Search

Introduction: Malaria molecular surveillance has the potential to generate information on biological threats that compromise the effectiveness of antimalarial interventions. This study aims to streamline surveillance activities to inform the new strategic plan of the Mozambican National Malaria Control Programme (2023-2030) for malaria control and elimination., Methods and Analyses: This prospective genomic surveillance study aims to generate Plasmodium falciparum genetic data to monitor diagnostic failures due to pfhrp2/3 deletions and molecular markers of antimalarial drug resistance, to characterise transmission sources and to inform the implementation of new antimalarial approaches to be introduced in Mozambique (chemoprevention and child malaria vaccination). The study, to be conducted between 2024 and 2026, will use three sampling schemes: a multicluster probabilistic health facility survey in the 10 provinces of the country to detect pfhrp2/3 deletions and markers of antimalarial drug resistance; dense sampling of all clinical cases in representative districts in the south targeted for elimination to characterise malaria importation and identify sources of transmission; and testing of pregnant women for malaria at their first antenatal care visit to assess malaria burden and molecular trends. Using a multiplex amplicon-based sequencing approach, the study will target microhaplotypes informative of genomic diversity and relatedness, as well as key drug resistance-associated genes, pfhrp2/3 deletion and malaria vaccine targets. Key genomic information will be visualised in a dashboard integrated into the District Health Information System V.2-based Malaria Information Storage System for programmatic use., Ethics and Dissemination: The protocol was reviewed and approved by the national ethics committee of Mozambique (Comité Nacional de Bioética para Saúde, Ref: 680/CNBS/23). Project results will be presented to all stakeholders using study-specific brochures and published in open-access journals., Trial Registration Number: NCT06529237., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Indoor residual spraying (IRS) has been and remains an important malaria control intervention in southern Mozambique, South Africa and Eswatini. A better understanding of the effectiveness of IRS campaigns is critical to guide future elimination efforts. We analyze the three IRS campaigns conducted during a malaria elimination demonstration project in southern Mozambique, the "Magude project", and propose a new method to calculate the efficacy of IRS campaigns adjusting for IRS coverage, pace of house spraying and IRS residual efficacy on different wall types. Anopheles funestus sensu lato (s.l.) and An. gambiae s.l. were susceptible to pirimiphos-methyl and DDT. Anopheles funestus s.l. was resistant to pyrethroids, with 24h post-exposure mortality being lower for An. funestus sensu stricto (s.s.) than for An. parensis (collected indoors). The percentage of structures sprayed was above 90% and percentage of people covered above 86% in all three IRS campaigns. The percentage of households sprayed was above 83% in 2015 and 2016, but not assessed in 2017. Mosquito mortality 24h post-exposure stayed above 80% for 196 days after the 2016 IRS campaign and 222 days after the 2017 campaign and was 1.5 months longer on mud walls than on cement walls. This was extended by up to two months when 120h post-exposure mortality was considered. The district-level realized IRS efficacy was 113 days after the 2016 campaign. While the coverage of IRS campaigns in Magude were high, IRS protection did not remain optimal for the entire high malaria transmissions season. The use of a longer-lasting IRS product could have further supported the interruption of malaria transmission in the district. To better estimate the protection afforded by IRS campaigns, National Malaria Control Programs and partners are encouraged to adjust the calculation of IRS efficacy for IRS coverage, pace of house spraying during the campaign and IRS efficacy on different wall types combined with wall type distribution in the sprayed area., Competing Interests: The authors have declared that no competing interests exist. Abt Associates Inc. provided support in the form of salaries for author NC, but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. This does not alter our adherence to PLOS ONE’s policies on sharing data and materials.

