For countries like Mozambique malaria isn’t just a killer; it’s an affliction. The disease sends thousands to an early grave every year, but the damage goes much further.
In 2017, there were some 10 million cases in this south-eastern African country. Malaria is one of the world’s leading causes of poverty and affects everything from the performance of children in school to the productivity of employees in the workplace. It disrupts everyday life while putting a heavy burden on the health system and on the government’s finances. About 40% of Mozambique’s population carry the malaria parasite.
The Government of Mozambique acknowledges the need for urgent and intensified action. “We are fully aware of – and take responsibility for – the need to accelerate the implementation of control measures to rapidly reduce the disease burden in Mozambique and support regional and global efforts to eliminate malaria,” said the Minister of Health, Dr Nazira Karimo Vali Abdula, at a UN General Assembly side event in New York in September 2018.
Mozambique is not alone. As the World malaria report 2018 notes, progress is insufficient to meet two critical targets of the Global technical strategy for malaria 2016-2030: reductions of at least 40% in global malaria cases and deaths compared to 2015 levels. Without headway in Mozambique and the 10 other highest-burden countries, where 70% of global malaria cases occur, the global community will begin to miss key milestones.
We are fully aware of – and take responsibility for – the need to accelerate the implementation of control measures to rapidly reduce the disease burden in Mozambique and support regional and global efforts to eliminate malaria.
Getting back on track will require better use of existing tools and scientific advances and innovation – a point emphasized by Dr Baltazar Candrinho, Mozambique’s National Malaria Control Programme manager. “With the current control tools, we will not be able to win the battle against malaria by 2030. We are implementing all WHO-recommended tools, and coverage has improved, but the cases are still there,” he says.
Dr Pedro Alonso, Director of the WHO Global Malaria Programme, notes the critical need for more funding – particularly at the domestic level – to expand access to existing malaria-fighting measures: “But we also need new tools and strategies that allow us to go beyond where we are right now,” he adds.
In 2017, a mass distribution campaign in Mozambique of more than 16 million insecticide-treated mosquito nets (ITNs), reached 97% of households nationwide. The country has meanwhile encouraged indoor spraying campaigns (IRS), where the inside surfaces of homes are coated with long-lasting insecticides, focusing on districts with high malaria transmission. Mozambique is also building its research capacities and working to establish a more robust health information system.
Earlier this year, the President of the Republic of Mozambique, Filipe Jacinto Nyusi, led the first national malaria forum. “Clear problems were identified, solutions to reduce the malaria burden were proposed and the importance of social and multisectoral responsibility were highlighted,” notes Dr Abdula. The forum served as a platform for the launch of “Zero Malaria Starts with Me,” a grassroots campaign promoting individual and community accountability in malaria responses.
“We believe that malaria prevention methods will only be effective if led by communities taking ownership of these interventions,” notes Dr Abdula. “Strengthening channels of communication, with a view to fostering social and behavioural changes, is therefore a priority.”
An end to malaria in Mozambique would release a disease dividend, freeing significant resources and a torrent of human potential. But that will require the continued scale-up of proven control measures as well as the development and testing of new tools and techniques.
Ongoing response and practices
The current possibilities and limitations of malaria tools have been illustrated by a programme in Magude district in Mozambique’s south-west, an area of about 60 000 people near the South African border.
The project explored what happens when every known answer to malaria control is gathered together and applied to a single targeted area. Starting in 2015, there was an intensive effort to interrupt local malaria transmission and then sustain the gains in a rural African setting with low-to-moderate transmission.
Programme staff deployed the best available tools, including ITNs and IRS (which each use a different insecticide), as well as mass drug administration (MDA), where curative pharmaceuticals are given to everyone able to tolerate them.
The results don’t provide a silver bullet – there is no simple answer to this most complex of diseases – but they were encouraging. Dr Francisco Saúte, scientific and programme director of the Malaria Elimination Initiative at the Manhiça Health Research Centre (MHRC) says the programme caused a significant reduction in malaria prevalence.
