Acknowledging the importance of national ownership for the success of any public health activity, the malaria elimination programme placed substantial efforts on the creation of a national platform to support the NMCP to design, fund and implement a national malaria elimination plan for the south. As a result, the Mozambican Alliance Towards the Elimination of Malaria (MALTEM) or “Aliança pela Eliminação de Malária em Moçambique” (ALEMMO) in Portuguese, was created as a collaboration between independent institutions working on malaria in Mozambique. Chaired by the NMCP, MALTEM was launched in July 2015 and included members from various sectors: Multilateral Agencies (WHO, Roll Back Malaria Partnership, United Nations Children’s Fund (UNICEF) and GFATM); bilateral agencies (PMI and United States Agency for International Development (USAID)); academic and research centres (CISM and ISGlobal); and private foundations (Good Bye Malaria (GBM), Fundação para o Desenvolvimento da Comunidade (FDC), BMGF, LCF, the Clinton Health Access Initiative (CHAI), Malaria Consortium and World Vision).
MALTEM’s main objectives stated in its Terms of Reference were to “create the necessary knowledge to inform an operational elimination plan and roadmap for malaria elimination in Mozambique; ensure that the NMCP has the necessary capacities to implement innovative strategies to improve control of malaria and interrupt transmission; align efforts for political engagement and raise further resources of funding including domestic ones; and identify synergies to ensure that potential overlaps or duplicated efforts are avoided and that the best uses of resources are guaranteed.” In-country members of MALTEM met regularly upon NMCP’s request and once a year with the MoH and its funders (BMGF and LCF).
An Advisory Committee for MALTEM (MAC) including malaria elimination experts and NMCP managers from Africa was constituted to provide independent scientific and strategic advice to MALTEM and support the evidence generation process to achieve malaria elimination in Southern Mozambique. MAC members met on an annual basis between 2015 and 2018. Finally, an independent national Malaria Technical Advisory Committee (MTAC) was created under a ministerial decree, to provide technical and scientific advice to the MoH to develop evidence-based policies for the control and eventual elimination of malaria in the country. This body contributed to provide a consensual and stable environment and robust leadership to strengthen the malaria control activities in Mozambique inspired on the successful model of the WHO Malaria Policy Advisory Committee (MPAC).
As a result of the creation of these platforms, the 2017–2022 National Strategic Plan of the Mozambican NMCP included the goal of malaria elimination and created a specific Technical Working Group (TWG), opening the doors to the development and implementation of a detailed subnational elimination plan for the southern, lowest endemic districts. An evaluation was conducted early in 2015 to identify the human resource needed to strengthen the central NMCP in order to respond to the demands posed by the elimination agenda. This analysis revealed that while most NMCP positions were already filled, the existing NMCP personnel lacked necessary core capabilities and competencies, including programme management, concept development, analytical skills and strategic planning, coaching and training skills. In addition to sharing the findings of this assessment with key NMCP stakeholders, three technical staff were hired by MALTEM and seconded to the NMCP to fill the most relevant gaps identified at the time, namely, one vector control officer at central level, one entomological assistant at provincial level (for Maputo province) and one surveillance officer at district level in Magude.
Moreover, in order to address some of the gaps identified in terms of core competencies and capabilities of the NMCP personnel, several MALTEM members organized short courses tailored to individuals at national, provincial, district and community level between 2015 and 2018 on a variety of topics relevant to malaria control and elimination. These courses included malaria surveillance and entomological training (by CISM and ISGlobal), as well as a variety of community-level training on IRS deployment (by Good Bye Malaria), community engagement (by CISM and FDC), and mass or focal drug administration (MDA) activities (by CISM and ISGlobal). Every year, since 2016, CISM and ISGlobal supported the participation of NMCP personnel at the Science of Eradication courses, organized by the Universities of Barcelona, Harvard, and Basel. Additionally, a large group of young Mozambicans was hired to take part in the research activities at CISM to acquire programme implementation and operational research experience, with the vision that they would maintain and expand the in-country expertise on malaria surveillance, epidemiology and entomology.
