key: cord-265589-mn2wr79n authors: buonsenso, d.; Iodice, F.; Cinicola, B.; Raffaelli, F.; Sowa, S.; Ricciardi, W. title: Management of malaria in children under 5-years-old during COVID-19 pandemic in Sierra Leone: a lesson learned? date: 2020-11-05 journal: nan DOI: 10.1101/2020.11.04.20225714 sha: doc_id: 265589 cord_uid: mn2wr79n Growing evidences are showing the potential indirect effects of COVID-19 on the health systems of low-resource settings, where diseases such as Tuberculosis, HIV and Malaria represent major killers. Therefore, we performed a retrospective study aimed to evaluate the impact of COVID-19 on Malaria programs in a peripheral region of Sierra Leone, previously involved by the Ebola outbreak in 2015, when malaria care have been impaired since local health systems were overwhelmed by Ebola cases. During COVID-19 in Sierra Leone, we did not notice a drop in malaria diagnosis in children, suggesting that a proactive approach in the management of malaria in endemic countries during COVID-19 may have had a positive impact. A comprehensive approach that include also educational activities to sensitize the local population, was useful to guarantee successful malaria diagnosis and treatment, and prevents excess of malaria deaths due to potential disruption of the local health systems related to the SARS-CoV-2 pandemic. Generated Statement: The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. I n r e v i e w . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted November 5, 2020. ; https://doi.org/10.1101/2020.11.04.20225714 doi: medRxiv preprint After the first description in China, SARS-CoV-2 spread all over the world and reached sub-Saharan Africa. Even in this part of the world, the number of COVID-19 cases and deaths are rising day by day, although not on a significant rate compared with Europe, Asia, North and South America. The reasons of such a difference are still unexplained, but multiple factors can be involved, including genetic differences and lack of testing points in most areas, particularly in the peripheries. Anyway, the arrival and continuous spread of SARS-CoV-2 in Africa is worrying major organiaztions (including the World Health Organization and major medical journals) because of the direct impact of the viral spread on a weak health system and the indirect effects of lockdown in a weak economic system (1) . Preliminary data arrived from Sierra Leone where we previously highlighted the social consequences of SARS-CoV-2 lockdown (2). We reported how restrictive measures had a strong impact on the population with majority of people who live in peripheries are losing their jobs and householders, the people to whom most of the family's financial support is assigned, having serious concerns in providing basic needs (water and food) to their relatives. However, it was immediately clear that a special attention of the health system should be paid to the possible effects of COVID-19 pandemic on other major killers in Africa: HIV, tuberculosis and Malaria. During the last decade, African countries greatly improved the care of patients with these conditions, thanks to a coordinated approach including governments acts, the support of major international agencies (such as the World Health Organization (WHO) and non-governmental organizations (NGO). However, the COVID-19 pandemic could possibly break a decade of successes in tuberculosis, HIV and Malaria care. The impact on tuberculosis and HIV care has been widely claimed (3) and we showed how the number of suspected and confirmed tuberculosis cases dropped in an outpatient unit in Sierra Leone (4) . The estimated impact of these measures on tuberculosis care could be considered impressive, with major organizations estimating millions of new cases in the next years due to missed diagnosis or incomplete treatments (and subsequent community spread) I n r e v i e w . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted November 5, 2020. ; https://doi.org/10.1101/2020.11.04.20225714 doi: medRxiv preprint during COVID-19 lockdown (https://www.theunion.org/news-centre/news/union-warns-the-covid-19-pandemic-must-not-divert-attention-from-the-needs-of-children-and-adolescents-in-tb-endemicafrican-countries). Importantly, there is the problem of stigmatization: people are worried to be recognized as COVID-19 patients and health center has been improperly recognized as potential spots where the contagion would be easier (4) . During Ebola Virus Disease (EVD) outbreak, several violent riots happened at health centers across the most involved countries, moved by the believe that medical staff were somehow responsible for spreading EVD to the villages. This resulted in further disruption of the control programs (5). During the World Malaria Day on April 25 th , fears about potential interruption of Malaria control programs in endemic countries due to COVID-19 have been raised (6) . Most of these fears come from the consequences