Indirect effects of the COVID-19 pandemic on malaria intervention coverage, morbidity, and mortality in Africa: a geospatial modelling analysis

Understanding the COVID-19 pandemic prevalence in Africa through optimal feature selection and clustering: evidence from a statistical perspective

The COVID-19 pandemic, which outbroke in Wuhan (China) in December 2019, severely hit almost all sectors of activity in the world as a consequence of the restrictive measures imposed. Two years later, Africa still emerges as the least affected continent by the pandemic. This study analyzed COVID-19 prevalence across African countries through country-level variables prior to clustering. Using Spearman-rank correlation, multicollinearity analysis and univariate filtering, 9 country-level variables were identified from an initial set of 34 variables. These variables relate to socioeconomic status, population structure, healthcare system and environment and the climatic setting. A clustering of the 54 African countries is further carried out through the use of agglomerative hierarchical clustering (AHC) method, which generated 3 distinctive clusters. Cluster 1 (11 countries) is the most affected by COVID-19 (median of 63,508.6 confirmed cases and 946.5 deaths per million) and is composed of countries with the highest socioeconomic status. Cluster 2 (27 countries) is the least affected (median of 4473.7 confirmed cases and 81.2 deaths per million), and mainly features countries with the least socioeconomic features and international exposure. Cluster 3 (16 countries) is intermediate in terms of COVID-19 prevalence (median of 2569.3 confirmed cases and 35.7 deaths per million) and features countries the least urbanized and geographically close to the equator, with intermediate international exposure and socioeconomic features. These findings shed light on the main features of COVID-19 prevalence in Africa and might help refine effectively coping management strategies of the ongoing pandemic.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10668-022-02646-3.

Spatiotemporal mapping of malaria incidence in Sudan using routine surveillance data

Malaria is a serious threat to global health, with over \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$95\%$$\end{document}95% of the cases reported in 2020 by the World Health Organization in African countries, including Sudan. Sudan is a low-income country with a limited healthcare system and a substantial burden of malaria. The epidemiology of malaria in Sudan is rapidly changing due to factors including the rapidly developing resistance to drugs and insecticides among the parasites and vectors, respectively; the growing population living in humanitarian settings due to political instability; and the recent emergence of Anopheles stephensi in the country. These factors contribute to changes in the distribution of the parasites species as well as malaria vectors in Sudan, and the shifting patterns of malaria epidemiology underscore the need for investment in improved situational awareness, early preparedness, and a national prevention and control strategy that is updated, evidence based, and proactive. A key component of this strategy is accurate, high-resolution endemicity maps of species-specific malaria. Here, we present a spatiotemporal Bayesian model, developed in collaboration with the Sudanese Ministry of Health, that predicts a fine-scale (1 km \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\times $$\end{document}× 1 km) clinical incidence and seasonality profiles for Plasmodium falciparum and Plasmodium vivax across the country. We use monthly malaria case counts for both species collected via routine surveillance between January 2017 and December 2019, as well as a suite of high-resolution environmental covariates to inform our predictions. These epidemiological maps provide a useful resource for strategic planning and cost-effective implementation of malaria interventions, thus informing policymakers in Sudan to achieve success in malaria control and elimination.

Malaria Publications before and during COVID-19 Pandemic: A Bibliometric Analysis

Coronavirus disease 2019 (COVID-19) has been reported to affect malaria intervention strategies, the suspension of malaria elimination programs, and the publication of malaria research. We compared differences in authorship, affiliations, countries, funding sources, article types, keywords, languages, and citations between studies published before and during the COVID-19 pandemic. The searches were performed online using the Scopus database on 8 April 2022. The searches were limited to two periods: before the COVID-19 pandemic (2018–2019) and during the COVID-19 pandemic (2020–2021). The information of authorship, affiliations, countries, funding sources, article types, keywords, languages, and citations between studies published before and during the COVID-19 pandemic were compared using frequency and percentage. The relationships between the most productive authors, countries, affiliations, journals, and frequently used keywords were visualized using the VOSviewer (version 1.6.18) software. A total of 2965 articles were identified in two periods and, among those, 1291 relevant studies were included. There was no difference in malaria publications before and during the COVID-19 pandemic (679 articles, 52.6% vs. 612 articles, 47.4%). Compared between the two periods, the preliminary trend of malaria publications in terms of authorship, affiliations, countries, funding sources, article types, keywords, languages, and citations were different. In conclusion, the current study showed the preliminary trends in malaria publications before and during the COVID-19 pandemic. The findings of this study would encourage researchers to perform a scoping review or systematic review to better understand the direction of malaria publications during the COVID-19 pandemic.

In Silico Study and Excito-Repellent Activity of Vitex negundo L. Essential Oil against Anopheles gambiae

(1) Background: Essential oil from Vitex negundo is known to have repellent and insecticidal properties toward the Anopheles gambiae and this is linked to its monoterpene and sesquiterpene content. In this work, an effort is made to delineate the constitution of V. negundo essential oil (VNEO) and their interaction with odorant-binding proteins (OBPs) of A. gambiae and hence access its repellent efficiency as cost-effective and safer malaria vector control alternatives. (2) Methods: Anopheles species authentication was performed by genomic DNA analysis and was subjected to behavioral analysis. GC-MS profiling was used to identify individual components of VNEO. Anopheles OBPs were obtained from the RCSB protein data bank and used for docking studies. Determination of ligand efficiency metrics and QSAR studies were performed using Hyper Chem Professional 8.0.3, and molecular dynamics simulations were performed using the Desmond module. (3) Results: GC-MS analysis of VNEO showed 28 compounds (monoterpenes, 80.16%; sesquiterpenes, 7.63%; and unknown constituents, 10.88%). The ligand efficiency metrics of all four ligands against the OBP 7 were within acceptable ranges. β-selinene (−12.2 kcal/mol), β-caryophellene (−9.5 kcal/mol), sulcatone (−10.9 kcal/mol), and α-ylangene (−9.3 kcal/mol) showed the strongest binding affinities for the target proteins. The most stable hydrophobic interactions were observed between β-selinene (Phe111 and Phe120), Sulcatone (Phe54 and Phe120), and α-ylangene (Phe111), while only sulcatone (Tyr49) presented H-bond interactions in the simulated environment. (4) Conclusions: Sulcatone and β-caryophyllene presented the best log p values, 6.45 and 5.20, respectively. These lead phytocompounds can be used in their purest as repellent supplement or as a natural anti-mosquito agent in product formulations.

Spatial and spatio-temporal epidemiological approaches to inform COVID-19 surveillance and control: a review protocol

INTRODUCTION

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection that cause coronavirus disease 2019 (COVID-19) have afflicted millions worldwide. Understanding the underlying spatial and temporal dynamics can help orient timely public health policies and optimize the targeting of non-pharmaceutical interventions and vaccines to the most vulnerable populations, particularly in resource-constrained settings. The review systematically summarises important methodological aspects and specificities of spatial approaches applied to COVID-19 in Africa.

METHODS

Thematically selected keywords will be used to search for refereed studies in the following electronic databases PubMed, SCOPUS, MEDLINE, CINHAL, and Coronavirus Research Database from January 2020 to February 2022. Two independent reviewers will screen the title, abstracts, and full texts against predefined eligibility criteria based on the study's characteristics, methodological relevance, and quality. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020 procedures will be adhered to during the reporting process.

DISCUSSION

COVID-19 modeling remains in its infancy, and research is needed to characterize uncertainty and validate various modeling regimes appropriately. It is anticipated that the review will aid spatial, spatio-temporal modeling decisions necessary for mitigating the current and future pandemics.

SYSTEMATIC REVIEW REGISTRATION

CRD42021279767.

The impact of the COVID-19 pandemic on malaria in returning travellers in Canada: a retrospective population-based cohort study

In high-income, low-prevalence settings, travel patterns largely govern malaria transmission; the COVID-19 pandemic has led to travel restrictions resulting in a decrease in malaria case incidence. The proportion of travellers seeking pre-travel has decreased; with the easing of borders, an increase in malaria cases may occur.

