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Impact of the COVID-19 Pandemic on Malaria Prevention in Africa: Evidence from COVID-19 Health Services Disruption Survey

July 2021
International Journal of TROPICAL DISEASE & Health 9(6):287

July 2021
9(6):287

Authors:

Binyam Tariku Seboka

Dilla University

Samuel Hailegebreal

Wachemo University

Robel Hussen Kabthymer

Monash University (Australia)

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Background: The Coronavirus Disease 2019 (COVID-19) pandemic has caused an unprecedented disruption in healthcare systems throughout the world. This paper evaluated COVID-19's impact on malaria-related health services in Africa. Hence, measuring the disruption on malaria preventive and curative programs is essential for effective counteracts and future planning.

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Research Article

Journal of Tropical Disease and Public Health

ISSN: 2329-891X

OPEN ACCESS Freely available online

J Trop Dis Vol. 9 Iss. 6 No: 287 1

Impact of the COVID-19 Pandemic on Malaria Prevention in Africa:

Evidence from COVID-19 Health Services Disruption Survey

Binyam Tariku Seboka1*, Samuel Hailegebreal2, Robel Hussen Kabthymer1, Helen Ali1, Delelegn Emwodew

Yehualashet1, Abel Desalegn Demeke3, Endris Seid Amede4

1School of public health, Dilla University, Dilla, Ethiopia; 2Department of Health Informatics, Arbaminch University, Arbaminch, Ethiopia; 3Department

of Nursing, Dilla University, Dilla, Ethiopia; 4Department of Psychiatry, Dilla University, Dilla, Ethiopia

ABSTRACT

Background: The Coronavirus Disease 2019 (COVID-19) pandemic has caused an unprecedented disruption in healthcare

systems throughout the world. This paper evaluated COVID-19’s impact on malaria-related health services in Africa. Hence,

measuring the disruption on malaria preventive and curative programs is essential for effective counteracts and future planning.

Methods: The research used data from the 2020 Premise COVID-19 Health Services Disruption Survey. Data were collected

from 14,615 respondents to measure malaria related prevention and curative service utilizations in 20 African countries. In

the analysis, other than descriptive statics and Chi-square test. Wilcoxon signed-rank test was employed to compare change in

the Insecticide-Treated Net (ITN) ownership rating before and during the COVID-19 pandemic. Further, McNemar’s test was

used to assess change in malaria testing.

Results: Household ITN ownership rating declined significantly after the onset of the pandemic in march 2020 compared to

the previous ownership or purchase rating before the COVID-19 onset. The COVID-29 pandemic had not impacted malaria

testing utilization significantly. However, a drop in healthcare utilization was ascribed to fear of acquiring COVID-19 at health

facilities, limited access due to movement restrictions, and dedication of health facilities as COVID-19 treatment centres.

Conclusion: The COVID-19 pandemic had a significantly negative effect on the prevention of malaria in Africa, which is

evident by a decline of interventions during the pandemic. Interventions and strategies aimed at reducing and controlling

burden of malaria in Africa, mainly in the malaria endemic settings should give attention to lessen the disruption and integrate

this with pandemic response. It is critical for these services to continue during and after the epidemic.

Keywords: COVID-19; Impact; Malaria prevention; Malaria; Africa

Correspondence to: Binyam Tariku Seboka, School of public health, Dilla University, Dilla, Ethiopia, Telephone: +251920612180; E-mail: biniyamt@

du.edu.et

Received date: March 10, 2021; Accepted date: April 24, 2021; Published date: June 30, 2021

Citation: Seboka BT, Hailegebreal S, Kabthymer RH, Ali H, Yehualashet DE, Demeke AD, et al. (2021) Impact of the COVID-19 Pandemic on Malaria

Prevention in Africa: Evidence from COVID-19 Health Services Disruption Survey. J Trop Dis. 9:287.

permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

INTRODUCTION

The Coronavirus Disease 2019 (COVID-19) pandemic has caused

unprecedented disruption to healthcare systems throughout the

world [1,2]. In Africa, this pandemic has forced healthcare leaders

to take drastic public health measures, such as restrictions to

movement, absenteeism, behavioral changes, closure of institutions

and interruption of supply chain, and etc [3,4]. While these

measures helped countries to successfully slow down the spread of

the infection and relieve the public health systems. Consequently,

these measures are also expected to affect the progress that is made

to mitigate the burden of endemic and epidemic infectious diseases

in the content [5-7].

