Potential Impact of COVID-19 on malaria programmes in developing countries
The RBM Partnership to End Malaria is the global platform for coordinated action against malaria. It mobilises resources for action and forges consensus among partners. The Partnership comprises more than 500 partners committed to end malaria, including malaria endemic countries, their bilateral and multilateral development partners, the private sector, nongovernmental and community-based organisations, foundations and research and academic institutions.
The RBM Partnership is working to ensure that the spread of COVID-19 does not compromise access to malaria prevention, diagnosis and treatment services, which are saving almost 600,000 lives and preventing nearly 100 million infections each year. Our top priority is to ensure the supply of vital malaria control tools used to protect millions of people across the world, particularly in countries with a high burden of the disease, as well as their safe delivery, including availability of personal protective equipment (PPE) for frontline health workers.
The COVID-19 pandemic has created a risk of excess morbidity and mortality globally, not just from the virus itself but also from the wide-ranging disruptions to health systems, medical supply chains, and other supporting businesses and organisations, all of which are preventing the delivery of essential and life-saving health services.
Disruptions to malaria programmes have been linked to over 75 major resurgences in the past. These well-documented events were usually limited to one country or a region and linked directly to national decisions to suspend or reduce funding for antimalaria activities. The COVID-19 pandemic presents a unique challenge through its global scale. A simultaneous disruption of malaria programmes across most malaria-endemic countries could precipitate an unprecedented global resurgence in the disease, reversing decades of progress in a short period of time.
The precise scale of such a resurgence will depend on a number of factors and is impossible to accurately quantify at this stage. However, preliminary models suggest a worst-case scenario that would return the state of the global malaria fight to that seen before the year 2000 and undo the significant progress of the last twenty years and squander the significant financial investments that have supported this progress to date.
Those most at-risk for serious adverse effects from malaria infection include children under five, who comprise two-thirds of malaria deaths, and pregnant women. We would expect a similar pattern of mortality given a major resurgence. As with the 2014–2016 Ebola outbreak in West Africa, which resulted in 7,000 additional malaria deaths in children under five in Guinea, Liberia, and Sierra Leone, deaths resulting from cutting essential health services, due to over-burdened health systems or aggressive prevention measures may even exceed the deaths from the COVID-19 pandemic alone.
The coming weeks and months ahead will see the start of the malaria transmission season in many countries across Africa and Asia. Ensuring that funding, personal protective equipment, and essential malaria commodities are in place can make the critical difference in avoiding major outbreaks and protecting the significant gains made in the fight against malaria since the start of the 21st century. This also includes the broader gains in Universal Health Coverage (UHC), improved well-being, and associated economic improvements that have been made possible through reduced malaria morbidity and mortality.
Since the onset of this pandemic, the RBM Partnership has been working closely with countries, donors, international organizations, and other stakeholders to ensure that populations at-risk for malaria continue to receive essential prevention, diagnosis, and treatment services, as well as updated guidance in a rapid and effective fashion. Receipt and uptake of these essential services is key to saving almost 600,000 lives and preventing nearly 100 million new malaria infections each year.
Efforts to limit the spread of COVID-19 are necessary to ensure that health systems are not overwhelmed. In parallel, countries are also requiring additional support to continue safely delivering life-saving malaria prevention, diagnostic and treatment services, such as universal coverage campaigns for long-lasting insecticidal nets (LLINs), seasonal malaria chemoprevention (SMC) and indoor residual spraying (IRS), focusing on reaching those at highest risk, including women and children under five and internally displaced persons living in sub-standard accommodations in Sub-Saharan Africa and high-burden areas in Asia-Pacific. Cessation of these services greatly increases the risk of malaria infection and death among the most vulnerable, as well as adding higher malaria case burdens to already stressed community health workers, clinics and hospitals.
Long-lasting insecticidal nets (LLINs) are one of the key malaria prevention commodities, protecting communities by preventing biting and reducing vector density. The large-scale distributions and uptake by communities of these nets are responsible for 68% of the malaria cases prevented in Africa since 2000. High-burden malaria-endemic countries deliver LLINs through mass distribution campaigns every three years, which is often complemented by rolling distribution systems (ie routine – antenatal care (ANC) & Expanded Programme on Immunizations (EPI) and school-based distributions) to maintain high LLIN coverage among the population. This year, important LLIN distribution campaigns and campaign planning exercises were scheduled to take place in 29 African countries to replace old, worn-out nets among some of the highest burden populations in the world.
The recommendations in place to address COVID-19 have required updating the guidelines for LLIN distribution, with significant implications for the management, training, commodity supply, distribution methods, and funding for the campaigns. In the immediate aftermath of new, national-level COVID-19 policies, several countries placed their LLIN campaigns on hold.