Building International Capacity for Citizen Scientist Engagement in Mosquito Surveillance and Mitigation: The GLOBE Program's GLOBE Observer Mosquito Habitat Mapper

The GLOBE Program's GLOBE Observer Mosquito Habitat Mapper is a no-cost citizen scientist data collection tool compatible with Android and iOS devices. Available in 14 languages and 126 countries, it supports mosquito vector surveillance, mitigation, and education by interested individuals and as part of participatory community surveillance programs. For low-resource communities where mosquito control services are inadequate, the Mosquito Habitat Mapper supports local health action, empowerment, and environmental justice. The tangible benefits to human health supported by the Mosquito Habitat Mapper have encouraged its wide adoption, with more than 32,000 observations submitted from 84 countries. The Mosquito Habitat Mapper surveillance and data collection tool is complemented by an open database, a map visualization interface, data processing and analysis tools, and a supporting education and outreach campaign. The mobile app tool and associated research and education assets can be rapidly deployed in the event of a pandemic or local disease outbreak, contributing to global readiness and resilience in the face of mosquito-borne disease. Here, we describe the app, the Mosquito Habitat Mapper information system, examples of Mosquito Habitat Mapper deployment in scientific research, and the outreach campaign that supports volunteer training and STEM education of students worldwide.

The truncated AaActin1 promoter is a candidate tool for metabolic engineering of artemisinin biosynthesis in Artemisia annua L

Malaria is a devastating parasitic disease with high levels of morbidity and mortality worldwide. Artemisinin, the active substance against malaria, is a sesquiterpenoid produced by Artemisia annua. To improve artemisinin content in the native A. annua plants, considerable efforts have been attempted, with genetic transformation serving as an effective strategy. Although, the most frequently-used cauliflower mosaic virus (CaMV) 35S (CaMV35S) promoter has proved to be efficient in A. annua transgenic studies, it appears to show weak activity in peltate glandular secretory trichomes (GSTs) of A. annua plants. Here, we characterized the 1727 bp fragment upstream from the translation start codon (ATG) of AaActin1, however, found it was inactive in tobacco. After removal of the 5' intron, the truncated AaActin1 promoter (tpACT) showed 69% and 50% activity of CaMV35S promoter in transiently transformed tobacco and stably transformed A. annua, respectively. β-glucuronidase (GUS) staining analysis showed that the tpACT promoter was capable of directing the constant expression of a foreign gene in peltate GSTs of transgenic A. annua, representing higher activity than CaMV35S promoter. Collectively, our study provided a novel promoter available for metabolic engineering of artemisinin biosynthesis in A. annua.

Investigating the impact of multiple feeding attempts on mosquito dynamics via mathematical models

A deterministic differential equation model for the dynamics of terrestrial forms of mosquito populations is studied. The model assesses the impact of multiple probing attempts by mosquitoes that quest for blood within human populations by including a waiting class for mosquitoes that failed a blood feeding attempt. The equations are derived based on the idea that the reproductive cycle of the mosquito can be viewed as a set of alternating egg laying and blood feeding outcomes realized on a directed path called the gonotrophic cycle pathway. There exists a threshold parameter, the basic offspring number for mosquitoes, whose nature is affected by the way we interpret the transitions involving the different classes on the gonotrophic cycle path. The trivial steady state for the system, which always exists, can be globally asymptomatically stable whenever the threshold parameter is less than unity. The non-trivial steady state, when it exists, is stable for a range of values of the threshold parameter but can also be driven to instability via a Hopf bifurcation. The model's output reveals that the waiting class mosquitoes do contribute positively to sustain mosquito populations as well as increase their interactions with humans via increased frequency and initial amplitude of oscillations. We conclude that to understand human-mosquito interactions, it is informative to consider multiple probing attempts; known to occur when mosquitoes quest for blood meals within human populations.

Cost-effectiveness of Coronavirus Disease 2019 Vaccination in Low- and Middle-Income Countries

BACKGROUND

Despite the advent of safe and effective coronavirus disease 2019 vaccines, pervasive inequities in global vaccination persist.

METHODS

We projected health benefits and donor costs of delivering vaccines for up to 60% of the population in 91 low- and middle-income countries (LMICs). We modeled a highly contagious (Re at model start, 1.7), low-virulence (infection fatality ratio [IFR], 0.32%) "Omicron-like" variant and a similarly contagious "severe" variant (IFR, 0.59%) over 360 days, accounting for country-specific age structure and healthcare capacity. Costs included vaccination startup (US$630 million) and per-person procurement and delivery (US$12.46/person vaccinated).

RESULTS

In the Omicron-like scenario, increasing current vaccination coverage to achieve at least 15% in each of the 91 LMICs would prevent 11 million new infections and 120 000 deaths, at a cost of US$0.95 billion, for an incremental cost-effectiveness ratio (ICER) of US$670/year of life saved (YLS). Increases in vaccination coverage to 60% would additionally prevent up to 68 million infections and 160 000 deaths, with ICERs <US$8000/YLS. ICERs were <US$4000/YLS under the more severe variant scenario and generally robust to assumptions about vaccine effectiveness, uptake, and costs.

CONCLUSIONS

Funding expanded COVID-19 vaccine delivery in LMICs would save hundreds of thousands of lives, be similarly or more cost-effective than other donor-funded global aid programs, and improve health equity.

Rethinking integrated service delivery for malaria

Despite worldwide efforts and much progress toward malaria control, declines in malaria morbidity and mortality have hit a plateau. While many nations achieved significant malaria suppression or even elimination, success has been uneven, and other nations have made little headway-or even lost ground in this battle. These alarming trends threaten to derail the attainment of global targets for malaria control. Among the challenges impeding success in malaria reduction, many strategies center malaria as a set of technical problems in commodity development and delivery. Yet, this narrow perspective overlooks the importance of strong health systems and robust healthcare delivery. This paper argues that strategies that move the needle on health services and behaviors offer a significant opportunity to achieve malaria control through a comprehensive approach that integrates malaria with broader health services efforts. Indeed, malaria may serve as the thread that weaves integrated service delivery into a path forward for universal health coverage. Using key themes identified by the "Rethinking Malaria in the Context of COVID-19" effort through engagement with key stakeholders, we provide recommendations for pursuing integrated service delivery that can advance malaria control via strengthening health systems, increasing visibility and use of high-quality data at all levels, centering issues of equity, promoting research and innovation for new tools, expanding knowledge on effective implementation strategies for interventions, making the case for investing in malaria among stakeholders, and engaging impacted communities and nations.

COVID-19 and resilience of healthcare systems in ten countries

Declines in health service use during the Coronavirus Disease 2019 (COVID-19) pandemic could have important effects on population health. In this study, we used an interrupted time series design to assess the immediate effect of the pandemic on 31 health services in two low-income (Ethiopia and Haiti), six middle-income (Ghana, Lao People's Democratic Republic, Mexico, Nepal, South Africa and Thailand) and high-income (Chile and South Korea) countries. Despite efforts to maintain health services, disruptions of varying magnitude and duration were found in every country, with no clear patterns by country income group or pandemic intensity. Disruptions in health services often preceded COVID-19 waves. Cancer screenings, TB screening and detection and HIV testing were most affected (26-96% declines). Total outpatient visits declined by 9-40% at national levels and remained lower than predicted by the end of 2020. Maternal health services were disrupted in approximately half of the countries, with declines ranging from 5% to 33%. Child vaccinations were disrupted for shorter periods, but we estimate that catch-up campaigns might not have reached all children missed. By contrast, provision of antiretrovirals for HIV was not affected. By the end of 2020, substantial disruptions remained in half of the countries. Preliminary data for 2021 indicate that disruptions likely persisted. Although a portion of the declines observed might result from decreased needs during lockdowns (from fewer infectious illnesses or injuries), a larger share likely reflects a shortfall of health system resilience. Countries must plan to compensate for missed healthcare during the current pandemic and invest in strategies for better health system resilience for future emergencies.

