The prevalence and distribution of malaria in Mpumalanga Province before and during COVID-19 (2017 - 2022).

Background: South Africa (SA) has committed to eliminating malaria by 2028. However, the initial target was set for 2023. Additionally, the ongoing COVID-19 pandemic and the emergence of drug and insecticide resistance have been identified as potential stumbling blocks in the achievement of this goal. The impact of COVID-19 on the prevalence and distribution of malaria in SA is unclear.

Objective: To describe the trends and distribution of malaria before and during the pandemic and its associated lockdown strategies in one of the country's malaria-endemic provinces, Mpumalanga Province.

Method: A descriptive, retrospective and cross-sectional study was conducted using Mpumalanga provincial malaria case data extracted from the provincial District Health Information System 2. The impact of COVID-19 on the prevalence and distribution of malaria was assessed in Mpumalanga Province between 2017 and 2022 using descriptive trend analysis. Malaria cases before (2017 - 2019) and post- COVID-19 (2020 - 2022) were cross-tabulated using Stata version 17. We used χ2 tests to test for significant differences, set at p<0.05.

Results: During the study period, 25 380 malaria cases were reported, with the majority men (61%) >26 years old, with reported international travel, primarily to Mozambique. Limpopo Province (93%) accounted for most of the locally imported cases. Headaches and fever were the most common symptoms before and post COVID-19, while asymptomatic malaria carriage was higher during and post COVID (p<0.05). Prior to the pandemic reporting of the preferred treatment for uncomplicated malaria, Coartem use was at 53%, declining to 21% thereafter. Although COVID-19-related restrictions on human movement greatly reduced the malaria burden in Mpumalanga Province, the high-risk group (young mobile men) remained unchanged over the study period. Of concern were the marked reduction in the reporting of Coartem doses administered and the increased prevalence of asymptomatic carriage since 2020. The importation of malaria poses one of the biggest challenges to malaria elimination in Mpumalanga Province.

Conclusion: This study highlighted the impact of COVID-19 and its related lockdown restrictions on the delivery of malaria health services in Mpumalanga Province. If malaria elimination is to be achieved, all aspects of the malaria programme must be strengthened urgently. Additionally, the health system and cross-border collaborations must also be strengthened.