In Africa, malaria is one of the major public health problems, which

is the leading cause of morbidity and mortality in the content.

According to the latest world malaria report, there were 229 million

cases of malaria and an estimated 409 000 deaths worldwide in

2019. Out of all malaria cases and deaths in the world in 2019,

where African regions account for more than 94% [8]. Given the

negative consequences of malaria on population health, the World

Health Organization (WHO) 2015, endorsed the Global Technical

Strategy for Malaria prevention which extends from 2016 to 2030,

with its targets of reducing malaria incidence and mortality rates by

90% in 2030 [9,10]. Insecticide-Treated Net (ITN) use regarded as

one of the core interventions among the strategies against effective

malaria vector prevention along with indoor residual spraying, and

intermittent preventive treatment for pregnant women, and drugs

and diagnostics [11,12].

Seboka BT, et al.

OPEN ACCESS Freely available online

J Trop Dis Vol. 9 Iss. 6 No: 287 2

Malaria-related health services have been argued to be an

important factor in reducing the burden of malaria epidemic in

Africa. Dealing with COVID-19 is likely to create imbalances

in healthcare provision, disruption of essential prevention and

control programs due to relocation of resources[13-15]. Reduction

in ITN ownership rating and limitations to access essential malaria

testing and treatment care which are associated with the COVID-19

crisis could potentially affect malaria-related programs negatively

[6,14,16]. This may result in failure of malaria elimination goal

designed to achieve the sustainable development goal.

In line with other ongoing research studies conducted across the

globe, we aimed to assess the impact caused by COVID-19 crisis

on malaria-related health services in Africa by using evidence from

Premise COVID-19 Health Services Disruption Survey, which is

conducted in 20 malaria endemic countries in the content. Given

ITN, malaria testing and malaria treatment programs are the major

interventions to reduce the burden of malaria [9,11,12]. Findings

of this study will help to improve our understanding of the scope of

possible disruption on malaria related public health interventions

and healthcare services utilizations, and underscore the need of

strengthening health systems.

METHODS

Study design, setting and population

The Health Services Disruption was measured using COVID-19

Health Services Disruption Survey 2020 through the Premise

platform [17]. The data from July 2020 malaria-related health

service disruption is archived in Institute for Health Metrics and

Evaluation (IHME) which are freely available for research purposes

[18]. This research only assess the malaria related health service

disruption in 20 malaria-endemic countries in Africa. Respondents

from the general population in this pre-post single group cross-

sectional survey were administered through an online survey to

measure level of change in malaria prevention measures and malaria

service before and immediately after the onset of COVID-19.

Data source and Study variables

This study analysed data obtained from the 2020 Premise Malaria

COVID-19 Health Services Disruption Survey implemented by

IHME, Bill and Melinda Gates Foundation (BMGF), Premise

Data Corporation [17,18]. The sample comprised of 14,615

respondents, which designed to provide estimates on key indicators

of malaria prevention and malaria related health services in Africa.

This study used the ownership of ITN as the main outcome

variable. The ownership of ITN defined as the number or rating

of ITN purchased or owned in the household before and during

COVID-19. In addition, respondent malaria testing utilization

was assessed, if a respondent had malaria symptom and visit

healthcare provider both before and after the onset of COVID-19.

Further, respondent malaria treatment utilization was assessed, if a

respondent had tested positive for malaria both at before and after

the onset of COVID-19.

Data management and analysis

We used STATA version 14.1 software for data cleaning and

analysis. Descriptive and summary statistics were conducted to

describe malaria prevention and malaria care utilization among

respondents before and after the onset of COVID-19. Further, chi-

square test was employed.

Assessing the impact of COVID-19

To assess changes in ITN ownership, Non-parametric paired

Wilcoxon signed rank test was used to compare the number of

ITN ownership or purchase rating in the household before and

after the onset of COVID-19. In addition, Non-parametric paired

Mcnemar test was used to compare the utilization of malaria

testing service among respondents before and after the onset of

COVID-19. Furthermore, p-values of <0.05 were considered

statistically significant.