Backward bifurcation and optimal control in a co-infection model for SARS-CoV-2 and ZIKV

In co-infection models for two diseases, it is mostly claimed that, the dynamical behavior of the sub-models usually predict or drive the behavior of the complete models. However, under a certain assumption such as, allowing incident co-infection with both diseases, we have a different observation. In this paper, a new mathematical model for SARS-CoV-2 and Zika co-dynamics is presented which incorporates incident co-infection by susceptible individuals. It is worth mentioning that the assumption is missing in many existing co-infection models. We shall discuss the impact of this assumption on the dynamics of a co-infection model. The model also captures sexual transmission of Zika virus. The positivity and boundedness of solution of the proposed model are studied, in addition to the local asymptotic stability analysis. The model is shown to exhibit backward bifurcation caused by the disease-induced death rates and parameters associated with susceptibility to a second infection by those singly infected. Using Lyapunov functions, the disease free and endemic equilibria are shown to be globally asymptotically stable for R 0 1 , respectively. To manage the co-circulation of both infections effectively, under an endemic setting, time dependent controls in the form of SARS-CoV-2, Zika and co-infection prevention strategies are incorporated into the model. The simulations show that SARS-CoV-2 prevention could greatly reduce the burden of co-infections with Zika. Furthermore, it is also shown that prevention controls for Zika can significantly decrease the burden of co-infections with SARS-CoV-2.

Anopheles stephensi in Africa requires a more integrated response

There are increasing reports of the Asian malaria mosquito, Anopheles stephensi invading and spreading in Eastern Africa. We discuss the importance of these invasions in the context of broader challenges facing malaria control in Africa and argue against addressing it as an isolated problem. Anopheles stephensi is only one of multiple biological threats facing malaria control in the region—and is itself an indication of wide-ranging weaknesses in vector surveillance and control programs. Expanded investigations are needed in both urban and rural areas, especially in countries serviced by the Indian Ocean trade routes, to establish the full extent and future trajectories of the problem. More importantly, instead of tackling this vector species as a stand-alone threat, affected countries should adopt more integrated and multi-sectorial initiatives that can sustainably drive and keep out malaria.

Reflections on the 2021 World Malaria Report and the future of malaria control

The World Malaria Report, released in December 2021, reflects the unique challenges currently facing the global malaria community. The report showed the devastating toll of malaria, with an estimated 627,000 people losing their lives to the disease in 2020. The improved methodological approach used for calculating cause of death for young children revealed a systematic underestimation of disease burden over the past two decades; and that Africa has an even greater malaria crisis than previously known. While countries were able to prevent the worst-case scenarios, the disruptions due to the COVID-19 pandemic revealed how weak health systems and inadequate financing can limit the capacity of the continent to address the malaria challenge. African countries also face a convergence of biological threats that could redefine malaria control, notably widespread pyrethroid resistance and emerging resistance to artemisinin. Despite these challenges, there is cause for optimism in lessons learned from the COVID-19 pandemic, recent acceleration of cutting edge research and development, and new partnerships that encourage leadership from and ownership by affected countries. This article presents key insights from the 2021 World Malaria Report and reflections on the future trajectories: it was informed by an in-depth discussion with leading malaria experts from the World Health Organization (WHO), the Bill & Melinda Gates Foundation, and the U.S. President's Malaria Initiative (PMI). The discussion took place during the 34th edition of the Ifakara Master Classes, held virtually on December 15th, 2021.

Title: A Comprehensive Review on Classifying Fast-acting and Slow-acting Antimalarial Agents Based on Time of Action and Target Organelle of Plasmodium sp

The clinical resistance towards malarial parasites has rendered many antimalarials ineffective, likely due to a lack of understanding of time of action and stage specificity of all life stages. Therefore, to tackle this problem a more incisive comprehensive analysis of the fast and slow-acting profile of antimalarial agents relating to parasite time-kill kinetics and the target organelle on the progression of blood-stage parasites was carried out. It is evident from numerous findings that drugs targeting food vacuole, nuclear components, and endoplasmic reticulum mainly exhibit a fast-killing phenotype within 24h affecting first-cycle activity. Whereas drugs targeting mitochondria, apicoplast, microtubules, parasite invasion and egress exhibit a largely slow-killing phenotype within 96-120h, affecting second-cycle activity with few exemptions as moderately fast-killing. It is essential to understand the susceptibility of drugs on rings, trophozoites, schizonts, merozoites, and the appearance of organelle at each stage of 48h intraerythrocytic parasite cycle. Therefore, these parameters may facilitate the paradigm for understanding the timing of antimalarials action in deciphering its precise mechanism linked with time. Thus, classifying drugs based on the time of killing may promote designing new combination regimens against varied strains of P. falciparum and evaluating potential clinical resistance.

Risk associations of submicroscopic malaria infection in lakeshore, plateau and highland areas of Kisumu County in western Kenya

BACKGROUND

Persons with submicroscopic malaria infection are a major reservoir of gametocytes that sustain malaria transmission in sub-Saharan Africa. Despite recent decreases in the national malaria burden in Kenya due to vector control interventions, malaria transmission continues to be high in western regions of the country bordering Lake Victoria. The objective of this study was to advance knowledge of the topographical, demographic and behavioral risk factors associated with submicroscopic malaria infection in the Lake Victoria basin in Kisumu County.

METHODS

Cross-sectional community surveys for malaria infection were undertaken in three eco-epidemiologically distinct zones in Nyakach sub-County, Kisumu. Adjacent regions were topologically characterized as lakeshore, hillside and highland plateau. Surveys were conducted during the 2019 and 2020 wet and dry seasons. Finger prick blood smears and dry blood spots (DBS) on filter paper were collected from 1,777 healthy volunteers for microscopic inspection and real time-PCR (RT-PCR) diagnosis of Plasmodium infection. Persons who were PCR positive but blood smear negative were considered to harbor submicroscopic infections. Topographical, demographic and behavioral risk factors were correlated with community prevalence of submicroscopic infections.

RESULTS

Out of a total of 1,777 blood samples collected, 14.2% (253/1,777) were diagnosed as submicroscopic infections. Blood smear microscopy and RT-PCR, respectively, detected 3.7% (66/1,777) and 18% (319/1,777) infections. Blood smears results were exclusively positive for P. falciparum, whereas RT-PCR also detected P. malariae and P. ovale mono- and co-infections. Submicroscopic infection prevalence was associated with topographical variation (χ2 = 39.344, df = 2, p<0.0001). The highest prevalence was observed in the lakeshore zone (20.6%, n = 622) followed by the hillside (13.6%, n = 595) and highland plateau zones (7.9%, n = 560). Infection prevalence varied significantly according to season (χ2 = 17.374, df = 3, p<0.0001). The highest prevalence was observed in residents of the lakeshore zone in the 2019 dry season (29.9%, n = 167) and 2020 and 2019 rainy seasons (21.5%, n = 144 and 18.1%, n = 155, respectively). In both the rainy and dry seasons the likelihood of submicroscopic infection was higher in the lakeshore (AOR: 2.71, 95% CI = 1.85-3.95; p<0.0001) and hillside (AOR: 1.74, 95% CI = 1.17-2.61, p = 0.007) than in the highland plateau zones. Residence in the lakeshore zone (p<0.0001), male sex (p = 0.025), school age (p = 0.002), and living in mud houses (p = 0.044) increased the risk of submicroscopic malaria infection. Bed net use (p = 0.112) and occupation (p = 0.116) were not associated with submicroscopic infection prevalence.

CONCLUSION

Topographic features of the local landscape and seasonality are major correlates of submicroscopic malaria infection in the Lake Victoria area of western Kenya. Diagnostic tests more sensitive than blood smear microscopy will allow for monitoring and targeting geographic sites where additional vector interventions are needed to reduce malaria transmission.

Impact of the COVID-19 pandemic on malaria cases in health facilities in northern Ghana: a retrospective analysis of routine surveillance data

Background

The COVID-19 pandemic and its collateral damage severely impact health systems globally and risk to worsen the malaria situation in endemic countries. Malaria is a leading cause of morbidity and mortality in Ghana. This study aims to describe the potential effects of the COVID-19 pandemic on malaria cases observed in health facilities in the Northern Region of Ghana.

Methods

Monthly routine data from the District Health Information Management System II (DHIMS2) of the Northern Region of Ghana were analysed. Overall outpatient department visits (OPD) and malaria case rates from the years 2015–2019 were compared to the corresponding data of the year 2020.

