Selected image: Anopheles stephensi mosquito receives a meal of blood from a human host through its pointed trunk. Photo: Reuters / Jim Gathany / CDC
Two of the nine global public health awareness days are related to malaria: World Malaria Day on April 25th and World Mosquito Day, which commemorates the discovery by Sir Ronald Ross on August 20, 1897 that Anopheles mosquitoes attacked malaria parasites transferred to people.
Both World Malaria Day and World Mosquito Day are particularly relevant for Africa. The continent is the world’s largest malaria burden. Ninety-three percent of the 228 million malaria cases and 94 percent of the 405,000 malaria deaths reported worldwide in 2018 were in Africa.
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Unfortunately, in most of the African countries south of the equator, observations these days fall outside of the main malaria transmission season. This dampens the effects of these awareness days. For this reason, the South African Development Community declared the first or second week of November to be Malaria Week in the region, with November 6 being designated as South African Development Community Malaria Day. The aim was to provide accurate malaria news at the start of the malaria transmission season in southern Africa.
Malaria in southern Africa
Malaria is endemic in 14 of the 16 South African countries, with the exception of Lesotho and the Seychelles. However, the prevalence of malaria in these 14 countries varies greatly.
Mozambique and the Democratic Republic of the Congo are among the six countries that accounted for more than 50% of all cases reported in 2018. On the other hand, Mauritius eliminated malaria in 1998 and is now preventing the reintroduction of the disease.
Four other countries in the region are currently trying to eradicate malaria, namely Botswana, Eswatini, Namibia and South Africa.
However, the countries in southern Africa are closely linked. A large number of highly mobile and migrant population groups as well as frequent cross-border movements pose considerable challenges in achieving a malaria-free region. This is especially true since mosquitoes and parasites do not respect national borders.
The South African development community created a regional malaria control coordinator, Elimination Eight (E8), to coordinate malaria control activities in eight countries in the region. This has now been extended to all malaria-endemic countries in the South African development community. Elimination Eight is also focused on ensuring that accurate malaria news is widely available.
Malaria control in the time of COVID-19
South Africa is an example of the challenges facing the entire region. The steady introduction of malaria from neighboring countries remains a major barrier to the country’s ambitions to eradicate the disease.
The vaccine trial volunteers are waiting to participate in a human clinical trial for potential vaccines against COVID-19 at the Wits RHI Shandukani research center in Johannesburg, South Africa, August 27, 2020. Photo: Reuters / Siphiwe Sibeko
The already heavily strained South African health system was negatively affected by the COVID-19 pandemic. Routine health care such as tuberculosis and HIV care has been severely disrupted.
The World Health Organization also warned that COVID-19 could significantly disrupt malaria control activities.
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South Africa responded quickly by changing malaria control practices and protocols. The aim was to ensure the safety of health care workers, malaria control staff, and the communities they serve. Because fever is a symptom of both malaria and COVID-19, people from malaria-endemic areas were tested for both COVID-19 and malaria during the community testing phase of the COVID-19 control strategy.
South Africa’s strict lockdown restrictions on provincial and international movements have significantly reduced the country’s malaria burden. Just over 1,000 cases were reported between May and October this year. The opening of the South African borders created a lot of enthusiasm. However, this increased mobility at the start of the country’s malaria season is cause for concern.
Healthcare workers and the general public need to remember that not all fevers are due to COVID-19. Other infectious diseases could be the cause. In addition, fever sufferers must remember to provide their doctor with detailed travel reports to aid in making the correct diagnosis.
Gauteng has a significant number of malaria deaths in a province where malaria is not endemic. This is because the disease has been misdiagnosed in a number of patients who have not traveled. These are patients who suffer from Odysseus malaria, colloquially known as “taxi malaria”. These cases are due to an infectious mosquito that “stopped” a journey from an endemic area. More than ever, it is critical that malaria be considered when a patient has a fever.
The COVID-19 pandemic has already changed the world and posed many public health challenges. However, preventable, treatable diseases like malaria must not be allowed to rebound.
Jaishree Raman is associated with the Antimalarial Resistance Surveillance Laboratory and Malaria Operational Research of the National Institute for Communicable Diseases.Medical Scientist, National Institute for Communicable Diseases.