Between 2022 and 2023, the Mozambican National Malaria Control Programme developed a locally-tailored implementation strategy for programmatic mass drug administration (pMDA), which was piloted in Chidenguele (Manjacaze District), southern Mozambique. Two rounds of door-to-door pMDA with dihydroartemisinin-piperaquine were conducted, targeting 59,271 individuals in 14,818 households, according to administrative data. Satellite imagery was used to support household enumeration and field navigation. An evaluation of the pMDA was conducted. Coverage was assessed using programmatic data and a community household survey (n = 770 individuals). A quasi-experimental design, using neighboring areas not receiving pMDA as a comparison group, was used to evaluate the impact of the pMDA on clinical malaria incidence during the ensuing 22 months through a controlled interrupted time-series analysis of routine surveillance data, adjusting for covariates. According to programmatic data, household availability coverage (households reached/target households) increased from 59.4

BACKGROUND:Novel antimalarial combinations are needed to address the threat of emerging resistance to artemisinins. This study evaluated the safety, tolerability, pharmacokinetics, and efficacy of a single oral dose of cabamiquine-pyronaridine for the treatment of uncomplicated Plasmodium falciparum malaria. METHODS:This two-part, multicentre, open-label, phase 2a study (CAPTURE 1) enrolled patients aged 12-55 years from five hospitals in four countries across Africa with acute uncomplicated P falciparum monoinfection, defined by microscopically confirmed parasitaemia, with parasite densities of 1000-50 000 asexual parasites per μL in part A and 1000-150 000 asexual parasites per μL in part B; exclusions included mixed Plasmodium infections, severe malaria, liver abnormalities, and previous antimalarial use. In part A, patients received a single oral dose of 330 mg cabamiquine free base and 360 mg pyronaridine tetraphosphate. In part B (cohort B0), patients received 660 mg cabamiquine and 720 mg pyronaridine adjusted for bodyweight. Additional planned cohorts B1, B2, and B3 (control) were not initiated owing to early trial termination after cohort B0 in part B following higher-than-predicted cabamiquine exposure, data monitoring committee concerns about 2-day dosing, and high observed efficacy in the studied cohorts. The primary outcomes were safety and tolerability, assessed through the incidence, severity, and seriousness of study intervention-related treatment-emergent adverse events (TEAEs), and day 28 post-treatment efficacy in treated patients assessed using PCR-corrected adequate clinical and parasitological response (ACPR). This study is registered with ClinicalTrials.gov, NCT05689047, and is complete. FINDINGS:Between March 29, 2023, and May 8, 2024, 75 patients were screened, of whom 38 patients were enrolled (12 in part A and 26 in part B) and treated in the study. TEAEs occurred in 25 (65·8%) of the 38 patients and were predominantly mild or moderate in severity (grade 1 or 2), and no serious adverse events or deaths were reported. The day 28, PCR-corrected ACPR in part A was 91·7% (11 of 12 patients [95% CI 64·6-98·5]) and 92·3% (24 of 26 patients [95% CI 75·9-97·9]) in part B. INTERPRETATION:A single dose of cabamiquine-pyronaridine showed promising safety and efficacy in this proof-of-concept trial in adults and adolescents, which supports further development for combination therapy in larger trials and in children. FUNDING:Merck KGaA, the EDCTP2 Programme, and the Swedish International Development Cooperation Agency (Sida).

