This study evaluated the impact of the COVID-19 pandemic on the number of outpatient visits, malaria disease burden, and case management practices between April 2020 and March 2021 using routine surveillance data collected at 17 high volume public outpatient facilities in areas of varying malaria transmission across Uganda. In this study the number of outpatient visits, malaria cases, and non-malaria visits as well as most indicators of malaria case management did not reflect any significant changes in the first year following the onset of the COVID-19 epidemic. However, from October 2020 through March 2021, a modestly lower mean proportion of suspected malaria patients received an RDT for malaria diagnosis compared to what was predicted for that period. Notably, this difference was not reflected by a change in the proportion of patients with suspected malaria who underwent diagnostic testing, as microscopy was available as an alternative to RDTs. A similar trend was observed in the last six months of observation for the mean proportion of malaria cases prescribed AL.
The emergence and rapid spread of COVID-19 across the world has created massive global disruptions on health systems, social services, and economic activity (14). The disruption in health services is expected to be magnified in sub-Saharan Africa to a greater degree than in other regions due to relatively weak health service infrastructures, low clinician to population ratios, limited laboratory capacity, and a higher burden of other infectious diseases (15). Delivery of malaria preventive measures and care services are some of the activities most likely to be affected by the epidemic given the high prevalence of malaria in the region (16). Indeed, there are predictions that malaria cases will increase, and malaria related mortality may nearly double, decelerating any gains attained in the last decade (3, 12, 17, 18). Uganda, one of the highest malaria burden countries in sub-Saharan Africa, was predicted to be one of the countries most likely to be affected by the COVID-19 pandemic. According to a WHO modelling study, by the end of 2020 in a scenario where LLIN campaigns are not implemented and LLINs continuous distributions and access to effective antimalarial treatment are reduced by up to 75% malaria deaths could increase by 200% in Uganda (12). A study by Bell et. al. predicted less disastrous effects resulting from a widespread COVID-19 outbreak compared to the impact of lockdowns on malaria programs (Bell, 2020).
However, contrary to those worst-case scenarios, these data suggest that despite travel restrictions and other lockdown measures, access to care and malaria case management were largely unaffected by the COVID-19 pandemic in the first year after it was confirmed in Uganda. This could be because 75% of the population in Uganda resides in rural areas where patients seeking care either walk or ride bicycles to the health facilities (19), making access to care possible even with restrictions to motor vehicle movements. In addition, the health system is structured in such a way that most of the health care staff are housed at or near the facilities; furthermore, travel permits were provided for health workers who needed to travel long distances to their duty stations, preventing the staff shortages that would likely have limited access to malaria care. Finally, planned malaria control activities, including the mass LLIN distribution campaign (implemented between June 2020 and March 2021) and IRS rounds, were successfully implemented despite the pandemic.
In addition, the outbreak was expected to increase fever cases because COVID-19 and malaria both present with fevers. However, community transmission of COVID-19 remained low during the first year following the outbreak; this may explain the fact that this analysis showed no increase in non-malarial visits or proportion of cases with suspected malaria. However, a decrease in the proportion of patients tested for malaria using RDTs was observed. This may be because of global supply chain issues that resulted in local stock outs of RDTs. In the last year, there was a noted global decline in malaria RDT production and supply, with manufactures shifting in focus from RDTs to COVID-19 point of care tests (20, 21). Importantly, the decrease in proportion of RDTs used as the laboratory diagnostic did not affect whether or not patients received a diagnostic test for suspected malaria, because microscopy was available as an alternative diagnostic at the MRCs.
There was also a modest decrease in the mean proportion of malaria cases prescribed AL, the standard of care for the treatment of uncomplicated malaria in Uganda, seen in the last six months of observation. Uganda’s Ministry of Health secured funding to procure dihydroartemisinin-piperaquine (DP) for use as an alternative first line treatment for uncomplicated malaria in the event of treatment failure for patients using AL and for prescription to all patients with severe malaria following completion of three intravenous artesunate doses. From 2020 to-date, DP has been available at some public health facilities for use as an alternative first line treatment for patients with treatment failure due to AL and all patients diagnosed with severe malaria following completion of artesunate treatment, leading to an increase in the number of patients prescribed DP. Therefore, the decrease in prescriptions of AL observed in the last six months of the study may not be due to a decrease in supply or availability of AL due to the COVID-19 pandemic but instead due to changing prescription practices in response to policy changes regarding DP. There was no direct data on AL stock captured at these health facilities over the timeframe of the analysis, as such we were unable to conclusively attribute this decline to AL stock-outs at the facilities.
Other studies in similarly resource-restricted settings have shown varied impacts of the COVID-19 pandemic on malaria burden and deaths. A brief report published regarding patients at one health facility in Sierra Leone showed a decrease in the number of malaria cases diagnosed in children younger than 5 years of age in April 2020 compared to April 2019, but this had recovered by May 2020 (22). However, this study was at a single health facility, did not account for seasonality, and only observed three months of the post-COVID period. A larger study in Zimbabwe, which utilized routine malaria surveillance data collected from all public and private health facilities from January 2017 to June 2020, found an excess of over 30,000 malaria cases from January to June 2020 compared to an average over the same period from 2017, 2018, and 2019 data (23). This study also found that the number of malaria deaths recorded from January to June 2020 exceeded the annual totals for 2018 and 2019. However, while they describe these increases by comparing numbers from January 2020 to June 2020 to prior data, they do not make any statistical inference regarding their findings and note the limitations of routine surveillance data regarding data quality. A particular strength of the study presented here is the use of a quasi-experimental, interrupted time series study design which accounted for pre-COVID trends, other factors such as seasonality, rainfall, differences in study site, and concurrent LLIN and IRS campaigns to predict outcomes one year after the onset of COVID-19. In addition, the MRCs included had a full three years of pre-COVID data that had undergone a supervised data cleaning process, resulting in less than 5% missing data.
Several limitations of this study are worth noting. First, the impact of the COVID-19 pandemic on malaria mortality was not assessed, as these data were not available. Second, data was only available on antimalarial prescription practices and not whether antimalarial drugs were actually available and administered. Third, COVID-19 cases were still relatively low in Uganda during the period this study was conducted, and it is likely that the impact of the COVID-19 pandemic on malaria indicators may change as community transmission increases, especially with the Delta variant now in the country. This is already being observed as the number of cases observed between March and July 2021 has doubled compared to what was observed between March and July 2020 (90,656 versus 40,962) (24). Thus, conclusions only reflect the effect of the COVID-19 on malaria indicators in the first year after arrival of COVID-19 in Uganda. Notably, COVID-19 is on the rise in Uganda and the Government of Uganda has imposed a second lockdown in June 2021. Further study on the impact of the epidemic and lockdown policy is needed. Fourth, this study makes use of high-quality data from 17 MRCs across varied transmission settings in Uganda, which may not be representative of the entire country. Though similar outcomes are available through national health management information systems (HMIS) databases, HMIS data have been shown to suffer from increased ‘missingness’ and quality control problems(25, 26) and to provide robust estimates these data were not included. Fifth, though ITSAs are known to be a robust method of utilizing longitudinal data for estimating causal effects (27, 28), we cannot rule out that estimates may have been subject to unmeasured confounding.