The spread of COVID-19 in Africa as it enters malaria transmission season could have devastating consequences for the region.

In my opinion, we’ll be facing a crisis for malaria in the coming months Dr Etienne Bilgo IRSS/Centre Muraz, Burkina Faso

At the time of writing, confirmed COVID-19 cases have surpassed 2.7 million worldwide, with over 190,000 recorded deaths. For many countries, the situation remains critical and relies on an array of containment and mitigation measures to limit further spread.

In Africa, all but two countries have been affected by the virus. There are currently 28,000 confirmed cases in the continent, but there is fear that the virus is spreading undetected and that facilities and infrastructure in Africa will not be able to handle the kinds of outbreaks that have been seen in Europe and the US.

A report published last month by The WHO Collaborating Centre for Infectious Disease Modelling within the MRC Centre for Global Infectious Disease Analysis (MRC GIDA), Abdul Latif Jameel Institute for Disease and Emergency Analytics (J-IDEA) at Imperial College London analysed the effect of the COVID-19 pandemic in the absence of interventions. The report found that in a typical low-income setting, there will be 25 times more people needing critical care beds than there are beds available, compared to 7 times more in a typical high-income setting.

Many of the confirmed cases in Africa are clustered in North and West Africa, and for Burkina Faso, a country of around 20 million people that sits between the Sahara Desert and the Gulf of Guinea, the effects of the virus are already having serious consequences. Dr Etienne Bilgo, a medical entomologist and research fellow at IRSS/Centre Muraz, based in Bobo-Dioulasso, the second city of Burkina Faso explained to the Imperial College Network of Excellence in Malaria that the 41 COVID-19 associated deaths in the country, which represents over 6% of total diagnosed cases “is very high and shows how weak our system is. We don’t have the infrastructure or resources to cope with such high numbers of sick people”.

Burkina Faso has 4 hospitals that have been dedicated to COVID-19 in- patients, 3 in the capital, Ouagadougou, and 1 in Bobo-Dioulasso. In total they have 11 available ventilators. Many other African countries have fewer or no ventilators, and according to the WHO there are fewer than 2,000 ventilators in the continent for over a billion people. Contrast this with the UK which was in possession of 5,000 ventilators when the pandemic began.

A population already suffering

Some of the most proven effective measures against COVID-19 transmission are, in Africa, much more difficult to put into practice. Measures such as regular hand washing are hampered by the fact that 40% of Sub-Saharan Africans do not have access to clean water. Social distancing and lockdowns are limited in their effect because economic hardship for people of many countries means that they live day-to-day and require work to survive, and because, on average, households contain a larger number of people often with several generations of the same family.

At the time of writing, there’s little data about how those suffering from COVID-19 fare when infected with other diseases such as malaria, TB and HIV, or how much more susceptible they might be to COVID-19 with weakened immune systems caused by those diseases. However, modelling published in the Lancet Infectious Diseases in 2015 by a team of researchers at MRC GIDA at Imperial College found that if malaria care had ceased as a result of overwhelmed healthcare systems during the Ebola epidemic in 2014, then it would have produced 2.6 - 4.9 million additional untreated malaria cases and 5,700 - 21,400 more malaria-attributed deaths in Guinea, Sierra Leone and Liberia alone.

The takeaway from that modelling study suggests that, while in the middle of this kind of epidemic it’s essential to continue implementing strategies to prevent malaria in anticipation of the malaria transmission seasons. This includes strategies such as mass drug administration and the distribution of bednets, and it’s a message that was reiterated by the WHO last month. However, there is fear from within Africa that there will be a repeat of 2014.

“The current priority for the government is COVID-19, so the impact of malaria is going to be completely overshadowed”, says Dr Etienne Bilgo in Burkina Faso. “In my opinion, we’ll be facing a crisis for malaria in the coming months, because while the current priority in Burkina Faso is to control the COVID-19 epidemic and care for sick people, malaria interventions like the distribution of bed nets and drugs, or indoor spraying, monitoring and surveillance is going to be reduced, and unfortunately we’ll see the impact of that in the months to come.”

Malaria transmission season

The WHO estimate that in 2017 alone there were 200 million cases of malaria in Africa, 92% of the world’s total in that year. In a malaria eradication report published by the WHO earlier this week, it was emphasised that despite “huge progress” in reducing malaria cases and deaths between 2000-2015, in the last 5 years progress has stalled. They state that “without massive concerted and coordinated action” a 2030 target of reducing incidence and mortality by 90% is “unlikely”.

Much of West Africa is currently in its dry season, when countries see far fewer malaria cases because mosquitoes often breed in standing water that remains as a result of rainfall. In the wet season, mosquitoes become more abundant and malaria cases increase. For Burkina Faso, as for many other West African countries, the wet season will begin in the next few weeks, and by the time it ends, around September, the country will see millions of malaria cases and hundreds of thousands of hospitalisations as a result. The hope is for Africans that this period doesn’t coincide with a significant COVID-19 outbreak.

There is hope expressed by Imperial College Chair in Infectious Disease Epidemiology and Imperial College Malaria Network member, Prof Azra Ghani, who told the New Scientist earlier this month that because COVID-19 appears to be affecting older people more and because low-income countries have much younger populations, “we’d expect more infections in low-income settings but there’d be less severe cases”. While fellow Imperial Malaria Network member, Prof Neil Ferguson emphasised, in this MRC GIDA article published last month, that “countries need to act collectively to rapidly respond to this fast-growing epidemic”, and the hope is that as the peaks of outbreaks in Europe pass, demand for vital personal protective and medical equipment lessens and may become available for Africans.

On World Malaria Day 2020, while COVID-19 continues to sadly take lives and make headlines, history and the Ebola epidemic of 2014 tells us that malaria becomes even more devastating when priorities shift, and guards are let down. On the eve of the rainy season for the areas of greatest malaria incidence, the world’s attention must not be distracted from malaria if it is to avert hundreds of thousands of additional deaths.