Several advocacy events were organized involving various Mozambican leaders at all levels. These included briefings with community leaders, district/province health and administrative leaders, as well as the Minister of Health. These meetings aimed to socialize the idea of elimination and establish an inclusive decision-making process to ensure national ownership at all levels. The advocacy effort was also aimed at raising domestic financial commitments both from the private sector as well as from the government. While political commitment was achieved at all levels, leveraging national resources for malaria elimination was challenged by the massive financial crisis that the country is experiencing since 2015.
Strengthening epidemiological and entomological surveillance systems
In 2015, the Mozambique Health Information System changed the procedures for collecting malaria data from the district to the national level, from a paper-based system to an electronic system using the District Health Information System 2 (DHIS2) platform to obtain monthly malaria indicators from all districts in the country, with support from the GFATM. Aggregate malaria data are reported by age group (below and above 5 years of age), including total outpatient visits, RDTs and/or microscopy performed, positive RDTs/microscopy, suspected malaria cases (if not tested for any reason but assumed to be malaria according to symptoms) and treatment provided (ACT). However, data from health facilities (HF) and community health workers (CHW) are still collected on paper and sent to the district to be entered electronically into DHIS2. Since 2015, the malaria elimination programme further expanded the DHIS2 system to obtain monthly electronic data from all HFs and CHWs in four of the eight districts of Maputo Province, namely Marracuene, Moamba, Manhiça, and Magude; while also establishing a rapid reporting system for weekly data collection in the district of Magude. Quarterly data quality audits were gradually established in the 4 districts to evaluate the timeliness, completeness, and accuracy of the data collected.
An entomological surveillance platform was established at six sentinel sites in Magude district in 2015 and in one additional sentinel site in Xinavane town in 2016 to (i) better tailor vector control strategies to the entomological context of the area and (ii) assess the effectiveness of vector control interventions. Vector species composition, mosquito densities and infection rates were monitored in/around Magude town, and insecticide resistance was monitored annually to inform the selection of IRS insecticides. Monthly residual efficacy of IRS was also monitored.
Based on lessons learned, entomological surveillance activities were redesigned in 2018 and new entomological surveillance techniques were implemented, such as human-baited tent traps placed both indoors and outdoors, early-morning pyrethrum spray catches, and window exit traps. Activities were also expanded to Gaza and Inhambane provinces in order to collect essential, timely and quality entomological information to monitor the vector population and inform the IRS strategy planned for Gaza and Inhambane under the MOSASWA regional initiative.
The “Magude” project: assessing the feasibility of malaria elimination
Despite the successes in controlling the disease in sub-Saharan Africa, the region still houses the countries with the highest malaria burden in the world [33]. Interrupting malaria transmission and, ultimately, eliminating the parasite from this region is a long-term goal that will require innovation through research and deployment of elimination strategies specifically tailored to high burden areas [34]. This was precisely the goal of the Garki Project, undertaken in Northern Nigeria in the context of the Global Malaria Eradication Program (GMEP) between 1969 and 1976, to assess the feasibility of interrupting transmission in the African savanna with the tools available at the time. This project compared 7 rounds of IRS with propoxur, to the same IRS approach in combination with 9 or 23 rounds of MDA using sulfalene-pyrimethamine throughout a 2-year period. The main conclusion from the Garki project was that malaria burden had been significantly reduced through these strategies, but elimination was not achieved during the established intervention period with the interventions deployed, and malaria rebounded after its discontinuation [35].
The results have often been interpreted as a confirmation that the goal was at that point unachievable. However, today, newly available tools, together with innovative strategies, may facilitate achievement of malaria elimination in the low transmission areas of Africa [14]. In line with the renewed interest in malaria elimination in southern Mozambique, a malaria elimination project called the “Magude project” was designed by ISGlobal, CISM and the NMCP to revisit the feasibility of malaria elimination in endemic countries of Africa with the currently available tools and technologies.
