Aiming for elimination

Dr Richard Steketee, Project Director, MACEPA

The Malaria Control and Elimination Partnership in Africa (MACEPA) has been working in Zambia for more than a decade to support the country’s efforts to improve malaria control and ultimately eliminate malaria. Starting in 2014, the MACEPA team collaborated with the National Malaria Control Programme and supported Zambian health officials to conduct one of the largest MDA studies to date.

Dr Richard Steketee explains what the study revealed and the necessary attributes of medicines for MDA.

1. Can you explain how MDA was rolled out in Zambia?

A team of partners1 developed a pilot project in Southern Province in a hightransmission area, where in some places 50–60% of the population were infected with malaria at the end of the transmission season. We mapped out the health facility catchment areas and randomly divided them into three groups: MDA, fMDA or the control group. All groups were provided with good insecticide-treated net coverage, indoor residual spraying, malaria prevention during pregnancy, and case management (with laboratory testing, treatment and case investigation where possible). We did two rounds of the interventions each year for 2 years.

2. What were the key findings?

With the first year of data evaluation, we saw enormous reductions in malaria cases in health facilities, through community outreach and in malaria prevalence rates across all groups, with the greatest reduction of around 90% in the MDA group, 80% in the fMDA and 70% in the control. We were not surprised to see the impact was so positive in the control since they were getting the best care, in terms of prevention and treatment as mentioned, and possibly benefited from a community effect – the overall reservoir was reduced by the trial.

The aim was to shrink the case burden enough so that individual case investigation becomes feasible. We were able to get to that point in a low transmission area in 1 year with MDA.

3. What role do you believe MDA has as we move towards malaria elimination?

It has a key role to play in getting us to malaria elimination – I think of it as an accelerator. It can take transmission from fairly high to very low levels in a short time. Our study also shows that you might also get there with fMDA but it would probably take longer than with MDA.

4. Why was Eurartesim® (dihydroartemisininpiperaquine: DHA-PQP) selected for the trial?

MDA benefits from a highly effective and long-acting drug that both clears infections and protects against reinfection, which is why we chose Eurartesim. The prophylactic effect is probably critical. An acceptable safety profile is also fundamental: you are giving medicines to entire populations of people, most of whom are not sick.
In the future, a single-dose drug would be great; permitting a one-time directly observed treatment enabling us to ensure everyone receives a complete treatment. That said, in Zambia, the vast majority of people took all three doses as recommended – perhaps because we have been working there for some time developing strong community relations, another critical factor for successful MDA.

View our glossary for definitions of Mass Drug Administration (MDA), Focal MDA (fMDA) for malaria, case investigation and more.