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Background Malaria eradication remains the long-term vision of the World Health Organization (WHO). However, whether malaria elimination is feasible in areas of stable transmission in sub-Saharan Africa with currently available tools remains a subject of debate. This study aimed to evaluate a multiphased malaria elimination project to interrupt Plasmodium falciparum malaria transmission in a rural district of southern Mozambique. Methods and findings A before-after study was conducted between 2015 and 2018 in the district of Magude, with 48,448 residents living in 10,965 households. Building on an enhanced surveillance system, two rounds of mass drug administrations (MDAs) per year over two years (phase I, August 2015–2017), followed by one year of reactive focal mass drug administrations (rfMDAs) (phase II, September 2017–June 2018) were deployed with annual indoor residual spraying (IRS), programmatically distributed long-lasting insecticidal nets (LLINs), and standard case management. The four MDA rounds covered 58%–72% of the population, and annual IRS reported coverage was >70%. Yearly parasite surveys and routine surveillance data were used to monitor the primary outcomes of the study—malaria prevalence and incidence—at baseline and annually since the onset of the project. Parasite prevalence by rapid diagnostic test (RDT) declined from 9.1% (95% confidence interval [CI] 7.0–11.8) in May 2015 to 2.6% (95% CI 2.0–3.4), representing a 71.3% (95% CI 71.1–71.4, p < 0.001) reduction after phase I, and to 1.4% (95% CI 0.9–2.2) after phase II. This represented an 84.7% (95% CI 81.4–87.4, p < 0.001) overall reduction in all-age prevalence. Case incidence fell from 195 to 75 cases per 1,000 during phase I (61.5% reduction) and to 67 per 1,000 during phase II (65.6% overall reduction). Interrupted time series (ITS) analysis was used to estimate the level and trend change in malaria cases associated with the set of project interventions and the number of cases averted. Phase I interventions were associated with a significant immediate reduction in cases of 69.1% (95% CI 57.5–77.6, p < 0.001). Phase II interventions were not associated with a level or trend change. An estimated 76.7% of expected cases were averted throughout the project (38,369 cases averted of 50,005 expected). One malaria-associated inpatient death was observed during the study period. There were 277 mild adverse events (AEs) recorded through the passive pharmacovigilance system during the four MDA rounds. One serious adverse event (SAE) that resulted in death was potentially related to the drug. The study was limited by the incomplete coverage of interventions, the quality of the routine and cross-sectional data collected, and the restricted accuracy of ITS analysis with a short pre-intervention period. Conclusion In this study, we observed that the interventions deployed during the Magude project fell short of interrupting P. falciparum transmission with the coverages achieved. While new tools and strategies may be required to eventually achieve malaria elimination in stable transmission areas of sub-Saharan Africa, this project showed that innovative mixes of interventions can achieve large reductions in disease burden, a necessary step in the pathway towards elimination. Trial registration ClinicalTrials.gov NCT02914145., Beatriz Galatas and colleagues evaluate a multi-intervention program for malaria prevention in southern Mozambique., Author summary Why was the study done? The World Health Organization (WHO) has the vision of malaria eradication. However, whether malaria elimination is possible in areas of stable transmission in sub-Saharan Africa remains a subject of debate. The Magude project was designed to evaluate the feasibility of malaria elimination using the prevention and treatment tools currently available, in a malaria endemic district of southern Mozambique. What did the researchers do and find? The project was divided into two phases aimed to drastically decrease the number of malaria cases to zero (phase I) and to sustain the gains for one year after phase I (phase II). The impact of the project was monitored through changes in the prevalence of infections in the community, the incidence of clinical cases detected at the health facilities (HFs), and the number of cases averted. Reductions of 84.7% of prevalence and 65.6% of incidence were observed during the project, which translated to an estimated 38,369 (76.7%) cases averted. What do these findings mean? Results from this project indicate that the implementation of a package of interventions in sub-Saharan Africa cannot interrupt malaria transmission, and therefore malaria elimination in these areas remains a long-term goal for which new tools and strategies may be required. In spite of this, the Magude project revealed that an intensive implementation of currently available tools recommended by WHO can achieve major reductions in malaria transmission and burden of disease.

BACKGROUND: Maternal mortality is a major health problem concentrated in resource-poor regions. Accurate data on its causes using rigorous methods is lacking, but is essential to guide policy-makers and health professionals to reduce this intolerable burden. The aim of this study was to accurately describe the causes of maternal death in order to contribute to its reduction, in one of the regions of the world with the highest maternal mortality ratios. METHODS AND FINDINGS: We conducted a prospective study between October 2002 and December 2004 on the causes of maternal death in a tertiary-level referral hospital in Maputo, Mozambique, using complete autopsies with histological examination. HIV detection was done by virologic and serologic tests, and malaria was diagnosed by histological and parasitological examination. During 26 mo there were 179 maternal deaths, of which 139 (77.6%) had a complete autopsy and formed the basis of this analysis. Of those with test results, 65 women (52.8%) were HIV-positive. Obstetric complications accounted for 38.2% of deaths; haemorrhage was the most frequent cause (16.6%). Nonobstetric conditions accounted for 56.1% of deaths; HIV/AIDS, pyogenic bronchopneumonia, severe malaria, and pyogenic meningitis were the most common causes (12.9%, 12.2%, 10.1% and 7.2% respectively). Mycobacterial infection was found in 12 (8.6%) maternal deaths. CONCLUSIONS: In this tertiary hospital in Mozambique, infectious diseases accounted for at least half of all maternal deaths, even though effective treatment is available for the four leading causes, HIV/AIDS, pyogenic bronchopneumonia, severe malaria, and pyogenic meningitis. These observations highlight the need to implement effective and available prevention tools, such as intermittent preventive treatment and insecticide-treated bed-nets for malaria, antiretroviral drugs for HIV/AIDS, or vaccines and effective antibiotics for pneumococcal and meningococcal diseases. Deaths due to obstetric causes represent a failure of health-care systems and require urgent improvement.