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Hospital attendance, malaria prevalence and self-medication with an antimalarial drug before and after the start of COVID-19 pandemic in a sentinel site for malaria surveillance in Gabon

Malaria Journal volume 24, Article number: 28 (2025) Cite this article

Abstract

Background

The negative impact of COVID-19 pandemic on healthcare service utilization has been reported in several countries. In Gabon, data on the preparedness for future pandemic are lacking. The aim of the present study was to assess the trends of hospital attendance, malaria and self-medication prevalences as well as ITN use before and during Covid-19 first epidemic waves in a paediatric wards of a sentinel site for malaria surveillance, in Libreville, Gabon.

Methods

This was a retrospective descriptive and hospital-based survey which was conducted at the Regional Hospital of Melen Estuaire (RHME). Census of files of patients below 18 years of age attending for fever management with a result of malaria biological diagnosis from January 2018 to December 2022 was conducted. Comparison of the prevalence of microscopic malaria, ITN use, self-medication and the fever duration prior the screening before and after year 2020 was performed using bivariate and multivariate analysis.

Results

Overall, 14428 febrile participants were screened for malaria. A 15% increase in the number of febrile patients was observed between 2019 and 2020 while this rate was above 100% in 2021 and 2022. The frequency of self-medication significantly doubled in 2020 and 2021 compared to the pre-COVID-19 period (p < 0.01). Previous self-medication was more common during the COVID-19 period compared to the COVID-19 one (aOR = 2.15 [1.91–2.42]) (p < 0.01). Among the 7259 (51.2%) patients screened after 3 days of fever onset, self-anti-malarial treatment was reported for 17.5% of them in 2019 and for more than 30% of them from 2020: 33.3% in 2020, 35.0% in 2021 and 32.3% in 2022 (p < 0.01). The median of fever duration was significantly higher in the group of participants with a previous self-medication (p < 0.01). Positive blood smears frequency was higher in the COVID-19 period (35.6%; n = 3876/10868) compared to the pre-COVID-19 period (23.6%) (OR = 1.79[1.59–2.02], (p < 0.01).

Conclusion

Malaria prevalence and care-seeking behaviours for fever management in children significantly changed during the COVID-19 epidemic phase and subsequent years in the main malaria sentinel surveillance site of Gabon.

Background

Since 2000–2005 substantial progress in malaria control has been performed through malaria national control programmes and health ministry policies in endemic countries. According to Roll Back Malaria initiative implementation of malaria prevention strategies, treatment guidelines, and vector control programmes have been deployed [1, 2]. However, despite these efforts last decades, malaria morbidity and case fatality rates remain non negligible. In 2022, 249 million malaria cases were estimated in 85 malaria endemic countries, an increase compared to the 245 million reported in 2020. This increase mainly occurred in countries of the World Health Organization (WHO) African Region [2]. During the same period, the COVID-19 outbreak spread throughout all continents. It was declared a public health emergency of international concern in January 2020 and pandemic on March 2020 by the WHO. COVID-19 sanitary crisis was associated with an important dysfunction in health systems throughout the world notably in Africa [3]. Implementing control measures, such as border closures, movement restrictions, social distancing and school closures were recommended to slowdown the spread of the disease and to prevent healthcare system overwhelming [4]. In African countries, restrictions included also travel bans, curfew and lockdowns [5]. Following this, reductions in the demand and provision of basic health care services were noted. A direct or an indirect impact on health service frequentation for non-COVID-19 diseases, such as malaria, was observed in some countries of SSA [6, 7]. Between 2019 and 2021, additional 13.4 million malaria cases were reported and attributed to disruptions during the COVID-19 pandemic [8]. Furthermore, malaria cases incidence (i.e. cases per 1000 population at risk) which reduced from 82 in 2000 to 57 in 2019, increased to 59 in 2020.

