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World Health Organization: Tailoring malaria interventions in the COVID-19 response

April 22, 2020 - 15:34 -- Malaria World

During the COVID-19 pandemic, the malaria community must remain committed to supporting the prevention of malaria infection, illness and death through preventive and case management services, while maintaining a safe environment for patients, clients and staff. Deaths due to malaria and its comorbidities (anaemia, undernutrition, etc.) must continue to be prevented.

This document provides overarching principles as well as specific technical guidance for malaria interventions, including prevention of infection and disease, care and treatment of cases, testing, clinical services, supply chain and laboratory activities, during this time of the evolving COVID-19 pandemic. This document will be updated as the situation changes.




Jointly addressing endemic malaria and pandemic COVID-19

Malaria is a widespread endemic disease that causes illness in approximately 230 million people and kills approximately 430 000 people each year. Over the past two decades, ministries of health (MoHs), national malaria control programmes (NMCPs), district health offices, health facilities and community health workers (CHWs) have done substantial work to dramatically control the disease, and progress is tangible and visible in communities.

Currently, there are effective and affordable prevention measures for malaria. Tests and highly effective drugs that clear the parasite can be used in health facilities or in the community. Trained health staff and CHWs provide interventions to prevent, diagnose and cure malaria. Together, these assets have led to significant success in reducing the morbidity and mortality of malaria over the years.

The rapid emergence and spread of COVID-19 across the world has created massive global disruptions that are impacting people’s lives and well-being. There is an urgent need to aggressively tackle COVID-19. Remarkable work is already underway to discover better tests to identify who has the disease and to find preventive and treatment tools to stop the infection. As this work continues, we will need to slow and stop the spread of the disease, provide care for COVID-19 patients, and minimize the impact of the epidemic on health systems, social services and economic activity. Actions to limit transmission from one person to another include reductions in social movement, physical distancing, handwashing and the use of personal protective equipment (PPE) in high-risk settings.

While taking these measures, it is essential that other killer diseases, such as malaria, are not ignored. We know from the recent Ebola outbreak in west Africa that a sudden increased demand on fragile health services can lead to substantial increases in morbidity and mortality from other diseases, including malaria. The COVID-19 pandemic could be devastating on its own – but this devastation will be substantially amplified if the response undermines the provision of life-saving services for other diseases.

The response to the COVID-19 pandemic must utilize and strengthen the infrastructure that has helped health programmes to address malaria and other infectious diseases around the world. If supported, these health systems will help to curb the impact of the COVID-19 epidemic and maintain essential health services. If the systems and staff are not well engaged, however, the gains made in saving lives from malaria and other diseases over the past 20 years may be lost.

In this context, MoHs and NMCPs must ensure that malaria control efforts (and efforts to control other endemic diseases) are not hampered or neglected as they tackle the COVID-19 pandemic. Their people and their systems will be the backbone of the COVID-19 response. This is not the time to stymie health services and undo past gains against known killer diseases. However, it is the time to strengthen investments in the health system and in community measures so that together we can take on the challenge. This document provides guidance to Member States on how to ensure the maintenance of malaria services as part of the essential health package in the country while working to control COVID-19.

