Sheikh N, Maheshwari C. Malaria amidst COVID-19 in the Central African Republic. HPHR. 2021;48.
The WHO World Malaria Report 2020 states that 94% of malaria cases and 95% of its mortality globally are from Africa. However, in Africa, these rates are expected to be higher due to under detection and asymptomatic cases. In the Central African Republic (CAR), malaria is known to be holoendemic and is transmitted throughout the year. Every year, malaria turns out to be more deadly and destructive in September during the rainy season than any other time. It is the main cause of death for children under five in the country. During periods when malaria transmission is high, eight out of ten pediatric patients are diagnosed with malaria; which results into subsequent complications such as dehydration and anemia. The natural disasters like floods, conflict and violence in CAR are further inflating the epidemiology of this infectious disease resulting in the inability of the people to access care or preventive measures. Consequently, given the limited health care facilities, 57% of its population is in need of humanitarian aid. This situation is expected to further worsen as COVID-19 strikes the country. As of May 22, 2021, there were a total of 7, 010 confirmed cases of COVID-19 in the Central African Republic in which 96 deaths were recorded. This pandemic further adds burden to a country that is already facing long years of fight against malaria on top of being decimated by decades of violent conflict and poverty. Furthermore, this paper aims to discuss the impact of COVID-19 on malaria in the Central African Republic.
Malaria is the main medical and public health concern in CAR which accounts for 42% of diseases, and 47% among displaced populations.1-2 It is diagnosed in 71.5% in the outpatient visits and 61% in the inpatients. In 2013 it was the cause of morbidity of 59% in all age groups compared to 40% in 2001 (an increase of 19%, from 2001 to 2013).3 From 2009 to 2014, 81% of the people (200,000 people) tested positive for malaria by rapid diagnostic test (RDT).3 In 2017, the rate increased by 6%, and the people who were suspected of malaria were screened with RDT wherein the results showed that 86% of them were malaria positive. 3 The WHO Malaria Report indicates that the prevalence has continued to increase from 2015 to 2018 in CAR.
Malaria in CAR is the main cause of death in children less than 5 years of age.2-4 In 2015, 50 to 60% of the admitted cases were due to malaria, with a mortality rate as high as 30 to 50% of the cases.4 In a retrospective study analyzing malaria results in the sentinel site databases of the Institute Pasteur in Bangui (IPB), the influenza surveillance system from 2015 to 2018 showed that there was no difference in the prevalence of sex. However, it showed that the most affected group was children 1-4 years with a rate of 76%, followed by the age group 5-15 years with a rate of 73%. Moreover, the rates for less than 1 year olds, more than 50 year olds, and age group 15-49 years were as follows: 60%, 67%, and 56%, respectively.2 In addition, this study shows that the prevalence of malaria has dropped in 2016 from 81% to 56% in 2018 . A higher prevalence in rural areas than in semi urban and urban areas is noted. Pregnant women as a vulnerable group are also affected.2
In 2017, the prevalence of malaria in children aged 6 months to 5 years was 73%. However, this rate varies by regions1,3,4 in which the northern parts of the country are mostly affected with a rate of 90%,1,4 followed by western and south regions with rates of 70% and 20%, respectively. Between 2015 and 2018, the prevalence fell by 9% and the death rates decreased by 25%.1 The goal is to eliminate malaria by 2030 in CAR, however, the lack of a functional surveillance system is deemed to limit this target.
