Africa must not allow COVID-19 to disrupt malaria control in pregnant women, argues James Tibenderana.
The COVID-19 pandemic is forcing national governments around the world to take actions they never dreamed they would take. The virus is snatching away lives, locking down our societies, closing borders and dominating global health discourse.
The pandemic must be tackled but it would be unwise — and dangerous — to forget about the world's other deadliest diseases such as malaria during this health emergency.
Malaria hasn't gone away because of COVID-19. We need to ensure that people are protected. Tackling COVID-19 must not hamper the fight against malaria. Also, there is a particular group of people that is at considerable risk for both malaria and COVID-19: pregnant women.
In 2018, the World Health Organization (WHO) Africa region alone had 93 per cent of the estimated 228 million malaria cases worldwide.
Of these, 11 million pregnant women in Sub-Saharan Africa were infected with malaria, contributing to 872,000 children with low birthweight, 10,000 maternal deaths and 100,000 newborn deaths.
Severe anaemia from malaria in pregnancy and low birthweight contribute to maternal and newborn deaths respectively. Malaria in pregnancy during the COVID-19 pandemic is a huge problem that can be solved through only proper attention and action.
As we celebrate World Malaria Day 2020 today under the theme — Zero Malaria Starts with Me —in the continuing COVID-19 pandemic, the need to ensure pregnant women get zero malaria must be the responsibility of all but even more so for African governments.
Protecting pregnant women
COVID-19 has not yet swamped Africa in the same way it has affected Europe, Asia and North America. As of 23 April, there were 16,829 confirmed cases of COVID-19 and 748 deaths across Africa whereas the WHO European region had 1,251,458 confirmed cases and 113,336 deaths, with the WHO's South-East Asia region having 36,039 confirmed cases and 1,498 deaths, according to the WHO.
Africa has a brief window of opportunity to prepare properly and protect pregnant women from both COVID-19 and malaria simultaneously.
Every country needs to designate antenatal care as an essential health service that will not be interrupted by lockdowns and physical distancing. All pregnant women should have access to safe, effective and uninterrupted antenatal care.
Adequate safety measures need to be put in place to protect pregnant women and medical staff at antenatal clinics. Personal protective equipment must be supplied to staff, handwashing stations must be installed, and more frequent antenatal care clinics need to be held to enable the enforcement of physical distancing.
Grouping pregnant outpatients based on the severity of their medical problems and testing should occur outside the clinics, with those testing positive for COVID-19 being separated from other expectant mothers. Testing for malaria and COVID-19 is critical to protecting pregnant women and providing the care they need.
Where lockdowns are imposed, pregnant women must still be allowed to attend antenatal appointments - and when they are unable to attend, midwives should be allowed to hold outreaches that bring services close to the expectant mothers' homes.
Treatments and nets
The availability of preventive treatment for malaria in pregnancy - specifically sulfadoxine-pyrimethamine (SP) - needs to be prioritised during the pandemic, with all pregnant women given access to this treatment when they visit the antenatal clinic.
Before the pandemic hit, only an estimated 31 per cent of pregnant women in Sub-Saharan Africa were receiving the WHO-recommended minimum three doses of preventive treatment according to World malaria report 2019. Without swift intervention, this number will drop even further during the COVID-19 outbreak, putting thousands of lives at risk.
Too few pregnant women are receiving the preventive medicine they need to protect themselves and their babies from malaria. Some of the reasons as to why include stock-outs of SP, lack of updated recording forms, the spread of misinformation and uncertainty about what happens at the antenatal clinic. Operational research is needed to find out why this number is so low. The pandemic will only exacerbate this situation.
As the focus and funding shifts away from malaria and towards COVID-19, it is likely that research and development on alternative medicines for preventing malaria in pregnant women in order to reduce the reliance on SP will grind to a halt.
This is a serious concern, especially because potential resistance of malaria parasites to SP will not make this drug remain effective forever. We need new, fast solutions, and the pandemic cannot be allowed to delay this life-saving work.
Another crucial tool in the battle against malaria in pregnancy is the long-lasting insecticidal net. Every pregnant woman in malaria endemic countries needs to sleep under one every night. This practice must be reinforced during the pandemic, and nets must continue to be distributed to vulnerable populations during nationwide lockdowns.
Spreading the message
While governments are educating their people on how to protect themselves and their families from COVID-19, the message must come through loud and clear that routine preventive care - including antenatal care - for malaria will continue as normal.
Key malaria messages must be maintained throughout the health system, and the vulnerability of pregnant women to both malaria and COVID-19 must be made clear to the women themselves and their families.
Pregnant women should be urged to sleep under insecticide-treated nets every night, and advised on how to seek help if they start to show either COVID-19 or malaria symptoms. Their families and friends must play their part too, and abide by the COVID-19 guidelines to help protect pregnant women from the virus.
Time to act is now
National governments' acting swiftly to combat COVID-19 is a right move but speed is not the only necessity here. National governments need to consult all levels of the health system in their countries, and connect with communities, to ensure that lockdowns and other COVID-19 preventive measures are nuanced and context specific.
Blanket lockdowns on movement will hamper the anti-malaria effort, and put people at risk. Pregnant women need to continue visiting antenatal clinics, community health workers still need to diagnose and treat malaria.
The window of opportunity is open right now but it may not be too long before COVID-19 hits Africa harder. We can save countless lives of pregnant women and their babies if we act now.
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