Thus, COVID-19 pandemic may have severely impacted the national control programmes preventive activities and the population healthcare-seeking behaviours [9–10]. Highlighting the devastating consequences of COVID-19 epidemic in malaria endemic countries would be helpful for a better preparedness for future epidemics [3, 10, 11]. Together, local data should be generated for a tailored emerging infectious diseases epidemic responsiveness.

In Gabon, where malaria transmission is perennial, the actual prevalence of clinical malaria is around 23–30% according to the data provided by the sentinel sites for malaria surveillance [12]. In the country, the first case of COVID-19 has been reported in March 2020 and the lockdown was declared. Sanitary restrictions to slowdown the virus transmission were applied during two years, until March 2022 [13]. Therefore, the aim of the present study was to assess the trends of attendance, malaria and self-medication prevalence as well as ITN use in a paediatric ward of a sentinel site for malaria surveillance before and during COVID-19 first epidemic waves in Libreville, Gabon.

Methods

Study design, site and population

This was a retrospective descriptive and hospital-based survey which was conducted at the Regional Hospital of Melen Estuaire (RHME) located 11 kms from Libreville, the Capital city of Gabon. Melen and Libreville are cities of the Estuaire province that was the epicentre of COVID-19. The RHME is one of the sentinel sites for malaria surveillance set up by the Malaria National Control Programme (MNCP). In this sentinel site, febrile patients benefit from free malaria diagnosis, and haematological parameters assessment if required by the medical doctor. This activity is performed routinely by the team of the Department of Parasitology-Mycology of Université des Sciences de la Santé (DPM-USS) in collaboration with the MNCP.

Patients and parents/guardians attending the sentinel site are informed that their anonymized information will be used for public health or research purpose, according to the Ministry of Health, the MNCP, the RHME and the DPM-USS convention rules and procedures. Therefore, each one provides a consent for data use.

Population inclusion criteria were fever or self-reporting fever during the previous 24 h, age below 18 years old (< 18 years) and the availability of malaria biological test results in hospital records. Thus, a census of files of patients attending for fever management and malaria diagnosis at the RHME from January 2018 to December 2022 was conducted. A structured case report form was used to extract the following data: age, gender, date of malaria screening, tympanic temperature, insecticide-treated net (ITN) use the night before the consultation, report of self-medication with an anti-malarial drug prior to the screening, and the results of the malaria tests.

Malaria diagnosis at the RHME

Blood sample was collected for finger for thick and thin blood smears realization after the patients had given their consent. Briefly, thick blood smears were done according to the method of Lambaréné [14]. After the slides reading, a patient was considered free of malaria if no malaria parasites were seen in 100 microscopic fields per slide using immersion oil. The thin blood smear reading was done to identify Plasmodium species. The slides reading was performed by two trained technicians, and by a third one in case of discordant results. Malaria cases were defined as febrile patients or patients with history of fever with a positive blood smear.

Covid-19 data collection

Data on COVID-19 cases in Gabon were collected from national epidemiologic reports of the Copil Coronavirus (COVID-19) response national committee [13]. These data consisted of monthly number of patients with a positive SARS-CoV-2 RT-PCR test result in 2019–2022.

Definitions

According to their age, patients were stratified in three groups as follows: children below 5 years of age (< 5 years), between 5 and 10 years of age, and between 11 and 17 years of age. The pre-COVID-19 period was considered for the period lasted from first January 2018 to 31st December 2019.The COVID-19 period was considered from March 2020 to 31st December 2022. Because there was an interruption of 90% of the sentinel site activities due to a strike in the paediatric ward, from January to February 2020 and the first case of COVID-19 was confirmed in Gabon the 12th of March 2020, data from January to February 2020 were not included into Year 2020 data. Regarding the fever duration before the screening, it was considered that patients had an early visit when they presented for malaria screening less than 3 days after the onset of fever, and a late visit when they consulted more than 1 week after.

