The virus that causes COVID-19, the SARS-CoV-2 virus, has rapidly spread across the world. On April 23, there were more than 2.7 million reported cases and 192,000 deaths globally. As the pandemic continues its path to low and low-middle income countries (LMICs), its impact is likely to be even more devastating, potentially reversing recent gains made in the management of other communicable diseases.
Of particular concern is the impact of the COVID-19 pandemic on malaria. There were an estimated 228 million cases of malaria and it caused 405,000 deaths in 2018. Sub-Saharan Africa accounted for approximately 93% of all cases and 94% of deaths, with more than two-thirds of deaths occurring among children below the age of five. The majority of people in malaria-endemic countries live in poverty and already face struggling health care systems and a scarcity of skilled health workers, both of which present additional barriers to accessing health care services. Nonetheless, progress in tackling malaria in the past 15 years has been notable. Both cases and deaths due to malaria have declined by about 50% since 2000. During this period, an additional eleven countries were declared malaria free by the World Health Organization (WHO). However, since 2014, due to extrinsic challenges (of which financing was one), progress has stalled. Without any risk mitigation strategies, disruption to malaria programs as a result of the spread of COVID-19 in malaria-endemic countries will set progress back even further.
Africa accounts for 94% of the global burden of malaria and suffers the greatest toll from the disease in terms of mortality and morbidity. There are valuable lessons to be learned from the Ebola outbreak in West Africa in 2015, in which the numbers of additional deaths due to malaria were greater than those caused by the Ebola outbreak itself. As Ebola cases overwhelmed health-care infrastructure, insufficient resources for malaria control in these regions led to increased mortality and morbidity. In Guinea, the official number of reported deaths from malaria in 2014 was 1,067, compared with 108 deaths reported in 2013. In Guinea, Liberia, and Sierra Leone combined, there were an estimated 7,000 additional malaria-associated deaths among children aged less than five as a result of the Ebola outbreak. Health centers were overwhelmed and patients with febrile illness became increasingly reluctant to access formal health care services. Even where they did attend clinics, health care providers were apprehensive about drawing blood, which is necessary for the diagnosis of malaria.
COVID-19 has been slow to arrive and spread across Africa. There are currently 27,773 reported cases due to the disease on the continent with 15,624 occurring in the malaria-endemic countries. While these numbers appear manageable compared with those reported in the United States and Europe, it is unlikely that Africa will be exempted from the exponential spread of this contagion. Lessons from countries in which outbreaks have appeared small and contained illustrate that the window of opportunity before caseloads start to double every few days is narrow.
It is unclear whether malaria infection presents an additional risk factor for becoming infected with COVID-19 or the severity of the infection. Nevertheless, there are several reasons to be concerned about malaria within the current context of the COVID-19 pandemic.
Clinical management and diagnosis of malaria
Malaria illness shares some of the same symptoms as COVID-19 illness: fever, headache, body aches, and weakness. A key strategy to prevent the progression of malaria infection to severe disease is prompt diagnosis and effective treatment by qualified providers at health facilities or in the community within 24 hours of the onset of symptoms. Under COVID-19 lockdown conditions, if a child presents with these symptoms, the child may not access treatment from a health facility given official COVID-19 advice to stay home if only mild symptoms are experienced. If the child does present at a health care facility or to a community health worker (CHW), will s/he get tested for malaria and obtain anti-malarial medicines, or receive only a COVID-19 test? Furthermore, given that malaria can co-exist with other infections, the confirmation of malaria infection using a diagnostic test does not rule out the possibility that a patient might also be suffering from COVID-19; similarly, testing positive for COVID-19 does not mean that an individual does not also have malaria infection.
One of the recent deaths was in an asthmatic treated for malaria and later diagnosed with COVID-19. In my opinion, the challenge in the management of malaria during the COVID-19 outbreak is that the guideline for COVID-19 requests that suspected cases do not come to the health facility but call the toll-free line for a health worker to come to them. My concern is that patients may stay at home and not be treated which will increase the number of malaria deaths
Quote by Dr Elizabeth Chizema, Coordinator, End Malaria Council and former Director of the National Malaria Elimination Center, Zambia.
Access to services
Travel restrictions may make it difficult for patients to access health services, particularly for those individuals that live in remote areas. Others may be reluctant to seek treatment out of fear of exposure to the virus in crowded facilities.
