Eliminating Malaria in Tanzania: Lessons from China’s Success
My name is Yeromin Mlacha, and I’m a vector biologist from Tanzania. I love studying mosquitoes and find their mating behavior really interesting. Sometimes, you will see a large swarm of mosquitoes buzzing above your head. Those are male mosquitoes showcasing how strong they are, all gathered around one or two females. The female then chooses one male to mate with. They fly up to mate, and after mating, that male never returns. However, my research is not just about understanding these behaviors but also about controlling mosquitoes and the diseases they spread.
Malaria, as one of the most well-known and deadly mosquito-borne diseases, causes nearly 600,000 deaths worldwide each year, with Tanzania being one of the 11 countries that bear 70% of the global malaria burden. There is a town in the country called Ifakara, meaning “the place to die” in the local language due to its history as a malaria hotspot. My institution, the Ifakara Health Institute, aims to improve health and well-being through research, education, and service, particularly against malaria.
Tanzania has made great strides in the fight against malaria, reducing disease mortality by 71% from 1990 to 2021. However, progress plateaued by 2017, and a significant obstacle to continued progress is our lack of an effective surveillance and response system, largely due to the absence of a proper address system to track patients.
Unlike us, China successfully achieved malaria elimination by 2021 after decades of effort, which is a remarkable feat for a country that reported 30 million cases annually in the 1940s. Among all the measures taken in China, most notably, it pioneered a surveillance and response strategy known as “1-3-7,” which shortened the time for local health authorities to report malaria cases and begin testing others for exposure to the parasite.
From 2015 to 2021, my institution collaborated with the National Institute of Parasitic Diseases at China CDC on a project aimed at applying China’s experience in Tanzania.
We initially wanted to implement the 1-3-7 model in Tanzania but encountered two major challenges. First, the model requires on-site investigations within three days, necessitating a comprehensive address system, which we lack. Second, the model is primarily designed for low-endemic areas and focuses on individual cases. However, in Tanzania, with its high malaria prevalence, health facilities report many cases daily, often from various villages.
After research and discussion, we decided to remove the “3” from the 1-3-7 model. From past experience, 95% of the cases in our country are locally acquired, which differs from the situation in China. Therefore, with limited resources, we can omit on-site investigations to determine whether cases are locally acquired or imported.
In our modified model, called “1,7 malaria reactive community-based testing and response (1,7-mRCTR),” we track villages rather than individual cases. This system will count the cases that go to health facilities according to the source villages, and list the three villages with the highest malaria incidence in the past seven days.
In response, our trained community health workers go to these villages to conduct testing and treatment. They would form a temporary station and invite everyone to come and be screened for malaria. Those who test positive will be given anti-malarial drugs. All of this is free.
Another lesson we learned from China is the importance of health education. We follow China’s good practice by delivering educational messages during visits to health facilities tailored to different age groups. For example, for young people, who make up the majority of the population, we came up with the Malaria Cup football game because they love football. Teams from each village come to participate in the competition, and the winners will receive prizes. This allows us to reach many adolescents simultaneously in one location and educate them.
Our two-year intervention in two areas resulted in a dramatic decline in malaria cases and prevalence. For example, malaria prevalence fell by 81% in the entire intervention group, which was a huge improvement compared to where it started.
Then we launched the second phase of the project, expanding the research area and carrying out work in three districts to further verify the feasibility and potential of 1,7-mRCTR.
But we also encountered some challenges.
In Africa, malaria affects rural communities far from health facilities. Sometimes it might be a three-hour drive through mud to get to a village, sometimes you need to walk five kilometers. This also explains why people don’t go to medical facilities. Worse still, during the second phase of the project, the COVID-19 outbreak led to a suspension of activities involving gatherings, including those using 1,7-mRCTR. As a result, our project was suspended for at least 13 weeks.
Because of these challenges, we expected that the second phase might not turn out as well as the first. Surprisingly, the overall prevalence in the three intervention areas was reduced by 55%.
Currently, we are working on the third phase, with discussions ongoing between the governments of China, Switzerland, and Tanzania. And good news is that 1,7-mRCTR is also being piloted in Zambia, Senegal, and Burkina Faso. But before it can be fully rolled out, several rounds of analysis, including cost analysis and cost-benefit analysis, are still needed.
It is safe to conclude that 1,7-mRCTR proves to be a promising tool for reducing the burden of malaria in highly endemic areas. Despite its ominous name, Ifakara is now one of the safest places, with malaria nearly eliminated after years of cooperative efforts.
I hope that the method we inherited from China and have implemented in Tanzania, combined with other measures such as long-lasting insecticidal nets, innovative antimalarial drugs, and vaccines, will help the entire African continent achieve malaria elimination sooner.
About the author:
Yeromin Mlacha is a vector biologist and malaria prevention and control expert at the Ifakara Health Research Institute in Tanzania.
