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Combatting Malaria in the Comoros Islands: How China Almost Got it Right

China’s ground-breaking anti-malarial intervention in the Comoros, where malaria is the number one cause of death across all populations, has resulted in the East African island nation being named by the World Health Organisation as “one of six African countries on course to eliminate malaria by 2020”. Unlike in the more densely inhabited Grand Comore and Anjouan islands with a moderate transmission rate of 10–35%, malaria had a prevalence rate of 90% in Moheli. According to a Moheli resident: “The disease situation was so severe that residents of other islands were afraid to travel here.”

The small population size, and the geographic and climatic variability across the islands, which contributes to the difference in the malaria endemicity and transmission patterns across the country, makes the Comoros a great location for pilot implementation of novel antimalarial projects.

In 2007, China began the implementation of the first phase of the Fast Elimination of Malaria by Source Eradication (FEMSE) project in the country. By the time, the Comoros had already undertaken a number of unsuccessful antimalarial projects, providing its residents with items such as long-acting insecticide-treated mosquito nets and indoor residual sprays.

The FEMSE project began in Moheli and gradually expanded to the other islands. Leaving Grand Comore and Anjouan as the control populations in the initial intervention phase is a good practice because it enabled the project team to determine that there were cross-island impacts of the project.

The project involves mass drug administration (MDA) utilizing Artequick (a fourth-generation combination of artemisinin and a small dosage of primaquine) administered to all age groups of a defined population (except those with contraindications to the therapy) at the same time regardless of infection status. MDA aims to eliminate malaria parasites directly from the human population. Since malaria does not affect animals, eliminating it from humans can eradicate the disease. A year after the implementation of FEMSE project, malaria was controlled in Moheli. According to the Comoros Ministry of Health, the incidence and parasite carrying rate of malaria decreased by 99%, and no one died from malaria in that year (2008). The project reached out to more than 95% of the Moheli population and about 93% of the Anjouan population. As of 2014, over 50% participation rate has been reported in Grand Comore (no recent data is available). However, this rate should have increased since the project is still ongoing there.

Seven years after project initiation, Moheli and Anjouan were declared malaria-free. In 2016, the Comoros Ministry of Health reported that all 16 cases of the disease in these islands were imported. In 2018, Comoros won the African Leaders Malaria Alliance award.

Today, the FEMSE project in the Comoros is widely regarded as China’s most successful health project in Africa. Experts believe that total eradication of malaria by 2030, as articulated in the African Union’s Agenda 2063, is possible if the improved version of this project is implemented in other African countries but the FEMSE model has been rejected by some African countries because of ethical concerns surrounding the exposure of healthy people to drugs.

President’s Support Overcomes Skepticism of China’s Motives

Perhaps the most apparent best practice from this project is its involvement in extensive collaboration between Chinese and Comorian stakeholders.
The project was jointly implemented by the Guangzhou University of Chinese Medicine, the Comoros Ministry of Health, and representatives of the National Malaria Control Programme of Comoros. During the first MDA phase, then president of Comoros, Ahmed Abdallah Mohamed Sambi, was the first to ingest the drug and he campaigned for public participation in the project.

According to all the project beneficiaries interviewed for the article, this act of his instilled public trust in the project leading to widespread population engagement.
One of them did state that he was skeptical of the intentions of China. He initially warned his family not to participate in the MDA program because he did not want his loved ones to be “guinea pigs for China’s unholy experiment”. However, after the president became the face of the project, he had a change of heart. Another stated that the approval of the project by village leaders and religious elders further strengthened her resolve to receive the drugs.

Taking the Message To Villages So Remote “the President Hasn’t Even Been There”

Publicity of the project is a best practice that generated widespread community participation in the project. The project was promoted through 155 community discussions, approximately 10,000 brochures, 3,500 posters, 340 banners, 300 radio announcements, 90 newspaper reports, and 20 television announcement

Furthermore, the nonprofit sector was carried along during the project implementation. For instance, national and international organizations and schools participated in explaining the MDA strategy and its potential benefits. Thousands of community youths were trained to administer the drugs, monitor its adverse effects, and verify existing research findings.

According to one of these volunteers, they reached out to all villages in her Island “even the ones the president has never been to”. Furthermore, according to a resident in Moheli, “Zero palu, je m’engage!” (“Zero malaria starts from me!”) has become a popular slogan.

