A witness to malaria's devastation

“I would need more than ten fingers to count the number of times I suffered from malaria,” shares Manuela Brito, a nurse, a fieldworker for a malaria project, and one of the next generation of women who believe that there is no time to be lost in the fight against malaria.

For several years, Brito worked as a nurse in a maternal health unit. “It was hard to witness the fear in the eyes of pregnant women suffering from malaria. No amount of verbal reassurance could alleviate their concerns, after all, the threat of malaria loomed over two lives, not just one. And yet, those who make it to the hospital are still the lucky ones.”

Door-to-door

Brito leads a team of field workers implementing the BOHEMIA project in the Mopeia district of Mozambique. Over the last two years, she has taken on a variety of tasks – training and monitoring fieldworkers, collecting household data, testing children for malaria, and distributing the trial medicine.

“Mopeia is one of the hardest-hit regions in the entire country. Two rainy seasons, poor access to health facilities, and poverty exacerbate the situation.” Brito explains. “Our job is not easy. Not only is it physically exhausting to go door-to-door in hamlets dispersed across remote areas, but it can also be emotionally draining to face the devastation of malaria on a daily basis.”

It takes a community

Community acceptance is key to the success of new health interventions. Anthropologist Marla Rufai joined BOHEMIA's social sciences team to unpack some of the nuances of working with the community for the smooth implementation of the MDA.

In the early stages of the project, the social sciences team spent months conducting participatory research in the region, understanding socio-cultural cues that would later aid in the implementation of the trial. Gender roles, social activities, and perceptions about health systems were some of the many themes that the researchers sought to understand.

“Some of the perks of integrating social sciences in the BOHEMIA project have been: high acceptance rates of the intervention, quick dispelling of misinformation, and stronger social ties between the project team and the community,” concludes Rufai.

Animals in a malaria trial

Almudena Sanz initially joined BOHEMIA as part of her Master's thesis research. “I realized that the link between human and animal health was fairly unexplored in approaches to tackle disease transmission,” shares Sanz.

So, she teamed up with her colleague Mussa Sale and set up the veterinary arm of the trial in Mopeia. The hypothesis of this sub-study is: Given that some mosquitoes are zoophagic, that is, they feed at least partly upon animals, reductions in malaria transmission could be greater in areas where ivermectin has also been administered to cattle and pig populations as compared to those in which only humans received treatment.

The most challenging part of her work was to convince the pig and cattle owners to not slaughter or sell their animals during the 6-month trial!

The resistant vector

The BOHEMIA insectary is a scientific marvel in Mopeia village. With thousands of breeding larvae and mosquitoes, two temperature-regulated rooms, several microscopes, and a highly skilled team, the insectary has everything an entomologist can dream of.

The entomology team is seeking to understand how the ivermectin MDA affects malaria vector populations and their transmission activity. “By targeting mosquitoes indoors and outdoor, this approach might complement the existing tools like bed nets and residual spraying,” explains Claida Alves.

Research reveals that Mozambique records some of the highest levels of insecticide resistance in southern Africa. “We have generated insecticide resistance profile data for malaria vectors in the Mopeia district. This data shows that malaria vectors in Mopeia are resistant to multiple insecticides, highlighting the need for new vector control tools and strategies," she adds.

Joining the dots

For a project the size of BOHEMIA, datasets are massive. Yet, women like Paula Ruiz-Castillo, Mirene Adão, Verónica Ribeiro, Marta Ribes, and Aina Casellas rose up to the challenge of joining the dots. Their work can be largely divided into three stages.

While Ruiz-Castillo and Ribes designed and developed the data processes, Adão and Ribeiro worked in the field, collecting huge amounts of data, cleaning it rapidly, investigating errors, as well as monitoring progress in the field.

“Our data manager took a 'clean as you go' approach where we tried to detect and fix errors in parallel to the data collection process. Thanks to this approach, our analysts will have an easier time working with the datasets,” explains Ruiz-Castillo.

Analyst Casellas is not one to be intimidated by the numbers. “The size of our data is our strength. I am excited to see what the statistical analyses reveal about the safety and efficacy of this intervention.”

Mopeia, a site for cutting edge health research

Mopeia was a blank slate when the trial coordinator Patricia Nicolas first arrived. She and her team set out to establish a quality site, equipped with all the human and material resources to carry out a large-scale trial.

“It was a huge challenge to implement such a big project in a new trial site like Mopeia. Yet, we paved new paths, building strong community-led networks to reach remote populations and work together to test this novel and complementary tool against malaria,” shares Nicolas.

For Amélia Honwana, a doctor in the project's medical team, BOHEMIA was also an opportunity to support the local health system. “When I am not working on the project, you will usually find me in the local hospital, helping out in the emergency room.”

Though the BOHEMIA project in Mozambique will end in the coming months, the human and physical infrastructure in Mopeia will remain. “We hope that the community networks, the demographic data, and the fully equipped research centre serve other projects that aim to conduct health research in the area,” concludes Mary Mael, the project manager.