Shrikant Nema1, 2
1Division of Vector-Borne Diseases, ICMR-National Institute of Research in Tribal Health, PO Garha, Nagpur Road, Jabalpur-482003, M.P., India; 2School of Biotechnology, Rajiv Gandhi Proudyogiki Vishwavidhalya (State Technological University of Madhya Pradesh), Bhopal, 462 023, Madhya Pradesh, India
India along with 25 other countries has set the goal of malaria elimination by 2030. Out of these 26 countries, 22 are affected with COVID-19. We propose herewith that such countries, e.g., India must plan and manage the COVID-19 situations in a way not to hinder targeted malaria elimination goal.
Keywords: COVID-19, Malaria elimination, India
COVID-19 and Malaria: The Indian perspective
The pandemic coronavirus disease 2019 (COVID-19) was first reported in Wuhan, China, in late December 2019 and quickly spread to213 countries of the globe. As of 23rd April 2021, about 144 million confirmed cases with 2.1% of deaths are reported globallyi, with India contributing around 16263695 confirmed cases with 186920 deaths (as of 23rd April 2021) and still countingii. The sudden emergence and high transmissibility of COVID-19 infection are posing new challenges all over the endemic countries as well as in 26 different countries that have aimed for elimination of malaria by the year 2030.
Like many malaria-endemic countries, India also has achieved a significant reduction in malaria cases and stepping towards elimination . However, due to a rise in the trajectory of COVID-19 cases in ten highly malaria-endemic states of India such as Uttar Pradesh, Karnataka, Telangana, Chhattisgarh, Gujarat, Madhya Pradesh, Maharashtra, Kerala, Orissa, and Rajasthan which contributed about 71% of the malaria infection in 2019iii are of concern on the fulfilment of the targeted malaria elimination goal. India is the second-most populous country in the globe and due to extensive population mobility many people are found to have close contact with travellers returning from COVID-19affected countries, which might have affected rising cases of COVID-19 .
COVID-19 had appeared suddenly and become a serious public health concern that needs urgent attention for control. On the contrary, malaria, being an age-old mosquito-borne human disease transmitted by Anopheles vector causes serious health hazards both in terms of mortality and morbidity year-by-year in tropical and sub-tropical regions of the world.
We herewith highlight possible challenges in malaria control efforts in India due to the COVID-19 outbreak in the Indian context which might trigger the policymakers for non-stop malaria control efforts.
Challenges in malaria elimination effort due to COVID-19 outbreak in India
The quick action plan of the Indian government to curb the coronavirus infection such as strengthening the diagnostic capacity, social distancing and complete lockdown  are important precautionary steps to curtail the infection and prevent the community transmission. Due to restricted movement of the essential workforce and intermittent supply chains might have resulted in shortage of essential malaria commodities that are important for elimination effort. These are (i) rapid diagnostic tests (RDTs), (ii) antimalarial medicines,(iii) long-lasting insecticidal nets, and(iv) Indoor residual spray. The malaria T3 strategy (Track, Test, Treat)iv which was designed to provide diagnosis, treatment, and surveillance might create difficulties for reaching out to patients during the lock-down period, although the healthcare delivery system remains fully operational. Furthermore, considering the severity of COVID-19, several diagnostic manufacturers who were involved in the production of malaria RDT kits would possibly have been diverted to strengthen the diagnostic capacity of COVID-19. For example, in 2018, 10.5 million malaria RDT’s were distributed in Indiav; therefore, managing the malaria RDTs stock is essential. We should learn from the experience of an Ebola outbreak in Guinea, Liberia, and Sierra Leone where malaria cases had increased by up to 1million in 2014 due to restricted supplies of insecticide-treated bed nets . Similarly, an increase in malaria cases was observed at the time of the H1N1 flu pandemic outbreak in Mexico in 2009 and during the civil war situation in Tajikistan in 1992-93.
Season of malaria transmission in India begins in May, and the peak is seen after the monsoon in July and August, with April and May are preparatory months when preventive measures such as fogging, fumigation and awareness campaigns are undertaken. Diversion of public health facilities and measures and diversion of resources towards COVID-19 would daunt malaria control efforts. To avoid such stress in the management of the healthcare system, supply chain management and essential/non-essential commodities should be well-established in advance in the malaria-endemic regions.