Abstract Background The World Health Organization (WHO) recommends Mass Drug Administration (MDA) to reduce malaria transmission in low-transmission settings, with a target coverage of at least 80%. To maximize impact, the development of effective and sustainable programmatic implementation strategies is essential. Between December 2022 and February 2023, two rounds of programmatic MDA (pMDA) were implemented in Chidenguele, in Gaza province, Mozambique. The target population was approximately 59,271 individuals. Door-to-door drug distribution, using dihydroartemisinin-piperaquine, was guided by satellite imagery-based mapping. Methods A mixed-methods evaluation was conducted to assess operational performance —including acceptability, appropriateness, coverage, feasibility, fidelity, and adoption— using a community household survey (n = 770), a health staff survey (n = 28), and field observations (n = 149). Results Among household survey participants eligible for medication during round 2, 96,2% (607/631) accepted to participate in the pMDA. All health staff survey participants and 91,3% (703/770) of household survey participants considered taking antimalarials while asymptomatic to be an acceptable preventive measure. All health staff survey participants (28/28) and 84,1% (648/770) of household survey participants felt the intervention was appropriate for reducing malaria transmission in the community. Programmatic or contact coverage (proportion of survey participants that received pMDA treatment) reached 73,9% (569/770), while operational coverage (proportion of those present at the time of the intervention that received pMDA treatment) was 90,2% (569/631). All health staff survey participants (28/28) considered the pMDA implementation strategy feasible to implement. In terms of fidelity, direct observations of pMDA household visits showed that pMDA distribution teams correctly explained the purpose of the visit in 74,5% (111/149) of interactions, requested verbal consent in 86,6% (129/149), and emphasized the importance of completing the treatment in 60,4% (90/149). Health staff survey participants showed strong willingness to adopt the procedures, with 86.0% (24/28) and 96.0% (27/28) expressing high commitment in rounds 1 and 2, respectively. Conclusions Despite the pMDA delivery strategy being implemented with good operational performance and being well accepted by the community and health staff, reaching the 80% coverage target remains challenging. Sustained collaboration and active engagement from communities, partners, and policymakers, and enhancement of some key outcomes, such as the fidelity of the implementation, are critical to improving coverage and ensuring the success of pMDA campaigns.

Malaria remains a significant public health concern in Mozambique. Early diagnosis and the prompt use of effective drugs are essential for malaria control in endemic regions. This review aims to synthesize the existing evidence concerning the efficacy of artemether-lumefantrine (AL) in treating uncomplicated Plasmodium falciparum malaria in Mozambique. This systematic review and meta-analysis include studies evaluating the efficacy of AL using the World Health Organization standard protocol in Mozambique across children under 5 years of age and adults, regardless of publication year. The main outcome was efficacy, defined as the proportion of participants who had an adequate clinical and parasitological response, without or with Polymerase Chain Reaction (PCR) correction. Other outcomes included day 3 positivity rate, early treatment failure, late clinical failure and late parasitological failure. Data were obtained from electronic searches of PubMed and ScienceDirect citations. The Rayyan software assessed the adherence of all studies to the stipulated inclusion criteria. The studies' risk of bias was assessed using the Cochrane Handbook for Systematic Reviews of Interventions. Pooled efficacy was calculated based on the per-protocol population. The heterogeneity between studies was assessed using Cochran’s Q statistic, the τ2, and the I2 statistic, and all statistical analyses were performed using the R software. Six studies, comprising 20 single-arm trials and including 1862 participants, were included in the analysis. Studies were conducted across Mozambique and enrolled both children and adults from the country’s three main regions (South, Centre, and North). The pooled uncorrected efficacy of AL was 91.0

Introduction: Healthcare workers (HCWs) faced a heightened risk of SARS-CoV-2 infection compared to the general population. The Bacillus Calmette-Guérin (BCG) vaccine, used for over a century, is known to modulate immune responses to various pathogens, including the SARS-CoV-2. This study examines the association between lifetime BCG vaccination and the risk of SARS-CoV-2 infection among HCWs in Cape Verde. Methods: We conducted a case-control study among HCWs in Cape Verde in 2021. Cases were HCWs, 18 years or older who tested positive for SARS-CoV-2 via PCR or Rapid Antigen Test, identified by Public Health Authorities, while controls were HCWs, 18 years or older with no reported or suspected SARS-CoV-2 infection, confirmed by POC Rapid Antigen Test. Both were selected from HCWs of three hospitals on Santiago and São Vicente islands in Cape Verde. The primary outcome measured was the status of SARS-CoV-2 infection (yes/no), and the primary exposure examined was BCG vaccination status (yes/no). The study also considered sociodemographic, epidemiological, and employment variables. Data collection was conducted using an electronic questionnaire applied to all participants, and analysis employed a maximum likelihood forward selection logistic regression model to assess the impact of BCG vaccination on the odds of SARS-CoV-2 infection. Results: The study included 215 cases and 250 controls. Most cases of SARS-CoV-2 infection that occurred before completion of COVID-19 vaccination were identified through epidemiological surveillance or among people who reported being quarantined and/or absent from work after diagnosis. Hospitalization for COVID-19 was required for 7.7% of the cases. Persistent symptoms following COVID-19 were reported in fewer than 1% of cases. Having at least one child in the house, not having double employment, and being of normal weight were more likely to be observed among cases than controls. BCG vaccination showed no association with SARS-CoV-2 infection (aOR of BCG-vaccinated vs. not BCG-vaccinated = 0.76 [0.48; 1.20]). Completing the COVID-19 vaccination regimen was associated with reduced odds of SARS-CoV-2 infection, but there was likely some reversed causation, as vaccination was postponed for 6 months post-COVID-19 infection for cases. Conclusions: Lifetime BCG vaccination did not reduce the likelihood of SARS-CoV-2 infection among HCWs.

