Science - USA (2020-08-21)

892 28 AUGUST 2020 • VOL 369 ISSUE 6506 sciencemag.org SCIENCE

PHOTO: YANICK FOLLY/AFP/GETTY IMAGES

B

ack in March when COVID-19 hit,

Pedro Alonso became alarmed about a

different infectious disease. “I thought

I would be witnessing the biggest ma-

laria disaster in 20 years,” says Alonso,

a malaria scientist at the World Health

Organization (WHO). African countries went

on lockdown to curtail COVID-19; worried

about mass gatherings, they suspended cam-

paigns to distribute mosquito-fighting bed

nets. Fears abounded that with clinics over-

whelmed by COVID-19, patients would be

unable to get treatment for malaria, which

kills an estimated 405,000 per year, mostly

African children. In the worst case scenario,

models projected, malaria deaths could more

than double this year.

“It does not seem to be happening,” Alonso

says. Lobbied hard by WHO’s Global Malaria

Programme (GMP), which he heads, and its

partners, countries resumed bed net cam-

paigns. Rapid diagnostic tests and effective

malaria drugs remain available. The situa-

tion could still go south as the COVID-19 epi-

demic accelerates, but for now, Alonso says,

“We probably stopped the first big blow.”

In March, WHO recommended that coun-

tries halt mass vaccination campaigns for

measles and other diseases, fearing they

might spread COVID-19 (Science, 10 April,

p. 116). Like other health agencies, the Af-

rica Centres for Disease Control and Pre-

vention advised people to stay home unless

they were very, very sick, Alonso says. But a

broad lockdown would be “a bullet straight

to the heart of the malaria program,” he

says. “For the past 40 years we have been

saying that malaria can kill within hours. If

a child has fever ... go straight to the clinic.”

By 25 March, WHO had issued guidance

telling countries they should proceed with

malaria prevention and treatment—and

could do so safely. “WHO was very effective

in getting the message out,” says Thomas

Churcher of Imperial College London (ICL),

who published an alarming model about

the effects of scaling back malaria interven-

tions in Nature Medicine on 7 August.

The distribution of insecticide-treated

bed nets was GMP’s first concern. Malaria

deaths plunged from an estimated 839,

in 2000 to 405,000 in 2018 largely thanks

to the massive net rollout across Africa. But

bed nets need to be replaced every 3 years,

as the insecticide wears off and nets tear.

Twenty-six African countries had scheduled

mass distribution campaigns this year—but

in March, many were wary of proceeding.

Benin was the most urgent priority. It had

already completed the first phase of its cam-

paign, distributing vouchers door to door that

families could use to pick up their bed nets

from a central point 1 month later. But the

government had canceled the second phase.

The concern was that people, worried about

supplies, would rush to distribution centers

to pick up their nets, says Marcy Erskine of

the International Federation of the Red Cross

and Red Crescent Societies. “Crowds can be

very difficult to control,” she says, making

physical distancing all but impossible.

“We all knew if Benin did not go ahead,

there would be a massive domino effect” on

other countries, Erskine says. So GMP and its

partners—including the Global Fund to Fight

AIDS, Tuberculosis and Malaria; the U.S.

President’s Malaria Initiative; and the Alli-

ance for Malaria Prevention (AMP)—started

to lobby leaders in Benin and elsewhere, she

says, armed with models. AMP advised coun-

tries on how to reduce COVID-19 risks—for

instance, by distributing nets door to door

instead of from a central point.

Benin agreed, distributing 8 million nets

in April and setting an example for other

governments, says Sussann Nasr of the

Global Fund: “In the end, every country

said yes.” Still, “We don’t want to get a false

sense of security,” Nasr says. “We have to be

sure that the 2021 countries do their cam-

paigns, too,” says Hannah Slater, a modeler

at PATH, a global health nonprofit in Seat-

tle. The same holds for indoor spraying with

insecticides and seasonal chemoprevention,

in which children are given antimalaria

drugs during the disease’s high season.

Even if preventive interventions continue,

malaria deaths could soar if sick children

don’t receive effective treatment—for in-

stance, because frightened mothers keep

them home. The ICL model projects that if ac-

cess to treatment drops by 50% for 6 months,

129,000 additional malaria deaths would oc-

cur between May 2020 and May 2021.

Getting a fix on how many children are

being treated is tough, Alonso says. But

there are ominous hints. Antenatal visits

are down in some places, and that’s where

pregnant women, who are very vulnerable

to severe malaria, receive chemoprevention

and bed nets along with regular checkups.

And routine immunizations for diseases such

as measles have fallen off. “What I really

worry about is a child who won’t be treated

and deaths will go uncounted,” says Regina

Rabinovich of the Harvard T.H. Chan School

of Public Health—a problem even before the

pandemic. Undercounting probably explains

the “paradoxical” finding that reported ma-

laria cases are down this year, Alonso says.

Churcher fears some countries may see

COVID-19 peak during the high malaria

season, leaving fragile health systems deal-

ing with simultaneous epidemics. Even

countries that go into strict lockdown must

continue malaria services, he says: “It’s not

a trade-off. You have to do both.” j

Leslie Roberts is a journalist in Washington, D.C.

Countries avert disaster by resuming bed net campaigns

GLOBAL HEALTH

By Leslie Roberts

A malaria worker distributes bed nets

on 28 April in Cotonou, Benin.

Pandemic’s fallout on malaria

control appears limited so far

Published by AAAS