Impact of the Covid-19 Pandemic on Severe Childhood Malaria at the University Hospital of Brazzaville

Introduction: Malaria management has been a source of concern for health systems since the advent of the Covid-19 pandemic. Objective: To assess the impact of the Covid-19 pandemic on severe childhood malaria in Brazzaville. Material and Method: A quasi-experimental intervention/non-intervention study was carried out between March and October 2020 in the pediatric departments of the Brazzaville University Hospital. Children aged three months to 15 years hospitalized were the target population. Two groups were formed: the “intervention” group, that of children hospitalized between March and October 2020 and the “control” group that of those hospitalized between January and August 2015. The study variables were epidemiological, clinical, biological and therapeutic. Chi-square and T-Student tests were used. The impact of the intervention was assessed by the absolute risk difference. Results: Of 1392 children hospitalized, 199 (14.6%) had severe malaria with an average age of 6.94 years. These were children under 5 years old n = 95 (47.7%) of low socioeconomic level n = 145 (72.9%) seen on average after 4.6 +/− 2.4 days. Repeated convulsions (56.8%) morbidity and mortality in severe malaria since the beginning of the Co-vid-19 pandemic encourages the maintenance of the balance between the management of the Covid-19 pandemic and that of other worrying health problems.


Introduction
Malaria, a major public health problem [1], is an endemic for which many resolutions have been taken: that of Abuja: "to roll back malaria" [2], the United Nations Millennium Declaration (UN): building together a more secure, prosperous and equitable world [3], the Millennium Development Goals (MDGs) [3] and the Sustainable Development Goals for the eradication of malaria in many countries by 2030. In 2019, 229 million cases of malaria were recorded worldwide, including 213 million in Africa. There were 409,000 deaths and, children under five were the most affected [4]. The severe forms are the fifth leading cause of death from infectious diseases in the world and second in Africa [5]. The high prevalence and relative mortality are variable: 18% -67.8% in the Democratic Republic of Congo (DRC) [6], 21.7% in Senegal [7], 55.8% in Mali [8] and 53 % in Niger [9] with respectively 4%, 24%, 10%, and 3.6% of deaths.
In Congo, the prevalence of severe forms of malaria was 11.2% in 2016 and mortality 6.5% [10]. While African populations continue to pay the heavy price for severe malaria [5], the Covid-19 pandemic risks are hampering the efforts of health systems around the world [11]. Our study aimed to assess the impact of the covid-19 pandemic on severe childhood malaria at the University Hospital of Brazzaville and the objectives: determine the frequency of severe malaria; describe the clinical, para-clinical, therapeutic and evolutionary aspects; identify the factors associated with the death of a child hospitalized for severe malaria during the Covid-19 pandemic period and report the indicators of its impact on severe childhood malaria in Brazzaville.

Materials and Methods
We carried out a quasi-experimental intervention/non-intervention study between March and October 2020, i.e. in eight months. Three of the four pediatric departments of the University Hospital of Brazzaville: grandchildren pediatrics, infant pediatrics and that of Pediatric Intensive Care (ICU) formed the framework of the study. The target population, made up of children aged three months to 15 years hospitalized in the aforementioned services was divided into two groups: group 1 or "intervention", that of children hospitalized between March and October 2020 and group 2 or "control". That of children hospitalized be-Open Journal of Pediatrics tween January and August 2015, eight months [10].
Children aged three months to 15 years hospitalized in the aforementioned services whose discharge diagnosis included, among other things, the item "severe malaria" [12] were included. Severe malaria was defined by the World Health Organization criteria [13]. This was a simple and consecutive probability sampling taking into account medical records and service registers. The sample size of group 2 "control" was that of the study carried out in the same wards in children admitted for "severe malaria" [10]. That of group 1 "intervention" was calculated from the SCHWARTZ formula. The minimum sample size was set at 153 patients.
The sample size of group 1 "control" corresponded to that of the studycarried out in the same services by Okoko [10], on "severe malaria" in children at the In all cases, the criteria for cure were the achievement of apyrexia and the Open Journal of Pediatrics denial of thick gout. The other criteria, depending on the clinical form were the recovery of consciousness, the re-coloring of the mucous membranes, the integuments and the appearance of the urine, the resumption of food and walking, a hemoglobin level within the limits of normal and normalization of renal function.

Data Analysis
The software Epi info version 7.2 and Stata 13 were used for data processing.
Chi-square and T-Student tests for the comparison of proportions and means.
The significance level was set p less than or equal to 5% and the confidence interval at 95%. The impact of the intervention was assessed by the absolute risk difference (DR).

Ethical Considerations
To carry out this work, approval from the Scientific Research Ethics Committee (CERSSA) in Congo as well as a research authorization issued by the Faculty of Health Sciences of Marien Ngouabi University were obtained. (96.5%) and in another locality of Congo n = 7 (3.5%). They came from home without prior recourse to a health center n = 107 (53.8%); referred from a basic hospital n = 58 (31.1%), an integrated health center n = 11 (5.5%) and a doctor's office n = 19 (9.6%).
The mean length of hospital stay was 2 ± 1.5 extreme days (1 and 7 days) in the fatalities and 3 ± 3.5 extreme days (1 and 4 days) in the living.

