The spread of COVID-19 across Africa is predicted to increase the existing burden of other major deadly infectious diseases, such as malaria, tuberculosis and AIDS. As of 10 August 2020, there had been 19,462,112 COVID-19 cases globally reported to the World Health Organization (WHO), of which 884,990 cases were from Africa (https://covid19.who.int/). Several African countries have moved into and out of lockdowns, restrictions, border closures and flight disruptions, and there is general panic and apprehension among both urban populations and rural populations. COVID-19 has caused disruptions to health services and a drop in outpatient visits in some places1,2, which has affected the extent to which case management of malaria is possible. In this issue of Nature Medicine, Sherrard-Smith et al. describe their modeling study quantifying the potential impact of the spread of COVID-19 on morbidity and mortality from Plasmodium falciparum malaria across sub-Saharan Africa (SSA) and highlight important negative consequences of COVID-19 on malaria-mitigation strategies3.

While it is assumed that malaria and COVID-19 do not directly influence the transmission or severity of each other, COVID-19 affects malaria in other ways. In countries in which malaria is endemic, the national infectious-disease response is understandably focused on the COVID-19 pandemic, and there are resulting repercussions on already overstretched and under-resourced health systems. Health systems have become overwhelmed with patients who have COVID-19, and lockdown and other measures introduced to slow transmission interrupt access to routine care and prevention services and medicines. Services such as the widespread use of long-lasting insecticidal nets (LLINs) and indoor residual spraying (which affects vectors of the malaria parasites) are likely to have been interrupted. Furthermore, seasonal malarial chemoprevention and routine case management at all healthcare facilities, such as testing, treating with artemisinin combination therapy and tracking, could have been disrupted. Compounding these issues, the symptoms of both malaria and COVID-19 include fever, which poses diagnostic and management dilemmas where testing facilities are not optimal.

Sherrard-Smith et al. modeled four different scenarios3. First, they modeled unmitigated COVID-19 to illustrate how a rapid epidemic would be highly disruptive to malaria services but for a limited period. Second, they modeled mitigation in which social contact was reduced but the effective reproduction number (Rt) remained above 1, which caused a longer-lasting COVID-19 pandemic. Third, they modeled suppression, in which social distancing reducing Rt to <1 remained in place until alternative strategies to contain COVID-19 were available, with malaria activities potentially disrupted for a year. Fourth, they modeled suppression lift, in which suppression was sustained but then subsequently lifted, which resulted in a resurgence of the COVID-19 pandemic. Worryingly, they found that all four COVID-19 scenarios were projected to result in substantial additional deaths from malaria and that while implementing COVID-19-mitigation strategies substantially reduced COVID-19 mortality, the prolonged period of health-system disruption would cause considerably increased malaria deaths.

As with all epidemics and pandemics, COVID-19 has had its own fair share of myths, some of which have affected malaria control adversely or positively. In Sierra Leone, during the distribution of LLINs, there was widespread social-media misinformation that the nets and their use could cause COVID-19 transmission3. In addition to the structural challenges noted above, such misinformation could cause reduced uptake and reduced use of the LLINs, with the consequence of reduced vector control and increased transmission events. On the other hand, a bizarre side effect of the misinformation that antimalarial medications are potent against COVID-19 has been an increased uptake of antimalarial drugs and herbs in SSA, which has potentially caused increased chemoprevention of malaria in adults4,5.

The models of Sherrard-Smith et al.1 concur with the prediction by the WHO that malaria-related death in SSA could more than double in 2020 because of disruptions in treatment and control programs and that malaria deaths in SSA could reach an estimated 769,000 by the end of 2020 (ref. 6) (Fig. 1). Due to the COVID-19 pandemic, people may be reluctant to seek early diagnosis and treatment for malaria because they are worried about going to clinics, and malaria staff may have been reassigned to work on COVID-19. While African countries have issued recommendations on measures to sustain malaria-control efforts and gains, coordinating provisions for the early diagnosis of malaria in people with fever in endemic areas, and how to differentiate the diagnostic processes for malaria from those for COVID-19 in health services remain challenging7. Activities for malaria control that should continue are vector control, continued provision and use of LLINs, indoor residual spraying and chemoprevention for pregnant women and children in targeted communities, and adapted health messages that incorporate physical-distancing guidelines for COVID-19 with activities for malaria education and prevention.

Fig. 1
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Predicted distribution of deaths associated with malaria and COVID-19 in Africa.

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The Ministries of Health and National Malaria Control Programs of all African countries must ensure that activities for the prevention and treatment of malaria continue to be implemented during the COVID-19 era8. This will require the National Malaria Control Programs to fully engage with national COVID-19 programs so that testing for both COVID-19 and malaria occurs together; to ensure a continuous supply of, and access to and use of, insecticide-impregnated nets; and to prioritize the areas of highest malaria burden where resources are limited9. To prevent the spread of COVID-19 during insecticide spraying and the distribution and delivery of nets, staff should wear face masks, observe physical and social distancing and have regular health checks. Community leaders should be involved in the promotion of behaviors that will prevent malaria transmission and encourage early care-seeking behavior10. Potentially contradictory messages must be avoided, and regular educational messages through media, radio and text messaging should be used, inviting the general public to seek early health care.

As an interesting observation from available WHO data on the number of COVID-19 cases and deaths in African countries, it appears that the COVID-19 pandemic has not taken off in Africa as anticipated months ago, especially in high malaria-endemic countries (apart from in South Africa, which is a low malaria zone). Any potentialCOVID-19–malaria interactions in SSA should thus be investigated.

For now, the modeling studies of Sharrard-Smith et al.1 remind all to keep our guard up against malaria as well as against COVID-19 to try to avoid excess deaths.