The RBM Partnership is working on a country-by-country basis to support the redesign and rescheduling of LLIN campaigns ahead of the upcoming malaria transmission season while still taking into consideration safety precautions for health care workers who will be undertaking the distributions and recipient communities. For example, partners have already provided support to Benin, Guinea-Bissau, and Niger and these countries have recently confirmed that they will continue their LLIN distribution campaigns this year as scheduled.
Keeping all 29 African countries with planned 2020 LLIN campaigns on schedule is a top priority, which will require additional financial resources for planning, distribution, training, and social/behaviour change communications, as well as additional commodities to ensure the safety of distributors and beneficiaries (e.g. face-masks, gloves, soap, hand-sanitizer, etc).
Like LLIN campaigns, annual delivery of Indoor Residual Spraying (IRS) provides critical protection to households and communities. IRS campaigns are highly time-sensitive as they must be effected at the start of the malaria transmission season and with high population coverage (>80% of the target households is recommended to ensure protective efficacy). In line with WHO-guidance, IRS campaigns are typically rolled-out in communities which are not covered by LLINs. Their timely execution is thus equally important for preventing excess morbidity and mortality. This year, 11 African countries have planned IRS campaigns and require additional financial resources for planning, training, social/behavioural change communications, and COVID-19 related protective commodities.
In countries with highly seasonal malaria transmission, as in the Sahel region of West Africa, seasonal malaria chemoprevention (SMC), or the seasonal distribution of prophylactic antimalaria drugs to children under five, has been used effectively in recent years to prevent mortality among this particularly vulnerable age group.
SMC campaigns require health personnel to visit at-risk areas and administer malaria drugs to small children at regular intervals throughout the malaria transmission season. WHO and partners have coalesced around recommendations to ensure SMC activities can be safely and effectively carried out in the context of common COVID-19 recommendations as the risk-benefit in reducing malaria in this age group is paramount to ensure health facilities are not overwhelmed with malaria cases at the same time as COVID-19 infections may be peaking.
This year, 13 countries are scheduled to carry out annual SMC campaigns, which will require additional financial resources to adapt these campaigns to the COVID-19 response context especially ensuring safety for those administering the medicines.
As COVID-19 further makes its way into malaria endemic countries, the challenges of differential diagnosis for febrile illness will become increasingly acute. With greater numbers of febrile cases, overconsumption of Rapid Diagnostic Tests (RDTs) for malaria poses a major risk. Likewise, the potential recommendation to treat febrile cases presumptively for malaria in the context of high COVID-19 transmission could lead to the overconsumption of artemisinin-based combination therapies (ACTs) and disrupt treatment algorithms stemming from malaria positive or negative confirmation. Similarly, without adequate SARS-CoV-2 testing, presumptive COVID-19 diagnoses and treatment without ruling out other febrile diseases could propagate malaria, dengue and other infections with similar symptoms.
At this time, the risks of COVID-19 and malaria co-morbidity are poorly understood and may pose additional, unforeseen challenges in case management. Protocols for COVID-19 treatment itself may also disrupt the consumption of malaria commodities, with some countries using antimalarials as COVID-19 treatment. This poses a particular risk for management of P.vivax malaria, which is typically managed with chloroquine. Finally, there are major risks associated with care-seeking behaviour in the context of COVID-19, as people with fevers may be reluctant to seek treatment out of fear of contracting or spreading COVID-19.
Likewise, the hardships and risks on healthcare workers at facility and community levels may disrupt the overall quality of malaria case management. Additional resources will be needed both to prevent and respond to these types of disruptions at all levels of the health system.
Cross Disease Issues
We recognize that the challenges faced by malaria programmes are echoed across a variety of other health issue areas including HIV/AIDS, tuberculosis, vaccine preventable diseases, management of malnutrition, ANC and neglected tropical diseases. Hard-won gains in addressing these health issues have been core drivers in mortality reductions in low and middle-income countries over the past two decades. Preventing disruptions to essential health services must be seen as a core element of the response to COVID-19. As disruptions occur, resources must be mobilised in the most flexible form for countries to adapt and use as needed with overall morbidity and mortality as the basis for measurement.
 Cohen, J.M., Smith, D.L., Cotter, C. et al. Malaria resurgence: a systematic review and assessment of its causes. Malar J 11, 122 (2012). https://doi.org/10.1186/1475-2875-11-122
 Wang, J., Xu, C., Wong, Y. K., He, Y., Adegnika, A. A., Kremsner, P. G., ... & Liao, F. L. (2020). Preparedness is essential for malaria-endemic regions during the COVID-19 pandemic. The Lancet.
 On tailoring malaria interventions in the COVID-19 response, see: https://www.who.int/malaria/publications/atoz/tailoring-malaria-interventions-in-the-covid-19-response/en/
 Ibid., also see https://allianceformalariaprevention.com/about/amp-guidelines-and-statements/