Statistical analyses

All data were double entered and recorded in Redcap software. All analyses were performed using Statview 5.0 software. Continuous data are presented with median and interquartile ranges (25e–75e interquartile range) and qualitative data with frequency and percentages. Differences between groups were analyzed using the Chi-squared test, Fisher’s exact test, for qualitative data and the Kruskall–Wallis or Mann–Whitney tests for quantitative data, as appropriate. Association between malaria prevalence, ITN or self-medication use with years were assessed by considering year 2019 as reference for the pre-COVID 19 period. Indeed, an ITN national campaign was performed in 2018, therefore, as ITN distribution did not included all age groups and its use is associated with malaria prevalence, the year 2019 during which no specific malaria intervention was performed was considered as the year of reference. The bivariate analysis assessed the crude Odds and its 95% confidence interval (cOR [95% CI] of positive blood smears (malaria), self-medication and ITNs use according to year and age. The multivariate logistic regression analysis allowed the assessment of the adjusted Odds ratios (aOR) [95%CI] of these factors according to the years. When malaria was considered as the dependent variable, age, ITN use and self-medication were considered as independent variables. When self-medication was considered as the dependent variable, age and ITN use were considered as independent variables. When ITN use was considered as the dependent variable, age and self-medication were considered as independent variables. The percentage of increased hospital attendance was calculated considering the year 2019 as baseline, data from 2019 was compared to each of the other year’s data. A p-value below 0.05 was considered significant.

Ethical considerations

In Gabon, the Ministry of Health, represented by the MNCP, has committed the Department of Parasitology-Mycology and Tropical Medicine of the Faculty of Medicine of Libreville to monitor malaria prevalence and anti-malarial drug resistance in sentinel sites for malaria surveillance. The approval was obtained by the MNCP for the publication of the data. Adolescents and children’s parents or guardians attending the sentinel site were informed on the purpose of the use of their data, for public health or research purpose. In this context, patients and the guardian or parent of the children included were informed of the activities in this sentinel site and their signed consent was obtained. Children over the age of 12 gave their consent to participate in the study. In case of positive blood smears, patients were treated according to national recommendations.

Results

Number of screened febrile patients

During the study period 14428 febrile participants were screened for malaria. Female represented 48.6% (n = 7009) of the patients. No difference according to the gender was observed in the study population (p = 0.88). Age was reported for 14277 patients. The less than 5 years old children represented two third of them (63.6%; n = 9083), the 5–10 years old, almost the quarter (24.5%; n = 3495) and the adolescents, 12% (11.9%; n = 1699). This distribution did not significantly change over the study period (Fig. 1). The total number of children attending for malaria diagnosis significantly increased from 2018 to 2022 (p < 0.01), while the median age, the median temperature the day of consultation did not significantly vary (Table 1). The number of febrile patients increased of near 15% between 2019 and 2020, while the rate was above 100% in 2021 and 2022. It was 6 to tenfold higher in each age group (Fig. 1).

Fig. 1
figure 1

Evolution of the number of the screened febrile patients stratified by age between 2018 and 2022 and percentage of increase of febrile patients number at the sentinel site for malaria surveillance, RHME, Gabon

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Table 1 Socio-demographic and clinical characteristics of the study participants
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As during the pre-COVID 19 period, the number of attendees and the median age were comparable between year 2018 and year 2019, the year 2019 was considered as the reference for the further comparative analysis, between pre-COVID-19 and COVID-19 periods.

Fever duration before the consultation

Fever duration was for 14173 participants. More than 50% of the patients attending for fever management after 3–7 days of fever (n = 7259; 51.2%), 47.0% (n = 6659) consulted before 3 days and 1.8% (n = 255) came to hospital after 1 week. According to the year, the proportion of patients with a late visit (at least 1 week after the beginning of the fever) was significantly lower in 2019 (0.7%; n = 12/1717) and the highest in 2020 (2.6%; n = 49/1915) (p < 0.01), while it was comparable between year 2021 (1.7%) and year 2022 (1.5%) (p = 0.66).

