How Zambia is beating malaria

COMMENT

As doctors, we have seen the devastating effect of malaria on children, families and communities. We have heartbreaking memories of patients lost to this preventable disease. But we are now witnessing a new history.

On April 25, Zambia launched a national elimination strategy. We are aggressively pursuing the goal of a malaria-free country by 2021. Because we are building on an effort that dramatically reduced the disease, we expect our intense investment and commitment to show substantial progress as soon as 2018.

Zambia’s ambitious approach – “zambitious” as we call it here – comes from impatience with business as usual. In the past, it was common for clinic beds to be full of people suffering from malaria. Yet now in many places, this is not the case. How did this happen?

Simply put, it was steadfast political will backed by strong and united partners. We embody this strategy: ministry of health leadership combined with support from the Global Fund to Fight Aids, Tuberculosis and Malaria, the United States President’s Malaria Initiative, Path (through its malaria control and elimination partnership in Africa programme), the World Bank and other partners. Add to that growing evidence about what is needed and what works, including near real-time data on the local malaria situation.

Zambia has a history of not settling for the status quo. We were the first country to adopt artemisinin-based combination therapies, the treatment that replaced chloroquine. We are the only African country to have done five national malaria surveys to measure progress. And Zambia commits more domestic funding to malaria than any other country in the region.

Thankfully, we are not alone. Zambia sits on the northern edge of the Elimination 8, a coalition of eight Southern African countries committed to malaria elimination by 2020.

Some of the worst malaria on the planet is on our northern border and we were not expected to achieve elimination until 2030.

But we decided to try new approaches to shorten the timeline.

A decade ago, most countries used only localised strategies. Zambia decided to take malaria control interventions &ndash: bed nets, insecticides, diagnostics and drugs – nationwide.

Many said the health system could not handle it. But we succeeded – evidence showed that malaria cases in children and malaria deaths were more than halved.

Now we are again choosing the bold path. We are convinced that we can reach national elimination with smart application of our tools, including accelerators that quickly lower transmission by tracking down and killing the malaria parasite.

One of the most promising accelerators is malaria mass drug administration (MDA). A short-term intervention, MDA is designed to clear malaria infections out of entire communities. It is especially useful at reducing the asymptomatic reservoir of the disease – malaria parasites that linger in people who do not show any symptoms, yet can still spread the disease if they are bitten by a mosquito.

MDA was tried before, but was never fully successful because there was no follow-up plan. Zambia decided to see if MDA could be effective when combined with modern diagnostic tests, new malaria drugs, improved local surveillance systems and, most importantly, national and community commitment. Our MDA study was a serious intervention on a grand scale. More than 150000 people in Southern Province were treated during the malaria MDA trial in 2015 and 2016.

The result: in two years, an 87% reduction in cases in the study area and a 97% reduction in facility-reported malaria deaths.

By the end of the study – the results were published in 2016 in the Journal of Infectious Diseases – more than half of the 60 health facility areas had no malaria infections. Most promising of all, we saw a 93% reduction in malaria in children in Southern Province.

The lessons learned from this study are being used to inform our ongoing zambition. In December, we treated 243 957 people over a 21-day period. Later this year, we are expanding MDA to Western Province.

Accelerators such as MDA are one time-bound component in the elimination toolbox. Once transmission is reduced to low levels, trained community health workers step in to identify and treat any remaining or imported infections. More than 2 500 such workers were chosen by their communities to conduct malaria surveillance at the household level. Each month they relay information into the national database using mobile phones, helping us determine where to target our resources.

We are working with modellers and data experts from around the world to help guide the programme. One effort, called Visualize No Malaria, sifts through layers of data, creating maps and figures to predict, for example, where transmission outbreaks are likely. The national malaria programme’s insectary and lab are also tracking mosquitoes and analysing DNA in the malaria parasite to better understand patterns of infection.

Every day is a fight against the malaria parasite and its mosquito vector, and progress represents lives saved and lives freed from disease – Zambians who are healthy to plant crops, mine copper, pursue studies and advance beyond the status quo.

Success in Zambia will serve all of our neighbours, providing them with further protection. The region must recognise this historic opportunity and increase its commitment. Our dramatic success against malaria may cause government and donor purse strings to tighten in the belief that malaria is no longer a “problem”. But any step back runs the risk of resurgence. Zambia’s national elimination must be part of a regional elimination, which is a critical component of global eradication.

We are determined to see Zambia free from malaria in our lifetimes, dispatching it to the dustbin of diseases. We can imagine no greater gift for our children.

Dr Elizabeth Chizema is the director of the National Malaria Elimination Centre at Zambia’s ministry of health. Dr Nanthalile Mugala is the programme director for Zambia at Path, an international health organisation

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