Malaria May Still Be 2020’s Biggest Killer

Six months into the coronavirus outbreak, children have largely been spared its worst effects. But the pandemic may well cause hundreds of thousands of children to die this year: not from COVID-19, but from malaria.

The World Health Organization (WHO) warned in April that disruptions to malaria prevention and treatment caused by the coronavirus could see malaria deaths double this year. The increase alone—estimated at the worst case to be 369,000—would almost equal the current confirmed death toll of COVID-19. With peak malaria season rapidly approaching in major malaria-endemic countries, the window of time in which to avoid disaster is rapidly closing.

Ebola outbreaks provide worrying precedent. The 2014 outbreak in West Africa wreaked havoc on health systems, affecting not only those suffering from Ebola but also those suffering from such diseases as malaria, HIV, and tuberculosis. The death toll from other diseases was greater than that of Ebola itself. In the most recent Ebola outbreak in the Democratic Republic of the Congo in 2018, the most affected province experienced an eightfold increase in malaria incidence.

A coronavirus response strategy that ignores malaria in endemic countries will harm the response to both diseases. The increase in malaria mortality could prove to be one of the deadliest consequences of the pandemic, with young children, who represent the bulk of malaria casualties, particularly hard-hit. A surge in malaria will also harm efforts to tackle the coronavirus, placing massive stress on health systems when they can least afford it. And because both COVID-19 and malaria present with fevers, integrating malaria response is important for correctly identifying COVID-19 cases.

“It’s like the perfect storm,” said Melanie Renshaw of the RBM Partnership to End Malaria.

The storm will hit Africa hardest. Malaria once ravaged the American South to such an extent that the Centers for Disease Control and Prevention was headquartered in Atlanta to focus on eradicating the disease, which is now largely restricted to the tropics. According to WHO, over 90 percent of malaria cases and deaths take place in sub-Saharan Africa. Children under 5 represent two-thirds of all malaria deaths, with pregnant women forming another particularly vulnerable demographic.

Because stagnant water enables the breeding of mosquitos, most malaria transmission takes place during the rainy season. Many of the most severely malaria-affected countries are in West Africa, where the rains last from roughly May to September.

Insecticide-treated bed nets represent the most widespread form of malaria prevention. Every three years, malaria-endemic countries conduct mass campaigns to distribute bed nets to their populations, and campaigns were due in 2020 in many countries. Twenty-seven sub-Saharan African countries representing 85 percent of the region’s malaria cases and deaths had bed net distribution campaigns planned for 2020, according to WHO.

Due to lockdowns and overstretched government resources, distributing the bed nets has become a more difficult task. While countries such as Benin and Sierra Leone have been able to go forward with their bed net distribution campaigns, others including Nigeria and Ghana have yet to do so. Renshaw and other experts remain cautiously optimistic that almost all bed net distribution campaigns will go ahead, but the window of time before peak malaria season is rapidly closing. Additional preventive measures, including seasonal chemoprevention and indoor residual spraying, have also been disrupted.

The pandemic poses a number of other challenges. Health workers and patients alike will initially struggle to know whether a fever indicates COVID-19 or malaria. When COVID-19 emerged in North Darfur, many of those suffering from the disease were dismissive of the threat, believing they had malaria. Malaria could also be mistaken for COVID-19. Any time a person with malaria arrives at a health center with a fever, health workers may fear the patient could infect them with COVID-19.

Health workers also find it difficult to distinguish COVID-19 and malaria without an adequate supply of personal protective equipment and diagnostics. While disruptions to global supply chains initially limited access to these commodities and antimalarial medications, the key producers India and China have since eased lockdowns, and the situation has mostly returned to normal. International partners are carefully coordinating shipments to ensure African countries maintain stocks of key commodities. But second waves of the coronavirus outbreak could well disrupt supply chains again.

U.S. President Donald Trump has touted hydroxychloroquine’s efficacy against COVID-19 and took the medicine himself despite limited evidence of its benefits and potentially harmful side effects—which, in turn, led to a huge spike in prescriptions and sales of the critical drug. Supply chains are further endangered when scientists explore the use of malaria treatments for COVID-19. No aspect of malaria has generated more coverage in recent months than the antimalarial drugs chloroquine and hydroxychloroquine. While chloroquine and hydroxychloroquine were previously used extensively for malaria, the strain of malaria most common in Africa is now largely resistant to the medicines. However, chloroquine is still used in Latin America, and one of the key components in the medicine is used in some antimalarials that are widely used in Africa. U.S. President Donald Trump has touted hydroxychloroquine’s efficacy against COVID-19 and took the medicine himself despite limited evidence of its benefits and potentially harmful side effects—which, in turn, led to a huge spike in prescriptions and sales of the critical drug.

