Routine Malaria Control During the Covid-19 Pandemic in The Kingdom of Eswatini: A Benefit-Risk Analysis of Health Benefits Versus Excess Risk of Sars-Cov-2 Infection

Introduction: The ongoing COVID-19 pandemic is the most sustained disruptive and lethal disease outbreak since the 1918 influenza pandemic. As witnessed globally, the COVID-19 pandemic has the potential to overburden health systems and delay achievement of set targets for elimination or control. Discovery and implementations of effective treatments and/or vaccines for SARS-CoV-2 would reduce the duration and intensity of social distancing required to maintain control of the COVID-19 pandemic. The substantial progress made by the Kingdom of Eswatini in reducing the malaria burden could be jeopardised by the current COVID-19 pandemic. This study aims to describe potential effects of the COVID-19 pandemic on malaria incidence in the Kingdom of Eswatini. Methods: This study employed a retrospective analytical study using monthly malaria morbidity data on the overall number of outpatients. Confirmed malaria cases were extracted from the National Malaria Programme database derived from routine passive reported malaria cases in health facilities and from reactive case detected malaria. Malaria diagnosis was based either on the results of rapid diagnostic tests or microscopy. The data have been processed with Microsoft Excel Version 16.52 and analysed with Stata IC Version 16 (Stata-Corp, College Station, TX, USA). Findings: During March 2020, the number of confirmed malaria cases in Eswatini increased by 107% in March 2020 when the RSA, Mozambique and the Kingdom of Eswatini announced implementation of the first lockdown and travel restrictions. A majority of the cases confirmed in March were local cases, contrary to previous reports where imported cases were among the majority of cases reported in the country during each transmission season. The increase of cases in March 2020 suggests that intervention measures were implemented at reduced levels due to COVID-19 restrictions. Conclusion Neglecting malaria control interventions during the COVID-19 pandemic could prove catastrophic for malaria elimination in Eswatini. Malaria could develop into a scenario worse off than COVID-19 if neglected. Diagnosis for COVID-19 could be coupled with malaria diagnosis to avoid missing malaria cases during the COVID-19 pandemic.