“The drop in prevalence – community-based, but also incidence at health facilities – was around 86% and we’ve been able to maintain it for over a year after the MDA. The issue now is how you sustain those gains and move even further,” he said.
Mozambique is also among a group of countries leading a new response, called the "High burden to high impact" approach, to accelerate malaria control efforts globally. The approach was catalyzed by WHO and the RBM Partnership to End Malaria.
Malaria provides a range of challenges that need to be tackled with a range of tools. Making a significant impact is problematic because of what Dr Saúte terms the “asymptomatic reservoir” of people with malaria feeding transmission because they unknowingly have residual Plasmodium parasites in the bloodstream and, as such, do not report to health facilities for appropriate diagnosis and treatment.
Reviewing the Magude district programme, he points out that to succeed, very high MDA coverage – at least 80% – is needed. “But not everyone could take the drugs, so we were never even close to 80%, and there was still a big mass of infection left in the community,” he noted.
Dr Saúte says the project was also dogged by travellers entering and leaving the region, and by new adaptive behaviour patterns of mosquitoes biting people outdoors or leaving the house right after biting to avoid contact with the insecticide on the sprayed walls.
Mosquito resistance to insecticides is another key concern. According to the latest World malaria report, resistance to the four commonly used insecticide classes – pyrethroids, organochlorines, carbamates and organophosphates – is widespread in all major malaria vectors across the WHO regions of Africa, the Americas, South-East Asia, the Eastern Mediterranean and the Western Pacific.
There are a number of programmes to improve current tools, says Alexandra Cameron, senior technical officer for malaria at Unitaid, the health innovation funding initiative.
Under the next-generation IRS (NgenIRS) programme, the organization has provided US$ 65 million to the Innovative Vector Control Consortium (IVCC) and partners to accelerate scaling-up of the next generation of indoor insecticides through a co-payment programme aimed at lowering IRS costs for country programmes.
One such IRS product has been trialled in the high-transmission area of Mopeia District in Zambezia Province, where half the participating villages were given IRS with a newly deployed insecticide and all had long-lasting insecticidal nets (LLINs). This has produced encouraging preliminary results.
Designed to extend the effect of IRS and to counter pyrethroid resistance, the new insecticide lasts about twice as long as some of the earlier formulations – for six months when sprayed on concrete and wood, and five months on mud.
Unitaid has also been involved with the introduction of a second new insecticide for use in IRS, which contains a new active ingredient for vector control. It was first introduced in 2017 and provides an alternative option for insecticide resistance management.
Researchers hope that, ultimately, countries will be able to rotate insecticides, reducing the ability of mosquitoes to develop resistance. That ability to rotate control formulas hasn’t begun yet, but Unitaid sees the availability of a second product as a major milestone for the project.
Dr Saúte in Maputo mentions another possible new tool: attractive-toxic sugar baits, a simple technology that laces a sweet substance with insecticide. Such an approach would be cheap and simple, but it is untested as yet. A low-cost approach that may be closet to deployment is a new class of bed net that includes the chemical piperonyl butoxide (PBO). This was shown to significantly reduce malaria infection in children when tested at a site in Tanzania.
Hi-tech answers will take longer to deploy, given the need to evaluate them first. Nonetheless Mozambique was a key testing ground for the RTS,S vaccine, which will be deployed as a pilot programme in selected areas of three African countries in 2019. The vaccine’s proof of concept trial was held in Mozambique in 2001, showing the vaccine offered partial immunity to African children, and Mozambique was also part of the Phase III trial.
“Mozambique has made a sustained contribution to the RTS,S vaccine development over more than a decade and has high hopes for its success,” says Dr Saúte.
There are also high hopes for a long-established drug, Ivermectin. For many years, Ivermectin has been prescribed for parasitic worm infections, but only more recently was it noticed that the drug killed mosquitoes which had bitten those who had taken it.