“Anywhere you’re hearing about chloroquine being used for COVID, that has pulled down on the starting materials that can be used for antimalarials,” said George Jagoe, the head of access and product management at Medicines for Malaria Venture. Unconvincing trial results on chloroquine and hydroxychloroquine’s efficacy against COVID-19 have finally decreased larger demand for the medicines. However, other malaria drugs could face similar competition if new treatments or diagnostics for COVID-19 emerge that producers deem more profitable.

Even if African countries maintain adequate supplies of antimalarials and diagnostic tests, malaria deaths could skyrocket if people suffering from malaria cannot access them at health facilities. Few developments would harm access to malaria treatment more than major COVID-19 outbreaks, which would deplete the supply of health workers and make travel to health centers difficult and dangerous.

African governments responded quickly to the COVID-19 pandemic and thus far have largely avoided mass outbreaks like those in Europe and the United States. But significant outbreaks have been reported in Tanzania and northern Nigeria, and early indications suggest that people suffering from malaria are staying away from health facilities.

In Ghana, attendance at maternal and child health services has dropped by 50 percent nationwide, according to Fred Binka, a professor of clinical epidemiology at Ghana’s University of Health and Allied Sciences. Health workers in Nigeria and Benin also report fewer people coming to health facilities. This drop in attendance does not suggest that malaria infections have decreased, but rather that fewer people are being treated for the disease. And because children and pregnant women are the most at-risk groups, decreased attendance could lead to increased deaths as those suffering from malaria do not receive treatment in time. Due to the difficulty of tracking these deaths, the COVID-19 pandemic’s full effect on malaria will not be known until after malaria season, if ever. Still, sufficient time remains to prevent the worst-case scenarios.

Governments and international partners have already taken a number of positive steps. WHO provided guidance on how to adjust malaria programming to account for COVID-19. The Global Fund to Fight AIDS, Tuberculosis and Malaria provided additional financing and allowed reprogramming. Supply chains are gradually stabilizing. Most importantly, African countries have prevented mass outbreaks of COVID-19 and largely maintained functioning health systems.

While African governments deserve credit for their quick response to the pandemic, it’s critical to ensure malaria remains a top priority. Given malaria’s seasonal nature and the complications it produces for COVID-19 response, it deserves particularly prompt attention from countries in which peak malaria season is approaching. While governments will need to adapt some existing practices, they can learn from how other governments have responded to the challenges produced by the pandemic. Benin’s use of door-to-door bed net delivery instead of central gathering points provides one important example. But if they delay, the damage could be even worse than the direct effects of COVID-19 itself.

Governments will also have to ensure those suffering from malaria seek treatment. The police brutality that some African countries have employed in enforcing lockdowns and quarantines is clearly counterproductive, deterring those who should travel to health facilities. More broadly, after months of encouraging people to stay at home, governments now have to ensure populations understand that they should quickly seek treatment if they experience signs of malaria. Governments must communicate these messages widely and provide versions in local languages. Lastly, health facilities and malaria monitoring need to remain active at the local level.

Governments in malaria-endemic countries must rise to the challenge, but they have been dealt an extraordinarily bad hand. Niger has to control malaria, fight a pandemic, and provide all the other services any health system needs with $29 per person per year. Of the 20 countries that represent 85 percent of global malaria deaths, 13 spend more money servicing debt than they do on health care. Debt relief would ensure meager budgets can focus on providing life-saving health care, but private creditors have largely refused to even consider suspensions. Policies that limit access to vital supplies, like the restrictions on U.S. aid funds being used to purchase personal protective equipment, will also have deadly consequences.

In the longer term, donor countries must ensure that the scaling up of funding to respond to COVID-19 does not cut into future malaria funding. Even before the pandemic, the Lancet warned that an additional $2 billion a year is needed to eradicate malaria by 2050.

While malaria eradication remains achievable in the coming decades, much depends on whether this year ultimately represents a bump in the road or a U-turn. The next month will be critical as governments, civil society, and international partners try to pull off a delicate balancing act to keep both COVID-19 and malaria under control. If they fall short, hundreds of thousands more parents will be mourning the loss of a child this year. Many of those children will die at home, with their deaths never recorded. But the loss will be felt all the same.