New Delhi: As India grapples with the COVID-19 pandemic, the yearly malaria crisis is looming and must get due attention, the World Health Organization (WHO) and the medical journal Lancet have warned in separate statements. “Do not scale back your planned malaria prevention, diagnostic and treatment activities,” Pedro Alonso, director of the WHO Global Malaria Programme, said on March 25, 2020.

India is among the 11 most malaria-affected countries in the world. In 2018, it accounted for nearly 430,000 cases, government data show. With 95% of the country’s population living in malaria endemic regions, experts tell IndiaSpend that preventive measures and awareness campaigns are likely to be hit as the health system is busy attending to COVID-19.

March and April are crucial months when preventive measures such as fogging, fumigation and awareness campaigns are undertaken.

“The peak season for malaria starts from May and a spike is seen after the monsoon, in July and August,” said Madhu Gupta from the Department of Community Medicine and School of Public Health at the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh. “To prevent cases during these months, preventive measures and awareness campaigns begin in March and April. It is an apprehension that malaria prevention might take a backseat since resources are being directed towards COVID-19 but we need to ensure that does not happen. Spreading awareness about malaria and preventive measures are very important.”

The Lancet’s March 16, 2020 warning for malaria-prone countries such as India reminds how the deadly Ebola outbreak, which claimed 9,428 lives between 2014 and 2016 in West African countries, coincided with nearly 900% rise in the number of malaria deaths.

The warning also explains the similarity in symptoms of COVID-19 and malaria. “The early symptoms of COVID-19, including fever, myalgia and fatigue, might be confused with malaria and lead to challenges in early clinical diagnosis,” the comment published in the Lancet said. “There is, therefore, a real and pressing danger for malaria-endemic regions when faced with the threat of a novel infectious disease outbreak.”

“Outbreak of COVID-19 does not mean that the government is going to spend the money allocated for malaria control on the pandemic,” said Avdhesh Kumar, additional director with the Malaria Control Project at the National Vector Borne Disease Control Programme of the Ministry of Health and Family Welfare (MoHFW). He added that it was too early to comment on the issue.

The number of COVID-19 cases has been rising fast, as has the number of samples being tested, and states which have carried out extensive tests have detected more cases, as we reported on . March 25, 2020. As of April 2, 2020, India had recorded 2,069 COVID-19 cases, with 53 fatalities, according to Coronavirus Monitor, a HealthCheck database.

With the number of COVID-19 cases rising, the concentration of the healthcare machinery to combat the pandemic will be a challenge to India’s fight against malaria, said Anant Bhan, a Pune-based researcher in global health, bioethics and health policy.

Malaria deaths in West Africa during Ebola crisis

Explaining how the Ebola outbreak hampered malaria control in Africa, the Lancet paper says countries including Guinea, Liberia and Sierra Leone were the worst hit as fewer people sought medical attention at early stages.

This resulted in 1,067 malaria deaths in Guinea alone, nearly nine times more than the 108 deaths in 2014, compounded by 2,446 deaths from Ebola. “More alarmingly, it was estimated that there were about 7,000 additional malaria-associated deaths among children younger than five years in Guinea, Liberia and Sierra Leone due to the Ebola outbreak,” the paper added.

Nineteen countries in sub-Saharan Africa and India carry almost 85% of the global malaria burden, according to the WHO’s World Malaria Report 2019.

Key measures to fight malaria

  • Providing insecticide-treated nets
  • Indoor residual spraying
  • Providing malaria chemoprevention for pregnant women and young children
  • Presumptive malaria treatment
  • Mass drug administration

Source: World Health Organization

Malaria preparedness, testing

India is among the 11 most malaria-affected countries in the world, which together account for 70% of global cases. In 2018, India registered 414,000 fewer malaria cases than in 2017--a 49% decrease over 2017 and a 60% decrease over 2016, government data show.

India’s successful malaria preventive strategies include indoor insecticide spraying, reduction of mosquito-breeding spots, and free distribution of long-lasting insecticidal nets. Treating asymptomatic or afebrile malaria played an important role in reducing malarial infections, we reported in November 2018.

Currently, India accounts for 3% of global malaria cases and aims to eliminate the disease by 2030. The current situation with COVID-19, however, poses a threat to India’s progress in reducing malaria cases, experts told IndiaSpend.

The 21-day lockdown across the country, which has forced people to remain indoors, has also stopped the anti-malaria awareness campaign. “If the required awareness is not spread and people do not pay attention, it might worsen the situation,” Gupta of PGIMER said. “This includes the campaign on all vector-borne diseases like dengue and chikungunya.”

“In Punjab--a malaria endemic region--there is a curfew and all work has stopped,” Gupta added, by way of an example, “The healthcare system is focused on dealing with COVID-19.”

The focus on COVID-19 could lead to a fall in testing for malaria too. “During the lockdown, you might not be able to do routine activities for vector control,” said Bhan. “These activities come under essential services but it might not be given the same priority. This is true for not just malaria but also for TB and diarrhoea control or for any other routine programme including immunisation.”

“For example, all municipal staff--who are also in-charge for ensuring sanitation, vector control, fogging--have been assigned to do contact placing,” he added. “That’s all they need to do for two months--contact placing of those who might be infected by COVID-19. Then, who will be doing those routine activities? We do not have a backup available.”

Therefore, it becomes imperative for health system leadership at various levels--national, regional, local, municipal--to ensure that these routine programmatic activities are kept running and they do not suddenly stop, Bhan said.

Kumar from the government’s Malaria Control Project, however, said malaria cases can be dealt with at the village level and would not overwhelm city hospitals as they did in the past. Over time, India has built capacity to deal with malaria at the village level, Kumar said--including provision of beds, diagnostic kits, healthcare professionals and treatment facilities, so that resource dependency on hospitals has reduced. If a patient gets diagnosed with malaria, treatment starts in the village itself, the requirement of hospitalisation does not arise, Kumar added, “There may be a few cases of course, but we don't think it will happen.”

Asked how village healthcare infrastructure would cope if COVID-19 were to spread to villages, and if that would affect the capacity to deal with malaria, Kumar said, "What happens will depend on many factors, how much COVID spreads, how many malaria cases are there. We don't know either at this point, there can't be generic assumptions.”

(Tiwari is a principal correspondent with IndiaSpend.)

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