Imported malaria is a critical obstacle to achieving elimination in low transmission settings, but importation classification tools combining human mobility and parasite genomics are lacking. A Bayesian model combining epidemiological, human mobility, and parasite genetic data was developed to estimate malaria importation and geographic origins of Plasmodium falciparum cases. Using microhaplotype-based genetic relatedness from 1605 samples across nine Mozambican provinces in 2022, the study focused on two low-transmission districts in the south: Magude and Matutuine. Parasites from southern Mozambique showed lower genetic relatedness to those from northern/central regions (0.021) than the national average (0.034, p<0.001), indicating limited connectivity. Overall, 42% (88/207) of infections in these districts were classified as imported, mainly originating from Inhambane province (63% [55/88]). Imported cases showed higher parasite complexity than local ones (odds ratios [OR] = 1.3). Importation rates differed markedly between districts – Matutuine (48.60%, 87/179) was far more affected than Magude (10.71%, 3/28) – highlighting the need for localised rather than uniform elimination strategies. In Matutuine, importation appears to be actively sustaining transmission, suggesting that reducing malaria burden in source regions (particularly Inhambane) and targeting travellers from central and northern Mozambique would have the greatest elimination impact.

BACKGROUND:The RTS,S/AS01E malaria vaccine provides partial protection against Plasmodium falciparum, largely mediated by antibodies targeting the circumsporozoite protein. Correlates of protection remain incompletely defined and have focused mainly on peak IgG responses to the immunodominant NANP-repeats, with less known about antibody durability or responses to the C-terminus of circumsporozoite protein. METHODS:In this observational study, we evaluated IgG responses to NANP-repeat, C-terminus, and full-length circumsporozoite protein constructs at five timepoints before and after primary and booster vaccination, in children aged 5-17 months from six African countries enrolled in the RTS,S/AS01E phase 3 trial (NCT00866619, 2009-11). Antibody kinetics were analysed with linear regressions, and associations with clinical malaria risk over 1 year with Cox models. FINDINGS:Between May 25, 2009, to March 5, 2010, 1292 children were recruited and included for analysis in this study. IgG levels declined more slowly for C-terminus than for NANP-repeat over 17 months after primary vaccination (geometric mean fold change 0·099 [95% CI 0·089-0·110] vs 0·055 [0·048-0·062]; p<0·0001). The booster significantly enhanced C-terminal IgG, exceeding post-primary peak levels (geometric mean fold change 1·98 [95% CI 1·77-2·21]), whereas NANP-repeat responses were restored but remained below post-primary levels (geometric mean fold changes 0·57 [95% CI 0·51-0·63]). Higher circumsporozoite protein IgG levels correlated with reduced malaria risk, particularly during maintenance phases, with stronger associations for C-terminus, which remained independently protective after adjustment for NANP-repeat antibodies (hazard ratio 0·60, 95% CI 0·43-0·83; p=0·0021). After boosting, maintenance but not peak IgG levels correlated with reduced malaria risk. INTERPRETATION:IgG to circumsporozoite protein C-terminus are more durable than those to the NANP-repeats. Antibody maintenance emerges as a stronger predictor of RTS,S/AS01E vaccine efficacy than peak responses. FUNDING:USA National Institute of Allergy and Infectious Diseases, National Institutes of Health; PATH and Malaria Vaccine Initiative; Spanish Ministerio de Economía y Competitividad; Instituto de Salud Carlos III; CERCA programme; and Secretaria d'Universitats i Recerca del Departament d'Empresa i Coneixement, Generalitat de Catalunya.