There is widespread concern for health workers on the frontline and their risk of exposure, illness, and ongoing transmission of COVID-19. Recognizing that health workers are at higher risk of exposure to COVID-19, particularly where personal protective equipment (PPE) and infection prevention measures are insufficient, health workers may be reluctant to provide routine services for malaria and other diseases. In addition, travel restrictions may make it difficult for some health workers to get to their workplaces, while others may fall sick with COVID-19, leading to a much-reduced capacity in the health system in countries where human resources are already scarce (e.g., compare Italy, with 420 physicians per 100,000 population, with Tanzania, at 2 physicians per 100,000 population). Task shifting to the more urgent need presented by COVID-19 may compromise the management of other diseases such as malaria. Furthermore, in many LMICs, one health worker (often not a physician) will be tasked with managing a multitude of issues; adding another disease may devastate an already stressed health system.
Perhaps the biggest threat to malaria control efforts is the withdrawal of funding. There is already a global gap of more than USD 3 billion annually in the resources needed to achieve the targets as outlined in the Global Technical Strategy for malaria. In many low-income malaria-endemic countries, external donor funds make up more than 50% of the total financing needed for their malaria response. The Global Fund announced new guidance in March to enable countries to strengthen their response to COVID-19, by using existing grants in a swift and pragmatic way. Twenty-one countries have already received support via this mechanism. While these funds are vital to help countries prepare for COVID-19, resources will also be diverted from critical HIV, TB, or malaria programs. Bilateral donors facing the economic fallout from COVID-19 are also likely to decrease their aid allocations for health and malaria. Indeed, governments themselves are likely to divert malaria funds to the more pressing COVID-19 response.
The COVID-19 pandemic has disrupted the production and supply of many products, including malaria commodities, manufactured in various countries around the world.
China and India are the primary sources of many malaria commodities, including the active pharmaceutical ingredient for artemisinin-based combination therapies (ACTs), the first-line treatment for malaria. Companies in India, which is currently under lockdown, supply over 20% of all basic medicines to Africa, especially generic drugs. Disruptions in the supply chains of several other essential malaria commodities, including rapid diagnostic tests (RDTs), have been reported as an indirect consequence of the COVID-19 pandemic. The lack of availability of preventive tools and life-saving medicines will likely lead to an increase in malaria mortality and morbidity. At the same time, there have been increases in demand, as people around the world have become anxious and started to stockpile basic medicines. Ever since US President Donald Trump began referring to the potential of chloroquine, normally used to tackle Plasmodium vivax malaria, as a treatment for COVID-19, there has been a global surge in demand for this medicine.
Interruption of prevention programs
Insecticide-treated net (ITN) and indoor residual spraying (IRS) campaigns require the training of groups of health workers and contact between health workers and community members to deliver these services. Several IRS campaigns have already been suspended in a number of malaria-endemic countries due to concerns around COVID-19. Seven countries have ITN campaigns planned for the period June-October; these may be interrupted if the pandemic reaches critical levels and social distancing measures become a concern. Other concerns include the use of ITNs for sick people. Most households share bed nets, which means that if an individual is sick, someone will be left not sleeping under a net.
During the Ebola epidemic, many victims were buried along with ITNs that had been used in the household, due to the fear that nets had become contaminated leaving the family without. Similarly, several malaria-endemic countries refused shipments of ITNs manufactured in China due to concerns around COVID-19 being transmitted via the nets (personal communication, Alliance for Malaria prevention).
Additionally, a consortium established for testing malaria vaccines has joined the fight against COVID-19, potentially diverting resources from malaria vaccines and placing the development of new vaccine candidates at risk.
Shortages of commodities due to disruptions in production and supply chains can lead to the erratic supply of quality-assured medicines, creating opportunities for counterfeiters to exploit gaps in the market. This may lead to the increased use of substandard, counterfeit, or falsified medicines, risking the lives of individuals with malaria and other diseases.
Soon after WHO declared COVID-19 a pandemic, Interpol’s global pharmaceutical crime fighting unit made 121 arrests across 90 countries in just seven days, resulting in the seizure of dangerous pharmaceuticals worth more than USD 14 million. Large quantities of fake chloroquine have been discovered in circulation in the Democratic Republic of Congo, Cameroon, and Niger.
We risk a parallel pandemic, of substandard and falsified products, unless we all ensure that there is a global co-ordinated plan for co-ordinated production, equitable distribution and the surveillance of the quality of the tests, medicines and vaccines. Otherwise the benefits of modern medicine... will be lost.