of EVD on malaria care in 2014-2016, when the number of malaria diagnoses, the number of patients with malaria seeking appropriate health care and the volume of malaria treatments being dispensed dropped significantly compared with previous years (6) (7) (8) . It was estimated that about 7000 additional malaria-associated deaths among children younger than 5 years in Guinea, Liberia, and Sierra Leone due to the Ebola outbreak (6, 9) . In the case of Ebola, clinical similarity of EVD with malaria, fear of contracting Ebola in the healthcare facilities, and interruption of distribution of insecticide-treated bed-nets (ITNs) were all contributing factors leading to disruption of malaria care (10) . There is now the real possibility that COVID-19 could have the same indirect impact on Malaria. Considering that Malaria mainly kills children under five years of age, while COVID-19 is relatively mild in this group (11) , the potential effects of disrupted malaria programs on children's health could be massive. Therefore, we performed this retrospective study aimed to evaluate the impact of COVID-19 on Malaria programs in a peripheral region of Sierra Leone, previously involved by the EVD outbreak in 2015. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted November 5, 2020. Personal data were not collected. In Sierra Leone, the first COVID-19 presumptive cases have been documented at the end of March 2020 and lockdown declared in April 2020. On May 2020, the lockdown has been retired but people were not allowed to move between districts. Descriptive and statistical analyses performed with STATA v16. Dataset available upon reasonable request contacting the corresponding author. During the period analysed, fluctuations in Malaria diagnoses have been documented ( figure 1 ) and, although on April 2020 there has been reduction in diagnosed cases compared with March 2020 and April 2019 (P 0.01), the number of cases did not differ from April 2018 (P > 0.05, figure 1a and 1b) . On May 2020 a new raise in malaria diagnoses was found, compared with April 2020, but comparable to May 2019 and 2018 (P > 0.05, figure 1c ). The number of malaria deaths in children younger than I n r e v i e w . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted November 5, 2020. ; https://doi.org/10.1101/2020.11.04.20225714 doi: medRxiv preprint 5 years of age was similar in 2018 and 2019, and 2 cases detected from January to May 2020 (potentially a similar rate/year considering the short timeframe evaluated in 2020) (figure 1d). Looking at the trend of Malaria diagnoses in children under five years of age along the three investigated years, the number of diagnoses did not change significantly during COVID-19. Although an initial drop of Malaria cases has been documented in April 2020, when Sierra Leone started the lockdown due to the first cases of COVID-19, we cannot exclude that it is a casual fluctuation in Malaria diagnoses. Interestingly, when the lockdown was retired at the beginning of May 2020, a sudden increase in Malaria diagnoses have been registered. Again, a causal relationship with the reduction of restrictive measures related to COVID-19 cannot be demonstrate, but not even excluded. According to local doctors and community health workers, in Sierra Leone health authorities and healthcare workers worked hard to ensure that people would not miss malaria care as happened during EVD outbreak. In fact, despite at the beginning of April 2020 local health workers reported an initial reduction on malaria diagnosis, mainly due to fear of contracting COVID-19 in the health centers, after a number of health education activities people came back to the health facilities when needed. In fact, on May 2020, when COVID-19 cases were still increasing in the country, the number of malaria diagnoses in our center in children under 5 years of age raised as well. To achieve this result, the Sierra Leone government took preventive strategies after the lessons learned during EVD outbreak. In particular: -Education and information strategies aimed to eliminate the perception that health staff is infecting people with COVID-19 -Continuous health education on the use of insecticide treated net which has helped greatly in the reduction of malaria positive cases I n r e v i e w . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted November 5, 2020. ; https://doi.org/10.1101/2020.11.04.20225714 doi: medRxiv preprint the routine immunization activities to infants aged 10 weeks to 9 months nationwide free distribution of ITNs given to every household in May 2020, while this campaign has been interrupted during the previous Ebola outbreak systematic malaria diagnostics as part of fever management and measures for early detection and treatment of malaria, including presumptive malaria treatment -Implementation of community-based health workers for social engagement and monitoring of peripheries -Continuation of malaria drug and test supply This experience in a local health center previously involved by the EVD shows how a pro-active approach is necessary in order to keep appropriate care for major killers in Africa, performing proactive screening not only to diagnose COVID-19 but also Malaria. This is a necessary step in sub-Saharan Africa since a missed diagnosis of malaria bear significant public health consequences for the community allowing the further spread of Malaria, similarly to a missed diagnosis of COVID-19 (12) . The clinical presentation of malaria is similar to COVID-19; moreover, both can be asymptomatic or pauci-symptomatic or even present with systemic critical disease (12) . This further emphasizes the need to actively look for both diagnoses in malaria endemic countries. We are aware that our report has several limitations to address. The retrospective nature is a limitation itself. Moreover, we have been able to collect absolute numbers, and no comprehensive epidemiological/demographic data from the health center are currently available, since the pandemic and the related restrictions are creating a higher workload for local workers and, at the same time, is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted November 5, 2020. ; https://doi.org/10.1101/2020.11.04.20225714 doi: medRxiv preprint extremely low in the area. Therefore, there were no enough human resources, and time, to allow us a timely and more detailed data collection. Also, ecological changes during the three study periods may have potentially influenced the trend of local malaria diagnoses, although currently there are no published evidences of unusually different rainy or dry seasons in the study period. Last, our data reflects the results of a national campaign in a single health center in Sierra Leone, therefore these data cannot be generalized to the whole country or, in general, to Sub-Saharan Africa. Although some difficulties in keeping effectively active Tuberculosis centers in sub-Saharan Africa has been already documented in Sierra Leone (4), in the case of Malaria in young children, the national health system has been apparently more successful, at least in the initial phases of the pandemic, since after an initial reduction of new diagnoses in April (first month of local lockdown), on May 2020 a raise of new cases has been registered. Obviously, the management of chronic conditions could be considered more difficult, as direct-observed therapies require multiple evaluations that during lockdown are not easily allowed, and telemedicine services are not yet implemented in low-income countries. However, our study, although limited by its retrospective nature, can suggests that a proactive approach in the management of malaria in endemic countries during COVID-19, even including educational activities to sensitize the local population, is important and may be potentially useful in order to guarantee successful malaria diagnosis and treatment. However, long-term observational studies including more centers, and particularly the peripheral health centers of low-income countries, are needed to understand if a proactive and educational approach will be sufficient to prevent excess of malaria deaths due to disruption of the local health systems related to the SARS-CoV-2 pandemic. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted November 5, 2020. ; https://doi.org/10.1101/2020.11.04.20225714 doi: medRxiv preprint I n r e v i e w . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted November 5, 2020. ; https://doi.org/10.1101/2020.11.04.20225714 doi: medRxiv preprint I n r e v i e w . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted November 5, 2020. ; https://doi.org/10.1101/2020.11.04.20225714 doi: medRxiv preprint Africa in the Path of Covid-19 Social consequences of COVID-19 in a low resource setting in Sierra Leone, West Africa Tuberculosis and HIV responses threatened by COVID-19 COVID-19 effects on Tuberculosis care in Sierra Leone Preparedness is essential for malaria-endemic regions during the COVID-19 pandemic Effect of the Ebola-virus-disease epidemic on malaria case management in Guinea, 2014: a cross-sectional survey of health facilities Effects of response to 2014-2015 Ebola outbreak on deaths from malaria, HIV/AIDS, and tuberculosis Malaria morbidity and mortality in Ebola-affected countries caused by decreased health-care capacity, and the potential effect of mitigation strategies: a modelling analysis Children with Covid-19 in Pediatric Emergency Departments in Italy COVID-19 and malaria: A symptom screening challenge for malaria endemic countries We are grateful to all our colleagues that supported the development of local health services and training of community health workers in the Western Rural Area of Sierra Leone and, in particular, We are also grateful to Cassa Galeno, which granted Danilo Buonsenso a project aimed at the development of an Italian-Sierra Leone research network in pediatrics.