Severe pediatric malaria remains a pressing global health issue. Laboratory parameters may provide early risk and severity stratification for better disease management, beyond current clinical severity scores. This study aimed to identify host biomarkers of immune and endothelial activation and parasite biomass in children with severe malaria (SM) compared to uncomplicated malaria (UM). We conducted a case-control study in a rural hospital in southern Mozambique from 2014 to 2016, recruiting patients under 10 years old with Plasmodium falciparum SM as cases, and patients with UM matched by age, sex, and parasitemia as controls. We compared plasma levels of biomarkers associated with total parasite mass (HRP-2), biomarkers of host response to infection (Angpt-1, Angpt-2, sTie-2, BDNF, CysC, sFlt-1, IL-6, IL-8, IP-10, sTNFR-1 and sTREM-1). All biomarker levels except Angpt-1, BDNF and CysC were significantly higher in children with SM. HRP-2 levels significantly differed between cases and controls, strongly correlating with Angpt-2, sTie-2, sFlt-1, TNRF, and sTREM-1, both in SM and UM. In conclusion, host biomarkers indicative of immune and endothelial activation were associated with malaria severity and HRP-2, even after controlling for matching variables, potentially offering targets for risk-stratification and adjuvant therapy.

Malaria remains a preventable and treatable disease; however, recent efforts to reduce mortality have plateaued. Although artemisinin-based combination therapy demonstrates high efficacy in controlled clinical settings, its real-world effectiveness is often compromised by suboptimal patient adherence. Specifically, the artemether–lumefantrine regimen, administered twice daily over 3 days, has been associated with reduced compliance due to its complexity. Simplified therapeutic regimens that enhance adherence could, therefore, play a critical role in reinvigorating progress toward malaria elimination. Over the past decade, substantial progress has been made in the discovery and development of new chemical entities for malaria treatment, although the most advanced candidate still requires a 3-day dosing regimen. Treatment shortening most likely requires multiple drug combinations. Multi-drug regimens, such as artemether–lumefantrine–amodiaquine appear to be well tolerated, but these are under development to address emerging resistance to lumefantrine and will be unlikely to improve compliance. Sulfadoxine–pyrimethamine was originally developed as a single-dose curative treatment for malaria, and although use was curtailed early due to rapid selection for resistance, it continues to be deployed as a single therapy or in combination with other medicines, in treatment and in prevention. Combining with artemisinin-based combinations would be an option for potential treatment shortening. Of the registered antimalarial treatments, only a few of the artemisinin-based combinations are suitable. Mefloquine is excluded for tolerability concerns, amodiaquine because of its use in seasonal malaria chemoprevention, and lumefantrine and piperaquine due to concerns of emerging resistance. Pyronaridine–artesunate emerges as a promising candidate for association with sulfadoxine–pyrimethamine. A four-drug, single-dose antimalarial regimen would transform compliance, and play a major role in disease elimination. However, to ensure its success it will be important to assess the safety and tolerability of the novel association and understand its efficacy in regions with evolving resistance to sulfadoxine–pyrimethamine. Clinical studies need to assess the risk for selection of strains with novel resistance mechanisms against artesunate or pyronaridine. Importantly, a comprehensive clinical evaluation will generate valuable real-world insights into community acceptance and operational feasibility. This information will be an important foundation for future design of single dose malaria therapies involving new chemical entities.

