Preparedness is essential for malaria-endemic regions during the COVID-19 pandemic
Authors: Jigang Wang, Chengchao Xu, Yin Kwan Wong, Yingke He, Ayôla A Adegnika, Peter G Kremsner, Selidji T Agnandji, Amadou A Sall, Zhen Liang, Chen Qiu, Fu Long Liao, Tingliang Jiang, Sanjeev Krishna, Youyou Tu
Journal: The Lancet (2020)

The coronavirus disease 2019 (COVID-19) pandemic that first emerged in Wuhan in China's Hubei province1Zhu N Zhang D Wang W et al.A novel coronavirus from patients with pneumonia in China, 2019.N Engl J Med. 2020; 382: 727-733Crossref PubMed Scopus (18588) Google Scholar has quickly spread to the rest of China and many other countries. Within 3 months, more than 125 000 people have been infected and the death toll had reached over 4600 worldwide on March 12, 2020.2WHOCoronavirus disease 2019 (COVID-19) situation report—52.https://www.who.int/docs/default-source/coronaviruse/20200312-sitrep-52-covid-19.pdf?sfvrsn=e2bfc9c0_2Date: March 12, 2020Date accessed: March 13, 2020Google Scholar In an attempt to contain the virus, the Chinese Government has made unprecedented efforts and invested enormous resources and these containment efforts have stemmed the spread of the disease.3WHOReport of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19). World Health Organization, Geneva2020Google Scholar As of March 12, 2020, malaria-endemic regions in Africa have reported a few imported COVID-19 cases including in Nigeria, Senegal, and the Democratic Republic of the Congo.2WHOCoronavirus disease 2019 (COVID-19) situation report—52.https://www.who.int/docs/default-source/coronaviruse/20200312-sitrep-52-covid-19.pdf?sfvrsn=e2bfc9c0_2Date: March 12, 2020Date accessed: March 13, 2020Google Scholar Africa needs to be prepared to deal with COVID-19, given the infectious potential of the disease and its capacity to undermine malaria control efforts.4Nkengasong JN Mankoula W Looming threat of COVID-19 infection in Africa: act collectively, and fast.Lancet. 2020; (published online Feb 27.)https://doi.org/10.1016/S0140-6736(20)30464-5Summary Full Text Full Text PDF Scopus (230) Google Scholar In addition to the shared vigilance that countries around the world should maintain, regions need to consider their local malaria epidemic and take additional measures for preparation. There are relevant lessons from the 2014–16 outbreak of Ebola virus disease in west Africa. The emergence of Ebola in malaria-endemic countries, including Guinea, Liberia, and Sierra Leone, led to a public health emergency and dealt a heavy blow to malaria control efforts. In Guinea alone, an estimated 74 000 fewer malaria cases than expected were seen at health facilities compared with years without Ebola because of decreases in the number of patients with malaria seeking appropriate health care and the volume of malaria treatments being dispensed.5Plucinski MM Guilavogui T Sidikiba S et al.Effect of the Ebola-virus-disease epidemic on malaria case management in Guinea, 2014: a cross-sectional survey of health facilities.Lancet Infect Dis. 2015; 15: 1017-1023Summary Full Text Full Text PDF PubMed Scopus (109) Google Scholar Contributing factors to this situation were the close resemblance of early Ebola symptoms with malaria, leading to difficulties in early diagnosis, and the fear on the part of community members of contracting Ebola in the health-care facilities. As Ebola 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 1067 (WHO estimate 9428) compared with 108 reported in 2013, and there were 2446 deaths from Ebola virus disease in 2014.6WHOWorld malaria report 2015. World Health Organization, Geneva2015Google Scholar More alarmingly, it was estimated that there were about 7000 additional malaria-associated deaths among children younger than 5 years in Guinea, Liberia, and Sierra Leone due to the Ebola outbreak.7Parpia AS Ndeffo-Mbah ML Wenzel NS Galvani AP Effects of response to 2014–2015 Ebola outbreak on deaths from malaria, HIV/AIDS, and tuberculosis, west Africa.Emerg Infect Dis. 2016; 22: 433-441Crossref PubMed Scopus (222) Google Scholar There is, therefore, a real and pressing danger for malaria-endemic regions when faced with the threat of a novel infectious disease outbreak. While our knowledge of COVID-19 is still developing, it is a highly contagious disease that is thought to spread primarily from human to human through direct contact and inhalation of respiratory droplets. Carriers with mild or no symptoms can probably transmit the virus.8Hoehl S Berger A Kortenbusch M et al.Evidence of SARS-CoV-2 infection in returning travelers from Wuhan, China.N Engl J Med. 2020; (published online Feb 18.)DOI:10.1056/NEJMc2001899Crossref PubMed Scopus (429) Google Scholar In addition to China, Italy, Iran, and South Korea are among the countries with local outbreaks that could be exporting the disease and increasing exposure risks. With Africa's increasing global connectivity, the unfortunate likelihood of a continental outbreak cannot be ruled out.9Gilbert M Pullano G Pinotti F et al.Preparedness and vulnerability of African countries against importations of COVID-19: a modelling study.Lancet. 