Malaria Elimination: How To Do It?

A few years ago, the people and institutions involved in the fight against malaria decided to once again set in motion the machinery to engage in an all-out battle against this parasitic disease. As a result, malaria elimination has suddenly become one of the top 10 priority issues on the agendas of many health ministries, financial entities and nongovernmental organisations.

We decided to use a full-on attack on all fronts against both the parasite that causes malaria and the mosquito vector that transmits the parasite

However, the big question remains: how can malaria be eliminated? To answer this logical but complex question and to support the governments undertaking this difficult task, eminent malaria specialists and their teams all over the world are working to find efficient and effective ways to eliminate malaria in different settings.

And I find myself immersed in this exciting global effort to reinforce public health systems and to carry out the necessary research into the social, operational and policy issues involved in this endeavour. My name is Beatriz Galatas. I am 25 years old and an epidemiologist. I am employed by the Barcelona Institute for Global Health (ISGlobal), and have been working for the past two years at the Manhiça Health Research Centre (CISM) in Mozambique. In 2013, I joined ISGlobal to work with the distinguished Spanish malaria specialist Pedro Alonso and his team of scientists at CISM, who were working on a plan to eliminate malaria in southern Mozambique. The primary objective was to design an effective, evidence-based elimination programme that could be implemented by the countryís National Malaria Control Programme.  

One year later, the Mozambican Alliance Towards the Elimination of Malaria (MALTEM) was created with the support of the "la Caixa" Foundation Against Malaria programme and the Bill & Melinda Gates Foundation, and in September 2014 we were able to start taking concrete action.

The offensive began in August 2015 with a major campaign of indoor insecticide spraying in every house in the district

Since then, working with a great team composed mainly of young Mozambicans, we have planned and are carrying out a pilot malaria elimination project in Magude, a rural district in the southern part of the country. This work is being undertaken in close collaboration with the Mozambican Ministry of Health, which is leading the alliance.

In our first approach to malaria elimination, we decided to use a full-on attack on all fronts against both the parasite that causes malaria and the mosquito vector that transmits the parasite. The offensive began in August 2015 with a major campaign of indoor insecticide spraying in every house in the district (to reduce the density of mosquito malaria vectors in the area). This was followed by two rounds of mass administration of antimalarial drugs to the entire population of the area (to eliminate current infections and protect from future infections). This operation, so easy to describe in a couple of sentences, has been the most challenging task I have ever faced.

The first major challenge was to find and train a team of more than 500 people who could read and write and who knew the area and could work under the relentless African sun. After a rather complex selection process, we spent six weeks training and getting to know our future foot soldiers, day after day, packed into a hot room under renovation, which the local district hospital had kindly lent us. I have particularly fond memories of that phase because, while the team members learned about malaria, the different doses of the treatment regimen and how to prick a finger and use the blood in the rapid diagnostic test, we had to learn how to work with hundreds of people every day without losing our tempers or our sanity.

This operation has been the most challenging task I have ever faced

The first day of the mass drug administration campaign was particularly exciting. Chaos and conviction converged in a sea of white t-shirts and caps as the team prepared to put an end to the disease feared and detested by all. That was the moment our plans were put to the test. And, of course, not everything worked out exactly as we had hoped. But every day we improved our organisation, team work and motivation, although fatigue soon started to take its toll on everyone, particularly the CISM team. By the end of that first campaign, it had become an everyday occurrence to find an exhausted colleague curled up in a corner, trying to recover a bit so that they could continue working.

When you are managing a group of more than 500 people, every problem is multiplied by 500. If it rains, you need to buy 500 raincoats! When a car or a van breaks down, you have to find alternative transport no matter what. Nonetheless, as usual in this country, the good will of the field workers and the people in the community have made it possible for this difficult task to be accomplished professionally and with good humour.

When you are managing a group of more than 500 people, every problem is multiplied by 500. If it rains, you need to buy 500 raincoats!

Generating scientific evidenceóone of the main objectives of the pilot projectówas another daunting challenge, mainly because of the logistics involved. For example, the collation of data, a relatively simple aspect of any study, becomes problematic when it involves 250 tablets and daily data synchronisation with a central server in a setting where neither electricity nor Internet connections exist.  But, thanks to the innovative work of two young Mozambican computer specialists, many sleepless nights and two generators, we managed to gather the information needed to assess the project and to ensure that the data was secured. 

During the coming year, we will analyse the results of our intervention. Depending on the outcomes, we will also evaluate other possible plans. And if this intervention does not work, we will try something else. No one ever said that it was going to be easy! The philosophy that underpinned this project was learning by doing. For that reason, every situation, experience and challenge and all the evidence gathered during this process will help us plan the next intervention more effectively and improve our recommendations, so that the Mozambican Ministry of Health can ultimately incorporate the lessons learned into its strategy for the total elimination of the disease that causes the most harm in this country.

[This text was originally published in Spanish in El País - Planeta Futuro]