RESULTS

The COVID-19 malaria service disruption was assessed in terms of

ITN ownership, malaria testing, and malaria treatment utilization

activities. Data from a total of 14,615 respondents were used in

this analysis, among them 55.4% (8,146) had a family size less than

4 in their households and 10.9% (1,590) had a family size greater

than 10. Overall 67.4% of them reported having at least one ITN

in their household (Table 1).

Amongst 9,253 households reported to possess ITN, 75.4% (7,421)

had used at least one ITN the night before the survey took place,

whereas 24.6% (2,422) did not hang any bed net. Further, out of

households who did not hang any bed net, 44.2% (1,070) had 1 to

2 family size, 38.1% (922) had a family size greater than 3 who did

not sleep under bed.

Changes in ITN ownership

In this study a statistically, significant changes were found between

before and during COVID-19 in ITN ownership or purchase of

the households. In order to evaluate if there were any changes in

ITN ownership or purchase as a result of COVID-19, a Wilcoxon

Signed rank. Test revealed a statistically significant negative change

in household ITN ownership following the COVID-19 crisis,

Z=7.830, p=0.000.

Table 1: Background characteristics of respondents.

Variable Have bed net Frequency, n (%) Don’t have bed net Frequency, n (%) p-value χ2Tot al

Family size

1-4 5,168 (63.4) 2,978 (36.6) 8,146

5-9 3,467 (71.1) 1,412 (28.9) 4,879

Above 10 1,208 (75.97) 382 (24.03) 1,590

Had malaria symptoms before COVID-19

0Yes 4,841 (73.2) 1,770 (26.8) 6,611

NO 5,002 (62.5) 3,002 (37.5) 8,004

Had malaria symptoms during COVID-19

0Yes 3,996 (73.9) 1,412 (26.1) 5,408

NO 5,814 (63.6) 3,325 (36.4) 9,139

Seboka BT, et al.

OPEN ACCESS Freely available online

J Trop Dis Vol. 9 Iss. 6 No: 287 3

Table 2: Malaria related symptoms and service utilization before and during COVID-19 pandemic in Africa, 2020.

Variable Before COVID-19 During COVID-19

Had malaria symptoms (n=4,433) Frequency n (%) Frequency n (%)

Visit Healthcare provider for symptoms

Yes 3,710 (83.69) 3,649 ( 82.31)

No 723 (16.31 ) 784 (17.69)

Reason for not visiting

Decline to respond 25 (1.10) 23 (1.01)

Health facility closed 853 (37.49) 880 (38.56)

I did not seek medical help 524 (23.03) 515 (22.57)

Lack of money 360 (15.82) 306 (13.41)

No transportation 89 (3.91) 34 (1.49)

Partner or family does not approve 12 (0.53) 3 (0.13)

Turned away from a health facility 386 (16.97) 331 (14.50)

Fear of being infected with COVID-19 - 59 (2.59)

Treatment or tests unavailable - 67 (2.94)

Unable to access due to lockdown - 40 (1.75)

Tested for malaria during the visit (3,315)

Yes 2,422 (73.06) 2,530 (76.32)

No 893 (26.94) 785 (23.68)

Test result

Positive 1,263 (52.15) 1,303 (51.83)

Negative 839 (34.64) 939 (37.35)

Other (decline to respond, don’t know) 320 (13.21) 272 (10.82)

Changes in malaria service utilization

In this survey, a total of 4,433 respondents experienced symptoms

of malaria prior to and during COVID-19, while before pandemic

16.31% (723) felt uncomfortable to visit health provider and during

COVID-19 17.7% (784) felt uncomfortable with health provider

visit. Among respondents who visited healthcare providers,

following the COVID-19 pandemic, 76.3% (2,530) respondents

were tested for malaria, while 23.7% (785) respondents did not

tasted for malaria (Table 2).