After the completion of the project, the Comoros-China Malaria Control Centres was established on each island by the Guangzhou University of Chinese Medicine and the Comoros National Malaria Control Center. These centers are responsible for organizing, executing and formulating guidelines for malaria prevention and rapid control; curating and building the capacity of antimalarial teams; training district leaders; and monitoring and evaluating the long-term impacts of the project.

Comorian Staff Took Over Running of District Malaria Control Centers

The Comoros-China antimalarial team.

To establish a complete (village-district-county-island) malaria surveillance-response system, seven district and 97 county anti-malaria stations as well as seven diagnostic laboratories were established. The lab organizes at least two field trips each week to collect mosquito and blood samples from different areas of the country. After analysis, the district malaria control stations collate the reports from all stations in the county, sends them to the island control center every month, thereafter collectively analyzed by the National Malaria Control Cente

Initially, the centers were staffed by both the Chinese and local medical personnel, the latter trained to eventually take the baton from the former. This action was not pre-planned but was necessary considering language barriers and the need for Chinese personnel to return home.

FEMSE Project in Cambodia Informs the Comorian Iteration

Furthermore, promotion of impact sustainability is another best practice in this project. To prevent the re-emergence of the disease due to inter-border transmission, all visitors to the islands are encouraged to take one antimalarial drug per week during their stay. For those who refuse to take medication, rapid diagnostic tests are conducted. If the result comes back positive, the traveller is required to receive the drug and report to the National Malaria Control Center.

This measure was put in place because of the lessons learned by the Chinese team from their FEMSE project in Cambodia where, three years after the initiation of the project, the malaria rate in the trial area of Cambodia fell by 95%, only to rise again due to the reintroduction of the disease from abroad.

Non-Disclosure of Artequick’s Who Prequalification Status: “I Know Some People Who Feel Cheated”

There is an unresolved global controversy surrounding Artequick, the project’s drug of choice. Although the Food and Drug Administration (FDA) of China and Comoros have approved this drug, it is yet to receive the WHO PQ certification, which is fast becoming a pre-purchase requirement of international drug procurement agencies. According to some project beneficiaries, the drug administration team did not inform them that Artequick is yet to receive this certification.

These beneficiaries are unsure of how this knowledge would have affected their participation in the project. One of them said: “It might have been a blessing that I did not know about the lack of approval because the project has changed my life.”  Another said: “I know some people who feel cheated by the project’s team after their discovery of the drug’s lack of WHO approval.”  A third wonders if the country’s president knows about this “loophole”.

Transparency Could Have Averted Misgivings

During the sensitization campaigns, the project should have included details of the drug’s FDA approval and WHO prequalification status as well as the difference between these certifications.

The WHO PQ program was not established to supplant national drug regulatory bodies but to identify quality, safe and efficacious drugs for the United Nations procurement agencies. However, several other influential procurement agencies have adopted this standard, putting many drug manufacturers at a huge disadvantage.

Factors inhibiting drug manufacturers from seeking WHO PQ certification includes the high upfront assessment cost (up to US$25,000 per drug), limited information and technical support from the PQ team, and lack of an option to appeal decisions.

Diverging Opinions on the Incidence of Side Effects From Artequick: Where Is the Data?

The project involves asking healthy people to take a drug that could cause side effects such as vomiting, abdominal pain, transient hearing loss, and others. According to the Chinese project team, there was no evidence linking these reported side effects to the drug. They also estimate that only 1% of the project beneficiaries experienced adverse effects from the drug.

However, local health professionals hint that the susceptibility rate might be higher considering that hospital admission of patients doubled a week after the first MDA phase. The Comoros government believes otherwise, blaming a seasonal rise in flu cases for the surge in the hospital intake rate.

WHO experts interviewed for this article called the project’s strategy for monitoring side effects to be “insensitive and crude”. The project team only took into account reports of side effects from clinics administering the drug. They did not conduct extensive public surveys nor empirical studies to determine the incidence of side effects.

Experts posit that drug resistance to artemisinin has been reported in Southeast Asia.

The Future Beyond These Controversies

A professor at Guangzhou University of Chinese Medicine posited that a global implementation of the FEMSE project would cost US$30 billion. This seems like a fair amount considering that malaria is estimated to deprive the world of more than $US12 billion annually in lost productivity, investment and healthcare procurement costs.

Research should be done to determine if MDA implemented alongside vector control and case management will be more cost-effective than the current FEMSE project design, with effective systems and strategies in place to systematically monitor the possible adverse effects of MDA.

Esther Ejiroghene Ajari is the Founder and Director of The TriHealthon, a youth-led nonprofit promoting health equity in Africa through community development as well as theoretical and community-based research.

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