Characterizing persistent malaria transmission that occurs after the combined deployment of indoor residual spraying (IRS) and long-lasting insecticidal nets (LLINs) is critical to guide malaria control and elimination efforts. This requires a detailed understanding of both human and vector behaviors at the same temporal and spatial scale. Cross-sectional human behavior evaluations and mosquito collections were performed in parallel in Magude district, Mozambique. Net use and the exact time when participant moved into each of five environments (outdoor, indoor before bed, indoor in bed, indoor after getting up, and outdoor after getting up) were recorded for individuals from three different age groups and both sexes during a dry and a rainy season. Malaria mosquitoes were collected with CDC light traps in combination with collection bottle rotators. The percentage of residual exposure to host-seeking vectors that occurred in each environment was calculated for five local malaria vectors with different biting behaviors, and the actual (at observed levels of LLIN use) and potential (i.e. if all residents had used an LLIN) personal protection conferred by LLINs was estimated. Anopheles arabiensis was responsible for more than 74% of residents' residual exposure to host-seeking vectors during the Magude project. The other four vector species (An. funestus s.s., An. parensis, An. squamosus and An. merus) were responsible for less than 10% each. The personal protection conferred by LLINs prevented only 39.2% of the exposure to host-seeking vectors that survived the implementation of both IRS and LLINs, and it differed significantly across seasons, vector species and age groups. At the observed levels of bednet use, 12.5% of all residual exposure to host-seeking vectors occurred outdoor during the evening, 21.9% indoor before going to bed, almost two thirds (64%) while people were in bed, 1.4% indoors after getting up and 0.2% outdoor after leaving the house. Almost a third of the residual exposure to host-seeking vectors (32.4%) occurred during the low transmission season. The residual bites of An. funestus s.s. and An. parensis outdoors and indoor before bedtime, of An. arabiensis indoors when people are in bed, and of An. squamosus both indoors and outdoors, are likely to have sustained malaria transmission throughout the Magude project. By increasing LLIN use, an additional 24.1% of exposure to the remaining hosts-seeking vectors could have been prevented. Since An. arabiensis, the most abundant vector, feeds primarily while people are in bed, increasing net use and net feeding inhibition (through e.g. community awareness activities and the selection of more effective LLINs) could significantly reduce the exposure to remaining host-seeking mosquitoes. Nonetheless, supplementary interventions aiming to reduce human-vector contact outdoors and/or indoors before people go to bed (e.g. through larval source management, window and eave screening, eave tubes, and spatial repellents) will be needed to reduce residual exposure to the outdoor and early biting An. funestus s.s. and An. parensis., Competing Interests: The authors have declared that no competing interests exist. Abt Associates Inc. provided support in the form of salaries for author NC, but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. This does not alter our adherence to PLOS One’s policies on sharing data and materials.

The "Magude project" aimed but failed to interrupt local malaria transmission in Magude district, southern Mozambique, by using a comprehensive package of interventions, including indoor residual spraying (IRS), pyrethroid-only long-lasting insecticide treated nets (LLINs) and mass-drug administration (MDA). Here we present detailed information on the vector species that sustained malaria transmission, their association with malaria incidence and behaviors, and their amenability to the implemented control interventions. Mosquitoes were collected monthly between May 2015 and October 2017 in six sentinel sites in Magude district, using CDC light traps both indoors and outdoors. Anopheles arabiensis was the main vector during the project, while An. funestus s.s., An. merus, An. parensis and An. squamosus likely played a secondary role. The latter two species have never previously been found positive for Plasmodium falciparum in southern Mozambique. The intervention package successfully reduced vector sporozoite rates in all species throughout the project. IRS was effective in controlling An. funestus s.s. and An. parensis, which virtually disappeared after its first implementation, but less effective at controlling An. arabiensis. Despite suboptimal use, LLINs likely provided significant protection against An. arabiensis and An. merus that sought their host largely indoors when people where in bed. Adding IRS on top of LLINs and MDA likely added value to the control of malaria vectors during the Magude project. Future malaria elimination attempts in the area could benefit from i) increasing the use of LLINs, ii) using longer-lasting IRS products to counteract the increase in vector densities observed towards the end of the high transmission season, and iii) a higher coverage with MDA to reduce the likelihood of human infection. However, additional interventions targeting vectors that survive IRS and LLINs by biting outdoors or indoors before people go to bed, will be likely needed to achieve local malaria elimination., Competing Interests: The authors have declared that no competing interests exist.