BACKGROUND:Imported malaria from southern Mozambique drives low levels of disease transmission in KwaZulu-Natal, South Africa. Therefore, the South African Department of Health funded implementation of indoor residual spraying (IRS) in Mozambiquan districts identified as sources of malaria infection for border communities in KwaZulu-Natal. IRS was initiated in districts of Guija, Inharrime, Panda and Zavala. To determine impact of spraying on malaria transmission in these districts, data relating to incidence and prevalence was collected before spraying (2018) and before the second round of spraying was completed (2023). Implementation of IRS was also monitored to ensure optimal spray coverage was achieved. METHODS:The study was a cross-sectional survey conducted in 6 sentinel sites in each of the four afore-mentioned districts, focusing on children 6 months to < 15 years from selected households. There was a baseline and an endline cross-sectional survey. Baseline prevalence took place during March-April 2022 whereas the endline surveys occurred during February-March 2023. One hundred and twenty children from each sentinel site were tested for malaria using rapid diagnostic tests. Monthly malaria cases were obtained from health facilities in each study district. Spray data was obtained from LSDI2 initiative who implemented IRS in the targeted districts. RESULTS:The study showed a definite impact of IRS on malaria prevalence in the targeted districts. Prevalence for sentinel sites in Guija district indicated that the prevalence of malaria increased slightly from baseline to endline in all sentinel sites in Guija. Overall, there was no significant change in prevalence in Zavala, from baseline to endline (p-value = 0.611). Panda's overall malaria prevalence decreased from 19.20% to 10.82% (p-value < 0.001) whereas overall prevalence in Inharrime, decreased from 27.68% to 19.50% (p-value < 0.001). Malaria prevalence in children younger than 5 years decreased significantly in all four districts. In Panda there was a decrease in numbers of males and females being infected between surveys (p < 0.001), whereas for Inharrime the decrease was significant in females (p < 0.001). High coverage with IRS (> 95%) resulted in greater population protection. CONCLUSION:The study revealed that IRS implementation decreased malaria prevalence in Inharrime and Panda but not in Guija and Zavala. To ensure that cross-border movement of people does not result in increased malaria transmission, targeting areas identified as source of infection in travelers is paramount to reaching elimination.

Background:Pediatric febrile illnesses remain a leading cause of health care visits, morbidity, and mortality in low-resource settings. Their etiological diagnosis and outcome evaluation are challenging as available tools are limited. Herein, we describe the epidemiology, trends, and clinical outcomes of febrile pediatric outpatient clinic visits and inpatients during a 17-year-long period in Southern Mozambique. Methods:We retrospectively analyzed surveillance morbidity and demographic data from children <15 years old presenting with fever (≥37.5°C) at Manhiça District Hospital and 5 peripheral health posts from 2004 to 2020. We characterized diagnoses and clinical signs, stratified by outpatient clinic visits and hospitalizations, and calculated 7-day mortality odds, case fatality ratios (CFRs), and minimum community-based incidence rates. Results:A total of 664 223 outpatient visits and 23 166 hospitalizations were included. The median age (interquartile range) was 47.1 (20.0-92.3) months for outpatients and 21.2 (10.1-41.5) months for inpatients. The most frequent first encounter diagnoses included malaria (33.5%), upper (27.8%) and lower (10.1%) respiratory tract infections, and acute gastrointestinal infection (6.0%), whose frequencies showed a marked annual decline from 2004 to 2020, particularly among inpatients. All-cause 7-day mortality was 0.1% and 2.2% among outpatients and inpatients, respectively. Sepsis and meningitis were less common but presented the highest CFRs (9%-16%). Malnutrition and HIV infection were major contributors to inpatient mortality. Seizures, edema, dehydration, and reduced consciousness were strong predictors of death. Conclusions:Malaria, respiratory tract, and acute gastrointestinal infections represented the predominant causes of fever and mortality, with decreasing trends over time. This analysis underscores the value of epidemiological surveillance and the need for improved early diagnosis and clinical management tools for febrile children.

We describe the Pf8 data resource, the latest MalariaGEN release of curated genome variation data on over 33,000 Plasmodium falciparum samples from 99 partner studies and 122 locations over more than 50 years. This release provides open access to raw sequencing data and genotypes at over 12 million genomic positions. For the first time, it includes copy-number variation (CNV) calls in the drug-resistance associated genes gch1 and crt. As in Pf7, CNV calls are provided for mdr1 and plasmepsin2/3, along with calls for deletion in hrp2 and hrp3, genes associated with rapid diagnostic test failures. This data resource additionally features derived datasets, interactive web applications for exploring patterns of drug resistance and variation in over 5,000 genes, an updated Python package providing methods for accessing and analysing the data, and open access analysis notebooks that can be used as starting points for further analyses. In addition, informative example analyses show contrasting profiles of the decline of chloroquine resistance-associated mutations in Africa, and variation in copy number variation across 10 distinct sub-populations. To the best of our knowledge, Pf8 is the largest open data set of genome variation in any eukaryotic species, making it an invaluable foundational resource for understanding evolution, including that of pathogens.

