The impact of COVID-19 on developing countries
Humanitarian crises monitoring: longer-term issues, implications and lessons learned

Medicines for Malaria Venture, May 2020

Medicines for Malaria Venture (MMV) is a leading product development partnership (PDP) in antimalarial drug research. Its mission is to reduce the burden of malaria in disease-endemic countries by discovering, developing and facilitating delivery of new, effective and affordable antimalarial drugs.

Over recent years, MMV has developed end-to-end capabilities spanning drug discovery, development and delivery, that have brought new malaria medicines to millions in need. PDPs like MMV are contributing in important ways to the global effort against COVID-19.

As COVID-19 is spreading in malaria-endemic countries, fragile health systems will likely be overwhelmed.[1] There are already signs that control efforts for major killer diseases like malaria are being compromised by COVID-19, similar to the situation experienced with recent outbreaks of the Ebola virus. There are disruptions in global drug supply-and-distribution chains as key production sites for malaria medicines and drug starting materials have been negatively impacted by temporary factory closures or slowdowns due to COVID-19 national responses. Additionally, some manufacturers of key medicines for malaria are making commercial decisions to shift to mass production in favor of as-yet unproven COVID-19 medicines (e.g. chloroquine and hydroxychloroquine) at the expense of producing millions of artemisinin-based combination therapies (ACTs) for malaria (and other essential medicines).  The World Health Organization (WHO) has warned that disruptions in malaria service delivery resulting from COVID-19, specifically in the delivery of insecticide-treated net (ITN) campaigns and in access to malaria treatment services across sub-Saharan Africa, could lead to a doubling of malaria deaths in 2020 compared to 2018.[2] Until new prevention and treatment tools are developed, the pandemic’s impact on the malaria response are likely to last into the longer-term. In addition to the pandemic’s toll on health, the disease could result in widespread famine and long-term economic recession if no action is taken[3],[4] and seriously undermine the gains made towards achieving the Sustainable Development Goals (SDGs), in particular SDG3, as well as others, most notably Goals 1, 2,4, 5 and 6.

On 17th April 2020, MMV submitted its comments on the current situation and the immediate risks and threats of COVID-19 on developing countries. With this second response, MMV is submitting comments further to the International Development Committee’s request for feedback on the longer-term impact of COVID-19 on developing countries.

The direct longer-term impacts of the outbreak on developing countries

Understanding of the spread of COVID-19, its epidemiology and how it interacts with malaria in sub-Saharan Africa and the rest of the developing world is still limited.[5] However, it is expected that COVID-19 could recur in waves[6] over the next few years. In this case, the list of COVID-19 threats to malaria control efforts as described in MMV’s previous submission dated 17th April 2020 are relevant for the long term.

The similarities in symptoms (most importantly, fever) between COVID-19 and malaria (as well as other illnesses such as typhoid) mean that accurate differential diagnosis is critical – yet many countries will not have adequate access to diagnostics for COVID-19, leading to vast undetected reservoirs. Equally challenging, many front-line healthcare workers in Africa will continue to lack access to adequate Personal Protective Equipment (PPE), and as was seen with Ebola, will be understandably concerned about disease exposure when triaging patients with fever. One major implication of this concern is the likely spike in presumptive treatment of all fevers with antimalarials, since the use of rapid diagnostic tests (RDTs) requiring close patient contact and finger pricks to draw blood may end have to be abandoned in many healthcare settings.

The message that people with fever should remain at home as they could potentially be infected with COVID-19 could be life-threatening for people who have fever due to malaria, as severe malaria can kill within 24 hours. WHO has put out official guidance as of 17th April 2020 instructing malaria-endemic countries ‘not’ to follow the ‘stay-at-home’ guidance propagated in the event of fevers.  In malaria-endemic countries, people should therefore continue to be encouraged to seek immediate attention, particularly for children, when fever symptoms are present.

In WHO’s recent analysis of the potential impact of disruptions in malaria service delivery, the worst-case scenario could result in a death toll of 770,000 in 2020, which exceeds the total number of global malaria deaths reported globally in 2000.[7] Of these, approximately 70% would be among children under the age of 5. The estimated malaria deaths in sub-Saharan Africa alone could exceed 743,000.[8] WHO’s analysis only takes into account disruptions in the distribution of insecticide treated nets (ITNs), and access to diagnosis and effective treatment in Sub-Saharan Africa. Disruptions in seasonal malaria chemoprevention (SMC), indoor residual spraying (IRS), and global commodity supply chains were not included in the analysis. Therefore, additional excess morbidity and mortality should be anticipated in case disruptions to these services also occur.[9]

If no new diagnostic, prevention or treatment tools are developed or delivered to developing countries over the next few years, COVID-19 could continue to unravel malaria control efforts years into the future.