Self-medication with an anti-malarial drug prior to the consultation

Previous anti-malarial drug use was reported by 23.1% (n = 3314/14319) of the patients. Previous self-medication was more common during the COVID-19 period compared to the COVID-19 one (aOR = 2.15 [1.91–2.42]) (p < 0.01). The frequency of self-medication significantly increased from 1.3 fold to twofold in 2020 and 2021 compared to 2019 (p < 0.01) (Table 1). Indeed, the odd of self-medication was the highest in 2021 (Table 2).

Table 2 Unadjusted and adjusted Odds ratios of malaria, ITNs and drug use before and during the Covid-19 epidemic phase
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According to the age, younger children received less frequently an anti-malarial drug prior to the consultation at hospital compared to patients aged from 5 to 17 years old (Table 3). Adolescents had most often a presumptive treatment in 2019, 2020 and 2022, while children aged 5–10 years old had the highest rate of presumptive treatment in 2021 (Table 3). Globally, there was no significant change in the proportion of adolescents with prior anti-malarial treatment between 2020 and 2022 (p = 0.67).

Table 3 ITN use and self-medication with anti-malarial drug prevalence according to the age
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The median of fever duration before the screening was significantly higher in the group of participants with a home medication (3[2–5] days) compared to the group of children without drug administration (2[1–3] days) (p < 0.01). No difference was observed in both groups during the pre-COVID-19 period (3[2–5] days in case of self-medication, versus (3[2–4] days, in the absence of treatment) (p = 0.32). Among the 7259 (51.2%) patients screened after 3 days of fever onset, self-anti-malarial treatment was reported for 17.5% of them in 2019 and for more than 30% of them from 2020: 33.3% in 2020, 35.0% in 2021 and 32.3% in 2022 (p < 0.01). Almost half (46.9%; n = 92/196) of the patients who had a late visit used anti-malarial drugs prior to the consultation. This frequency was significantly lower in children who attended for fever management after 3–7 days (31.3%; n = 1953/6233) or who had an early visit (14.4%; n = 847/5858) (p < 0.01).

From 2020, patients with a previous anti-malarial treatment always consulted for fever later than their counterparts (Year 2020: 3 days versus 2 days, Year 2021: 3 days versus 2 days; Year 2022: 3 days versus 2 days, p = 0.01). In the same way, the proportion of participants with a self-medication who consulted late was the lowest in year 2019 (0.4%) and the highest in year 2020 (5.2%) (p < 0.01). This proportion decreased during years 2021 (3.5%) and 2022 (2.6%), but remained higher than the frequency in year 2019 (p < 0.01). In contrary, the prevalence of late consultation in the absence of a previous self-medication remained below 1.5% during the study period (0.8% during the pre-COVID-19 period, 1.5% in 2020, 1.0% in 2021 and 1.2% in 2022).

ITNs use

Almost half (48.9%; n = 7014/14342) of the study population slept under ITN the night before the screening (Table 1). The frequency of ITN use was the highest during the pre-COVID-19 period reaching 55% (n = 947/1722) in 2019; then it significantly decreased in 2020 and in 2021 (Table 1). The multivariate analysis showed that during the COVID-19 epidemic phase, the population was less likely to use a net compared to 2019 (Table 2). The lowest odds of ITN use were observed in 2021.

Children aged below five years old slept more often under an ITN, whereas no difference in ITN use rate was found between the older patients (p = 0.49). In 2022, while the frequency of net use increased in young children, it significantly decreased in adolescents, in comparison with the year 2021 (cOR = 0.68[0.52–0.89]; p < 0.01).

Trends in malaria prevalence

Blood smears were positive for more than one third (33.1%; n = 4769) of the study population. Microscopic malaria was diagnosed in 28.6% (n = 2602/14277) of the young children, in 38.2% (n = 1333) of those aged 5–10 years old and in 45.7% (n = 776) of the adolescents (p < 0.01). The median parasite density was 1960[280–17129]p/µL.