Monitoring the emergence and spread of drug-resistant parasites is essential for effective malaria control. Here, we describe the prevalence of genetic markers of Plasmodium falciparum antimalarial drug resistance and parasite population structure in Mozambique. Drug resistance loci and microhaplotypes were genotyped by multiplex targeted amplicon sequencing of 1146 P. falciparum samples collected in 2021 (n = 321) and 2022 (n = 825 rainy season, and n = 155 dry season). pfpm2 gene copy number (associated to piperaquine resistance) was assessed using real-time quantitative PCR. No pfk13 markers of partial artemisinin resistance nor pfpm2 duplications were observed. Prevalence of pfdhfr/pfdhps quintuple mutants associated with sulfadoxine-pyrimethamine (SP) resistance was high across all regions (> 92.5% in 2021 and > 87.8% in 2022), but pfdhps-A581G mutation was rare (1.6% in 2021 and 0.8% 2022). Both prevalence of mutations in pfdhps-436 (p < 0.001) and genetic complexity of infections increased from South to North. These results support the continued use of artemisinin-based combination therapies in Mozambique, call for a close monitoring of chemopreventive efficacy based on SP, and confirm the spatial genetic distinction in P. falciparum population observed across the country.

We describe the Pf8 data resource, the latest MalariaGEN release of curated genome variation data on over 33,000 Plasmodium falciparum samples from 99 partner studies and 122 locations over more than 50 years. This release provides open access to raw sequencing data and genotypes at over 12 million genomic positions. For the first time, it includes copy-number variation (CNV) calls in the drug-resistance associated genes gch1 and crt. As in Pf7, CNV calls are provided for mdr1 and plasmepsin2/3, along with calls for deletion in hrp2 and hrp3, genes associated with rapid diagnostic test failures. This data resource additionally features derived datasets, interactive web applications for exploring patterns of drug resistance and variation in over 5,000 genes, an updated Python package providing methods for accessing and analysing the data, and open access analysis notebooks that can be used as starting points for further analyses. In addition, informative example analyses show contrasting profiles of the decline of chloroquine resistance-associated mutations in Africa, and variation in copy number variation across 10 distinct sub-populations. To the best of our knowledge, Pf8 is the largest open data set of genome variation in any eukaryotic species, making it an invaluable foundational resource for understanding evolution, including that of pathogens.

BackgroundSeasonal malaria chemoprevention (SMC) is a highly effective intervention for malaria prevention in high burden areas with seasonal transmission, historically implemented in the Sahel. Mozambique contributes to 4% of global malaria cases. Malaria Consortium, in partnership with the National Malaria Control Programme, conducted a two-year phased SMC study in Nampula province using sulfadoxine-pyrimethamine (SP) plus amodiaquine (AQ), or SPAQ, in children under five. Phase one results presented here highlight acceptability, feasibility, and protective effect of SMC.MethodsA pragmatic type II hybrid effectiveness-implementation study design was adopted, using mixed methods. The study was conducted in three districts, utilizing: (1) non-randomized controlled trial reporting on malaria incidence; (2) drug resistance molecular marker study reporting on resistance marker changes over time; (3) coverage and quality assessment on the SMC distribution; and (4) a qualitative acceptability and feasibility assessment with stakeholders.ResultsChildren who received SMC had 86% (hazard ratio 0.14, 95% CI 0.09-0.24) lower hazards of developing clinical malaria during the peak transmission season compared with children in the comparison district. Prevalence of SP molecular markers associated with resistance was high at baseline (K540E 66.1%). SMC achieved high coverage of eligible children over four cycles (87.7%, 95% CI 83.9-90.8%). Qualitative results indicate SMC was positively accepted by the targeted community.ConclusionsResults suggest that SMC was effective at preventing clinical malaria, did not significantly impact resistance profile, and was feasible and acceptable in the context. Phase two will assess SMC impact in reducing malaria incidence and if chemoprevention efficacy of SPAQ is impacted by drug resistance and drug concentrations.

[This corrects the article DOI: 10.1371/journal.pone.0323117.].