With the help of governmental and non-governmental organizations, various programs and campaigns helped in alleviating the impact of malaria. These programs include the instigation of a community-based strategy involving community health workers (CHWs), mothers, and traditional health practitioners in the home management of uncomplicated malaria.5 The World Vision also spearheaded a massive anti-malaria campaign wherein nets were distributed to infants and pregnant women in order to cut malaria rates by 40% by 2021.6 These programs as well as other campaigns were able to curb the mortality of malaria from 700,000 in the early 2000s to 400,000 in 2020.7
As an example of carrying out special measures in the rapid mitigation of malaria during COVID-19 pandemic, Doctors Without Borders/Médecins Sans Frontières (MSF), a non-governmental organization, launched a mass drug administration of antimalarial treatments in CAR that ran in 3 stages. The first stage involved raising of awareness about the campaign through community leaders and radio broadcasting. Door-to-door distribution of the preventive treatment was the 2nd stage and the 3rd stage involved monitoring of the people’s compliance and identification of any side effects. Through this strategic program, the people were able to take the medications at the comfort of their own homes without being exposed in crowds at distribution sites. This campaign was able to provide preventive medications to 32,670 people in wherein 6,531 are children and 135 are pregnant women. Through such a program, a proven effective measure to reduce malarial morbidity and mortality became accessible and available to CAR despite the difficulty brought about by COVID-19.8
Presently, with the added burden of COVID-19 pandemic on top of governmental vulnerability, the WHO is concerned about not being able to reach the goals set in mitigating malaria. The death rates are expected to spike as the resources are being used in the fight against COVID-19 pandemic. The goal of having 90% fewer cases of infections and deaths by 2030 compared to 2015 might not be achieved because of the added burden in the healthcare system and scarcity in resources. As necessary steps were made to contain the pandemic, the access to diagnosis and treatment became more challenging and preventive measures such as distribution of Insecticide-Treated Nets (ITN) and Indoor Residual Sprays (IRS), were hampered.1,9 In addition to this, it was also reported that malaria could complicate the diagnosis of COVID-19 since similar symptoms such as body aches, weakness, headache, and fever are present at the onset of both diseases.7,10
According to WHO, confirmation of malaria through a diagnostic test does not rule out probable infection with COVID-19 and likewise, having a positive result for COVID-19 does not mean not having malaria infection.10 Furthermore, because of the imposed lockdowns and quarantine protocols, the CHWs who serve as the health lifeline of the villages in CAR had to limit their mobilization hence, affecting the already proven effective delivery of malaria care.
Similar to what happened during the Ebola epidemic in Africa, malaria transmission, cases, and mortality were affected by additional complications, in addition to health care centers being overwhelmed by the sheer number of patients-exacerbated by the lack of staff due to Ebola virus disease. Patients became hesitant to visit health centers because they were perceived as “a place where you go to die,” discouraging malaria patients from seeking treatment and instead going to traditional healers. Even in clinics where patients go to for diagnostic tests, technicians were reluctant to draw blood for microscopy to diagnose malaria. COVID-19 pandemic is way even worse than Ebola virus, because it is not just an epidemic but a pandemic with rapid transmission.11
WHO outlined certain recommendations for malaria-endemic countries. It is strongly encouraged that these countries should not suspend the planning for or implementation of ITN and IRS campaigns, which are essential vector control activities, provided that the delivery of these services should use best practices to protect health workers and communities. Special measures in the context of COVID-19 pandemic is also recommended. These include presumptive malaria treatment wherein the treatment of a suspected malaria case should proceed even without diagnostic confirmation. Another inclusion to these special measures is the massive drug administration (MDA) wherein all individuals in a targeted population are given antimalarial medications at repeated intervals whether they are symptomatic or not. However, these special measures although can help in rapidly reducing malaria morbidity and mortality, should only be done in the context of aiming to lower malaria-related mortality and keeping the healthcare workers and communities safe.
Malaria is the main cause of death of children under five. Before the COVID-19 pandemic, difficulties in delivering effective malaria treatments were already present due to decades of conflict, neglect and political instability. In addition to this, natural disasters such as floods, conflict and violence have worsened the inflating epidemiology of infectious diseases especially malaria cases yielding to its increased prevalence. CAR faces various challenges in decreasing malaria by 2030 due to lack of a functional surveillance system which limits the project. Access to malaria care is becoming challenging due to the limited mobilization of the HCWs because of the lockdown protocols, hampering the diagnosis of COVID-19. The WHO drafted recommendations for malaria-endemic countries and various NGOs started a mass administration of antimalarial treatments in CAR. Various programs and campaigns helped in relieving the impact of COVID-19 pandemic on malaria transmission and control.
Samar Mohammed Alhaj is with the School of Medicine, Ahfad University for Women, in Khartoum, Sudan.
Khlood Fathi Hassan is with the Faculty of Medicine, University of Khartoum, in Khartoum, Sudan. Hassan is a community medicine resident in the Sudan Medical Specialization Board; is interested in global health, medical education, and research; and aspires to become health minister of Sudan.
Catherine Hermoso is with the College of Medicine, Bicol University, Daraga, in Albay, Philippines.
Mohamed Babiker Musa is with the Faculty of Pharmacy, Omdurman Islamic University, in Khartoum, Sudan. Musa is a highly motivated pharmacist, leader, researcher, and global health enthusiast, with a successful record of achievements, certificates and workshops in the pharmacy field as well as in leadership, human development, and community service areas.
Attaullah Ahmadi is with the Medical Research Center, at Kateb University, in Kabul, Afghanistan.
Don Eliseo Lucero-Prisno III is with the Department of Global Health and Development, London School of Hygiene and Tropical Medicine, in London, United Kingdom, and the Faculty of Management and Development Studies, University of the Philippines Open University, in Los Baños, Laguna, Philippines.