Malaria prevention and treatment are being massively affected by the social distancing measures in place to limit the spread of COVID-19. 769,000 deaths are predicted from malaria this year, and a setback of over 20 years in malaria control if measures are not resumed.[1][2] The focus in reducing COVID-19 cases and deaths is an R0 number of <1; this could however drag out the disruption to essential malaria services. [3][4]
As frequently discussed in the UK media of late, the effects of the COVID-19 pandemic may have far-reaching consequences much greater than the deaths caused by the virus itself.[5][6][7][8]. In the form of indirect deaths (in the UK due to delays in cancer diagnosis and safety concerns surrounding GP visits). [9][10]
The direct impact of COVID-19 in Africa is, at present, relatively low with less than one case per 1,000 people; a lack of diagnostic testing was suggested as a possible explanation, with population antibody levels also higher than expected. [11] The youthfulness of the continent may well be a protective factor against fatal cases of COVID-19, however the major burden of this pandemic is set to come from excess malaria deaths if foreign aid measures are not fully resumed. [11][12]
Malaria is spread by female Anopheles mosquitoes (the vector) during a night-time blood meal and over two-thirds of deaths are in children younger than five. [13][14] General symptoms such as headaches, cough, fever and diarrhoea seen with mild (uncomplicated) malaria make it difficult to diagnose, and some symptoms overlap with COVID-19. [13][15] However, potential brain injury, septicaemia and organ failure can result from severe malaria and the burden often falls on the ‘poorest countries with the weakest health systems’. [13][16]
Africa (which has 93% of malaria cases and 94% of malaria deaths worldwide) has shown a 66% decrease in mortality from malaria in recent years, majorly through the use of insecticide treated nets (ITNs) along with indoor residual spraying (IRS) which both act preventatively as a vector control. [17][18] Rapid diagnostic testing can be used before antimalarials are given as treatment and these both rely on close contact however; social distancing measures in place to control the pandemic mean that this is not always possible. [17][18]
Modelling in April by the WHO (World Health Organisation) predicted a death toll of 769,000 in sub-Saharan Africa (double the reported figure for 2018) which would set back malaria control twenty years if ITN campaigns were suspended and access to antimalarials were reduced by three quarters. [1][2] The reproduction number R0 of less than 1 is the gold standard for reducing the spread and therefore deaths from COVID-19 (<1 means the pandemic is shrinking), however this could increase the deaths from malaria due to an extended disruption to prevention and treatment services [3][4]. Prevention strategies involve entering households and are likely to be significantly affected; nonetheless, if only 50% of treatment services are retained 100,000 deaths could still be prevented over 6 months. [3][17]
Malaria is not the only disease likely to spike during the prolonged course of this pandemic; the German Development Minister Gerd Müller warns also of the excess deaths from HIV and tuberculosis (500,000 globally for TB alone).[20] 66% of malaria programs have reported disturbance during COVID-19 (as well as 80% of HIV programs and 75% of TB programs) due to transport disruption, social restrictions/lockdowns and unwillingness of health workers to deliver or clients to seek health care.[12] These treatable conditions are set to become death sentences for many due to the precarious funding for and logistics of foreign aid programs that help to supply medicine and food.[12]
During the Ebola epidemic many were fearful of seeking aid and the reduction in access to healthcare lead to indirect deaths from malaria, HIV/AIDs and TB of 6,269 in Guinea (as well as 1,535 in Liberia and 2,819 in Sierra Leone). [19][21] The same reluctance to seek care may be the case in this pandemic and should be monitored, especially as those with fever (a cough and/or diarrhoea) symptoms may avoid care settings for fear of transmitting COVID-19 but could have undiagnosed malaria, requiring treatment.[15][19] Researchers from Imperial college London suggest new guidelines for sub-Saharan Africa; antimalarial treatment for (undiagnosed) children presenting with a fever could save 178,000 lives a year (assuming 70% were treated). [3][22]
This pandemic has also provoked economic (and therefore poverty and hunger) crises in many low- and middle-income countries (LMICs) disproportionately, and COVID-19 distancing strategies (such as lockdowns, restrictions on trade and school shutdowns) are affecting food delivery systems.[23] Malnutrition and child wasting are obvious side effects, with an extra 6.7 million children set to be affected during first 12 months of the pandemic (majorly in sub-Saharan Africa and south Asia), and the lack of nutrition can also in turn amplify the effects of COVID-19, particularly in young children. [23]
Bill Gates (Co-chair of the Bill and Melinda Gates foundation) warns countries not to choose COVID-19 over malaria; the successful management and eventual eradication of preventable and treatable diseases such as malaria (TB and HIV) will make us better prepared to fight future global health crises. [16]
Author; Amber Truepenny, DPhil in Chemistry, Hertford College
References:
[1] WHO. The potential impact of health service disruptions on the burden of malaria. [Online]. 2020. [Accessed 3rd October 2020]. Available from:https://www.who.int/publications/i/item/the-potential-impact-of-health-service-disruptions-on-the-burden-of-malaria
[2] Weiss et al. Indirect effects of the COVID-19 pandemic on malaria intervention coverage, morbidity, and mortality in Africa: a geospatial modelling analysis. The Lancet Infectious Diseases. 2020.
[3] Sherrard-Smith, E. et al. The potential public health consequences of COVID-19 on malaria in Africa. Nature Medicine. 2020, 26, pp. 1411-1416.