The indirect longer-term impacts of the outbreak on developing countries

Access to antimalarial medicines and the production of these medicines are being disrupted globally due to lockdowns, import-export delays and the redeployment of some antimalarials in response to COVID-19. Since chloroquine and hydroxychloroquine started being considered as potential prophylaxis and treatment options for COVID-19, some countries have started banning exports and sales in pharmacies and restricted use to hospitals, despite the lack of conclusive clinical evidence and studies confirming the utility of either drug for COVID-19 treatment or prophylaxis. Further, the lockdown of countries hosting major manufacturers of these medicines, key starting materials and active pharmaceutical ingredients has resulted in increased demand for these products, which now outweighs the supply. As an additional consequence and risk, the circulation of counterfeit drugs is also mounting. Equally worrying, there is evidence that key manufacturers of ACTs for malaria treatment are opting to shift manufacturing focus to chloroquine and hydroxychloroquine, thus creating a potential looming risk for the supply of widely used ACTs such as artemether-lumefantrine and artesunate-amodiaquine.

Disruptions in the supply of RDTs to sub-Saharan Africa now and in the longer term could increase presumptive treatment and increase demand for antimalarials. This practice is less than ideal, as it increases the probability of antimalarial stockouts, and the incorrect use of antimalarials.[10]  WHO considers that test-treat-track is the optimal way to deliver malaria case-management. Improved case detection as a consequence of increased diagnostic testing is required to help track trends in malaria and direct limited resources where they are needed most.[11]

Over the short term, the pandemic could lead to large-scale unemployment and significant income losses. Over the longer term, it could facilitate the spread of other diseases, cause widespread famine, and result in a human and economic disaster in developing countries.[12]

Lessons learned to inform the COVID-19 response now and over the longer-term

The 2014–2016 Ebola outbreak in Guinea, Liberia and Sierra Leone significantly disrupted malaria control efforts and led to a wide increase in malaria infections and mortality. Estimates indicate that deaths from malaria during the outbreak in those three countries may have exceeded 63,000 people[13], vastly exceeding deaths from Ebola (under 12,000 deaths from 2014-2016.) In the two subsequent years (2017-2018), as many as 40,000 people died from malaria in those countries after Ebola deaths dropped to zero.[14] In the wake of the West Africa Ebola outbreak both affected and neighbouring countries gained experience in responding to infectious diseases. These countries are therefore in a position to apply lessons learnt and benefit from investments made in preparedness, potentially able to respond and mitigate the impact of COVID-19.

It is essential that the responses to the developing world’s ongoing threats from COVID-19 and other infectious diseases such as malaria are robust and concurrently maintained. At the same time, MMV’s practices and principles to ensure antimalarials are effectively discovered, developed, and delivered to meet the needs of people could be applied to the development and delivery of new tools to fight COVID-19 in developing countries. 

Maintaining research and development into new tools

Coordinated global R&D and public-private collaboration against malaria and other diseases is critical to discover and develop new health tools for existing and new threats such as COVID-19.

R&D efforts to discover solutions for malaria and other pathogens are not necessarily mutually exclusive. For example, MMV has pioneered open approaches to boost early-stage drug discovery for malaria and other infectious diseases by promoting transparency and collaboration among project partners, giving scientists access to free data and materials. MMV’s Pandemic Response Box, which contains 200 antiviral compounds among 400 diverse molecules, is helping researchers identify hits and leads against a wide range of pathogens including pandemic fever viruses. Data from these will help inform the development of clinical trials.

Since the negative impact of this crisis will be greatest for the most vulnerable populations in resource-limited settings, these populations should remain targets in the discovery, development and delivery of new tools against COVID-19.

Maintaining production, delivery and supply chains

There is a need to maintain the delivery of routine malaria prevention and treatment services at community level as well as nationally. This effort comprises adequate safeguarding of the essential supply of treatments for major poverty-related diseases, such as malaria. Manufacturers, procurement partners and international organisations must continue to work together for the continuity of malaria drug supply.

Furthermore, as new diagnostics, vaccines or treatments against COVID-19 are being introduced in developing countries, external support, including the kind of external financing and distribution mechanisms that are used for HIV, TB and malaria, could be contemplated. Global coordination, and early, end-to-end planning are also needed so that lifesaving tools get into the hands of the people who need them as fast as possible.

The impact of the outbreak, and consequential mitigation measures, on fundraising

The prospect of various entwined complex health and humanitarian catastrophes in developing countries, leading into long-term global recession, could potentially result in the de-prioritisation of funding for access programmes for major poverty-related diseases as well as for research and development.

Now is the time to act. It is encouraging that the UK has taken a leading role and to date has pledged £744m towards the international response to developing countries in the COVID-19 crisis.[15] At the same time, the response to COVID-19 should be funded with new money and not drawn from already committed funding for ongoing threats from other infectious diseases, such as malaria.

Progress in the fight against malaria over the last 20 years has demonstrated that investments and the right mix of strategies has resulted in significant achievements. A leader in the fight against major poverty-related diseases such as malaria, the UK Government has helped prevent hundreds of thousands of deaths, including of pregnant women and children who are often the most vulnerable. Continued investment is critical to scaling up development of and access to innovative interventions in the fight against deadly diseases, as well as to ensure the strengthening of health systems globally – our first lines of defense against existing and emerging health threats.