Researchers have modelled the public health impact of COVID-19 on HIV, TB and malaria in low- and middle-income countries, finding disruption to health services could cause significant rises in cases and deaths from these diseases.
The analysis is presented in the two latest reports by The WHO Collaborating Centre for Infectious Disease Modelling within the MRC Centre for Global Infectious Disease Analysis (GIDA), and Abdul Latif Jameel Institute for Disease and Emergency Analytics (J-IDEA). The research is also published in The Lancet Public Health.
COVID-19 has the potential to cause disruptions to health services in different ways: through the health system becoming overwhelmed with COVID-19 patients, through measures introduced to slow transmission of COVID-19 inhibiting access to preventative interventions and services, and through supplies of medicine being interrupted.
Impact on malaria control
The pandemic is likely to severely interrupt health systems in Sub-Saharan Africa over the coming weeks and months. Approximately 90 per cent of malaria deaths occur in this region, with an estimated 380,000 deaths in 2018.
Much of the gain made in malaria control over the last decade has been due to the distribution of long-lasting insecticide-treated nets, which many Sub-Saharan Africa countries planned to distribute in 2020. However, the COVID-19 pandemic will likely disrupt these distributions, as well as other core health services, resulting in more malaria cases and deaths.
The team used COVID-19 and malaria transmission models to understand the impact on health services and distribution. The results demonstrate that depending on the course of the COVID-19 pandemic, a disruption of all malaria-control activities will result in large malaria epidemics across the region.
The report concludes that the malaria burden – the toll of new cases and deaths – in 2020 could be more than double that in the previous year. Over five years, the number of deaths could increase by 36 percent.
Prioritizing routine prevention strategies
The report shows that it is essential to prioritize the distribution of long-lasting insecticide-treated nets to mitigate this risk. Additional planning to ensure other malaria prevention activities are continued where possible, alongside planning to ensure basic access to antimalarial treatment, will further minimize the risk of substantial additional mortality associated with any malaria epidemics.
Dr Thomas Churcher, from the School of Public Health at Imperial, said: “COVID-19 will substantially increase the burden of malaria in Africa unless routine preventative strategies are prioritised now. Bed net distribution planned for this year needs to carried out before health systems become overwhelmed by COVID-19 to prevent communities having to deal with multiple health emergencies simultaneously.”
This independent report reinforces analysis released by the World Health Organisation supporting the call to minimize disruption to malaria prevention and treatment services during the COVID-19 pandemic to save lives from malaria in sub-Saharan Africa.
Critical strategies to tackle HIV and TB
The greatest impact on HIV is estimated to be from interruption to supply and administering of antiretroviral therapy (ART) – a combination of drugs that need to be taken daily – which may occur during a period of high or extremely high health system demand. This disruption could cause a 10 percent rise in deaths over five years.
Dr Britta Jewell, from the School of Public Health at Imperial, said: “For HIV programmes, the most critical aspect must be maintaining antiretroviral treatment for individuals currently living with HIV. If drug supply chains are not maintained, countries with high HIV prevalence could see a substantial rise in AIDS deaths from even a short-term interruption.”
For TB, the greatest impact is likely to be from reductions in timely diagnosis and treatment of new cases, which may result from a long period of COVID-19 suppression interventions. This could result in a 20 percent rise in deaths over five years.
Dr Nim Arinaminpathy, from the School of Public Health at Imperial, said: “In many ways, global TB control has been seeing important developments in recent years, for example, India’s large-scale engagement with their private healthcare sector. There remains much still to be achieved, in TB detection and prevention.
"It is therefore important to recognise the impact that the COVID-19 response could have, on such hard-won progress and prospects. Short-term disruptions can have long-term consequences for the millions of people suffering from TB; it is critical to ensure that these disruptions are minimised, through rapid restoration of TB services, as well as whatever supplementary measures are required to bring TB control efforts back on track.”
Prevention strategies required
In regions where there are large numbers of malaria, TB and HIV cases, over a five-year period the impact of healthcare disruption could be significant, and cause similar numbers of years of life lost as the direct impact from COVID-19. Maintaining the most critical prevention activities and healthcare services for HIV, TB and malaria could significantly reduce the overall impact of the COVID-19 pandemic, say the researchers.
Professor Timothy Hallett, from the School of Public Health at Imperial, said: “The COVID-19 epidemic might be an even bigger threat to public health than we have been thinking. By overwhelming the health system, causing people to stay away from hospitals and clinics, or forcing public health interventions to be cancelled, the COVID-19 epidemic could also cause spikes in deaths from other diseases that had been coming under control.
“In low- and middle-income countries with high burdens of HIV, TB and malaria, these disruptions could add significantly to the burden of COVID-19 itself and set back control efforts by years. An important part of minimising the overall impact of the COVID-19 epidemic in many settings around the world will be maintaining the most critical programs for HIV, TB and malaria, upon which so many people depend.”
Hogan et al. (2020). Potential impact of the COVID-19 pandemic on HIV, tuberculosis, and malaria in low-income and middle-income countries: a modelling study. The Lancet Public Health. DOI: https://doi.org/10.1016/S2214-109X(20)30288-6
Report 18 – The potential public health impact of COVID-19 on malaria in Africa
Report 19 – The Potential Impact of the COVID-19 Epidemic on HIV, TB and Malaria in Low- and Middle-Income Countries
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