The coronavirus disease 2019 (COVID-19) pandemic has posed a unique challenge to health care systems globally. To curb COVID-19 transmission, mitigation measures such as travel restrictions, border closures, curfews, lockdowns, and social distancing have been implemented. However, these measures may directly and indirectly affect the delivery and utilization of essential health services, including malaria services. The suspension of indoor residual spraying (IRS) and insecticide-treated net (ITN) distribution, shortages of malaria commodities, and reduced demand for health services have hindered the continued delivery of malaria services. The overall goal of this analysis was to describe the trends in malaria incidence and mortality in Zimbabwe prior to and during the pandemic to understand the consequences of COVID-19-related changes in the delivery and utilization of malaria services.
The first official cases of COVID-19 were reported in Wuhan, China in December 2019 after an outbreak of pneumonia of unknown origin was identified [1]. On 30 January, 2020, the outbreak was declared a public health emergency of international concern (PHEIC) by the World Health Organization (WHO) [2]. Two weeks later, the first case of COVID-19 was reported on the African continent in Egypt [3]. In response to the looming public health crisis, African governments introduced regulations and restrictions such as travel bans, border closures, curfews, lockdowns, and social distancing [4]. While these mitigation measures were aimed at slowing down the spread of COVID-19 and preventing healthcare systems from becoming overwhelmed, there have been wide-reaching unintended consequences on health systems. The demand for essential health services has been adversely affected by stay-at-home orders, stigma and fear of contracting COVID-19 infection, travel restrictions, increased financial barriers and misinformation about COVID-19 [5,6,7]. The provision of routine health services has been disrupted by the diversion of limited resources and health care workers for COVID-19 prevention and control efforts, the occupational risk faced by health care workers, the lack of personal protective equipment, and breakdowns in procurement and supply chains for medicines and commodities [7, 8]. Similar reductions in the demand and provision of essential health services were observed during the 2014–2016 Ebola outbreak in West Africa [9].
For national malaria control programmes, the reduced access to and availability of malaria services, disruptions in the production and supply of malaria commodities, and the suspension of IRS and ITN distribution campaigns have hindered the continued provision of malaria services during the COVID-19 pandemic [10]. Several modelling analyses have assessed the potential impact of disruptions in health service provision on malaria morbidity and mortality. Findings from these analyses have asserted that lack of continuity and disruption of malaria programmes could cause a COVID-19-induced malaria crisis, potentially reversing the gains towards malaria control and elimination [11,12,13,14]. More devastating effects of the pandemic are expected in Africa because of the disproportionate burden of infectious diseases, including malaria, weaker health systems and limited financial and human resources for health [11, 12]. One modelling analysis projected that if the distribution of ITNs was suspended and access to anti-malarial medicines reduced by 75%, an additional 769,000 malaria deaths would occur in sub-Saharan Africa in 2020 [14]. Another modelling analysis estimated that in malaria-endemic areas, the disruption of planned ITN distribution campaigns, because of the COVID-19 pandemic, could cause a 36% increase in malaria deaths in the next five years [12]. COVID-related reductions or suspensions of ITN and IRS campaigns, which are the cornerstone of malaria vector control in Africa, were projected to give rise to the largest number of additional malaria deaths [11,12,13,14]. These estimates most likely underestimate the potential excess mortality as the underlying models do not account for disruptions in the delivery of other life-saving malaria interventions, such as seasonal malaria chemoprevention (SMC) and intermittent preventative treatment in pregnancy (IPTp) [15]. However, these initial estimates inform pandemic response by forecasting morbidity and mortality, estimating healthcare system requirements and assessing the effectiveness of various containment and mitigation strategies.
Malaria transmission within Zimbabwe is spatially heterogenous; areas from the northwest to southeast borders of the country are characterized as high malaria-risk zones, while, areas along the central plateau and in the southwest of the country experience little to no malaria transmission [16]. The rainy season typically runs from October to April, with increasing average annual rainfall from the west to the east of the country [17]. Half (50%) of the population is at risk of malaria infection [18]. For vector control, the National Malaria Control Programme (NMCP) implements a two-pronged approach that targets the deployment of either ITNs or IRS to malarious districts. In moderate and high transmission areas, 51% of households own at least one ITN for every two household members, and 85% of households own at least one ITN and/or are protected by IRS, showing high levels of protection [19].
In Zimbabwe, the first official case of COVID-19 was reported on 20 March, 2020 [20] (Fig. 1). The delay in identifying the first COVID-19 cases, despite several people exhibiting symptoms after international travel has been attributed to the lack of COVID-19 testing capacity and resources [21, 22]. In response to COVID-19, the Government of Zimbabwe introduced public health measures to curb the spread of disease on 30 March, 2020 [6, 21, 22]. These measures included closure of borders, restrictions on in-country travel, bans on public gatherings, the closure of schools, colleges and universities, and the designation of quarantine and isolation facilities for suspected and confirmed COVID-19 cases [22, 23]. There was a peak in the number of COVID-19 cases and deaths in September and October 2020 (Fig. 1). Since December 2020, the country has been experiencing a second wave of COVID-19 with a higher transmission rate [24]. The second wave coincides with the onset of the rainy season and the start of increased malaria transmission season. As of 21 April, 2021, a cumulative 37,859 confirmed COVID-19 cases and 1,553 deaths had been reported in Zimbabwe according to the WHO (Fig. 1) [24].
Understanding the indirect consequences of the COVID-19 pandemic remains key to developing health system resilience, allocating limited resources to pandemic response while maintaining essential health services, and sustaining efforts to control malaria and address other health priorities. Therefore, monitoring malaria morbidity and mortality is essential to tracking the consequences of COVID-19-related changes to the delivery and utilization of malaria services [25]. The overall goal of this analysis was to describe the trends of malaria incidence and mortality in Zimbabwe prior to and during the COVID-19 pandemic to inform program planning and decision-making. Using routine data from the national health management information system (HMIS), this analysis described the spatial and temporal trends of malaria incidence and mortality from January 2017 to June 2020. These findings may help improve understanding of the indirect health consequences of the pandemic and draw attention to the need for sustained efforts to control malaria amidst the pandemic.