Results

Compared to the corresponding periods of the years 2015–2019, overall visits and malaria cases in paediatric and adult OPDs in northern Ghana decreased in March and April 2020, when major movement and social restrictions were implemented in response to the pandemic. Cases slightly rebounded afterwards in 2020, but stayed below the average of the previous years. Malaria data from inpatient departments showed a similar but more pronounced trend when compared to OPDs. In pregnant women, however, malaria cases in OPDs increased after the first COVID-19 wave.

Conclusions

The findings from this study show that the COVID-19 pandemic affects the malaria burden in health facilities of northern Ghana, with declines in inpatient and outpatient rates except for pregnant women. They may have experienced reduced access to insecticide-treated nets and intermittent preventive malaria treatment in pregnancy, resulting in subsequent higher malaria morbidity. Further data, particularly from community-based studies and ideally complemented by qualitative research, are needed to fully determine the impact of the pandemic on the malaria situation in Africa.

National, regional, and global estimates of anaemia by severity in women and children for 2000-19: a pooled analysis of population-representative data

BACKGROUND

Anaemia causes health and economic harms. The prevalence of anaemia in women aged 15-49 years, by pregnancy status, is indicator 2.2.3 of the UN Sustainable Development Goals, and the aim of halving the anaemia prevalence in women of reproductive age by 2030 is an extension of the 2025 global nutrition targets endorsed by the World Health Assembly (WHA). We aimed to estimate the prevalence of anaemia by severity for children aged 6-59 months, non-pregnant women aged 15-49 years, and pregnant women aged 15-49 years in 197 countries and territories and globally for the period 2000-19.

METHODS

For this pooled analysis of population-representative data, we collated 489 data sources on haemoglobin distribution in children and women from 133 countries, including 4·5 million haemoglobin measurements. Our data sources comprised health examination, nutrition, and household surveys, accessed as anonymised individual records or as summary statistics such as mean haemoglobin and anaemia prevalence. We used a Bayesian hierarchical mixture model to estimate haemoglobin distributions in each population and country-year. This model allowed for coherent estimation of mean haemoglobin and prevalence of anaemia by severity.

FINDINGS

Globally, in 2019, 40% (95% uncertainty interval [UI] 36-44) of children aged 6-59 months were anaemic, compared to 48% (45-51) in 2000. Globally, the prevalence of anaemia in non-pregnant women aged 15-49 years changed little between 2000 and 2019, from 31% (95% UI 28-34) to 30% (27-33), while in pregnant women aged 15-49 years it decreased from 41% (39-43) to 36% (34-39). In 2019, the prevalence of anaemia in children aged 6-59 months exceeded 70% in 11 countries and exceeded 50% in all women aged 15-49 years in ten countries. Globally in all populations and in most countries and regions, the prevalence of mild anaemia changed little, while moderate and severe anaemia declined in most populations and geographical locations, indicating a shift towards mild anaemia.

INTERPRETATION

Globally, regionally, and in nearly all countries, progress on anaemia in women aged 15-49 years is insufficient to meet the WHA global nutrition target to halve anaemia prevalence by 2030, and the prevalence of anaemia in children also remains high. A better understanding of the context-specific causes of anaemia and quality implementation of effective multisectoral actions to address these causes are needed.

FUNDING

USAID, US Centers for Disease Control and Prevention, and Bill & Melinda Gates Foundation.

Strategies to Promote Health System Strengthening and Global Health Security at the Subnational Level in a World Changed by COVID-19

Structural weaknesses in national health systems have led to huge variations in responses to COVID-19. This calls for a unified approach to health security and essential health services as public health threats and the expectation for health care systems to provide improved access and services at affordable cost increases.

Priorities of China's participation in global malaria elimination: the perspective of malaria endemic countries

Background

Malaria is one of the major diseases affecting global health, while progress in malaria control and elimination has stagnated in some endemic countries. China has been certificated malaria free by World Health Organization in 2021, and will get more involved on global malaria elimination. Further discussion is needed on how to collaborate with the malaria endemic countries and provide effective help. This study was to investigate the perceptions of malaria endemic countries on China’s contribution to global malaria elimination and to lay a foundation for further action.

Methods

Semi-structured interviews were conducted with key informants including national malaria project managers and technicians from malaria endemic countries. Thematic framework approach was used to analyze the data.

Results

Malaria endemic countries now face challenges in insufficient funds, technique, products, public health systems and inadequacy of international assistance. They hold a positive attitude towards cooperation with China and identified experience and technique exchange, personnel training, system building and scientific research cooperation as prioritized areas.

Conclusions

China could make full use of its own advantages in technique transfer, health system improvement, information system construction, and health human resource training and take an active part in global malaria elimination.

The Putative Bromodomain Protein PfBDP7 of the Human Malaria Parasite Plasmodium Falciparum Cooperates With PfBDP1 in the Silencing of Variant Surface Antigen Expression

Epigenetic regulation is a critical mechanism in controlling virulence, differentiation, and survival of the human malaria parasite Plasmodium (P.) falciparum. Bromodomain proteins contribute to this process by binding to acetylated lysine residues of histones and thereby targeting the gene regulatory machinery to gene promoters. A protein complex containing the P. falciparum bromodomain proteins (PfBDP) 1 and PfBDP2 (BDP1/BDP2 core complex) was previously shown to play an essential role for the correct transcription of invasion related genes. Here, we performed a functional characterization of a third component of this complex, which we dubbed PfBDP7, because structural modelling predicted a typical bromodomain fold. We confirmed that PfBDP7 is a nuclear protein that interacts with PfBDP1 at invasion gene promoters in mature schizont stage parasites and contributes to their transcription. Although partial depletion of PfBDP7 showed no significant effect on parasite viability, conditional knock down of either PfBDP7 or PfBDP1 resulted in the de-repression of variant surface antigens (VSA), which are important pathogenicity factors. This de-repression was evident both on mRNA and protein level. To understand the underlying mechanism, we mapped the genome wide binding sites of PfBDP7 by ChIPseq and showed that in early schizonts, PfBDP7 and PfBDP1 are commonly enriched in heterochromatic regions across the gene body of all VSA families, including genes coding for PfEMP1, RIFIN, STEVOR, and PfMC-2TM. This suggests that PfBDP7 and PfBDP1 contribute to the silencing of VSAs by associating with heterochromatin. In conclusion, we identified PfBDP7 as a chromatin binding protein that is a constitutive part of the P. falciparum BDP1/BDP2 core complex and established PfBDP1 and PfBDP7 as novel players in the silencing of heterochromatin regulated virulence gene families of the malaria parasite P. falciparum.

Malaria Epidemiology and COVID-19 Pandemic: Are They Interrelated?

Coronavirus disease 2019 (COVID-19) is a systemic disease, impacting multiple organs in the human body. But COVID-19 also impacts other diseases of relevance to public and planetary health. To understand and respond to the COVID-19 pandemic, we need an intersectional conceptual lens and systems thinking. For example, the strain on health care systems due to COVID-19 has adversely impacted global malaria elimination programs. With many epidemiological, clinical, and biological parallels documented, we examined in this study the scenario of malaria and COVID-19 syndemic in India. The disruptive influence of COVID-19 on the National Framework for Malaria Elimination (NFME), impact of unintended chemoprophylaxis, population genetic influences, and the shifting patterns of epidemiology are compared. Importantly, a time series analysis forecasted the burden of malaria increasing in the upcoming years. Although reported malaria cases showed a decline in 2020 compared to the previous years, an increase in cases was documented in 2021, with nine states reporting an increase up to July 2021. Pandemics often cause crosscutting disruptions in health care. Reshaping the priorities of the malaria elimination program and a diligent implementation of the priorities in the NFME would, therefore, be well-advised: (1) vector control, (2) antimalarial therapy recommendations, (3) monitoring drug resistance, (4) prevention of the spread of asymptomatic disease-causing low-density transmission, and (5) large-scale testing measures. In conclusion, the findings from the present study inform future comparative studies in other world regions to better understand the broader, systemic, temporal, and spatial impacts of the COVID-19 pandemic on existing and future diseases across public health systems and services.