There was a significant variation of malaria prevalence across the years (Table 1). Although the rate of positive blood smears was higher in the COVID-19 period (35.6%; n = 3876/10868) compared to the pre-COVID-19 period (23.6%) (OR = 1.79[1.59–2.02], p < 0.01), the median parasitaemia significantly decrease between both periods (Table 1). Indeed, febrile patients were 1.6 times more likely to have malaria in 2020 than in 2019 (Table 2). This risk increased to 2.7 times in 2022 (p < 0.01). According to the age, malaria prevalence significantly increased in all age groups with the same trend: it was the lowest among the youngest, and the highest in the adolescents (p < 0.01) (Fig. 2).

Fig. 2
figure 2

Malaria prevalence stratified by patients ‘age, between 2018 and 2022 at the sentinel site for malaria surveillance, RHME, Gabon

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A decrease of the proportion of positive blood smears was observed in 2021 in those aged between 5 and 17 years old (Fig. 2) (p = 0.02). The median age of the infected patients was always significantly higher compared to those with a negative blood smear (Fig. 2) (p < 0.01). The difference was the highest in 2020. Globally, it was 48[24–108] months in patients with a positive blood smear and 33[12–84] months in those with a negative blood smear (p < 0.01). The median age increased to 60[24–120] months in 2020 in case of positive blood smears and it decreased to 24[12–60] months in patients with a negative blood smear (p < 0.01). Afterwards, the age decreased in the group of positive blood smears (48[19–96] months) but it increased in the group of negative blood smears (36[12–60] months) in 2021 (p < 0.01) (Fig. 2).

According to the ITNs use, malaria prevalence was 31.6% (n = 2215/7014) among users vs 34.4% (n = 2523/7328) among non-users (p < 0.01). The difference was significant in 2020: 29.8% vs 35.1% among non-users (p = 0.01), but not in years 2019, 2021 and 2022. Moreover, malaria prevalence was significantly low in patients using anti-malarial drug self-medication in 2020 (23.6% vs 35.3% among non-users; p < 0.001) and 2021 (27.9% vs 31.8% among non-users; p = 0.01).

Between March 2020 and December 2021, there were four peaks of COVID-19 confirmed cases in Libreville (Fig. 3). Monthly analysis of the evolution of COVID-19 cases at the national level and of the number of hospital febrile attendees, showed a rise of the number of febrile patients attending for fever case management after July 2020, February–March 2021 and October 2021. Peaks of total number of malaria cases were also observed after May and October 2021 (Fig. 3).

Fig. 3
figure 3

Evolution of the number of the screened febrile patients and malaria cases according Covid-19 peaks occurrence between 2020 and 2021 at the sentinel site for malaria surveillance, RHME, Gabon

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Discussion

This hospital-based study assessed the impact of COVID-19 pandemic on febrile outpatient visit number, and on malaria indicators in the main sentinel site for malaria surveillance of Gabon, RHME. From 2019 to 2022, routine surveillance data collected showed a significant increase in the absolute number of febrile outpatients. This rise in health frequentation reached almost 200% in 2022 after the COVID-19 pandemic phase (Fig. 1). Such increase of the number of outpatients seeking care for fever during and after COVID-19 can be related to the reduced access to the healthcare structures around the RHME during the first waves in 2020. To our knowledge, this study carried out in the main sentinel site for malaria surveillance is the first reporting these malaria transmission key indicators in the capital city of Gabon, the centre of the COVID-19 epidemic in Gabon.

This significant augmentation of health frequentation was observed after the occurrence of each COVID-19 case peak in the country. This is probably due to the rush to the hospital of the patients who were advised to stay at home during these peaks and therefore prefer to keep their febrile children at home. Additionally, after each peak two healthcare-seeking behavior can explain the rise of higher frequency of outpatients’ hospital frequentation. The first one is due to the late visits at hospital of the cumulative number of children with fever or fever history who were kept at home during the peak. The second is related to the increased attendance of children whose parents had fear of SARS-CoV-2 infection in case of fever, they could easily reach the RHME for a rapid screening for SARS-CoV-2 infection [15]. These children systematically benefited from a malaria diagnosis at the RHME, when they had fever or a history of fever, a common symptom of both diseases.

