MDA” approach. The rationale for the deployment of this intervention is that as malaria transmission decreases, it becomes more focal, and targeted interventions are more efficient at tackling the remaining clusters of infections.

We have followed 2,201 index cases, and 7,382 individuals have been treated with DHApSince RCD was implemented, we have followed 2,201 index cases, and 7,382 individuals have been treated with DHAp. While the continuous detection of index cases implies that transmission has not yet been interrupted in Magude, no significant increase in cases has been observed during the current rainy season. Such preliminary observations could indicate that an RCD system could be useful at sustaining the gains achieved after the deployment of MDAs. But the question persists with regards to whether it will serve as a tool to cover the “last mile” and achieve malaria elimination.

A vida de Rosa: Tracking Malaria in Mozambique

On the occasion of World Malaria Day –April 25–, the photographer Alfons Rodríguez travelled to Mozambique to share with us the day to day life of Rosa, who works on the MALTEM project, and her contribution to the fight against malaria. We invite you to visit this story in pictures.

Rosa Mouzinho, a worker of the CISM, in Manhiça, Mozambique. ©Alfons Rodríguez