When COVID-19 was first reported, epidemiologists predicted unprecedented increase of deaths in countries with weak health systems that were already struggling to manage a large number of infectious diseases (Ellie SS 2020). Sub-Saharan Africa (SSA) accounts for nearly half (49%) of infectious diseases burden worldwide, with HIV, tuberculosis and malaria responsible for much of the mortality and morbidity caused by infectious diseases (C.M Michaud 2009, Snow RW & Omumbo JA 2006). As the total number of COVID-19 patients continue to increase worldwide, the African continent is seemingly less affected yet surpassing two millions of total confirmed cases and 59,746 COVID-19 related deaths (Africa CDC 2020).
Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) has become a backbone of testing SARS COV-2 globally. Laboratories in Africa face serious challenges of limited diagnostics infrastructure, great variety of testing protocols needing local validation, high cost of PCR tests, limited supply chain and analysis rendering difficult all possibilities of early diagnosis and isolation of contacts (Waidi Folorunso Sule et al. 2020, Kobia F. et al. 2020). As of December 1st 2020, Rwanda had done a total 629,131 RT-PCR tests for COVID-19 since the pandemic begun, and several rapid diagnostic kits are under assessment and validation process. Reliable COVID-19 testing is critical for countries in Sub-Saharan Africa that face a high burden of malaria, and clinicians are challenged to differentiate malaria signs and symptoms from those caused by COVID-19 infection. Malaria is a leading cause of childhood deaths in sub-Saharan Africa, with an incidence of 229 cases per 1000 population at risk, and 380,000 malaria deaths mainly among children under 5 reported in 2018 (WHO 2019).
In countries like Rwanda where 70% of malaria cases are treated at community level by community health workers – an approach that has helped to reduce malaria related deaths from 715 in 2016 to 314 in 2018 (Malaria Operational Plan FY 2020) – typical malaria signs and symptoms (fever, shivering, headache, fatigue, muscle aches, diarrhea, vomiting) are well known by lay providers and even by patients themselves. These overlap with common COVID-19 symptoms [see table 2 below].
Table 2: Comparison of signs and symptoms of Malaria versus COVID-19
Relatively unique for Malaria
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Common Signs and Symptoms
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Relatively unique for COVID-19
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Nausea, vomiting, dizziness, pale conjunctiva, jaundice, dark urine, confusion, seizures and coma.
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Fever, chills, headache, muscles pain and fatigue.
NB:
1. Complicated forms of Plasmodium falciparum infection can result in severe difficulty in breathing (due to ARDS, or severe anemia causing heart failure).
2. Abdominal pain and diarrhea can be seen in COVID-19 infection (although rare).
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Cough, sore throat, running nose, nasal congestion, new loss of smell and taste, chest pain and difficulty in breathing (due to ARDS). Sudden death from silent hypoxia and cardiac injury has also been cited.
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Although respiratory signs and symptoms are most pronounced in COVID-19 infection, a typical malarial disease complicated with Acute Respiratory Distress Syndrome (ARDS) is nearly undifferentiable from severe COVID-19 infection.
In most African countries, community health workers (CHWs) are the frontline workers dealing with malaria, diagnosing cases with rapid diagnostic tests and treating simple cases. The current lack of widely validated antigen tests for COVID-19 with comparable sensitivity and specificity to RT-PCR tests hinder the ability of CHWs to accurately differentiate malaria from COVID-19 infection.
It is very likely that unrecognized COVID-19 disease transmitters will lead to a much wider virus spread, especially by those patients for whom a concurrent malarial disease is easily confirmed using the widely available rapid tests.
The picture of COVID-19 in Africa is confused by other endemic diseases with similar presentation, causing major challenges in the management of multiple public health threats. There is a growing need to reinforce the ability of fragile health systems to discriminate between multiple common causes. Without improved access to simple diagnostic tests there is possibility of patients being diagnosed and treated for one infection, only to die of another.