Previous reports highlighted direct or indirect consequences of COVID-19 pandemic on public health services and consecutively on the burden of communicable disease in endemic countries [16, 17]. In this hospital, measures related to COVID-19 prevention and social distancing have been introduced during the pandemic but, patients had access to specialized consultations such as paediatrics. Nevertheless, in other health facilities such as university Hospital Centres, accessibility was reduced in some services, since the main activity was focused on COVID-19 cases management. Such strategy had an impact, not only on the number of consultations which has increased in neighbouring health structures, but also on the detection of malaria cases, leading to a rise of the number of patients diagnosed with malaria in this RH. Between 2011 and 2017, the RHME utilization rates for malaria diagnosis did not significantly change from 1,700 to 2,250 (data from the MNCP). At the national level, the MNCP reported that the number of suspected malaria (i.e. patients with fever or history of fever) was around 212,000–214,00 from 2016 to 2018, it was 214,000 in 2019 and 229,000 in 2021 [18].

In Gabon, during the year 2020, strong decisions were taken to implement strategies against COVID-19 propagation that have led to a decline of efforts made to control other endemic diseases notably other febrile illness such as malaria. COVID-19 pandemic has resulted in unprecedented challenges to health systems worldwide, including the control of non-COVID-19 diseases [6, 19].

Globally, less than 5% of the febrile patients seek care more than 1 week after the onset of fever. However, this proportion was the highest (almost 3%) during the year 2020, while it was less than 1% among the febrile patients seen during the year 2019. In 2021 and 2022, although a drop was reported, the frequency of late hospital visits remained higher compared to that reported in the year 2019. Such behaviour was found associated with a frequent self-medication with an anti-malarial drug. Indeed, the median duration of fever before the screening was significantly higher in the group of participants with a previous self-medication. Moreover, almost half of the patients with late consultation used anti-malarial drugs prior to the consultation. Such practice was less common among children who attended for fever management earlier. It was more often reported in years 2020 and 2021 compared to year 2019. This change of healthcare-seeking behaviour that began in 2020 was maintained in 2021 and 2022, most likely because of the continued intense communication on COVID-19 during this period.

The use of self-medication with an anti-malarial drug before consultation at hospital significantly increased from year 2019 (13.5%) to year 2021 (27.2%), translating a probable change in the fever case management behaviour. Indeed, from 2020, the proportion of anti-malarial drug users prior the screening for malaria was the twice of that estimated in 2019 in individuals of all age consulting for febrile illness notably in older children. A higher frequency of self-medication was previously recorded among older febrile patients seeking care in this healthcare structure over a period of 3 months [20]. One explanation could also be the presumptive treatment of a suspected COVID-19 with anti-malarial drugs which were considered, as possible treatment for SARS-Cov2. Through a survey performed in Benin, participants reported not seeking care during the pandemic because of SARS-CoV-2 infection fear and a high use of anti-malarial drugs to treat malaria and to prevent COVID-19 disease [15, 21].

The delay in the fever management associated with the presumptive treatment of fever could lead to an increase of the prevalence of severe malaria as shown in Nigeria [22]. In another way, healthcare service frequentation of patients with mild or more severe illness tended to decrease during the epidemic phase of COVID-19 [23]. In Uganda, the number of children treated for malaria, pneumonia and diarrhoea at hospital significantly decreased during the lockdown [16]. Likewise, in Cameroon, a decline of hospitalizations in paediatrics was observed during the pandemic [24]. Unfortunately, data on severe malaria cases were not collected in the present study.

In the same time, ITNs use was less frequent in 2020 and 2021. Although in Gabon, ITN coverage has not reached high levels, such decrease, while slight was concomitant to COVID-19 pandemic occurrence. A presumable reduced or interrupted distribution of ITNs in the country could be the main reason. This suggests reverse effects of the pandemic on malaria prevention measures as shown here by the drop of ITNs use from 2020.