[4] Adam, D. Nature Articles. A guide to R - the pandemic’s misunderstood metric. [Online]. 2020. [Accessed 3rd October 2020]. Available from: https://www.nature.com/articles/d41586-020-02009-w
[5] The Guardian. Thousands of cancer patients could die early due to coronavirus delays study finds. [Online]. 2020. [Accessed 3rd October 2020]. Available from: https://www.theguardian.com/society/2020/may/20/thousands-of-cancer-patients-could-die-early-due-to-coronavirus-delays-study-finds
[6] The Daily Mail. Britain's coronavirus crisis could result in 18,000 more people dying of cancer in next year while NHS faces backlog that could last 'many years' after two million operations were cancelled. [Online]. 2020. [Accessed 3rd October 2020]. Available from: https://www.dailymail.co.uk/news/article-8265851/Coronavirus-crisis-UK-result-18-000-cancer-deaths-year.html
[7] The Telegraph. Unexplained excess deaths at home almost nine times higher than those from Covid. [Online]. 2020. [Accessed 3rd October 2020]. Available from: https://www.telegraph.co.uk/news/2020/09/22/unexplained-excess-deaths-home-almost-nine-times-higher-covid/
[8] The Sun. COLLATERAL DAMAGE For every coronavirus death another life is lost to cancer, warns ex-health secretary Jeremy Hunt. [Online]. 2020. [Accessed 3rd October 2020]. Available from: https://www.thesun.co.uk/news/12816845/every-coronavirus-death-another-lost-cancer-jeremy-hunt/
[9] Maringe, C. The impact of the COVID-19 pandemic on cancer deaths due to delays in diagnosis in England, UK: a national, population-based, modelling study. The Lancet. 2020, 21(8), pp.1023-1034.
[10] HDR UK. The Big C isn't COVID-19 - it’s cancer. [Online]. 2020. [Accessed 3rd October 2020]. Available from: https://www.hdruk.ac.uk/news/the-big-c-isnt-covid-19-its-cancer/
[11] AAAS Science. The pandemic appears to have spared Africa so far. Scientists are struggling to explain why. [Online]. 2020. [Accessed 3rd October 2020]. Available from: https://www.sciencemag.org/news/2020/08/pandemic-appears-have-spared-africa-so-far-scientists-are-struggling-explain-why
[12] Friends of the Global Fight. How COVID-19 is affecting the global response to AIDS, tuberculosis and malaria. [Online]. 2020. [Accessed 3rd October 2020]. Available from: https://www.theglobalfight.org/covid-aids-tb-malaria/
[13] White, N.J., Pukrittayakamee, S., Hein, T.T., Mokuolu, O.A., Dondorp, A.M. Malaria. The Lancet. 2014, 383(9918), pp.723-735.
[14] WHO. WHO urges countries to move quickly to save lives from malaria in sub-Saharan Africa. [Online]. 2020. [Accessed 3rd October 2020]. Available from: https://www.who.int/news-room/detail/23-04-2020-who-urges-countries-to-move-quickly-to-save-lives-from-malaria-in-sub-saharan-africa
[15] CDC. Symptoms of Coronavirus. [Online]. 2020. [Accessed 3rd October 2020]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html
[16] Gates Notes. As COVID-19 spreads, don’t lose track of malaria. [Online]. 2020. [Accessed 3rd October 2020]. Available from: https://www.gatesnotes.com/Health/As-COVID-19-spreads-do-not-lose-track-of-malaria
[17] WHO. World Malaria Report 2019. [Online] Geneva: WHO Press, 2019. [Accessed 3rd October 2020]. Available from: https://www.who.int/publications/i/item/9789241565721
[18] WHO. World malaria report 2015. [Online]. Geneva: WHO Press, 2015. [Accessed 3rd October 2020]. Available from: https://apps.who.int/iris/bitstream/handle/10665/200018/9789241565158_eng.pdf?sequence=1
[19] WHO. Tailoring malaria interventions in the COVID-19 response. [Online]. Geneva: WHO Press, 2015. [Accessed 3rd October 2020]. Available from: https://www.who.int/malaria/publications/atoz/tailoring-malaria-interventions-covid-19.pdf
[20] Handelsblatt. Development Minister Müller: "Far more people will die from the consequences of the lockdown than from the virus". [Online]. 2020. [Accessed 3rd October 2020]. Available from: https://app.handelsblatt.com/politik/deutschland/coronakrise-entwicklungsminister-mueller-an-den-folgen-der-lockdowns-werden-weit-mehr-menschen-sterben-als-am-virus/26209144.html?ticket=ST-852596-JcPCPl4iKI6TOxh7fSzL-ap2
[21] Parpia, A.S., Ndeffo-Mbah. M.L., Wenzel N.S., et al. Effects of Response to 2014–2015 Ebola Outbreak on Deaths from Malaria, HIV/AIDS, and Tuberculosis, West Africa. Emerging Infectious Diseases. 2016. 22(3), pp. 433-441.
[22] Imperial College London. Mosquito net distribution could halve Malaria deaths in Africa during COVID-19. [Online]. 2020. [Accessed 3rd October 2020]. Available from: https://www.imperial.ac.uk/news/201513/mosquito-distribution-could-halve-malaria-deaths/
[23] Fore, H.H. et al. Child malnutrition and COVID-19: the time to act is now. The Lancet. 2020. 396(10250), pp.517-518