In many low-income countries, out-of-pocket expenditure for malaria already comprises a large proportion of household incomes. Increased demands on families are likely to push them further into poverty. The Organization for Economic Co-operation and Development (OECD) predicts that some countries could be dealing with the economic fallout of the COVID-19 pandemic for years to come.
New modelling analyses released by WHO and partners have estimated that severe disruptions to ITN campaigns and access to antimalarial medicines could lead to a doubling in the number of malaria deaths in sub-Saharan Africa this year compared with the number in 2018. Deaths in the 41 countries of sub-Saharan Africa alone could reach 769,000, reaching the levels of mortality seen in the region 20 years ago. Apart from the health toll of the disease, the additional economic impact from malaria could set the continent back decades; much could be lost due to the additional impact of malaria.
Unless mitigating action against the potential impact of COVID-19 is taken, malaria-endemic countries face the risk of resurgence and reversal of the gains made in the past two decades. Given that cases of COVID-19 in malaria-endemic countries have not yet reached critical levels, a narrow window of opportunity remains to continue progress towards the malaria endgame.
WHO recommends a continuation of malaria control efforts, delivery of intermittent preventive treatment in pregnancy (IPTp), seasonal malaria chemoprevention (SMC), and intermittent preventive treatment in infants (IPTi), as well as systematic malaria diagnostics, as part of fever management and measures for the early detection and treatment of malaria. At the same time, they recommend that best practices be observed to protect health workers.
To achieve these objectives, several risk mitigation actions will need to be employed and changes will be needed in the way malaria interventions are delivered, some of which have been identified by WHO in their malaria and COVID-19 guidelines:
- For malaria case management, messages on accessing treatment will need to be revised. More CHWs will need to be mobilized close to communities to triage malaria and suspected COVID-19 cases and provide diagnosis and treatment of malarial fevers.
- Clear guidelines and clinical algorithms will need to be developed so that health providers have the tools to perform a differential diagnosis for malaria, COVID-19, and other fever etiologies, with clear decision-making pathways for diagnosis, treatment, and referral based on the local risk of malaria. In addition, standard operating procedures to guide health worker and patient contact practices will need to be developed.
- Malaria diagnostics should be systematically added to fever management, including for suspected cases of COVID-19, and health-care facilities should be well-stocked with ACTs.
- Communication messages should be developed for communities about timely care-seeking for those with fever and where to seek treatment. These should include messages on probable causes of fever, the need for treatment-seeking, and the critical need for potential malaria patients to receive prompt diagnosis and treatment, as late diagnosis and treatment of malaria may be fatal.
- A lack of diagnostic tools (microscopy or RDTs) may necessitate presumptive treatment of fever with ACTs.
- Risk mitigation measures against fragile supply chains and long lead-times need to be considered in the context of COVID-19. There may be an increased demand for RDTs, or for ACTs if presumptive treatment is necessary. Larger quantities of safety stock positioned at decentralized locations may be needed. Stockpiling of surgical masks and other protective equipment should be carried out in advance and medical staff should be adequately trained in their use.
- During the Ebola epidemic, WHO published guidelines for temporary measures for malaria control in affected countries. These guidelines focused on deploying antimalarials through emergency mass drug administration campaigns, with the aim of reducing malaria morbidity and mortality and protecting frontline health care workers. Similar steps may need to be deployed with COVID-19 in malaria-endemic countries.
- Reporting issues and modified case definitions as a result of COVID-19 will impact apparent malaria epidemiological trends, which feed into critical malaria operational planning. Health management information systems (HMIS) should be monitored to correct for any unusual trends.
- ITN distribution campaigns planned for the rainy season a few months from now should be brought forward if possible. Routine distribution of ITNs through health facilities and antenatal clinics should be strengthened to ensure that they are available at the community level if mass distribution campaigns are disrupted.
- While governments may be forced to use their existing resources to tackle COVID-19 in the short-term, they must unanimously advocate for new funding to fight COVID-19 in the longer term.
As we commemorate World Malaria Day on April 25th, in the midst of the COVID-19 pandemic, we urgently need to take steps to ensure that malaria-endemic countries do not bear the additional burden of lives lost due to malaria, reversing the decades of progress that have been made. At the same time, political leaders must use the pandemic crisis to invest in universal health coverage, integrated surveillance, and stronger public health systems to safeguard against future threats to health security.