The impact of COVID-19 on communicable and non-communicable diseases in Africa: a narrative review

The global pandemic of coronavirus disease 2019 (COVID-19) has disproportionately impacted global human health, economy, and security. Because of weaker health-care systems, existing comorbidities burden (HIV, malaria, tuberculosis, and non-communicable conditions), and poor socioeconomic determinants, initial predictive models had forecast a disastrous impact of COVID-19 in Africa in terms of transmission, severity, and deaths. Nonetheless, current epidemiological data seem not to have matched expectations, showing lower SARS-CoV-2 infection and fatality rates compared to Europe, the Americas and Asia. However, only few studies were conducted in low- and middle-income African settings where high poverty and limited access to health services worsen underlying health conditions, including endemic chronic infectious diseases such as HIV and tuberculosis. Furthermore, limited, and heterogeneous research was conducted to evaluate the indirect impact of the pandemic on general health services and on major diseases across African countries. International mitigation measures, such as resource reallocation, lockdowns, social restrictions, and fear from the population have had multi-sectoral impacts on various aspects of everyday life, that shaped the general health response. Despite the vast heterogeneity of data across African countries, available evidence suggests that the COVID-19 pandemic has severely impacted the control and prevention programs, the diagnosis capacity and the adherence to treatment of major infectious diseases (HIV, TB, and Malaria) - including neglected diseases - and non-communicable diseases. Future research and efforts are essential to deeply assess the medium- and long-term impact of the pandemic, and to implement tailored interventions to mitigate the standstill on decades of improvement on public health programs.

Comparison of 19 major infectious diseases during COVID-19 epidemic and previous years in Zhejiang, implications for prevention measures

BACKGROUND

The global pandemic of coronavirus disease 2019 (COVID-19) has attracted great public health efforts across the world. Few studies, however, have described the potential impact of these measures on other important infectious diseases.

METHODS

The incidence of 19 major infectious diseases in Zhejiang Province was collected from the National Notifiable Infectious Disease Surveillance System from January 2017 to October 2020. The entire epidemic control phase was divided into three stages. The government deployed the first level response from 24 January to 2 March (the most rigorous measures). When the outbreak of COVID-19 was under control, the response level changed to the second level from 3 to 23 March, and then the third level response was implemented after 24 March. We compared the epidemiological characteristics of 19 major infectious diseases during different periods of the COVID-19 epidemic and previous years.

RESULTS

A total of 1,814,881 cases of 19 infectious diseases were reported in Zhejiang from January 2017 to October 2020, resulting in an incidence rate of 8088.30 cases per 1,000,000 person-years. After the non-pharmaceutical intervention, the incidence of 19 infectious diseases dropped by 70.84%, from 9436.32 cases per 1,000,000 person-years to 2751.51 cases per 1,000,000 person-years, with the large decrease in the first response period of influenza. However, we observed that the daily incidence of severe fever with thrombocytopenia syndrome (SFTS) and leptospirosis increased slightly (from 1.11 cases per 1,000,000 person-years to 1.82 cases per 1,000,000 person-years for SFTS and 0.30 cases per 1,000,000 person-years to 1.24 cases per 1,000,000 person-years for leptospirosis). There was no significant difference in the distribution of epidemiological characteristic of most infectious diseases before and during the implementation of COVID-19 control measures.

CONCLUSION

Our study summarizes the epidemiological characteristics of 19 infectious diseases and indicates that the rigorous control measures for COVID-19 are also effective for majority of infectious diseases.

Sub-national tailoring of malaria interventions in Mainland Tanzania: simulation of the impact of strata-specific intervention combinations using modelling

Background

To accelerate progress against malaria in high burden countries, a strategic reorientation of resources at the sub-national level is needed. This paper describes how mathematical modelling was used in mainland Tanzania to support the strategic revision that followed the mid-term review of the 2015–2020 national malaria strategic plan (NMSP) and the epidemiological risk stratification at the council level in 2018.

Methods

Intervention mixes, selected by the National Malaria Control Programme, were simulated for each malaria risk strata per council. Intervention mixes included combinations of insecticide-treated bed nets (ITN), indoor residual spraying, larval source management, and intermittent preventive therapies for school children (IPTsc). Effective case management was either based on estimates from the malaria indicator survey in 2016 or set to a hypothetical target of 85%. A previously calibrated mathematical model in OpenMalaria was used to compare intervention impact predictions for prevalence and incidence between 2016 and 2020, or 2022.

Results

For each malaria risk stratum four to ten intervention mixes were explored. In the low-risk and urban strata, the scenario without a ITN mass campaign in 2019, predicted high increase in prevalence by 2020 and 2022, while in the very-low strata the target prevalence of less than 1% was maintained at low pre-intervention transmission intensity and high case management. In the moderate and high strata, IPTsc in addition to existing vector control was predicted to reduce the incidence by an additional 15% and prevalence by 22%. In the high-risk strata, all interventions together reached a maximum reduction of 76%, with around 70% of that reduction attributable to high case management and ITNs. Overall, the simulated revised NMSP was predicted to achieve a slightly lower prevalence in 2020 compared to the 2015–2020 NMSP (5.3% vs 6.3%).

Conclusion

Modelling supported the choice of intervention per malaria risk strata by providing impact comparisons of various alternative intervention mixes to address specific questions relevant to the country. The use of a council-calibrated model, that reproduces local malaria trends, represents a useful tool for compiling available evidence into a single analytical platform, that complement other evidence, to aid national programmes with decision-making processes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-022-04099-5.

Asymptomatic Malaria Infections in the Time of COVID-19 Pandemic: Experience from the Central African Republic

According to the latest World Health Organization malaria report, 95% of 241 million global malaria cases and 96% of 627,000 malaria deaths that were recorded in 2020 occurred in Africa. Compared to 2019, 14 million more cases and 69,000 more malaria deaths were recorded, mainly because of disruptions to medical services during the COVID-19 pandemic. The aim of this study was to assess the prevalence of asymptomatic malaria cases in children and adults living in the Dzanga Sangha region in the Central African Republic (CAR) during the COVID-19 pandemic. Rapid immunochromatographic assays for the qualitative detection of Plasmodium species (P. falciparum, P. vivax, P. ovale/P. malariae) circulating in whole blood samples were used. A screening was performed in the group of 515 patients, 162 seemingly healthy children (aged 1–15) and 353 adults, all inhabiting the villages in the Dzanga Sangha region (southwest CAR) between August and September 2021. As much as 51.2% of asymptomatic children and 12.2% of adults had a positive result in malaria rapid diagnostic tests (mRDTs). Our findings demonstrated a very high prevalence of asymptomatic malaria infections in the child population. Limited access to diagnostics, treatment and prevention of malaria during the global COVID-19 pandemic and less medical assistance from developed countries may be one of the factors contributing to the increase in the prevalence of disease in Africa.

Estimated impact of the 2020 economic downturn on under-5 mortality for 129 countries

In low- and middle-income countries (LMICs), economic downturns can lead to increased child mortality by affecting dietary, environmental, and care-seeking factors. This study estimates the potential loss of life in children under five years old attributable to economic downturns in 2020. We used a multi-level, mixed effects model to estimate the relationship between gross domestic product (GDP) per capita and under-5 mortality rates (U5MRs) specific to each of 129 LMICs. Public data were retrieved from the World Bank World Development Indicators database and the United Nations World Populations Prospects estimates for the years 1990-2020. Country-specific regression coefficients on the relationship between child mortality and GDP were used to estimate the impact on U5MR of reductions in GDP per capita of 5%, 10%, and 15%. A 5% reduction in GDP per capita in 2020 was estimated to cause an additional 282,996 deaths in children under 5 in 2020. At 10% and 15%, recessions led to higher losses of under-5 lives, increasing to 585,802 and 911,026 additional deaths, respectively. Nearly half of all the potential under-5 lives lost in LMICs were estimated to occur in Sub-Saharan Africa. Because most of these deaths will likely be due to nutrition and environmental factors amenable to intervention, countries should ensure continued investments in food supplementation, growth monitoring, and comprehensive primary health care to mitigate potential burdens.

