Say Tchau Tchau to Malaria in the Southern African Region
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.
IRS with organophosphate, in addition to standard LLINs, provides additional protection against malaria transmission in Ghana, Mali, Mozambique, Zambia, and Uganda.
A summary through April 2019
Evidence from multiple countries demonstrates that IRS with new 3GIRS products is a wise public health investment, especially in areas with documented pyrethroid resistance, where house structures and population densities are appropriate, and even where net coverage is high.
Mozambique
A cluster randomised trial is underway in Mopeia District in the Zambezia Province of Mozambique, an area of high malaria endemicity(1). Evidence generated through this study will determine the incremental benefit of 3GIRS in reducing malaria incidence and at what level of cost-effectiveness. All villages in the study area have access to LLINs through mass and routine distribution campaigns, and half of the villages were randomised to receive IRS with Actellic® 300CS as well. Preliminary results from entomological monitoring and passive case reporting in 2017 show:
There was a 50% reduction in An. funestus densities in IRS villages
There were 20% fewer cases presenting at health facilities from IRS villages compared to non-IRS villages
Other project countries
Retrospective observational analyses of the impact of IRS are being supported in Zambia, Mali(2), Ghana, and Uganda. Results to date indicate that:
Mali
After introducing IRS in Mopti region in 2017, there was a 40% reduction in incidence over 4 months (~3,800 cases averted at district health facilities) in IRS communities
In Ségou region, IRS campaigns from 2012 – 2014 averted more than 300K cases over the 3 years
After removal of IRS, sharp increases in incidence were observed in both Bla (70% in 2015) and Barouéli (125% in 2017) districts
Ghana
In 2017, there were 414 fewer cases per 10,000 person-months in IRS vs. non-IRS districts in Northern Region
In 2017, IRS operations were reintroduced in the Upper East region – Kassena and Builsa districts – and case incidence rates fell by an average of 309 cases per 10,000 person months compared to 2016
Zambia
The odds of malaria infection were reduced in areas with IRS:
Non-3GIRS coverage was associated with a 9% reduction in parasite prevalence (AOR=0.91, 95% BCI 0.68-1.20)
IRS coverage with Actellic® 300CS, a 3GIRS product, was associated with a 26% reduction in parasite prevalence (AOR=0.74, 95% BCI 0.44-1.26)
Uganda
IRS with bendiocarb in 2015 (2 rounds) was associated with a 20% decrease in cases (AOR 0.8 [0.7 – 0.9])
IRS with Actellic in 2016 was associated with a 47% decrease (AOR 0.53 [0.43 – 0.66])
Further research and evaluation activities assessing the health impact and cost-effectiveness of 3GIRS are ongoing, and dissemination of final results are expected throughout 2019.
1. Chaccour, et al. 2018. BMJ Glob Health.3:e000610
2. Wagman, et al. 2018. Mal J. 17:19
Links to more news on evidence:
MIM conference, April 2018: sharing preliminary trial results
Working together with partners to expand the evidence base
Mulanje Mission Hospital (MMH) and the Fight Against Malaria 23rd April 2019Public-Private Partnership in Action
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.
IVCC Supporting PAMCA 7th October 2019IVCC had a strong presence at this years’ Pan African Mosquito Control Association (PAMCA) conference held in Yaoundé, Cameroon in September. Derric Nimmo, Technical Manager IVCC, Allison Tatarsky, University of California, San Francisco, Malaria Elimination Initiative and RBM VCWG New Tools, New Challenges and Fredros Okumu from the Ifakara Health Institute, Tanzania, co-organised a symposium entitled ‘Vector Control Innovations to drive progress in malaria and other mosquito borne disease control’ with an outstanding list of speakers to support the symposium.
The symposium delivered the latest research on an ever-expanding toolbox of vector control tools and approaches and disseminated important findings to the PAMCA membership and wider malaria community to inform future research and implementation of vector control across the African continent. It also made visible to national malaria programmes the diverse and high impact tools that can be integrated into countries’ vector control response now or in the future. Topics covered in this symposium were of significant importance to malaria burden reduction and elimination efforts and the control of other mosquito-borne diseases.
IVCC was a sponsor of PAMCAs 6th annual conference and exhibition
The session was co-chaired by Allison Tatarsky and Mercy Opiyo, Manica Health Research Centre, Mozambique, and ISGlobal, University of Barcelona.
Speakers at the symposium were:
Derric Nimmo, IVCC – Overview of the vector control pipeline and rational for an integrated vector management (IVM) response.
Ingrid Etoke, IVCC – The New New Nets project – project scale up and progress to date
Andrew Saibu, IVCC NgenIRS programme, and Richard Oxborough, Abt Associates– early results from PMI VectorLink rollout of 3rd generation IRS insecticides, Fludora Fusion and SumiShield.
Silas Majambere, Mosquito Consulting – Precision larviciding with drone technology and new longer lasting larvicides for Aedes and Anopheles control
Eric Ochomo, KEMRI/CDC – Ivermectin: results from IVERMAL in Kenya
Lina Finda, IHI – Spatial repellents: community-wide effect of transfluthrin-treated eave ribbons
IVCC Hosts 2019 Stakeholder Conference 7th October 2019Under the conference theme, ‘Partnering for Impact’, IVCC hosted its first stakeholder conference in three years in its home town of Liverpool on 19th September. Ahead of the full day conference at Liverpool’s Town Hall, 150 guests were invited a very special pre-conference dinner at Liverpool’s iconic Anglican Cathedral where they were able to meet and network over dinner whilst being treated to a stunning performance from mezzo soprano Jennifer Johnston, artist in residence at Liverpool’s philharmonic orchestra.
IVCC was delighted to welcome Dr Ruth Shakespeare, former medical director of the Mulanjee Mission hospital in Malawi, as the keynote speaker. Dr Ruth’s honest and very real testimony to the challenges of dealing with malaria on the ground grabbed everyone’s attention. Dr Ruth spoke passionately how her hospital ward can become overrun with malaria cases if there is no adequate vector control support in the local area, often with more than seventy percent of hospital beds being filled with children suffering from serious cases of malaria. However, Dr Ruth’s message was also one of real hope. Following the introduction of next generation IRS in the area, malaria cases have fallen dramatically. Moreover, Dr Ruth has shown how the mission hospital approach can be a model for how future IRS and other vector control initiatives can be efficiently and effectively rolled out across local community settings. (A full copy of Dr Ruth’s speech can be found here)
IVCC’s programme for the day was filled with a series of panel discussions and presentations from a range of distinguished guests drawn from all corners of the malaria community, including funders, industry, academia and regulators. As well as valuable networking time, attendees were also able to view an extensive scientific poster programme as well as see a demonstration of new ‘smart-lite’ IRS spray technology from Goizper.
A series of inspiring and thought-provoking sessions ensured that key challenges were discussed and debated and and where achievements had been made, they were appropriately recognised. IVCC would like to thank all participants for making our Stakeholder conference a highly engaging and successful event.