However, the increase in the number of respondents who took

malaria testing before COVID-19 and during COVID-19 was not

statistically significant (Mcnemar Test, p=0.31). Furthermore, a

total of 2,514 respondents were tested for malaria prior to and

during COVID, while before pandemic 52.2% of were tested

positive and during COVID 51.8% were positive (Table 2).

DISCUSSION

This study aimed to assess the difference in malaria preventive and

curative measures before and during COVID-19 pandemic, which

is focused on 20 malaria-endemic African countries and included

14,615 respondents from the general population. In our analysis,

due to COVID-19, a greater decrease was found in preventive

measures of malaria.

The result of the study showed that the COVID-19 pandemic has

decreased the overall household ITN ownership or purchasing

rating (p-value<0.05). After the onset of the pandemic respondents

demonstrated negative changes in household ITN ownership

rating, with effect sizes in the small to moderate range. This

decrease could be explained by the fact that resources (including

human resources) were reallocated to battle COVID-19, leaving

less capacity to address essential public health measures during the

outbreak [7,13,14,19]. Additionally, 67.4% of respondents own

at least one ITN in their household, 75.4% of the respondents

reported experiencing the use of ITN during sleep, while 24.6%

lack utilization. Even though, major progress are made in the

Africa in improving the ownership and use of ITNs in the content

to attain universal coverage mark which is nailed at 80% and above

[20], still major intervention are need considering the long-term

and short-term impact COVID-19 pandemic.

In within-person comparisons of malaria testing and treatment

service utilization, we find that during the COVID-19 pandemic

respondents did not differ significantly in utilizing malaria testing

service than earlier COVID-19. This finding is similar with a study

conducted in Sierra Leone which reported that COVID-19 did not

significantly impacted the diagnosis of malaria , and it accounts for

the comprehensive approach in malaria prevention which include

educational programs for the populations [15]. This finding is

different from other studies which shows the impact of COVID-19

on healthcare [2].

Findings of this study also reveal, the major challenges for

healthcare utilization among respondents in this study were 38.6%

respondents experienced closure health facilities, 2.6% of them

fear getting COVID-19 during visit, while 1.8% reported that they

were unable to access the service due to the lockdown restrictions.

Given this gap in services utilization, in the future it could have

a negative consequences on health conditions due to delayed

treatment. This similar finding could be justified that the impact

of COVID-19 on healthcare [1,16,21]. The findings of this study,

therefore, could be a pointer to further assess the negative effect of

COVID-19 on the delivery of health services.

There are some limitations of the current study that need to be

considered in interoperating the results. Firstly, the use of an

Seboka BT, et al.

OPEN ACCESS Freely available online

J Trop Dis Vol. 9 Iss. 6 No: 287 4

online survey may result in sampling bias, so results may not be

generalizable to the general population of countries in this study as

lack of representativeness of the major populations in Africa, which

lack online access. The inclusion of respondents through the use

of Premise platform may result selection bias. Furthermore, lack of

basic demographic information due to Premise privacy measures

limited the discussion of possible associated factors [17]. The

findings of this survey should be interpreted in the light of above

limitations. However, we believe that our findings and suggestions

will contribute immensely for better understanding of COVID-19

impact on this major public health epidemic in Africa.

CONCLUSIONS

Evidence suggested that the pandemic caused by the COVID-19

disease is leaving devastating consequences in our world from a

social, health, political, educational, and labour point of view. In

Africa, despite great the progress in reducing the burden of malaria

and improving access to malaria prevention and treatment services,

the occurrence COVID-19 could affect the progress that is made.

Based on the findings from this study, it appears that the

COVID-19 pandemic negatively affect the malaria prevention

programs, which caused a decrease in ITN distribution after the

onset off the pandemic. Further the pandemic also impacted

malaria testing and treatment programs that are undertaking by

healthcare providers. Our findings may further inform countries

to strengthened their malaria control and elimination efforts and

need to develop strategies that counteract the disruption caused in

malaria prevention and treatment services.

In sum, Africa should scale up its coverage of preventive and

curative malaria service through increasing investments to further

reduce the incidence and burden of malaria particularly among 20

malaria endemic countries.

ACKNOWLEDGEMENT

We would like to thank the IHME, Bill and Melinda Gates

Foundation (BMGF), Premise Data Corporation, for providing the

dataset used in this study.

