Mozambique represents 3% of the global burden of malaria but the fight-back is in motion. Public-private partnerships in the region are showing great progress in tackling malaria, protecting people and saving lives. Partnerships over the years supporting malaria control efforts have included ministries of health, The Global Fund, The US President’s Malaria Initiative (PMI), Bill & Melinda Gates Foundation, Goodbye Malaria, Nando’s, Coca Cola, Vodacom, BHP Billiton, Mozal, the Unitaid-supported NgenIRS project among others.
In southern Mozambique malaria has become much less of a threat to the lives of people living in the area. The Tchau Tchau malaria programme has been instrumental in this fight, by spraying the inner walls of houses in all of Maputo Province with long lasting insecticides. These insecticides are effective against pyrethroid resistant mosquitoes, but more expensive than the older insecticide options. The Unitaid-funded NgenIRS project has assisted Mozambique since 2017 with the procurement of 3GIRS at lower prices through a co-payment system. Savings to Mozambique have allowed the NMCP and its partners to expand, thereby protecting vulnerable populations from the devastating health and socio-economic impact of malaria.
The Tchau Tchau programme is part of the MOSASWA initiative, that commenced in 2014 to accelerate progress towards malaria elimination goals in this region and includes collaboration between Mozambique, South Africa and eSwatini (previously Swaziland).
Malaria incidence in Maputo province has decreased by almost 50% since 2014. The programme spanned all eight districts in the province in 2018 with a coverage rate of greater than 90%, protecting more than 1.2 million people. The successes, especially the great reduction of burden of disease in southern Mozambique, attest to the value of public-private partnerships with support and leadership from the National Malaria Control Programme. Funding from a consortium of donors, including the Global Fund, the private sector and more recently the Bill & Melinda Gates Foundation, supports further expansion to areas in the Gaza and Inhambane provinces.
MOSASWA is part of the broader southern African Elimination Eight (E8) Malaria Initiative consisting of eight endemic countries in this region. The frontline countries of Botswana, Namibia, South Africa and eSwatini are aiming to achieve zero local malaria transmission by 2020. Other countries including Angola, Mozambique, Zambia and Zimbabwe are setting their goal of saying “tchau-tchau” (bye-bye) to malaria by 2030. The success of NgenIRS in making multiple affordable 3GIRS products available to enable insecticide-resistance management will be a significant factor in helping to achieve this goal.
The Mulanje Mission Hospital (MMH) works closely with the National Malaria Control Programme (NMCP) of Malawi, ensuring quality delivery of vector control interventions to fight malaria in the district. The catchment population in Mulanje is approximately 85,000 people living in 72 villages.
The MMH vector control programme is implemented and managed by the hospital and is privately funded by the Good Little Company, Fane Valley Co-operative Society Ltd, Ardbarron Trust and Global Affairs Canada through Presbyterian World Service and Development. MMH has invested in indoor residual spraying (IRS) since 2012, when they began using alphacypermethrin, a pyrethroid insecticide, at an average cost of $3 a sachet. The malaria season dovetails with the rainy season, which starts in November and tapers off towards the end of April the following year. Households are sprayed before the peak of the transmission season to minimize contact between infective mosquitoes and people living in these communities.
After expanding IRS operations from 4 villages in 2012 to 22 villages in 2013, a marked decline in the number of u5 deaths was noted at the hospital – a trend that has been sustained over time, as IRS capacity has expanded even further and more effective products are being utilized.
Pyrethroid resistance was first detected by the University of Malawi, Chancellor College, in 2015, prompting the vector control programme to switch IRS active ingredients and adopt a 3rd generation IRS (3GIRS) product. Though the new 3GIRS product, Actellic® 300CS, is long-lasting and effective against pyrethroid resistance mosquitoes, it was also significantly more expensive. Maintaining coverage became a challenge: coverage dropped from 55 villages (47,000 people) in 2015 to 35 villages (30,000 people) in 2016.
MMH first approached IVCC regarding a potential partnership with NgenIRS in 2017, and with the support of NgenIRS the programme was able to procure Actellic® 300CS at a reduced price, less than $20 a bottle, that year. In 2018 the project was able to provide an additional co-payment, and the price dropped even further to $15 a bottle and the programme was able to cover 52 villages and protect an additional 12,000 people, a 28% increase over 2016.
In 2019, the programme will switch to SumiShield® 50WG, the second 3GIRS product out of 3 currently available, and an insecticide with a different mode of action. Annual rotation fulfills a vital part of vector control programmes’ insecticide resistance management plans and is in line with the WHO’s Global plan for insecticide resistance management in malaria vectors (GPIRM).
