COVID-19 in malaria-endemic regions: potential consequences for malaria intervention coverage, morbidity, and mortality
Authors: Miranda I Teboh-Ewungkem, Gideon A Ngwa
Journal: The Lancet Infectious Diseases (2020)

COVID-19 has had a massive impact on the populations and economies of the world. As of Sept 9, 2020, the virus has infected more than 27 million people in 216 countries and territories worldwide, and the number of deaths is approaching a million.1WHOCoronavirus disease (COVID-19) pandemic.https://www.who.int/emergencies/diseases/novel-coronavirus-2019Date: 2020Date accessed: September 4, 2020Google Scholar Although the spread of COVID-19 to Africa has been slow and its direct impact in Africa is below the level seen in other continents, the potential effects of COVID-19 on strategies and methods to combat other diseases such as malaria—which pose significant burdens on substantial proportions of the world and the African population, and especially children—are a cause for great concern. Thus, understanding how the COVID-19 pandemic could indirectly affect malaria control intervention strategies is urgent in all malaria-endemic regions, and especially those that are part of WHO's "high burden to high impact" initiative.2WHOWorld malaria report 2019.https://www.who.int/malaria/publications/world-malaria-report-2019/en/Date: Dec 4, 2019Date accessed: August 20, 2020Google Scholar Since 2010, active malaria intervention control strategies have had a positive effect on lowering malaria burden and morbidity in Africa and worldwide. These strategies include the use of long-lasting insecticide-treated nets (ITNs), indoor residual spraying,4Bhatt S Weiss DJ Cameron E et al.The effect of malaria control on Plasmodium falciparum in Africa between 2000 and 2015.Nature. 2015; 526: 207-211Crossref PubMed Scopus (1686) Google Scholar and timely access to antimalarial drugs, including the use of intermittent preventive treatment aimed at killing forms of the malaria parasite in infected individuals,5Teboh-Ewungkem MI Mohammed-Awel J Baliraine FN Duke-Sylvester SM The effect of intermittent preventive treatment on anti-malarial drug resistance spread in areas with population movement.Malar J. 2014; 13: 428Crossref PubMed Scopus (13) Google Scholar, 6Teboh-Ewungkem MI Prosper O Gurski K Manore CA Peace A Feng Z Intermittent preventive treatment (IPT) and the spread of drug resistant malaria.in: Jackson T Radunskaya A Applications of dynamical systems in biology and medicine. The IMA volumes in mathematics and its applications. vol 158. Springer, New York2015Crossref Google Scholar, 7Manore CA Teboh-Ewungkem MI Prosper O Peace A Gurski K Feng Z Intermittent preventive treatment (IPT): its role in averting disease-induced mortalities in children and in promoting the spread of antimalarial drug resistance.Bull Math Biol. 2019; 81: 193-234Crossref PubMed Scopus (7) Google Scholar in addition to the other mechanisms aimed at disrupting the transmission of malaria by exploiting the feeding behaviour and gonotrophic and reproductive cycles of mosquitoes.8Ngwa GA Teboh-Ewungkem MI Dumont Y Ouifki R Banasiak J On a three-stage structured model for the dynamics of malaria transmission with human treatment, adult vector demographics and one aquatic stage.J Theor Biol. 2019; 481: 202-222Crossref PubMed Scopus (10) Google Scholar, 9Slater HC Foy BD Kobylinski K et al.Ivermectin as a novel complementary malaria control tool to reduce incidence and prevalence: a modelling study.Lancet Infect Dis. 2020; 20: 498-508Summary Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 10Teboh-Ewungkem MI Ngwa GA Fighting malaria with ivermectin: a novel malaria control tool.Lancet Infect Dis. 2020; 20: 394-395Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 11Sherrard-Smith E Skarp JE Beale AD et al.Mosquito feeding behavior and how it influences residual malaria transmission across Africa.Proc Natl Acad Sci USA. 2019; 116: 15086-15095Crossref PubMed Scopus (119) Google Scholar However, despite the progress of the past decade, evidence suggests that the rate of reduction in malaria mortality in the WHO African Region has slowed since 2016, although total deaths due to malaria decreased overall.3WHOThe "World malaria report 2019" at a glance.https://www.who.int/news-room/feature-stories/detail/world-malaria-report-2019Date: Dec 4, 2019Date accessed: August 20, 2020Google Scholar In particular, from 2017 to 2018, among the ten African countries with the highest malaria burden, Ghana and Nigeria reported absolute increases in the number of malaria cases, while case numbers did not change substantially in seven countries and only Uganda reported a decrease.3WHOThe "World malaria report 2019" at a glance.https://www.who.int/news-room/feature-stories/detail/world-malaria-report-2019Date: Dec 4, 2019Date accessed: August 20, 2020Google Scholar Given that this deceleration could be compounded by the COVID-19 pandemic, there is an urgent need to quantify