DECLARATIONS

Ethics approval and consent to participate

Since the study was a secondary data analysis of publically available

survey data from the IHME program, ethical approval and

participant consent were not necessary for this particular study.

There are no names of individuals or household addresses in the

data files.

Availability of data and materials

Data we used for this study are publicly available in the IHME and

GBD programs which is freely accessible for research purposes at

Global Health Data Exchange.

Competing interests

The authors declare that they have no competing interests.

Funding

No funding was obtained for this study.

Authors’ Contributions

Proposal preparation, acquisition of data, analysis, and

interpretation of data was done by Seboka BT. Hailegebreal S,

Kabthymer RH, Ali H, Yehualashet DE, Demeke AD, and Amede

ES guided the study design data extraction and analysis. Seboka

BT drafted the manuscript and all authors have a substantial

contribution in revising and finalizing the manuscript. All authors

read and approved the final manuscript.

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Oct 2020
TROP MED INT HEALTH

The debate around the COVID‐19 response in Africa has mostly focused on effects and implications of public health measures, in light of the socio‐economic peculiarities of the continent. However, there has been limited exploration of the impact of differences in epidemiology of key comorbidities, and related healthcare factors, on the course and parameters of the pandemic. We summarise what is known about (a) the pathophysiological processes underlying the interaction of coinfections and comorbidities in shaping prognosis of COVID‐19 patients, (b) the epidemiology of key coinfections and comorbidities, and the state of related healthcare infrastructure that might shape the course of the pandemic, and (c) implications of (a) and (b) for pandemic management and post‐pandemic priorities. There is a critical need to generate empirical data on clinical profiles and the predictors of morbidity and mortality from COVID‐19. Improved protocols for acute febrile illness and access to diagnostic facilities, not just for SARS‐CoV‐2 but also other viral infections, are of urgent importance. The role of malaria, HIV/TB and chronic malnutrition on pandemic dynamics should be further investigated. Although chronic non‐communicable diseases account for a relatively lighter burden, they have a significant effect on COVID‐19 prognosis, and the fragility of care delivery systems implies that adjustments to clinical procedures and re‐organisation of care delivery that have been useful in other regions are unlikely to be feasible. Africa is a large region with local variations in factors that can shape pandemic dynamics. A one‐size‐fits‐all response is not optimal, but there are broad lessons relating to differences in epidemiology and healthcare delivery factors, that should be considered as part of a regional COVID‐19 response framework.

COVID-19 in malaria-endemic regions: potential consequences for malaria intervention coverage, morbidity, and mortality

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Sep 2020

Indirect effects of the COVID-19 pandemic on malaria intervention coverage, morbidity, and mortality in Africa: a geospatial modelling analysis