The district of Magude (Maputo province, southern Mozambique) was selected as the area where the feasibility of malaria elimination would be evaluated based on a series of district characteristics that would pose the type of challenges expected to be faced by the NMCP while implementing a malaria elimination campaign country-wide. This district was included in the baseline malaria surveys conducted in preparation for the 1960s elimination plan, which revealed a 44% prevalence of infection by microscopy in 1958 [7]. It also received the LSDI activities (Zone 3), during which the prevalence by RDT dropped from 77% in 2003 to 33% in 2005 [9] and to < 10% between 2008 and 2011 [36]. The number of cases reported per year from Magude after the end of LSDI increased from 9845 in 2012 to 13,661 in 2014 (38% increase). However, this increasing trend was generally observed throughout the country, but no comparisons could be made with regards to incidence trends during the LSDI due to the inaccuracy of the national routine surveillance data [3, 36].
The aim of the Magude project was to assess the feasibility and impact of a comprehensive malaria elimination package that combined routine malaria control activities with innovative interventions to interrupt transmission. The package of interventions consisted of: (i) standard of care using HRP2-based RDTs for diagnosis and artemether–lumefantrine for treatment, delivered by the MoH in the district; (ii) enhanced entomological and epidemiological intelligence through an improved surveillance and reporting system; (iii) a strong community engagement campaign to maximize acceptance and coverage of interventions; (iv) universal coverage of IRS with DDT and/or Actellic 300 CS (pirimiphos-methyl) performed at the end of the dry season on top of the LLINs distributed by the NMCP in 2014 and 2017; and (iv) two population-wide Mass Drug Administration (MDA) rounds with dihydroartemisinin–piperaquine (DHAp) per year for two consecutive years followed by reactive focal Mass Drug Administration (rfMDA) of contacts of passively detected cases. Several research studies also took place simultaneously in order to assess the clinical and socio-demographic profile of cases with malaria infection through time; the community’s adherence and acceptability to the interventions; DHAp safety and resistance; HRP2 deletions; LLIN integrity and bio-efficacy, the sleeping behaviours in the community in relation to LLIN use; the cost-effectiveness of the interventions, and their impact on school and work absenteeism.
The rationale was that a combination of vector control and population-wide anti-malarial drug interventions would lead to a significant reduction in the mosquito population, as well as in the human parasite reservoir. In the context of a diminished vector population, the long prophylactic effect of repeated anti-malarial drug doses would protect individuals from pre-treatment infected mosquitoes, while the new generation of mosquitoes would feed onto post-treatment non-infected humans thus leading to the interruption of the malaria transmission cycle.
The project was divided into three phases presented in Fig. 3 in detail:
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1.
Preparatory phase (September 2014 to August 2015) a census and a malaria infection prevalence survey were conducted to obtain community baseline data. Epidemiological and entomological surveillance systems were established. During this phase, two studies were performed in the neighbouring district of Manhiça to evaluate the efficacy of chloroquine and the prevalence of G6PD deficiency for the use of primaquine, to inform about their potential use in future elimination interventions [37, 38].
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Phase I (August 2015 to June 2017) implementation of the first set of interventions aiming at interrupting transmission. One round of IRS followed by two rounds of MDA were implemented during two consecutive rainy seasons. A community engagement campaign was also conducted to increase the use of LLINs and maximize acceptance of IRS and MDA. The census was updated in 2016 and two more malaria infection prevalence surveys were conducted at the end of each transmission season (May 2016 and May 2017).
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3.
Phase II and transition to programmatic mode (July 2017 to September 2019) implementation of a second set of interventions aiming at sustaining the gains achieved during phase I through the deployment of three more annual rounds of IRS at the end of the dry season of 2017, 2018 and 2019, coupled with rfMDA established in July 2017; a universal LLIN distribution conducted by the NMCP in December of 2017; two parasite surveys in May of 2018 and 2019; and another census update at the end of 2018.