Malaria affected more than 6000 people out of more than 15,000 febrile participants over the study period. Similarly, in the general population of Gabon, the incidence of malaria has increased from 58/1000 inhabitants in 2020 to 62/1000 inhabitants in 2021, that of children increased from 107/1000 to 131/1000 in the same period [18]. This augmentation of clinical malaria burden from that started in year 2020 was mentioned in other settings. Gavi et al. [25], in Zimbabwe found an excess of more than 30,000 of malaria cases during the first phase of COVID-19 pandemic, compared to the estimates of the previous years. Moreover, they also highlighted a higher incidence of malaria in areas with low malaria burden [25].

Although the current data cannot be generalized to the whole country, this increase is in line with the data reported by the WHO, indicating additional number of malaria cases during the COVID-19 pandemic in Africa [8]. Likewise, in the southeastern of Gabon, similar trends were observed during the pandemic [26]. However, in Ghana, Heuschen et al. [4] showed a potential effect of COVID-19 on malaria burden in health facilities with a decline of malaria rate in outpatients as well as inpatients except for pregnant women. In Uganda, Namuganga et al. [27] also reported a slight decrease of malaria proportion and a small effect of the pandemic on indicators of case management, notably after the lockdown policy implementation. In the capital city of Gabon, access to RHME that is located at 11 kms from Libreville was facilitated for populations seeking care, they benefitted from a free access to urban bus according to the government policy from the year 2020.

Regarding the preventive measures, the prevalence of malaria was slightly reduced in 2019, after a national ITN distribution campaign performed in 2018. ITN use is linked to ITN coverage and ownership. Thus, the campaign performed in 2018 was followed by an increase of ITN use in 2019 as recorded elsewhere [28, 29]. Malaria prevalence and incidence decrease generally one year after large net distribution, while a reduction of the coverage from 25 to 75% is followed by an increase in clinical malaria incidence and malaria deaths [30]. This would explain the slight difference in malaria prevalence observed between year 2018 (26.4%) and year 2019 (23.6%).

Although children younger than five years always represented more than 60% of the febrile patients attending for consultation at the RHME, older ones remained the most often infected by malaria parasites. Since more than 10 years, children older than 10 years are at higher risk of malaria compared to the youngest [31]. Unfortunately, data on adults, who were shown to be the target population of COVID-19, were not recorded. Indeed, this study location was the paediatric ward of RHME where only persons aged 0–17 years old receive care. Malaria indicators which are mainly used to characterize malaria transmission, coverage and impact of control measures, are preferably measured in children and pregnant women. Moreover, a very low prevalence of malaria in adults seeking care for COVID-19 was found in the main COVID-19 dedicated management site in Gabon [32]. While the information provided here cannot be translated to adult population or pregnant women it is important to notice that adults do not often seek care for an uncomplicated febrile illness, they prefer self-treating themselves with an anti-malarial drug [33].

In Franceville, a province located in the Southeast of the country, the raise of malaria prevalence which was observed in children in years 2020–2021 compared to year 2019, was not found in adults who consulted for fever in the same health structure from 2019 to 2021 [27]. Therefore the rate of adult hospitalizations for complicated malaria as well as ACT consumption data from 2018 to 2022 would provide useful additional information. In Uganda, a decrease of Artemether-Lumefantrine treatment prescription and a decrease of the number of RDTs tests of malaria were observed in the post COVID-19 period [28].

This study has some limitations. First, although they are the most affected by COVID-19, the present data cannot be translated to adults. The fear of COVID-19 would have prone the increase of hospital attendance. Secondly, the study was carried out in only public health structure. Nevertheless, the sentinel site of the RHME is the main sentinel site of malaria surveillance where febrile patients benefit from malaria biological diagnosis. There may be a variation according to the use of self-medication as well as accessibility to other health facilities at the time of the pandemic. Additional data should be collected in other healthcare structures in Libreville and its neighbouring areas since it was the epicentre of the COVID-19 pandemic. Finally, this study did not assess the trends of severe malaria prevalence and malaria case fatality rates which were shown to also be influenced by COVID-19. A deep investigation of the patient’s reason of consultations is a limit at the clinical level. This information would have help to better understand the patient behaviour.