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Sep 2020

Background: Substantial progress has been made in reducing the burden of malaria in Africa since 2000, but those gains could be jeopardised if the COVID-19 pandemic affects the availability of key malaria control interventions. The aim of this study was to evaluate plausible effects on malaria incidence and mortality under different levels of disruption to malaria control. Methods: Using an established set of spatiotemporal Bayesian geostatistical models, we generated geospatial estimates across malaria-endemic African countries of the clinical case incidence and mortality of malaria, incorporating an updated database of parasite rate surveys, insecticide-treated net (ITN) coverage, and effective treatment rates. We established a baseline estimate for the anticipated malaria burden in Africa in the absence of COVID-19-related disruptions, and repeated the analysis for nine hypothetical scenarios in which effective treatment with an antimalarial drug and distribution of ITNs (both through routine channels and mass campaigns) were reduced to varying extents. Findings: We estimated 215·2 (95% uncertainty interval 143·7-311·6) million cases and 386·4 (307·8-497·8) thousand deaths across malaria-endemic African countries in 2020 in our baseline scenario of undisrupted intervention coverage. With greater reductions in access to effective antimalarial drug treatment, our model predicted increasing numbers of cases and deaths: 224·1 (148·7-326·8) million cases and 487·9 (385·3-634·6) thousand deaths with a 25% reduction in antimalarial drug coverage; 233·1 (153·7-342·5) million cases and 597·4 (468·0-784·4) thousand deaths with a 50% reduction; and 242·3 (158·7-358·8) million cases and 715·2 (556·4-947·9) thousand deaths with a 75% reduction. Halting planned 2020 ITN mass distribution campaigns and reducing routine ITN distributions by 25%-75% also increased malaria burden to a total of 230·5 (151·6-343·3) million cases and 411·7 (322·8-545·5) thousand deaths with a 25% reduction; 232·8 (152·3-345·9) million cases and 415·5 (324·3-549·4) thousand deaths with a 50% reduction; and 234·0 (152·9-348·4) million cases and 417·6 (325·5-553·1) thousand deaths with a 75% reduction. When ITN coverage and antimalarial drug coverage were synchronously reduced, malaria burden increased to 240·5 (156·5-358·2) million cases and 520·9 (404·1-691·9) thousand deaths with a 25% reduction; 251·0 (162·2-377·0) million cases and 640·2 (492·0-856·7) thousand deaths with a 50% reduction; and 261·6 (167·7-396·8) million cases and 768·6 (586·1-1038·7) thousand deaths with a 75% reduction. Interpretation: Under pessimistic scenarios, COVID-19-related disruption to malaria control in Africa could almost double malaria mortality in 2020, and potentially lead to even greater increases in subsequent years. To avoid a reversal of two decades of progress against malaria, averting this public health disaster must remain an integrated priority alongside the response to COVID-19. Funding: Bill and Melinda Gates Foundation; Channel 7 Telethon Trust, Western Australia.

The potential public health consequences of COVID-19 on malaria in Africa

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Sep 2020
NAT MED

The burden of malaria is heavily concentrated in sub-Saharan Africa (SSA) where cases and deaths associated with COVID-19 are rising1. In response, countries are implementing societal measures aimed at curtailing transmission of SARS-CoV-22,3. Despite these measures, the COVID-19 epidemic could still result in millions of deaths as local health facilities become overwhelmed4. Advances in malaria control this century have been largely due to distribution of long-lasting insecticidal nets (LLINs)5, with many SSA countries having planned campaigns for 2020. In the present study, we use COVID-19 and malaria transmission models to estimate the impact of disruption of malaria prevention activities and other core health services under four different COVID-19 epidemic scenarios. If activities are halted, the malaria burden in 2020 could be more than double that of 2019. In Nigeria alone, reducing case management for 6 months and delaying LLIN campaigns could result in 81,000 (44,000–119,000) additional deaths. Mitigating these negative impacts is achievable, and LLIN distributions in particular should be prioritized alongside access to antimalarial treatments to prevent substantial malaria epidemics. Transmission dynamics models of COVID-19 and malaria reveal how different scenarios of COVID-19 spread and varying levels of interruption to antimalarial programs could result in increased deaths in sub-Saharan Africa.

COVID-19 in Africa: the spread and response

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Jun 2020

Given the current trends in incidence and underlying healthcare systems vulnerabilities, Africa could become the next epicenter of the COVID-19 pandemic. As the pandemic transitions to more widespread community transmission, how can the lessons learned thus far be consolidated to effectively curb the spread of COVID-19 while minimizing social disruption and negative humanitarian and economic consequences?

