Saturday, December 5

Using all existing tools against malaria is not enough to end it | Future Planet


Drugs, mosquito nets and insecticides. Amount of funds and a squad of half a thousand people. A team of researchers set out in 2014 to demonstrate whether with all the existing means recommended by the World Health Organization (WHO) it was possible to permanently eliminate malaria. To do this, they tried to supply malaria drugs en masse to an entire population, they distributed nets to protect them from the bites of mosquitoes, vectors of the disease, and insecticides were sprayed in every house to reduce the density of the insects. They did it in Magude, a very poor and rural district 150 kilometers north of the capital of Mozambique, with 48,448 inhabitants and 10,695 homes. And the result is already known: “The intensive use of currently available tools against malaria can achieve a significant reduction in the burden of the disease, but it is not enough to interrupt its transmission.”

Specifically, in Magude, it was possible to reduce malaria cases by 84.7% in three years – from a percentage of infected people of 9.1% to 1.4% at the end of the period – and it is estimated that avoided more than 38,300 cases. This is the conclusion reached by the Mozambican Alliance for the Elimination of Malaria (MALTEM), coordinated by the Barcelona Institute for Global Health (ISGlobal) and the Manhiça Health Research Center (CISM), with the support of the “la Caixa” Foundation and the Bill & Melinda Gates Foundation and in collaboration with the Mozambican Ministry of Health. Some results that just published the magazine PLOS Medicine.

“In September 2015 we sprayed the houses with insecticides that last between six and eight months and kill mosquitoes if they land on the wall,” recalls Beatriz Galatas, at that time researcher at ISGlobal and epidemiologist at MALTEM. In this “first phase of acceleration”, insecticide-impregnated mosquito nets were also distributed in each of the homes, explains the signatory of the study and currently a consultant in the WHO Global Malaria Program. “Then we distribute antimalarials to the entire population.”

This was such an ambitious experience to end malaria, a disease that in 2018 it affected 228 million people (4% in Mozambique) and killed 405,000, which many media turned their gaze to Africa to tell about it. The positive results were also monitored in the following months. They were so good, they thought they might interrupt the broadcast, Galatas acknowledges. In 2016 the same process was repeated and phase II began the following year. They repeated a round of spraying insecticides and distributing mosquito nets. “And an intervention focused on each case detected in the health center begins: we followed him home and gave antimalarials to his community,” he specifies.

Campaign for the massive administration of antimalarial drugs in Magude, Mozambique.
Campaign for the massive administration of antimalarial drugs in Magude, Mozambique.

In three years, as the researchers have just published, they achieved that reduction of almost 85% in the prevalence of the disease in Magude, where there are only 27 community health workers, nine rural health centers and another referral center with a hospitalization room in the main city, although the most serious cases are sometimes referred to hospitals in the Manhiça district. “And at the same time we did not see deaths from malaria again, except for one in the health center. Before there were more than five a year, let it be known,” details the epidemiologist. “These reductions are unprecedented. They are good news. The result is hopeful: with the tools we have it is possible to reach pre-elimination transmission levels. Although we have not been able to interrupt transmission,” reflects Galatas.

In Magude there are only 27 community health workers, nine rural health centers and another referral center with a small hospitalization room in the main city of the district

Now it is time to study what can be improved to defeat malaria, as the WHO has set as its goal. “We know that the coverage of the intervention is not perfect because there are people who stop taking the medicines, who do not sleep under the mosquito nets or suffer bites outside the houses,” he makes a first assessment. “That may be one reason why malaria cannot be eliminated with these tools. There may also be imported cases.”

Other learnings have to do with the logistics of the intervention. How do you inform and convince a population of 50,000 to participate in such complex research? ISGlobal and the CSIM have been working in the neighboring district of Manhiça for decades and the residents know them, but to those of Magude, they were complete strangers. “We started talking to the authorities, we identified the community leaders. We held meetings with them and with population groups,” says the expert. Thus, they learned about their level of knowledge of malaria, its myths, its remedies … With all this information they developed a communication strategy and obtained, in each round of the program, the informed consent of the 50,000 inhabitants of the place.

“That was one of the success factors, don’t underestimate the communication required.” Still, when the antimalarials were distributed, rumors began about deaths and rare adverse effects that had nothing to do with the treatment. According to the scientists’ data, there were actually 109 adverse events among all the inhabitants after the first administration of antimalarials. And among those normally associated with the medication, a recombinant artemisinin therapy: lack of appetite, vomiting or headaches that remitted after three days of treatment.

Are good news. The result gives hope: with the tools we have it is possible to reach pre-elimination transmission levels

Beatriz Galatas, epidemióloga

Is this model replicable? It is, according to Galatas. “But it does not mean that all countries can do it. You have to prepare. And once prepared, you need funds and resources to do it.” And keep it. “It is very likely that there will be upswings if the intervention in Magude is interrupted. The houses are made of straw, without water or sanitation and there are many mosquitoes,” says Galatas. Although the three years of study concluded in 2018, the project in Magude continues. “We merged it with another”, notes the specialist. But the last distribution of mosquito nets was in 2017 and the next will be in 2023. “There will be a lack of mosquito nets.” And the spraying of insecticides will focus on areas of high transmission, as well as the distribution of antimalarials, which will be done when cases are detected in a community. The intervention “is evolving towards sustainability.”

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