The successful public-private partnership between the NMCP, MMH and private funders with the assistance of a market shaping initiative NgenIRS (funded by Unitaid), showed great value in accelerating access to effective new vector control products, sustaining coverage and impacting lives in these malaria risk communities in Malawi.
An additional success story from Malawi comes from the NgenIRS partnership with the US President’s Malaria Initiative (PMI), which supports the NMCP with IRS through its VectorLink project in Nkhotakota District. Though the PMI/NMCP IRS program had stopped in 2012, the programme was restarted in 2018 and was able to protect more than 500,000 additional people.
To read more about the MPI VectorLink project in Malawi, click here.All Mosquitoes are Not Equal 27th April 2015
Possibly the most important malaria-transmitting mosquito in Africa is Anopheles gambiae, which likes to bite people indoors between dusk and dawn. This highly specialised behaviour has enabled vector control interventions such as indoor residual sprays and insecticide treated bednets to greatly impact malaria transmission in many regions of Africa.
But other species of mosquito mustn’t be overlooked if elimination and eradication of malaria is to be possible:
Anopheles arabiensis plays an important role in malaria transmission in many parts of Africa. Being more weakly endophilic (ie: likes biting indoors), it is impacted to a lesser extent by indoor focussed vector control tools.
Anopheles funestus is the predominant vector in many parts of Africa,too. Like An. gambiae it mainly bites at night, indoors.
Anopheles nili and Anopheles moucheti play an important role in malaria transmission in humid savannahs, degraded forests and forested areas of equatorial Africa. These mosquitoes are often found near streams and rivers where their immature stages are associated with floating vegetation and other debris.
These two understudied but locally important species, while often found bloodfeeding indoors at night, have a broader range of behaviours and will seek other hosts as well as people.
The variety of mosquito behaviour in Africa alone demands a better understanding that can lead to the development of vector control interventions that target these diverse species and the diversity in their habitat and behaviour.
And beyond Africa, the range of malaria vectors becomes even more complex. Here, there is not only a need for better understanding of the impact of existing vector control tools, but also a clear picture of the novel vector control tools that are needed, especially in low disease transmission settings.
Demonstrating the link between a particular intervention, and disease transmission is a challenging task. But it is a worthwhile and necessary investment for those serious about reducing the burden of malaria.Mosquito Nets Increase Agricultural Productivity 8th October 2015
Mosquito nets have saved millions of lives since they have been widely distributed in sub-Saharan Africa. And now a study in Zambia has shown that they also increase the local harvest.
The one year study of a farming community in Zambia demonstrated that a programme of subsidised net distribution yielded important economic benefits to rural communities due to preventative health investment.
When given access to free nets a typical harvest increased by 14.7%.
Bednets — good for health and good for the harvest.
Health and Agricultural Productivity: Evidence from Zambia; Fink, G. and Masiye, F. Journal of Health Economics 42, 151-164, (2015).
http://www.sciencedirect.com/science/article/pii/S0167629615000521?via%3DihubAfrican Scientists are the Key to African Challenges 8th September 2015
Is it time to recognise that African scientists are the key to African challenges? Listening to some of the excellent speakers at the European Congress on Ttropical medicine and Health has reminded me of just how much talent there is in Africa, and who is best situated to understand the urgency in the work we are engaged in and the very real local problems that are faced in making good ideas work in the field.
The latest member of the IVCC team, Dr Silas Majambere, our Senior Scientist, was speaking this morning about the progress that has been made in vector control. It was a clear and inspiring presentation that left me encouraged about how far we have come in driving back malaria and made me even more determined to see us finish the task and herald the end of this scourge of the African nations.
One of the questions he was asked related to the need for capacity building in Africa. His response was insightful and true. There is a new generation of African scientists, keen and talented, who are increasingly talking together about what they can do to make a difference in the countries where they grew up.
I remember when I visited Burkina Faso last year being impressed with the energy and knowledge of the local scientists we work with there. Some of the ideas we are currently exploring have come from their first-hand knowledge of the problems of malaria, and the life of the mosquitoes that transmit the disease. Visiting some of the local villages I was reminded of how little I know about the everyday lives of the people I am working for. Who best to understand the urgency and local realities than local people themselves.
As IVCC moves towards the final phase of developing new anti-malarial insecticides we are rightly proud of this monumental advance in the war against malaria. (Bear in mind these will be the first new public health insecticides in 30 years!) But now it is time to look towards the people who will benefit from these new tools and, not only harness their local understanding of how they should be applied, but also equipping this new generation of African scientists in finding their own solutions.
From what I have seen and heard I am greatly encouraged and hopeful that, given the tools they are more than able to finish the job.