Careful messaging is needed when advising those with Covid-19-like symptoms to stay at home, to avoid a huge spike in deaths from malaria and tuberculosis (TB) in some parts of Mozambique.
To keep the most vulnerable communities protected, the World Health Organisation (WHO) advises that support for programmes to combat malaria, HIV and TB, not only need to be maintained, but expanded while battling the coronavirus.
Fever, coughing, and shortness of breath – the main symptoms of Covid-19 – are also the main symptoms of TB, one of the leading causes of death for people with HIV in Mozambique, infecting 552 in every 100,000 people. Fever is also the key symptom of malaria, which accounts for 29% of all deaths in Mozambique, and 42% of deaths in children under five years old.
The WHO advises patients to stay at home if they feel unwell, as people infected with Covid-19 but with only mild symptoms risk spreading the virus throughout hospitals. Patients should seek medical treatment if they develop a fever, cough or difficulty breathing, but they should call the local health authority in advance, the WHO says.
However, some public health workers in Mozambique are concerned that patients will not know what local health authority number to call – or that the phone numbers provided will not be well attended. Patients may also avoid seeking medical care for fear of catching coronavirus.
Messaging from Mozambique’s Ministry of Health may therefore need to be adjusted in some parts of the country to ensure those with malaria and TB continue to seek treatment, said one public health expert with clinical and research experience in Mozambique.
“In an area like Mopeia district in Zambezia, where last year in May we recorded a prevalence of 75% of malaria in children, if you tell people to stay at home, or, even worse, if the police enforce that, you have a chance of causing harm,” the expert said.
Pedro Alonso, Director of the WHO Global Malaria Programme, is concerned that “Covid-19 could be a disaster for malaria.”
“We know when health systems get disrupted, malaria becomes the number one killer,” he told Forbes. “We saw this with Ebola in West Africa and DRC, and in Nigeria with civil war. With malaria, we will see the impact of Covid-19 straight away. If people stop going to health facilities and don’t get bed nets, we will see a massive increase in malaria mortality, mostly in kids and pregnant women,” he added.
Covid-19 cases still isolated
At the moment, Mozambique’s confirmed cases of coronavirus are at the LNG project site at Afungi in Cabo Delgado, where workers’ camps are now on lockdown, and in the cities of Maputo and Matola where the malaria rate is far lower than the rest of the country, so the risks of self-isolating at home with fever-like symptoms are lower.
The logistics of conducting at-home testing are also relatively easy in Maputo — but will be challenging in more remote areas of the country.
Given the different malaria risks and access to healthcare in different areas of the country, the messaging around Covid-19 could be adapted according to context, another healthcare worker told Zitamar. “While advice in an area with high Covid-19 risk, but low malaria risk and easy access to healthcare, may be to stay at home, it should be adapted in areas with high rates of malaria,” they said.
Recommendations could be even further adapted, particularly when it comes to treating patients under five, who tend to have positive outcomes for Covid-19, but negative outcomes for malaria. The advice could be for children to seek care, but for adults to first call local health services.
While geolocation using cell phone data makes this kind of targeted messaging possible, the level of organisation needed to implement it is currently well beyond the capacity of the Ministry of Health.
Lessons from Ebola
The WHO is aware of the need to act urgently to make sure malaria services are maintained from its experiences of dealing with Ebola in West Africa. During the 2014-2015 Ebola outbreak in Guinea, Liberia and Sierra Leone, additional deaths from HIV, TB and malaria as an indirect consequence of the outbreak exceeded those directly caused by Ebola as usual health service delivery was interrupted.
The main factors that contributed to the additional deaths was the suspension of programmes to hand out nets, the similarity of early Ebola symptoms with those of malaria leading to difficulties in early diagnosis, and the fear of contracting Ebola preventing those suffering from malaria from seeking treatment at health-care facilities.
WHO advice is to not only maintain but increase malaria control activities during these disease outbreaks.
“As Covid-19 continues its rapid spread, WHO would like to send a clear message to malaria-affected countries in Africa,” WHO’s Alonso said at the end of March. “Do not scale back your planned malaria prevention, diagnostic and treatment activities. If someone living in a place with malaria develops a fever, he or she should seek diagnosis and care as soon as possible.”
These measures include continuing delivery of insecticide-treated nets and indoor residual spraying, as well as intermittent preventive treatment with anti-malarial medication for pregnant women and young children.
Mass drug administration (MDA) — the administration of antimalarial treatment to every member of a defined population or every person living in a defined geographical area at around the same time and often at repeated intervals — could also ease the burden on health systems on the context of Covid-19.
“It would at least give the health system room to breathe, reduce the risk for a while, giving medical team the chance to address some of the other impacts of the coronavirus outbreak,” said the public health expert.
The distribution of nets should also continue, although strategies would need to be adapted to protect healthcare workers and the community from the spread of Coronavirus. The U.S. President’s Malaria Initiative advises increasing the number of hand-washing stations and soap at its operation sites, reinforcing morning health checks for team members, including temperature checks where feasible, wear N-95 masks and personal protective equipment before entering operation site and frequently wipe down surfaces such as door handles and hospital railings.
Even if Mozambique cannot implement all these measures, some steps could be taken – such as wearing cloth masks, and keeping distance on site.
However Covid-19 remains a big threat.
Recent modelling done by researchers at Imperial College London suggests that without control measures, Covid-19 could cause “7 billion infections and 40 million deaths globally in the coming year.” The researchers estimate that if aggressive control measures are introduced, it could cut this number by half, resulting in 20 million deaths.
“If accurate, this would make the COVID-19 pandemic the leading cause of infectious disease death globally by orders of magnitude, far exceeding the 1.5 million deaths per year from TB, 770,000 from HIV, and 405,000 from malaria in 2018,” says The Global Fund.
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