The impact of Covid-19 on malaria services in three high endemic districts in Rwanda: a mixed-method study

Background

Rwanda has achieved impressive reductions in malaria morbidity and mortality over the past two decades. However, the disruption of essential services due to the current Covid-19 pandemic can lead to a reversal of these gains in malaria control unless targeted, evidence-based interventions are implemented to mitigate the impact of the pandemic. The extent to which malaria services have been disrupted has not been fully characterized. This study was conducted to assess the impact of Covid-19 on malaria services in Rwanda.

Methods

A mixed-methods study was conducted in three purposively selected districts in Rwanda. The quantitative data included malaria aggregated data reported at the health facility level and the community level. The data included the number of malaria tests, uncomplicated malaria cases, severe malaria cases, and malaria deaths. The qualitative data were collected using focus group discussions with community members and community health workers, as well as in-depth interviews with health care providers and staff working in the malaria programme. Interrupted time series analysis was conducted to compare changes in malaria presentations between the pre-Covid-19 period (January 2019 to February 2020) and Covid-19 period (from March 2020 to November 2020). The constant comparative method was used in qualitative thematic analysis.

Results

Compared to the pre-Covid-19 period, there was a monthly reduction in patients tested in health facilities of 4.32 per 1000 population and a monthly increase in patients tested in the community of 2.38 per 1000 population during the Covid-19 period. There was no change in the overall presentation rate for uncomplicated malaria. The was a monthly reduction in the proportion of severe malaria of 5.47 per 100,000 malaria cases. Additionally, although healthcare providers continued to provide malaria services, they were fearful that this would expose them and their families to Covid-19. Covid-19 mitigation measures limited the availability of transportation options for the community to seek care in health facilities and delayed the implementation of some key malaria interventions. The focus on Covid-19-related communication also reduced the amount of health information for other diseases provided to community members.

Conclusion

The Covid-19 pandemic resulted in patients increasingly seeking care in the community and poses challenges to maintaining delivery of malaria services in Rwanda. Interventions to mitigate these challenges should focus on strengthening programming for the community and home-based care models and integrating malaria messages into Covid-19-related communication. Additionally, implementation of the interrupted interventions should be timed and overlap with the malaria transmission season to mitigate Covid-19 consequences on malaria.

Systems analysis of immune responses to attenuated P. falciparum malaria sporozoite vaccination reveals excessive inflammatory signatures correlating with impaired immunity

Immunization with radiation-attenuated sporozoites (RAS) can confer sterilizing protection against malaria, although the mechanisms behind this protection are incompletely understood. We performed a systems biology analysis of samples from the Immunization by Mosquito with Radiation Attenuated Sporozoites (IMRAS) trial, which comprised P. falciparum RAS-immunized (PfRAS), malaria-naive participants whose protection from malaria infection was subsequently assessed by controlled human malaria infection (CHMI). Blood samples collected after initial PfRAS immunization were analyzed to compare immune responses between protected and non-protected volunteers leveraging integrative analysis of whole blood RNA-seq, high parameter flow cytometry, and single cell CITEseq of PBMCs. This analysis revealed differences in early innate immune responses indicating divergent paths associated with protection. In particular, elevated levels of inflammatory responses early after the initial immunization were detrimental for the development of protective adaptive immunity. Specifically, non-classical monocytes and early type I interferon responses induced within 1 day of PfRAS vaccination correlated with impaired immunity. Non-protected individuals also showed an increase in Th2 polarized T cell responses whereas we observed a trend towards increased Th1 and T-bet+ CD8 T cell responses in protected individuals. Temporal differences in genes associated with natural killer cells suggest an important role in immune regulation by these cells. These findings give insight into the immune responses that confer protection against malaria and may guide further malaria vaccine development.

Trial registration: ClinicalTrials.gov NCT01994525.

Malaria remains a serious global health problem, causing hundreds of thousands of deaths every year. An effective malaria vaccine would be an important tool to fight this disease. Previous work has shown that irradiated sporozoites, the form of the malaria parasite injected into humans by mosquitos, are not capable of progressing to a symptomatic blood stage malaria infection, and act as a protective vaccine against future malaria exposure. However the mechanisms that produce this protection are unknown. In this work, we studied individuals vaccinated with irradiated sporozoites before being exposed to live malaria parasites. Roughly half of these individual were protected against malaria. By analyzing blood samples taken at multiple points after the first vaccination using RNA sequencing and flow cytometry we identified immune responses that differed between protected and non-protected study participants. Notably, we observed a rapid increase in inflammation and interferon-associated genes in non-protected individual. We also observed protection-associated changes in T cell and NK cell associated pathways. Our study provides novel insights into immune responses associated with effective malaria vaccination, and can point the way to improved design of whole-sporozoite malaria vaccine approaches.

Low incidence of COVID-19 case severity and mortality in Africa; Could malaria co-infection provide the missing link?

Background

Despite reports of malaria and coronavirus diseases 2019 (COVID-19) co-infection, malaria-endemic regions have so far recorded fewer cases of COVID-19 and deaths from COVID-19, indicating a probable protection from the poor outcome of COVID-19 by malaria. On the contrary, other evidence suggests that malaria might contribute to the death caused by COVID-19. Hence, this paper reviewed existing evidence hypothesizing poor outcome or protection of COVID-19 patients when co-infected with malaria.

Methods

PRISMA guidelines for systematic review were employed in this study. Published articles from December 2019 to May 2021on COVID-19 and malaria co-infection and outcome were systematically searched in relevant and accessible databases following a pre-defined strategy. Studies involving human, in vivo animal studies, and in vitro studies were included.

Results

Twenty three (23) studies were included in the review out of the 3866 records identified in the selected scientific databases. Nine (9) papers reported on co-infection of COVID-19 and malaria. Five (5) papers provided information about synergism of malaria and COVID-19 poor prognosis, 2 papers reported on syndemic of COVID-19 and malaria intervention, and 7 studies indicated that malaria protects individuals from COVID-19.

Conclusions

Low incidence of COVID-19 in malaria-endemic regions supports the hypothesis that COVID-19 poor prognosis is prevented by malaria. Although further studies are required to ascertain this hypothesis, cross-immunity and common immunodominant isotopes provide strong evidence to support this hypothesis. Also, increase in co-inhibitory receptors and atypical memory B cells indicate synergy between COVID-19 and malaria outcome, though, more studies are required to make a definite conclusion.

Low incidence and mortality rate of COVID-19 in malaria endemic regions

There have been reports of malaria and COVID-19 co-infection

Malaria could be the link for the reported low incidence of COVID-19 in Africa

Cross immunity and common immunodominant epitopes between Malaria and COVID-19, and antimalaria drugs could be the reason for observed low fatality and incidence rate of COVID-19 in malaria endemic regions.

Malaria infection and deaths could increase amid the COVID-19 pandemic due to interrupted malaria control interventions.

Study of epidemiological behaviour of malaria and its control in the Purulia district of West Bengal, India (2016-2020)

Purulia is a malaria-prone district in West Bengal, India, with approximately half of the blocks defined as malaria endemic. We analyzed the malaria case in each block of the Purulia district from January 1, 2016, to December 31, 2020. As per the API, 20 blocks of Purulia were assigned to four different categories (0-3) and mapped using ArcGIS software. An exponential decay model was fitted to forecast the trend of malaria cases for each block of Purulia (2021-2025). There was a sharp decrease in total malaria cases and API from 2016 to 2020 due to the mass distribution of LLINs. The majority of cases (72.63%) were found in ≥ 15-year age group. Males were more prone to malaria (60.09%). Malaria was highly prevalent among Scheduled Tribes (48.44%). Six blocks were reported in Category 3 (high risk) and none in Category 0 (no risk) in 2016, while no blocks were determined to be in Category 3, and three blocks were in Category 0 in 2020. The exponential decay model prediction is oriented towards gaining malaria-free status in thirteen blocks of Purulia by 2025. This study will incite the government to uphold and strengthen the current efforts to meet the malaria elimination goals.

Global estimates of pregnancies at risk of Plasmodium falciparum and Plasmodium vivax infection in 2020 and changes in risk patterns since 2000

BACKGROUND

Women are at risk of severe adverse pregnancy outcomes attributable to Plasmodium spp. infection in malaria-endemic areas. Malaria control efforts since 2000 have aimed to reduce this burden of disease.