Insecticide-treated nets for preventing malaria

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Nov 2018

Background: A previous version of this Cochrane Review identified that insecticide-treated nets (ITNs) are effective at reducing child mortality, parasite prevalence, and uncomplicated and severe malaria episodes. Insecticide-treated nets have since become a core intervention for malaria control and have contributed greatly to the dramatic decline in disease incidence and malaria-related deaths seen since the turn of the millennium. However, this time period has also seen a rise in resistance to pyrethroids (the insecticide used in ITNs), raising questions over whether the evidence from trials conducted before resistance became widespread can be applied to estimate the impact of ITNs on malaria transmission today. Objectives: The primary objective of this review was to assess the impact of ITNs on mortality and malaria morbidity, incorporating any evidence published since the previous update into new and existing analyses, and assessing the certainty of the resulting evidence using GRADE. Search methods: We searched the Cochrane Infectious Diseases Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL) published in the Cochrane Library, MEDLINE, Embase, LILACS, the World Health Organization (WHO) International Clinical Trials Registry Platform, ClinicalTrials.gov, and the ISRCTN registry for new trials published since 2004 and up to 18 April 2018. Selection criteria: We included individual randomized controlled trials (RCTs) and cluster RCTs comparing bed nets or curtains treated with a synthetic pyrethroid insecticide at a minimum target impregnation dose recommended by the WHO with no nets or untreated nets. Data collection and analysis: One review author assessed the identified trials for eligibility and risk of bias, and extracted data. We compared intervention and control data using risk ratios (RRs), rate ratios, and mean differences, and presented all results with their associated 95% confidence intervals (CIs). We assessed the certainty of evidence using the GRADE approach. We drew on evidence from a meta-analysis of entomological outcomes stratified by insecticide resistance from 2014 to inform the GRADE assessments. Main results: Our updated search identified three new trials. A total of 23 trials met the inclusion criteria, enrolling more than 275,793 adults and children. The included studies were conducted between 1987 and 2001.ITN versus no netsInsecticide-treated nets reduce child mortality from all causes by 17% compared to no nets (rate ratio 0.83, 95% CI 0.77 to 0.89; 5 trials, 200,833 participants, high-certainty evidence). This corresponds to a saving of 5.6 lives (95% CI 3.6 to 7.6) each year for every 1000 children protected with ITNs. Insecticide-treated nets also reduce the incidence of uncomplicated episodes of Plasmodium falciparum malaria by almost a half (rate ratio 0.55, 95% CI 0.48 to 0.64; 5 trials, 35,551 participants, high-certainty evidence) and probably reduce the incidence of uncomplicated episodes of Plasmodium vivax malaria (risk ratio (RR) 0.61, 95% CI 0.48 to 0.77; 2 trials, 10,967 participants, moderate-certainty evidence).Insecticide-treated nets were also shown to reduce the prevalence of P falciparum malaria by 17% compared to no nets (RR 0.83, 95% CI 0.71 to 0.98; 6 trials, 18,809 participants, high-certainty evidence) but may have little or no effect on the prevalence of P vivax malaria (RR 1.00, 95% CI 0.75 to 1.34; 2 trials, 10,967 participants, low-certainty evidence). A 44% reduction in the incidence of severe malaria episodes was seen in the ITN group (rate ratio 0.56, 95% CI 0.38 to 0.82; 2 trials, 31,173 participants, high-certainty evidence), as well as an increase in mean haemoglobin (expressed as mean packed cell volume) compared to the no-net group (mean difference 1.29, 95% CI 0.42 to 2.16; 5 trials, 11,489 participants, high-certainty evidence).ITN versus untreated netsInsecticide-treated nets probably reduce child mortality from all causes by a third compared to untreated nets (rate ratio 0.67, 95% CI 0.36 to 1.23; 2 trials, 25,389 participants, moderate-certainty evidence). This corresponds to a saving of 3.5 lives (95% CI -2.4 to 6.8) each year for every 1000 children protected with ITNs. Insecticide-treated nets also reduce the incidence of uncomplicated P falciparum malaria episodes (rate ratio 0.58, 95% CI 0.44 to 0.78; 5 trials, 2036 participants, high-certainty evidence) and may also reduce the incidence of uncomplicated P vixax malaria episodes (rate ratio 0.73, 95% CI 0.51 to 1.05; 3 trials, 1535 participants, low-certainty evidence).Use of an ITN probably reduces P falciparum prevalence by one-tenth in comparison to use of untreated nets (RR 0.91, 95% CI 0.78 to 1.05; 3 trials, 2,259 participants, moderate-certainty evidence). However, based on the current evidence it is unclear whether or not ITNs impact on P vivax prevalence (1 trial, 350 participants, very low certainty evidence) or mean packed cell volume (2 trials, 1,909 participants, low certainty evidence). Authors' conclusions: Although there is some evidence that insecticide resistance frequency has some effects on mosquito mortality, it is unclear how quantitatively important this is. It appeared insufficient to downgrade the strong evidence of benefit on mortality and malaria illness from the trials conducted earlier.

Covid-19 — Implications for the Health Care System

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