and analyse the potential impact of the pandemic on malaria control and intervention strategies. In The Lancet Infectious Diseases, Daniel Weiss and colleagues12Weiss DJ Bertozzi-Villa A Rumisha SF et al.Indirect effects of the COVID-19 pandemic on malaria intervention coverage, morbidity, and mortality in Africa: a geospatial modelling analysis.Lancet Infect Dis. 2020; (published online Sept 21.)https://doi.org/10.1016/S1473-3099(20)30700-3Summary Full Text Full Text PDF PubMed Scopus (117) Google Scholar quantified the indirect effects of COVID-19 on the distribution of ITNs and on access to effective antimalarial drugs—two key components of malaria control in Africa. Using a range of counterfactual scenarios based on different levels of reduction in ITN and antimalarial drug coverage, the authors estimated the additional morbidity and mortality due to malaria that might be seen in the year 2020 across malaria-endemic Africa. Current data were used to generate geospatial estimates of malaria infection prevalence, clinical case incidence and mortality, Plasmodium falciparum parasite rates, ITN coverage, and effective treatment availability. The anticipated malaria burden in the absence of COVID-19 disruptions served as a baseline for comparison. On the basis of their estimates, Weiss and colleagues concluded that COVID-19-related disruptions to malaria control efforts in Africa could lead to significant reversals of the progress made over the past two decades in reducing malaria morbidity and mortality, with a possibility of a near doubling in mortality due to malaria under the worst case scenario (combined reductions of 75% in effective antimalarial treatment and 75% in routine ITN distribution, with no mass ITN distribution campaigns).12Weiss DJ Bertozzi-Villa A Rumisha SF et al.Indirect effects of the COVID-19 pandemic on malaria intervention coverage, morbidity, and mortality in Africa: a geospatial modelling analysis.Lancet Infect Dis. 2020; (published online Sept 21.)https://doi.org/10.1016/S1473-3099(20)30700-3Summary Full Text Full Text PDF PubMed Scopus (117) Google Scholar Weiss and colleagues' work is very relevant and timely, and serves as a call to action for policy makers not to ignore the control measures needed to fight the threat of malaria when considering strategies to combat the COVID-19 pandemic. The authors suggest that an integrated approach, in which equivalent efforts to ensure malaria control procedures are sustained amid the response to the COVID-19 pandemic, is essential to the goal of continuing the downward trend in malaria mortality and morbidity. This work is important and urgent as it quantifies the potential increases in malaria-attributable morbidity and mortality in 2020 that might occur under plausible reductions in ITN and antimalarial drug coverage, serving to highlight the huge potential impact of COVID-19-related disruptions in malaria intervention and control strategies on malaria burden. Additionally, Weiss and colleagues' work prompts us to consider, in general, other indirect effects of the COVID-19 pandemic on malaria transmission dynamics. For example, given that fever is a common symptom in both diseases, it is important to educate both health-care providers and the population as a whole on the potential for misdiagnosis of malaria or COVID-19, as well as on the potential for co-occurence of the two diseases. Guidance on the need for and importance of testing for malaria and other diseases during the pandemic should be communicated to health-care providers and resources made available to faciliate this. Furthermore, communication of these messages to communities is important to ensure that people with malaria are not scared to visit hospitals and community clinics in fear of misdiagnosis, which could limit their timely access to safe and legitimate antimalarials. In addition, it is worth asking whether there could be an increased risk of mosquito bites for individuals or families observing isolation or quarantine (whether either individually or in groups) that warrants them to stay in the same locality for extended periods, especially if done so in the absence of ITNs. If so, then perhaps our concern with regard to malaria transmission should also extend to other mosquito-transmitted diseases. We declare no competing interests. MIT-E acknowledges that some of the authors' results cited in this Comment were funded by the NSF (grant 1815912). Indirect effects of the COVID-19 pandemic on malaria intervention coverage, morbidity, and mortality in Africa: a geospatial modelling analysisUnder pessimistic scenarios, COVID-19-related disruption to malaria control in Africa could almost double malaria mortality in 2020, and potentially lead to even greater increases in subsequent years. To avoid a reversal of two decades of progress against malaria, averting this public health disaster must remain an integrated priority alongside the response to COVID-19. Full-Text PDF Open Access