2020; (published online Feb 19.)https://doi.org/10.1016/S0140-6736(20)30411-6Summary Full Text Full Text PDF Scopus (744) Google Scholar Much like Ebola, the early symptoms of COVID-19, including fever, myalgia, and fatigue, might be confused with malaria and lead to challenges in early clinical diagnosis.1Zhu N Zhang D Wang W et al.A novel coronavirus from patients with pneumonia in China, 2019.N Engl J Med. 2020; 382: 727-733Crossref PubMed Scopus (18588) Google Scholar These features of COVID-19 and the previous experiences of the Ebola outbreak point to the need for malaria-endemic countries to consider preventive measures against not only the COVID-19 threat but also its likely impact on existing malaria control efforts. The containment efforts and research impetus being taken by China and other affected countries have bought valuable time for the rest of the world, and this time window should be used effectively by vulnerable regions. WHO is monitoring the fast-evolving situation of the COVID-19 epidemic and needs to advise the countries in the malaria-endemic regions on how to establish and effectively execute public health policies. Preventive measures for COVID-19, including case and contact tracing, quarantine and screening, as well as education to encourage good hand hygiene practices, should be in place. Additional and pre-emptive measures must be taken for malaria control in these countries, anticipating the potential challenge that would be faced by the public health system during an outbreak of COVID-19. In the case of Ebola, it was estimated that malaria cases in Guinea, Liberia, and Sierra Leone could have increased by up to 1 million in 2014 as a result of a cessation of distribution of insecticide-treated bednets (ITNs).10Walker PGT White MT Griffin JT Reynolds A Ferguson NM Ghani AC Malaria morbidity and mortality in Ebola-affected countries caused by decreased health-care capacity, and the potential effect of mitigation strategies: a modelling analysis.Lancet Infect Dis. 2015; 15: 825-832Summary Full Text Full Text PDF PubMed Scopus (125) Google Scholar Governments and health leaders in malaria-endemic regions must ensure that such stresses to medical infrastructure are minimised in the event of an outbreak of COVID-19. Resource allocation should be optimised whenever possible to ensure minimal disruption to malaria control should COVID-19 management become necessary. Management of medical supplies and stockpiling of surgical masks and other protective equipment should be done in advance and medical staff should be adequately trained in their use. In cases of emergency, mass drug administration and the distribution of ITNs might be considered for short-term malaria relief in hyperendemic areas. Such measures would also aid efforts in COVID-19 management by reducing the strain on medical resources and minimising confounding factors in diagnosis. Previous successful implementation of such measures occurred during Ebola outbreaks in Sierra Leone in 2014–15 and in the Democratic Republic of the Congo in 2018, in accordance with WHO guidelines.11Aregawi M Smith SJ Sillah-Kanu M et al.Impact of the Mass Drug Administration for malaria in response to the Ebola outbreak in Sierra Leone.Malar J. 2016; 15: 480Crossref PubMed Scopus (23) Google Scholar, 12WHOMalaria control campaign launched in Democratic Republic of the Congo to save lives and aid Ebola response.https://www.who.int/malaria/news/2018/malaria-control-campaign-drc/en/Date: Nov 28, 2018Date accessed: March 4, 2020Google Scholar In malaria-endemic regions, 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 artemisinin combination therapy drugs. Infection management protocols, such as social distancing, mask-wearing, and prompt seeking of diagnostic testing and necessary treatment, should be communicated in advance. These measures will require collective political will and unity in a coordinated effort by African countries. Although an outbreak of COVID-19 in malaria-endemic regions might not happen, we must nevertheless advocate caution and recognise that such pre-emptive measures are ultimately worthwhile. Preparedness is the key to navigating any public health crisis, and malaria-endemic countries must be prepared for the challenges that COVID-19 might bring while minimising disruption to malaria control. We declare no competing interests. Download .pdf (.27 MB) Help with pdf files Chinese translation of full text