Latest in the law of unintended consequences is the finding of a rising number of malaria deaths in Guinea as patients avoided treatment centers, fearing either being quarantined among those afflicted with Ebola, or being mistreated. A new study in The Lancet Infectious Diseases shows that the deaths from malaria are likely to greatly exceed the total number of deaths caused by Ebola itself.
There were an estimated 74,000 fewer cases of malaria seen in Guinea healthcare facilities, as outpatient attendance dropped almost in half. As lead author, Dr. Mateusz Plucinski (of the CDC and President’s Malaria Initiative) explained, “One problem is that the early symptoms of malaria (fever, headache, and body aches) mimic those of Ebola virus disease…Malaria is one of the main causes of fever and health facilities visits in Guinea, but our data suggest that since the start of the Ebola epidemic people with fevers have avoided clinics for fear of contracting Ebola or being sent to an Ebola treatment centre.” Interestingly, this treatment drop extended to districts without any reported Ebola cases.
Untreated malaria means more patients with fevers. Plucinski explains, “This puts extra pressure on an already overburdened health system owing to a greater number of suspected Ebola cases requiring triage and isolation at treatment centres. Malaria control efforts and care delivery must be kept on track during an Ebola epidemic so that progress made in malaria control is not jeopardised and Ebola outbreak response is not impeded.”
In response, Dr. Franco Pagnoni from the World Health Organisation, notes that the WHO guidelines recommend treating all febrile patients in an Ebola-affected area presumptively with antimalarials. He commented, “Benefits of mass drug administration include a rapid reduction in the malaria burden for a certain period, and a decrease in the incidence of febrile illnesses due to malaria. This reduces the presentation of patients who are febrile at Ebola evaluation facilities, results in a reduced risk of nosocomial transmission of Ebola virus to patients with malaria, and reduces the workload at those facilities.”
A similar pattern of changes in health-seeking behaviors was seen during the SARS epidemic, when fear among both patients and healthcare workers kept people from seeking or receiving needed care. In Guinea, malaria is the main cause of healthcare visits—30% of all. Rapid diagnostic tests and treatment are provided through public health facilities and a network of more than 3000 community health workers. (I saw a similar utilization of trained community health workers in Thailand).
In this study, funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria, and President’s Malaria Initiative, the authors surveyed 120 public health facilities in both Ebola-affected and unaffected regions of Guinea. They found a marked drop in patient visits and in numbers and the use of rapid diagnostic tests was more than halved. Similarly, patients treated with oral antimalarials (-24%) and injectable drugs (-30%) compared to the prior year.
Besides the excess in deaths due to untreated malaria—likely higher than those caused by Ebola itself—untreated malaria cases put an additional burden on already overtaxed Ebola treatment centers, because these patients required triage and isolation. It’s likely that some of these patients were then unnecessarily exposed to Ebola itself as this played out.
The experience of the WHO was similar, finding in Guéckédou and Kissidougou that less than 35% of patients with malaria, pneumonia, or diarrhea were seeking care. Strikingly, visits by children < 5 years old dropped from 200-250/day to 10-12/day. Immunization rates decreased, leading to a risk of resurgence of vaccine preventable diseases like measles.
Dr. Pagnoni concluded by stressing how critically important it is to maintain “the delivery of standard health services, such as distribution of long-lasting impregnated nets, vaccination, or community case management of child diseases with specific no-touch approaches appropriate to the context of the epidemic.” This is no mean feat, when your resources and personnel are already stretched to the limit.
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