Key recommendations

  1. Malaria-endemic country governments and their in-country and global partners should ensure flexibility and rapid response to safely serve clients/patients with malaria prevention and case management in areas affected by COVID-19. The country-specific malaria response should consider the critical preparedness, readiness and response actions for COVID-19:
  • Protect the health care workforce.
  • Protect clients and patients.
  1. National and local programmes should continue to provide core preventive and case management interventions for malaria (and other communicable diseases/conditions affecting the population), even with the risk of transmission of COVID-19. Malaria morbidity and mortality pose a substantial risk that is currently being reduced by key core interventions. The continued provision of these interventions is essential to save lives. All intervention delivery should consider the recommended personal and community precautions against COVID-19, which may vary depending on the intervention and its potential associated risk. Programmes should do the following:
  • Ensure that a focal point for malaria is a member of the National COVID-19 Incident Management Team.
  • Ensure continued engagement with all relevant national COVID-19 stakeholders and partners.
  • Ensure continued access to and use of recommended insecticidetreated mosquito nets (ITNs), with distributions organized to avoid large gatherings of people, and permit physical distancing of distributors and beneficiaries while adhering to local safety protocols.
  • Ensure the continuation of planned targeted indoor residual spraying (IRS) across communities and households, while closely respecting local protocols for both sprayer and household safety.
  • Encourage early care-seeking for fever and suspected malaria by the general population. To prevent a spike in severe malaria cases and deaths resulting from delayed care-seeking, national and local programmes should reaffirm messaging around prompt care-seeking, while being aware of local personal protection and physical distancing guidelines established by facilities and local authorities.
  • Ensure access to case management services in health facilities and communities with diagnostic confirmation (rapid diagnostic tests [RDTs] preferred over microscopy) for those suspected of having malaria.[1] Malaria can coexist with many other infections, and thus confirming malaria infection with a diagnostic test remains a critical component of malaria case management. The confirmation of a malaria infection does not rule out the possibility that the patient might also be suffering from COVID-19; similarly, suspected or confirmed COVID-19 patients in malaria-endemic areas should also receive a malaria diagnostic test.
  • Ensure treatment of confirmed malaria cases using locally recommended treatment for Plasmodium falciparum, P. vivax or other malaria parasites, and management of severe disease according to local protocols.
  • Ensure continued delivery of planned preventive services normally provided to specific target populations, including seasonal malaria chemoprevention (SMC) for young children, intermittent preventive treatment in infants (IPTi) and intermittent preventive treatment during pregnancy (IPTp), where currently recommended. Follow the national and local protocols for prevention and containment of COVID-19 when delivering malaria preventive services.
  1. Exceptional measures to control malaria – including mass drug administration (MDA) or presumptive treatment – may be required to minimize increased disease and death arising from the COVID-19 pandemic. These measures should only be applied following careful consideration of the context and should be undertaken with due regard to local guidance on reducing COVID-19 transmission.
  1. The core structures and systems for malaria should be maintained and strengthened as a central element of the COVID-19 response. These include:
  • Programme management and planning: NMCPs should be part of COVID-19 task forces in country to ensure that malaria policies and practices are coordinated along with the larger health system changes going into effect due to COVID-19.
  • Commodity supply chain and logistics: The COVID-19 pandemic has disrupted the production and supply of many commodities, including malaria commodities. Changes in malaria control activities may be necessitated by these disruptions (e.g., a lack of RDTs may result in presumptive treatment of fever with artemisinin-based combination therapies [ACTs]) or because of health worker and patient protection needs. Malaria control planning in the context of COVID-19 must consider fragile commodity availability and logistics systems (e.g., increased demand for RDTs, or for ACTs if presumptive treatment is necessary).
  • Information systems: Reporting issues and modified case definitions as a result of COVID-19 will impact apparent malaria epidemiological trends, which feed into critical malaria operational planning (e.g., commodity forecasting). Health management information system (HMIS) and surveillance strengthening efforts should focus on mitigating data quality issues as a result of COVID-19.
  • Communications and community engagement: Any changes to malaria activities will require close collaboration with social and behavior change communication (SBCC) experts and community leaders in order to ensure community uptake of behaviours to prevent malaria transmission and progression to severe disease. Community behaviours, especially around care-seeking, are likely to shift as a result of COVID-19, and national programmes should anticipate the need to mitigate a growing sense of distrust of health services.
  1. Follow best practices in the prevention and control of COVID-19 as per World Health Organization (WHO) recommendations.

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[1] In contrast to Ebola outbreaks in which blood exposure is a critical risk factor for disease transmission, the patient–health worker exposure is not markedly altered by testing for COVID-19 or malaria, while the benefits of knowing the causative infectious agent are substantial.