METHODS

We used data from the Malaria Atlas Project and WorldPop to calculate global pregnancies at-risk of Plasmodium spp. infection. We categorised pregnancies as occurring in areas of stable and unstable P. falciparum and P. vivax transmission. We further stratified stable endemicity as hypo-endemic, meso-endemic, hyper-endemic, or holo-endemic, and estimated pregnancies at risk in 2000, 2005, 2010, 2015, 2017, and 2020.

FINDINGS

In 2020, globally 120.4M pregnancies were at risk of P. falciparum, two-thirds (81.0M, 67.3%) were in areas of stable transmission; 85 2M pregnancies were at risk of P. vivax, 93.9% (80.0M) were in areas of stable transmission. An estimated 64.6M pregnancies were in areas with both P. falciparum and P. vivax transmission. The number of pregnancies at risk of each of P. falciparum and P. vivax worldwide decreased between 2000 and 2020, with the exception of sub-Saharan Africa, where the total number of pregnancies at risk of P. falciparum increased from 37 3M in 2000 to 52 4M in 2020.

INTERPRETATION

Historic investments in malaria control have reduced the number of women at risk of malaria in pregnancy in all endemic regions except sub-Saharan Africa. Population growth in Africa has outpaced reductions in malaria prevalence. Interventions that reduce the risk of malaria in pregnancy are needed as much today as ever.

Impact of COVID-19 on routine malaria indicators in rural Uganda: an interrupted time series analysis

Background

In March 2020, the government of Uganda implemented a strict lockdown policy in response to the COVID-19 pandemic. Interrupted time series analysis (ITSA) was performed to assess whether major changes in outpatient attendance, malaria burden, and case management occurred after the onset of the COVID-19 epidemic in rural Uganda.

Methods

Individual level data from all outpatient visits collected from April 2017 to March 2021 at 17 facilities were analysed. Outcomes included total outpatient visits, malaria cases, non-malarial visits, proportion of patients with suspected malaria, proportion of patients tested using rapid diagnostic tests (RDTs), and proportion of malaria cases prescribed artemether-lumefantrine (AL). Poisson regression with generalized estimating equations and fractional regression was used to model count and proportion outcomes, respectively. Pre-COVID trends (April 2017-March 2020) were used to predict the’expected’ trend in the absence of COVID-19 introduction. Effects of COVID-19 were estimated over two six-month COVID-19 time periods (April 2020-September 2020 and October 2020–March 2021) by dividing observed values by expected values, and expressed as ratios.

Results

A total of 1,442,737 outpatient visits were recorded. Malaria was suspected in 55.3% of visits and 98.8% of these had a malaria diagnostic test performed. ITSA showed no differences between observed and expected total outpatient visits, malaria cases, non-malarial visits, or proportion of visits with suspected malaria after COVID-19 onset. However, in the second six months of the COVID-19 time period, there was a smaller mean proportion of patients tested with RDTs compared to expected (relative prevalence ratio (RPR) = 0.87, CI (0.78–0.97)) and a smaller mean proportion of malaria cases prescribed AL (RPR = 0.94, CI (0.90–0.99)).

Conclusions

In the first year after the COVID-19 pandemic arrived in Uganda, there were no major effects on malaria disease burden and indicators of case management at these 17 rural health facilities, except for a modest decrease in the proportion of RDTs used for malaria diagnosis and the mean proportion of malaria cases prescribed AL in the second half of the COVID-19 pandemic year. Continued surveillance will be essential to monitor for changes in trends in malaria indicators so that Uganda can quickly and flexibly respond to challenges imposed by COVID-19.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-021-04018-0.

Competing Health Risks Associated with the COVID-19 Pandemic and Early Response: A Scoping Review

BACKGROUND

COVID-19 has rapidly emerged as a global public health threat with infections recorded in nearly every country. Responses to COVID-19 have varied in intensity and breadth, but generally have included domestic and international travel limitations, closure of non-essential businesses, and repurposing of health services. While these interventions have focused on testing, treatment, and mitigation of COVID-19, there have been reports of interruptions to diagnostic, prevention, and treatment services for other public health threats.

OBJECTIVES

We conducted a scoping review to characterize the early impact of COVID-19 on HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition.

METHODS

A scoping literature review was completed using searches of PubMed and preprint servers (medRxiv/bioRxiv) from January 1st to October 31st, 2020, using Medical Subject Headings (MeSH) terms related to SARS-CoV-2 or COVID-19 and HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition. Empiric studies reporting original data collection or mathematical models were included, and available data synthesized by region. Studies were excluded if they were not written in English.

RESULTS

A total of 1604 published papers and 205 preprints met inclusion criteria, including 8.2% (132/1604) of published studies and 10.2% (21/205) of preprints: 7.3% (68/931) on HIV, 7.1% (24/339) on tuberculosis, 11.6% (26/224) on malaria, 7.8% (13/166) on sexual and reproductive health, and 9.8% (13/132) on malnutrition. Thematic results were similar across competing health risks, with substantial indirect effects of the COVID-19 pandemic and response on diagnostic, prevention, and treatment services for HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition.

DISCUSSION

COVID-19 emerged in the context of existing public health threats that result in millions of deaths every year. Thus, effectively responding to COVID-19 while minimizing the negative impacts of COVID-19 necessitates innovation and integration of existing programs that are often siloed across health systems. Inequities have been a consistent driver of existing health threats; COVID-19 has worsened disparities, reinforcing the need for programs that address structural risks. The data reviewed here suggest that effective strengthening of health systems should include investment and planning focused on ensuring the continuity of care for both rapidly emergent and existing public health threats.

Can repurposing drugs play a role in malaria control?

Innovative drug treatments for malaria, optimally with novel targets, are needed to combat the threat of parasite drug resistance. As drug development efforts continue, there may be a role for a host-targeting, repurposed cancer drug administered together with an artemisinin combination therapy that was shown to improve the speed of recovery from a malaria infection.

Blackwater Fever in Pregnancy With Severe Falciparum Malaria: A Case of Imported Malaria From Nigeria to the United Kingdom During the COVID-19 Pandemic

We present the case of imported malaria in pregnancy to the United Kingdom (UK) from Nigeria, where a 28-year-old primigravida presented to our maternity assessment unit (MAU) with complaints of pyrexia, rigors and passing dark coloured urine. She gave a travel history of recent migration from Nigeria 10 days before presenting to our emergency department. She initially became unwell five days after her arrival with general malaise and myalgia. On day six, she developed lower abdominal pain and observed that her urine was dark in colour. This prompted her to contact her general practitioner (GP). Treatment for a urinary tract infection was initiated by the GP after a phone consultation in keeping with COVID-19 contingency guidance, and the patient was prescribed antibiotics for three days. She presented to the emergency department two days after completing the course of antibiotics where she complained of worsening pelvic pain, reduced foetal movements and passing black urine. She was treated as suspected COVID-19 and red flag sepsis. Obstetric review led to investigation and diagnosis of severe malaria in pregnancy, which was accompanied by blackwater fever (BWF). The patient recovered after three doses of artesunate. An ultrasound scan of the foetus revealed a congenital cardiac anomaly, which had not been detected in an earlier scan. There was no evidence of congenital malaria in the neonate after delivery. There are several novel aspects in this case as maternal mortality in severe Plasmodium falciparum can be significantly high. Those who survive the disease in pregnancy are also known to develop several complications such as intrauterine death and preterm labour. There was also the component of blackwater fever, which is a rare event associated with severe malaria, and it also has a mortality rate. Significant in her medical history was a diagnosis of the sickle cell trait, and we postulate that this feature gave an added protection from the complications of severe malaria in pregnancy as well as blackwater fever.

