Ebola epidemic in Guinea may have led to 74,000 extra untreated cases of malaria in 2014

The first systematic analysis of outpatient health-care use in an Ebola-affected country reveals that among the health facilities that stayed open during the epidemic, outpatient attendance fell dramatically -- by nearly half (42%) in certain age groups in the worst affected areas, with the number of treated malaria cases dropping by up to 69%.

"One problem is that the early symptoms of malaria (fever, headache, and body aches) mimic those of Ebola virus disease," says lead author Dr Mateusz Plucinski from the Centers for Disease Control and Prevention, Atlanta, and President's Malaria Initiative, USA. "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."

Dr Plucinski and colleagues did a cross-sectional survey of public health facilities in Guinea in December 2014, sampling 60 health facilities in the most Ebola-affected districts, and 60 in districts unaffected by Ebola. They also interviewed health-care workers, and analysed malaria indicators between 2011 and 2014, to establish the impact of the Ebola epidemic on outpatient visits, malaria cases, and malaria treatments in Guinea -- a country with intense, year-round, nationwide malaria transmission.

The researchers found a substantial fall in outpatient visits in surveyed health facilities (by 23103 [-11%]) and the number of patients receiving malaria treatments (oral drugs by 22655 [-24%] and injectable drugs by 5219 [-30%]) during the Ebola epidemic in 2014, compared with 2013. Substantially larger decreases were noted in Ebola-affected districts, particularly during the third wave of the epidemic (since August 2014). However, even districts with no reported Ebola cases saw substantial declines in malaria cases and the number of patients receiving malaria treatments.

In Ebola-affected districts, the proportion of community health workers who were working fell from 98% before Ebola to just under three-quarters (74%) after Ebola, while those actively treating malaria cases dropped from two-thirds to less than half (48%). This compares with an increase in operational community health workers (78% to 95%) and those treating malaria cases (63% to 96%) in districts unaffected by Ebola in the same time period.

Analysis of nationwide surveillance data confirmed the results from the health facility survey, showing that even before the third wave of the epidemic, weekly suspected malaria cases in districts affected by Ebola were already 22% lower than expected, and declined even more (by 42%) during the third wave of the epidemic.

According to Plucinski, "Untreated malaria cases lead to rising malaria death rates and more cases of fever in the community. 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."

Writing in a linked Comment, Dr Franco Pagnoni from the World Health Organization, Geneva, Switzerland discusses the recent WHO guidelines for malaria prevention in Ebola-affected areas that recommend providing malaria treatment to all patients with a fever, and malaria drugs to everyone in areas heavily affected by Ebola where malaria transmission is high. He writes, "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…To restore the credibility of health service delivery in the population, it is important that Ebola-virus-disease-specific activities in the communities, such as contract tracing and safe burials, are accompanied by 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."