Analytical Study
The delay in the consultation, beyond two days; the reason for consultation is anemia; repeated convulsions, examination signs including pallor, fever, respiratory distress; association with sickle cell anemia, sickle cell anemia; thrombocytopenia, hypoglycemia and length of hospital stay predicted death ( Table 2).

Comparative Analysis
The comparative elements between the control study and the control study on the elements of severity of severe malaria according to WHO are given in Table   3 and Table 4. Morbidity from severe malaria increased from 11.2% with a mortality of 6.2% in the control study in 2016 and in our study these figures are clearly increasing with a morbidity of 14.3% and a mortality of 13.1%.

Difference in Risk of Signs of Severity between the Two Groups
The risk difference is 0.1 for seizures; 1.7 for fever; 0.8 for coma; 1.5 for splenomegaly; 7.3 for anemia; 0.5 for hypoglycemia and 0.04 for renal failure. It follows that the percentage of subjects to be treated to prevent death from severe malaria during a Covid-19 pandemic is 100% for coma, convulsions and hypoglycemia; 66.6% for splenomegaly; 58.8% for fever and 13.7% for anemia.
Children under 15 have a relative risk of death from severe malaria 1.8 times higher during Covid-19 compared to those in the control study.

Discussion
As Covid-19 continues to occupy the political health agenda in many countries around the world, so does its impact on certain diseases which is becoming apparent. Malaria is one of them. The general objective of this study was: to assess the impact of the Covid-19 pandemic on severe childhood malaria in Brazzaville and specifically: to determine its frequency, to describe the nosological varieties, to assess the evolutionary profile, to identify the factors associated with deaths during the period of the Covid-19 pandemic and report the indicators of the impact of the Covid-19 pandemic on severe malaria in children hospitalized at the Brazzaville CHU by referring to a previous study [10] of which the methodology was identical to ours. The high mortality, attributable to severe malaria despite the efforts made for its reduction by the international community guided our choice, which was reinforced by the cry of alarm from the WHO which feared that the Covid-19 pandemic would be wiped out. The benefits obtained over the last twenty years by the health systems of the various countries [11]. To achieve our objectives, a cross-sectional study carried out in the largest hospital in Brazzaville seemed to us the ideal setting. However, the conduct of the study was a source of bias, including those relating to its implementation during the period of the health emergency coupled with the confinement of the population.
This study presents in its implementation somelimitations, relating to its duration, namely eight months, its implementation during a period of confinement, state of health emergency, source of recruitment bias.

Epidemiological Aspects
This work confirms the severity of severe malaria, the role of which in child mortality in developing countries is well known [14] [15] [16]. In the Congo, the relative mortality, which has fallen sharply, from 26.3% in 2010 [17]
As already reported, the neurological and anemic forms are predominant [6] [10] [22] [23] [24]. And that the association of severe malaria with sickle cell disease increases the risk of death.

Evolution and Risk Factors for Death
The progression to death observed in 13.1% of the children in this study and 6.5% in the control study [10] is in both cases more attributable to anemic and neurological forms but also to hypoglycemia and at thrombocytopenia. The predictive factors of death, which vary from one study to another, are: delayed consultation, fever, repeated convulsions, pallor, respiratory distress, sickle cell anemia, thrombocytopenia and hypoglycemia.

Influence of the Covid-19 Period on the Management of Severe Malaria
In March 2020, WHO underlined the value of maintaining activities for the prevention, diagnosis and treatment of malaria, key to the strategy to reduce the pressure on health systems when an additional burden is expected due to the Covid-19. These forecasts related to the disruptions observed in the supply chain of essential tools for the fight against malaria due to containment measures and the priority given to imports and exports of materials intended for the fight against Covid-19. In the context of a deficit of activities related to the fight against malaria, WHO estimated that "the number of deaths due to malaria in sub-Saharan Africa in 2020 would reach 769,000, a number twice as high as in 2018. This which would represent a return to the level of mortality observed for the last time in 2000" [25]. This is the case for our study, which reports severe malaria morbidity of 14.6% and mortality of 13.1% versus 11.6% morbidity and 6.5% mortality for the control study and a risk relative death rate 1.8 times higher during the period of the Covid-19 pandemic, thus confirming the WHO forecasts [26].

Conclusion
The morbidity and mortality linked to severe childhood malaria have doubled in Brazzaville since the advent of the Covid-19 pandemic. The anemic and neurological forms are the most observed. Delayed consultation, fever, repeated convulsions, pallor, respiratory distress, sickle cell anemia, thrombocytopenia and hypoglycemia are associated with death. Mortality from severe malaria is twice as high during the Covid-19 pandemic. It seems imperative for health systems to ensure that a balance is maintained between the management of the Covid-19 pandemic and that of other worrying health problems, including malaria.