Malaria and COVID-19 co-dynamics: A mathematical model and optimal control

Malaria, one of the longest-known vector-borne diseases, poses a major health problem in tropical and subtropical regions of the world. Its complexity is currently being exacerbated by the emerging COVID-19 pandemic and the threats of its second wave and looming third wave. We formulate and analyze a mathematical model incorporating some epidemiological features of the co-dynamics of both malaria and COVID-19. Sufficient conditions for the stability of the malaria only and COVID-19 only sub-models' equilibria are derived. The COVID-19 only sub-model has globally asymptotically stable equilibria while under certain condition, the malaria-only could undergo the phenomenon of backward bifurcation whenever the sub-model reproduction number is less than unity. The equilibria of the dual malaria-COVID19 model are locally asymptotically stable as global stability is precluded owing to the possible occurrence of backward bifurcation. Optimal control of the full model to mitigate the spread of both diseases and their co-infection are derived. Pontryagin's Maximum Principle is applied to establish the existence of the optimal control problem and to derive the necessary conditions for optimal control of the diseases. Though this is not a case study, simulation results to support theoretical analysis of the optimal control suggests that concurrently applying malaria and COVID-19 protective measures could help mitigate their spread compared to applying each preventive control measure singly as the world continues to deal with this unprecedented and unparalleled COVID-19 pandemic.

Serology for Plasmodium vivax surveillance: A novel approach to accelerate towards elimination

Plasmodium vivax is the most widespread causative agent of human malaria in the world. Despite the ongoing implementation of malaria control programs, the rate of case reduction has declined over the last 5 years. Hence, surveillance of malaria transmission should be in place to identify and monitor areas that require intensified malaria control interventions. Serological tools may offer additional insights into transmission intensity over parasite and entomological measures, especially as transmission levels decline. Antibodies can be detected in the host system for months to even years after parasite infections have been cleared from the blood, enabling malaria exposure history to be captured. Because the Plasmodium parasite expresses more than 5000 proteins, it is important to a) understand antibody longevity following infection and b) measure antibodies to more than one antigen in order to accurately inform on the exposure and/or immune status of populations. This review summarises current practices for surveillance of P. vivax malaria, the current state of research into serological exposure markers and their potential role for accelerating malaria elimination, and discusses further studies that need to be undertaken to see such technology implemented in malaria-endemic areas.

Towards global control of parasitic diseases in the Covid-19 era: One Health and the future of multisectoral global health governance

Human parasitic infections—including malaria, and many neglected tropical diseases (NTDs)—have long represented a Gordian knot in global public health: ancient, persistent, and exceedingly difficult to control. With the coronavirus disease (Covid-19) pandemic substantially interrupting control programmes worldwide, there are now mounting fears that decades of progress in controlling global parasitic infections will be undone. With Covid-19 moreover exposing deep vulnerabilities in the global health system, the current moment presents a watershed opportunity to plan future efforts to reduce the global morbidity and mortality associated with human parasitic infections. In this chapter, we first provide a brief epidemiologic overview of the progress that has been made towards the control of parasitic diseases between 1990 and 2019, contrasting these fragile gains with the anticipated losses as a result of Covid-19. We then argue that the complementary aspirations of the United Nations Sustainable Development Goals (SDGs) and the World Health Organization (WHO)’s 2030 targets for parasitic disease control may be achieved by aligning programme objectives within the One Health paradigm, recognizing the interdependence between humans, animals, and the environment. In so doing, we note that while the WHO remains the preeminent international institution to address some of these transdisciplinary concerns, its underlying challenges with funding, authority, and capacity are likely to reverberate if left unaddressed. To this end, we conclude by reimagining how models of multisectoral global health governance—combining the WHO's normative and technical leadership with greater support in allied policy-making areas—can help sustain future malaria and NTD elimination efforts.

COVID-19 pandemic in Africa: Is it time for water, sanitation and hygiene to climb up the ladder of global priorities?

In the current pandemic context, it is necessary to remember the lessons learned from previous outbreaks in Africa, where the incidence of other diseases could rise if most resources are directed to tackle the emergency. Improving the access to water, sanitation and hygiene (WASH) could be a win-win strategy, because the lack of these services not only hampers the implementation of preventive measures against SARS-CoV-2 (e.g. proper handwashing), but it is also connected to high mortality diseases (for example, diarrhoea and lower respiratory infections (LRI)). This study aims to build on the evidence-based link between other LRI and WASH as a proxy for exploring the potential vulnerability of African countries to COVID-19, as well as the role of other socioeconomic variables such as financial sources or demographic factors. The selected methodology combines several machine learning techniques to single out the most representative variables for the analysis, classify the countries according to their capacity to tackle public health emergencies and identify behavioural patterns for each group. Besides, conditional dependences between variables are inferred through a Bayesian network. Results show a strong relationship between low access to WASH services and high LRI mortality rates, and that migrant remittances could significantly improve the access to healthcare and WASH services. However, the role of Official Development Assistance (ODA) in enhancing WASH facilities in the most vulnerable countries cannot be disregarded, but it is unevenly distributed: for each 50-100 US$ of ODA per capita, the probability of directing more than 3 US$ to WASH ranges between 48% (Western Africa) and 8% (Central Africa).

Performance evaluation of RDT, light microscopy, and PET-PCR for detecting Plasmodium falciparum malaria infections in the 2018 Zambia National Malaria Indicator Survey

Background

Zambia continues to advance on the path to elimination with significant reductions in malaria morbidity and mortality. Crucial components that have contributed to progress thus far and are necessary for achieving the national malaria elimination goals include properly identifying and treating all malaria cases through accurate diagnosis. This study sought to compare and assess the diagnostic performance of Rapid Diagnostic Tests (RDT) and Light Microscopy (LM) with photo-induced electron transfer polymerase chain reaction (PET-PCR) as the gold standard using 2018 Malaria Indicator Survey (MIS) data across Zambia to better understand diagnostic accuracy metrics and how these vary across a transmission gradient.

Methods

Cross-sectional samples collected in a nationally representative survey from 7 provinces in Zambia were tested for the presence of malaria parasites by light microscopy (LM), rapid diagnostic test (RDT) and the gold standard PET-PCR. Diagnostic performance was assessed including sensitivity, specificity, negative- and positive-predictive values across a wide malaria transmission spectrum. Diagnostic accuracy metrics were measured, and statistically significant differences were calculated between test methods for different outcome variables.

Results

From the individuals included in the MIS, the overall prevalence of Plasmodium falciparum malaria was 32.9% by RDT, 19.4% by LM, and 23.2% by PET-PCR. Herein, RDT and LM diagnostic performance was compared against gold standard PET-PCR with LM displaying a higher diagnostic accuracy than RDTs (91.3% vs. 84.6% respectively) across the transmission spectrum in Zambia. However, the performance of both diagnostics was significantly reduced in low parasitaemia samples. Consistent with previous studies, RDT diagnostic accuracy was predominantly affected by a high rate of false positives.

Conclusions

RDTs and LM both perform well across a range of transmission intensities within their respective target applications, i.e., in the community, for the former, where ease of use and speed of result is critical, and at the health facility, for the latter, where accuracy is prioritized. However, the performance of both diagnostic methods is adversely affected by low parasitaemia infections. As Zambia moves towards elimination more sensitive tools may be required to identify the last cases.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-021-03917-6.

Digital technologies and COVID-19: reconsidering lockdown exit strategies for Africa

Widespread vaccination provides a means for countries to lift strict COVID-19 restrictions previously imposed to contain the spread of the disease. However, to date, Africa has secured enough COVID-19 vaccine doses for less than 5% of its population. With widespread vaccination not on the horizon for Africa, there is a strong emphasis on non-pharmaceutical interventions which include movement restrictions (lockdowns). This general COVID-19 pandemic response of imposing lockdowns, however, neglects to factor in non-fatal consequences leading to disruption socio-economic wellbeing of the society at large. The economy in most African countries can no longer sustain lockdown restrictions. Some studies have indicated that a hard lockdown statistical value of the extra lives saved would be dwarfed by its long-term cost. At the same time not responding to the threat of the pandemic will cost lives and disrupts the social fabric. This paper proffers ways to mitigate the both and advocate for better policymaking that addresses specific challenges in defined communities thus yield higher population welfare.

Increased risk of severe malaria in travellers during the COVID-19 pandemic

We observed an increase in severe cases of falciparum malaria among French service members (who are travellers in endemic areas) in 2020, associated with an increase in the time between onset of symptoms and diagnosis/treatment. The COVID-19 epidemic may have lengthened the malaria diagnosis process, mainly due to clinical similarities.