The Lancet Infectious Diseases
Jul 2015 Volume 15 Number 7 p747-866
http://www.thelancet.com/journals/laninf/issue/current

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Comment
Ebola: the hidden toll
Mary J Hamel, Laurence Slutsker
Published Online: 23 April 2015
Open Access
DOI: http://dx.doi.org/10.1016/S1473-3099(15)70167-2
Summary
The first anniversary of the west African Ebola epidemic has just passed. In Guinea, Liberia, and Sierra Leone, Ebola virus disease has resulted in more than 10 000 reported deaths while the virtual collapse of the countries’ health-care systems has contributed to countless more. In The Lancet Infectious Diseases, Patrick Walker and colleagues1 describe a mathematical model to estimate the effect of the ongoing Ebola disease epidemic on a less exotic and more familiar killer—malaria. The estimates are sobering, if not surprising: up to 10 900 additional malaria deaths in these three countries in 2014 can be attributed to the disruption of health-care services, with another 3900 attributed to lapses in the delivery of insecticide-treated bednets.

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Articles
Malaria morbidity and mortality in Ebola-affected countries caused by decreased health-care capacity, and the potential effect of mitigation strategies: a modelling analysis
Patrick G T Walker, PhD, Michael T White, PhD, Jamie T Griffin, PhD, Alison Reynolds, MA, Prof Neil M Ferguson, PhD, Prof Azra C Ghani, PhD
Published Online: 23 April 2015
Open Access
DOI: http://dx.doi.org/10.1016/S1473-3099(15)70124-6
Summary
Background
The ongoing Ebola epidemic in parts of west Africa largely overwhelmed health-care systems in 2014, making adequate care for malaria impossible and threatening the gains in malaria control achieved over the past decade. We quantified this additional indirect burden of Ebola virus disease.
Methods
We estimated the number of cases and deaths from malaria in Guinea, Liberia, and Sierra Leone from Demographic and Health Surveys data for malaria prevalence and coverage of malaria interventions before the Ebola outbreak. We then removed the effect of treatment and hospital care to estimate additional cases and deaths from malaria caused by reduced health-care capacity and potential disruption of delivery of insecticide-treated bednets. We modelled the potential effect of emergency mass drug administration in affected areas on malaria cases and health-care demand.
Findings
If malaria care ceased as a result of the Ebola epidemic, untreated cases of malaria would have increased by 45% (95% credible interval 43–49) in Guinea, 88% (83–93) in Sierra Leone, and 140% (135–147) in Liberia in 2014. This increase is equivalent to 3·5 million (95% credible interval 2·6 million to 4·9 million) additional untreated cases, with 10 900 (5700–21 400) additional malaria-attributable deaths. Mass drug administration and distribution of insecticide-treated bednets timed to coincide with the 2015 malaria transmission season could largely mitigate the effect of Ebola virus disease on malaria.
Interpretation
These findings suggest that untreated malaria cases as a result of reduced health-care capacity probably contributed substantially to the morbidity caused by the Ebola crisis. Mass drug administration can be an effective means to mitigate this burden and reduce the number of non-Ebola fever cases within health systems.
Funding
UK Medical Research Council, UK Department for International Development, Bill & Melinda Gates Foundation.