Conclusion

During COVID-19 epidemic phase and the following two years, an increase of hospital attendance of febrile children for malaria testing and of anti-malarial drug self-medication, a decrease of ITN use and a rise of clinical malaria cases were observed in Libreville. The present results also suggest that COVID-19 epidemic phases were followed by an increase in malaria prevalence in 2020, 2021 and 2022. Additional data such as qualitative study on population healthcare-seeking behaviours during epidemics as well as data from adults living in Libreville and surrounding areas would complete the present data, in order to design a strategy for malaria control during epidemics. Such real-world information are very important for the design of epidemics and pandemic preparedness strategy.

Availability of data and materials

No datasets were generated or analysed during the current study.

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Authors and Affiliations

  1. Department of Parasitology-Mycology and Tropical Medicine, Université Des Sciences de La Santé de Libreville, BP 4009, Libreville, Gabon

    Denise Patricia Mawili-Mboumba, Fanny Bertrande Batchy Ognagosso, Noé Patrick M’Bondoukwé, Jacques Mari Ndong Ngomo, Bridy Chesly Moutombi Ditombi, Bedrich Pongui Ngondza, Reinne Moutongo Mouandza, Coella Joyce Mihindou, Dimitri Ardin Mabika Moussavou, Ornella Anaïse Mbang Nguema & Marielle Karine Bouyou-Akotet

  2. Operational and Clinical Research Unit, Regional Hospital Estuaire Melen, Libreville, Gabon

    Denise Patricia Mawili-Mboumba, Fanny Bertrande Batchy Ognagosso, Noé Patrick M’Bondoukwé, Jacques Mari Ndong Ngomo, Bridy Chesly Moutombi Ditombi, Ahmed Adissa Agbanrin, Tatiana Nymane, Bedrich Pongui Ngondza, Reinne Moutongo Mouandza, Coella Joyce Mihindou, Dimitri Ardin Mabika Moussavou, Ornella Anaïse Mbang Nguema & Marielle Karine Bouyou-Akotet

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  1. Denise Patricia Mawili-Mboumba
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  2. Fanny Bertrande Batchy Ognagosso
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Contributions

D.P.M.M and B.A.M.K conceptualized the study, performed literature search, interpretation of data and drafted the manuscript. F.B.B.O; AAA, J.M.N.N; BCMD; CJM; RMM; TN; DAMM; O.A.M.N: collected, performed malaria diagnosis and data entry in the excel sheet. N.P.M and B.A.M.K: performed the statistical analysis. DPMM and BAMK wrote the manuscript draft. All authors revised the manuscript. D.PM.M. and B.A.M: revised the final manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Denise Patricia Mawili-Mboumba.

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Ethics approval and consent to participate

In Gabon, the Ministry of Health, represented by the Malaria National Control Programme, has committed the Department of Parasitology-Mycology and Tropical Medicine of the Faculty of Medicine of Libreville to monitor malaria prevalence and anti-malarial drug resistance in sentinel sites for malaria surveillance. The approval was obtained by the MNCP for the publication of the data. Adolescents and children’s parents or guardians attending the sentinel site were informed on the purpose of the use of their data, for public health or research purpose. In this context, patients and the guardian or parent of the children included were informed of the activities in this sentinel site and their signed consent was obtained. Children over the age of 12 gave their consent to participate in the study.

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Mawili-Mboumba, D.P., Batchy Ognagosso, F.B., M’Bondoukwé, N.P. et al. Hospital attendance, malaria prevalence and self-medication with an antimalarial drug before and after the start of COVID-19 pandemic in a sentinel site for malaria surveillance in Gabon. Malar J 24, 28 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12936-025-05272-2

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Keywords

Malaria Journal

ISSN: 1475-2875

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