COVID-19 along with malaria and co-infection with other viral diseases may complicate and increase the challenges in the early clinical diagnosis of malaria. This is because few patients were diagnosed with both COVID-19 and influenza virus with the common symptoms . A similar situation may be alarming in the malaria-endemic zone as the common symptoms of COVID-19 include fever, fatigue, myalgia, cold and cough which may confuse with malaria . Other vector-borne viral diseases (e.g. Dengue) may also be confusing, as, in some instances, false-positive dengue case was later confirmed to be COVID-19 positive . Keeping all these challenges in mind, it is important to highlight that diagnostic test of malaria and other vector-borne viral diseases must be recommended along with the COVID-19 suspected cases in the areas of high malaria and COVID-19 endemicity.
Health professionals engaged in malaria control and elimination program should be more careful by following the advisory guideline to avoid the COVID-19 infection during the malaria epidemiological surveys, diagnosis, and treatment. It is worth mentioning that in some patients, virus remains active as asymptomatic COVID-19 infection; such covert coronavirus infections  may pose a challenge in malaria surveillance. Therefore, health care leaders and workers in malaria-endemic regions must ensure that such containment practices should be implemented and public health policy needs should be established to effectively manage the COVID-19 and malaria cases simultaneously.
Coordinated action is necessary to manage the accessibility of key malaria control tools, particularly in areas with a high burden of the disease, and endeavor to curb the spread of COVID-19 must not compromise access to malaria prevention, diagnosis, and treatment services. If we fail to handle COVID-19 and malaria cases simultaneously, it could influence the success in the malaria elimination we have achieved so far, and we may not be able to attain the national malaria elimination goal in the stipulated time frame. Hence, proper vigilance in the malaria-endemic regions while dealing with the COVID-19 situation in India is essential.
1. Coronavirus disease (COVID-19) Situation Dashboard. Available: https://experience.arcgis.com/experience/685d0ace521648f8a5beeeee1b9125cd
2. Ministry of Health and Family Welfare | GOI RSS. Available:https://www.mohfw.gov.in/.
3. Malaria :: National Vector Borne Disease Control Programme (NVBDCP). Available:https://nvbdcp.gov.in/index1.php?lang=1&level=1&sublinkid=5784&lid=3689
4. WHO | T3: Test. Treat. Track initiative. Available: http://www.who.int/malaria/areas/test_treat_track/en/[Accessed: 11-Apr 2020]
5. World Malaria Report 2019. Available from:https://www.who.int/publicationsdetail/world-malaria-report-2019
1 Narain J et al. (2018) Eliminating malaria in India by 2027: The countdown begins! Indian J Med Res. 148, 123–126.
2 Pulla, P. (2020) Covid-19: India imposes lockdown for 21 days and cases rise. BMJ 368.
3 Walker, P.G.T. et al. (2015) Malaria morbidity and mortality in Ebola-affected countries caused by decreased health-care capacity, and the potential effect of mitigation strategies: a modelling analysis. Lancet Infect. Dis. 15, 825–832
4 Hsieh, Y.-H. et al. (2011) Early Outbreak of 2009 Influenza A (H1N1) in Mexico Prior to Identification of pH1N1 Virus. PLOS ONE 6, e23853
5 Aliev, S.P. (2000) [Malaria in the Republic of Tajikistan]. Med. Parazitol. (Mosk.)
6 Ding, Q. et al. (2020) The clinical characteristics of pneumonia patients coinfected with 2019 novel coronavirus and influenza virus in Wuhan, China. J. Med. Virol. DOI: 10.1002/jmv.25781
7 Wang, J. et al. (2020) Preparedness is essential for malaria-endemic regions during the COVID-19 pandemic. The Lancet.395, 1094-1096,
8 Yan, G. et al. (2020) Covert COVID-19 and false-positive dengue serology in Singapore. Lancet Infect. Dis.Published online March 4, 2020 https://doi.org/10.1016/S1473-3099(20)30158-4
9 Qiu J. (2020) Covert coronavirus infections could be seeding new outbreaks [published online ahead of print, Mar 20]. Nature. 10.1038/d41586-020-00822-x. doi:10.1038/d41586-020-00822-x