Mozambique goes to war with malaria

One of the main stages of the plan will be to eliminate enough mosquitoes so that people are not reinfected by the malaria parasite. [John Tann/Flickr]

In September, the international community adopted the Sustainable Development Goals, one of which was the pledge to contain malaria by 2030. In Mozambique, an international project promises to contribute. EURACTIV’s partner El País – Planeta Futuro reports.

150 km north of Maputo, the capital of Mozambique, an army of 538 people fight against a common enemy: the malaria parasite, plasmodium. They are seeking to eradicate a disease that not only plagues their area, but also much of the continent. If they are successful, they may be the example that the scientific and international community need in order to finally tackle an illness that killed 438,000 in 2015 and infected 214,000,000 people.

The group’s leader, Spanish researcher Beatriz Galatas, issues orders through a megaphone. Its mission is mass drug administration (MDA) to the local rural population, most of who are illiterate and live in rudimentary housing.

The operation is being carried out by the Alliance for the Elimination of Malaria in Mozambique, or Maltem, with the aim of declaring the province of Maputo disease-free by 2020. The first step is the Magude district, where 51,000 people live, before moving on to the rest of the area. It is hoped that if the maximum available resources are applied to the problem, then the disease will be eradicated within a certain period of time. The main weapons are mosquito nets, insecticides and drugs, all imperfect tools, but which have proved effective before in combatting the parasite. Indeed, thanks to such measures, the mortality rate in regard to malaria deaths has fallen by 60%, with the World Health Organisation (WHO) stating that millions of people’s lives have been saved as a result.

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The Mozambique plan consists of three main phases. The first is to fumigate as many homes as possible, in order to eradicate the disease’s vector, the mosquito. The insect transmits plasmodium from person to person through its bite. The second stage is to medicate the entire population with a drug that kills the parasite and prevents reinfection for four to five weeks. If all goes to plan, the population would be disease-free for around two months. Given that mosquitoes have a four-week lifespan, a entire generation of the insects would be born and would not transmit the parasite. After which, in the third phase, further monitoring and fumigation would be carried out if the parasite was detected anywhere.

On paper, the district of Magude would then be malaria-free. Ideally, the process would then be repeated elsewhere, in other at-risk areas. Unfortunately, there are a number of obstacles that stand in the way of the plan’s admirable goal. One of the main concerns is that fumigation of houses will not be sufficient in eliminating enough mosquitoes to make the plan a success, given that they could arrive from other areas, with the aid of the wind. Other considerations could include the migration of people from place to place, transporting the disease in the process, rejection of medication on cultural grounds or the development of insecticide-resistance among mosquitoes. Indeed, the Mozambique project is intended to provide the necessary scientific data to determine whether such schemes can be effective in the real world, what difficulties may arise and how much it will cost.

Eusebio Macete, director of the Health Research Centre in Mozambique (CISM), said that the plan was two years in the planning, at which time the scientific community finally believed that malaria could be eradicated. This formed part of the rationale to include the target of reducing malaria cases and deaths by 90% by 2030 as part of the United Nations’ Sustainable Development Goals (SDGs). In this context, in Zambia, Macete participated in a pilot-operation similar to the one now being attempted in Magude. The people at CISM, in conjunction with the WHO, settled on Mozambique as a test site because it presents real challenges that would be part and parcel of a full-scale operation to eradicate malaria. The district shares a border with South Africa and 9% of the population is infected with the disease, relatively low in comparison to other regions, where the figure often exceeds 50%.

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The team of people and organisations behind the plan is rather impressive, consisting of the Mozambican Health Ministry, CISM, the Bill and Melinda Gates Foundation and La Caixa, among others. The project has been provided with €21 million to achieve its targets.

Of this money, only €209,000 is earmarked for medicines. The drug of choice will be Eurartesim, a next-generation medicine that combines two active ingredients and which, although it has received necessary WHO-approval, is not yet publicly available. The real costs of the project will be technical and logistical, as well as analysing the results of the plan afterwards. Last September, when recruiting the 538 workers that will help carry out the plan, virtually the only requirement was the ability to speak Shangana, the local dialect, as most of the local people do not speak Mozambique’s official language, Portuguese.

Training consisted of 40 hours in which the recruits were taught the basics regarding malaria, something that many had only heard of in passing, as well as being instructed on how to take blood samples, geotag where tablets have been administered and how best to communicate to the locals that their homes are not being invaded or taken away. Bearing in mind, many of the recruits themselves have never seen a doctor in their life, let alone acted as a sort of proxy for one.

After this preparation, recruits combed the entire district to start talking and distributing drugs to the native population. Although not common, they did meet resistance. “Shortly after the first day, a woman died as a result of cancer. It was very difficult to explain that the cause of death was a tumour, not a malaria pill,” explained Galatas, the project leader. The rumour spread and there were some problems in getting people to take the medicine, which people had to accept by signing a consent form, often signed with just a fingerprint.

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It was not just suspicious locals that the team had to deal with in this preliminary stage; they also had to contend with elephants and thick vegetation to reach some communities. CISM employed the services of local mediators who were able to convince some more of the population to take the drug. After the first round of MDA, around 80% of the population had taken the medicine. Of the rest, a few refused, some were not reachable and the others were too young, pregnant or sick.

Parallel to this part of the plan, other work was being carried out to tackle the mosquito problem. Since early 2015, homes have been sprayed to try and eliminate the insect, with tests being carried out to see how effective the measure is in reducing their numbers and, as a result, the parasite. Other valuable information on what insecticide to use was gained. The investigation has also revealed that mosquito nets, long-used to try and prevent infection, have lost much of their effectiveness.

Whether the plan can be rolled out to other locations, is still not yet known. This month, the second round of MDA will be started and in the subsequent months, the disease and prevalence of mosquitoes will be tracked and monitored. The first results have been, cautiously, labelled as positive, give that it is early days and it is just an experimental plan. Since the first week of 2014, when 117 cases of malaria were recorded in Magude, the number has fallen to just 15. There are many factors at play, including reduced rainfall that would have reduced the insect population, but the team behind the plan are hopefully that their work is having an effect and that the target of eliminating malaria could soon be reached. \

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