World Malaria Day 2020 • Fighting malaria while fighting the COVID-19 pandemic

The WHO estimates that in 2018, there were 228 million cases of malaria in 89 countries, with 405,000 resulting deaths. No significant gains were made in reducing malaria cases from 2014 to 2018. As of April 21 2020 globally 2.2 million SARS-CoV-2 cases and 170,000 COVID-19-related deaths have been reported. The COVID-19 pandemic is causing morbidity, mortality, anxiety, and an economic free-fall that has never been seen before. It is difficult to predict the impact of the COVID-19 pandemic on malaria research and prevention. Over the last weeks several critical uncertainties have been identified.

Impact on healthcare

Malaria and COVID-19 are both causes of febrile illness. Those who look after malaria patients can be exposed to COVID-19. There is therefore an understandable reluctance of first-line care providers to continue their work as before. In SE Asia and Africa, village health workers (VHW) are trained to diagnose and treat malaria. However, it is unclear what VHWs should do when presented with suspected COVID-19 patients? Of even more urgent importance for health care workers is the question of how should they protect themselves? Individual countries are preparing to issue guidelines or have already done so, as has the WHO: staff working with febrile patients should wear at a minimum surgical masks and, where available, face shields. Handwashing and use of alcohol gels is mandatory. Patients testing positive for malaria should still be treated following government guidelines. Suspected COVID-19 patients should be immediately transferred in appropriate vehicles (not public transport) to designated clinics which can isolate, test, report, and follow these patients.

Impact on research

A range of countries have stopped all research activities by government decree, except those that are considered essential or linked to COVID-19.  Recruitment and follow-up of malaria study participants has stopped, and study participants are perhaps less than happy to be visited by research staff. As there is no clear end in sight when study activities can resume, researchers are therefore under considerable pressure. Who will pay staff and what should be done when promised milestones cannot be reached? Realising the urgent need for adjustments, some funding agencies have now released updates of their funding conditions.

Another critical part in global research are site visits for monitoring, and discussion with colleagues and planning activities. However, there is currently no indication when international travel will be possible again. International travel will be challenging during the months to come and it may take a year or more to return to anything similar to normal. Until it will become possible to restart research activities,  essential interactions such as study initiation “visits” may have to take place via teleconferencing.

Impact on funding

Research also requires continuous submission of funding applications and follow-up to negotiate contracts, approvals, and so on – this process has slowed down. Respondents in funding and regulatory agencies work from home, have limited access to documents in their offices, and can be distracted by more pressing personal worries. All sides will have to lower expectations what can and will be achieved in the remainder of 2020.

The pandemic has far reaching effects on nations’ economies too. One of the earliest effects for the health sector could be interruptions in the production and shipment of medical supplies. This could result in shortages of essential equipment and medication for malaria treatment. In view of the economic recession expected to follow the pandemic it is reasonable to expect that funding for malaria control and elimination could also be reduced. Large funders supported in part by taxpayer money such as The Global Fund to Fight AIDS, Tuberculosis and Malaria or UNITAID may find it difficult to collect pledged donations. While there are good reasons to think that the economies in Asia will recover in parallel with Europe and the US, the situation in Africa is more complicated. Though Africa has far fewer reported SARS-CoV-2 cases than Europe or Asia, it too will be hit by the shutdown. The prices of commodities are dropping, remittances have come to a halt, tourism has stopped, and investors are pulling out their money as fast as they can. Falling exchange rates will make imports and repayment of debts more difficult. While Europe and USA are now granting themselves trillions of dollars to rescue their economies, debt standstill or even better debt relief may well be essential to prevent a reversal of the progress that has been achieved in improving the control of malaria in many African nations.

Outlook

Despite these problems, we can use the infrastructure built for malaria control and elimination over the last decades to gain a better understanding of COVID-19. Skilled fieldworkers know how to collect samples for sero-surveys and conduct interviews. Researchers can help standardising recommendations for health workers presented with febrile patients. Laboratories can help in the development and evaluation of rapid diagnostic tests. Trialists and trials support groups have the skills to evaluate new treatments, prophylaxis, and vaccine candidates. Only a quick elimination of SARS-CoV-2 can prevent reversals of the achievements in malaria control.

Over the last weeks more people have become familiar with epidemiology and infectious disease control than ever before. There is a glimmer of hope that such an understanding will translate into a new appreciation for disease prevention (e.g. vaccines), corresponding investments and more young people willing to train and work in the control and elimination of infectious diseases.

Call for papers

To highlight the importance of malaria research, PLOS Medicine will soon be launching a Collection sponsored by the Mahidol Oxford Tropical Medicine Research Unit (MORU) focussing on treatment and elimination of P. vivax malaria, which in the past has received less attention than P. falciparum. To accompany this Collection, PLOS Medicine are now inviting submission of reports of high-quality research studies with the potential to inform clinical practice or thinking relevant to P. vivax malaria. The submission deadline for consideration for this Collection will be September 28, 2020.

Lorenz von Seidlein is an Associate Professor at Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand

Image Credit: Will Crowne/ DFID