The Covid-19 pandemic has major consequences on the functioning of health services and direct and indirect effects on the burden of various diseases [29, 30]. In this paper, effects of the pandemic on malaria case numbers in health facilities of northern Ghana, a region highly endemic for malaria, are described.
In northern Ghana, a slight but significant decline was observed in malaria cases during the 2nd and 3rd quarter of 2020. This decline is even more significant considering that the period coincides with the rainy season in northern Ghana (May-November) when usually the majority of malaria cases are recorded. Cases only rebounded to the average levels of previous years at the end of 2020. This pattern was visible in both, outpatient and inpatient settings, but more pronounced in the hospitalized population. The same applies to children and adults, where reductions were also observed in both groups, but were more marked in children under five years of age. The marked decline in March/April 2020 can be explained by the extensive movement and gathering restrictions and early stay-at-home advices for COVID-19-like symptoms unless these get severe. Such measures have likely supported the hesitancy to visit health facilities during the pandemic, which in turn poses a major risk for developing severe malaria [13, 31]. The decline observed in March/April 2020 was even more remarkable in inpatients. This does not support our initial hypothesis, that in cases of more severe malaria manifestation, patients were still brought to health facilities and hospitalized, despite the pandemic. The findings from this analysis support the hypothesis, that the reported malaria burden in health facilities will shrink due to the effects of the COVID-19 pandemic in highly malaria-endemic countries . They also support results of the WHO World Malaria Report , and they agree with results of similar studies from other SSA countries classified as highly endemic for malaria, such as Sierra Leone, Uganda and the Democratic Republic of the Congo [33,34,35,36].
The distinct decrease of OPD visits in the health facilities of northern Ghana in September 2020 could be explained by unusual heavy floods that started mid-August, which might have further complicated the access to health services. These floods have provided a favourable habitat for Anopheles mosquitoes, what could explain the observed increase of malaria cases in October 2020.
Malaria cases seen in health facilities among pregnant women show a different trend. After a decline in April 2020, cases have rebounded rapidly in this population and reached even higher levels compared to previous years. The most likely explanation of such an opposite trend would be the early hesitancy of pregnant women to visit health facilities. This is probably due to the fear of getting infected with COVID-19, combined with initial disruptions of the provision of IPTp to women in antenatal care (ANC) services as well as the disruption of routine distribution of ITNs . The disrupted access to and delivery of ANC services is likely to explain the malaria case trend in April. However, without IPTp and ITNs, more women were at risk for malaria thereafter, which can explain the subsequent rise in malaria cases over the following months. Also, many pregnant women probably have sought the missed ANC with subsequent malaria diagnosis after the initial movement restrictions were lifted.
Ghana had already achieved high levels of ITN coverage, and no ITN mass campaign was planned for 2020 . However, the routine distribution of ITNs, which is usually done in health facilities during ANC sessions and in primary schools, needed to be adapted to the COVID-19 measures, which included school closures from March 2020 until January 2021 [38, 39]. Also the seasonal malaria chemoprevention intervention for children and the annual indoor residual spraying of insecticides, which both require physical contact between the health workers and the community, needed to be modified [40, 41]. As another consequence of the COVID-19 pandemic, the provision of rapid diagnostic tests for malaria was fragile, which may have led to under-diagnosis of cases . The main explanation for the lower number of malaria cases seen in health facilities was limited access to health facilities – public transportations were unavailable or unaffordable, and health facilities were closed or only provided reduced services [43, 44]. This is supported by findings from a study from Rwanda which showed that health facility visits for malaria decreased while community health services for malaria increased . Finally, reports of hesitancy to visit health facilities due to fear of getting infected with COVID-19 were common [37, 42]. Last but not least, the malaria health care worker capacities were limited due to frequent reassignments to the control of COVID-19, to stigmatization or absence following quarantine, or to the development of COVID-19 disease or even death [14, 39, 45].
This study has strengths and limitations. A strength of the study is that the data represent a whole year of follow-up into the pandemic, which provides a more comprehensive picture of the effects compared to the previous studies with much shorter study periods. Also, the subgroup analysis of children under the age of five and pregnant women allows for a more complete picture. A major limitation is that the surveillance system itself may probably have been affected by the pandemic, producing a bias in the reported numbers. Massive underreporting could have falsified the observed trends and our conclusions. Moreover, it is not clear if the quality of surveillance data is fully comparable during the five years observed. The data from the Northern Region of Ghana may also not be representative for other malaria endemic areas in SSA, thus, the study has a limited external validity. Absenteeism in health facilities by people with malaria symptoms that have switched to self-medication or traditional medicine or that could not afford reaching official health care during the pandemic could also have had an albeit unknown effect on the malaria figures . Especially in the first months of the pandemic, many people may have used malaria medication off-label to prevent and treat COVID-19 what may also have impacted the malaria situation .