Rwanda

Photo: Smiling boy East Africa

Malaria facts

Malaria continues to be a major public health concern and priority in Rwanda because it is considered one of the leading causes of morbidity and mortality. The entire 12.9 million population in Rwanda is at risk for malaria and pregnant women, children under five years of age, and refugees are among the most vulnerable groups.[1] 

Between 2005 and 2011, Rwanda’s scale-up of interventions successfully reduced malaria incidence by 86% and in-patient malaria deaths by 74%, with at least 8 districts achieving pre-elimination. Rwanda then experienced an upsurge in malaria cases during 2012 to 2017.Malaria incidence increased from 48 cases per 1,000 in 2012 to 403 per 1,000 in 2016, while mortality increased by 41% during this period. In response to the malaria upsurge, Rwanda’s Malaria and Other Parasitic Diseases Division (MOPDD) conducted an in-depth data analysis and identified potential contributing factors, including: 

  • Changes in rainfall and temperature 
  • Increased agricultural irrigation that led to increased water bodies 
  • Resistance to insecticides (pyrethroids) that resulted in ineffective preventive measures such as insecticide-treated mosquito nets (ITNs) and indoor residual spraying (IRS), 
  • Shifts in mosquito behavior to early and outdoor biting 
  • Insufficient coverage of interventions including ITNs and IRS, and  
  • Increased case detection and reporting rate from health facilities and community into the system. 

The MOPDD subsequently developed and implemented a Malaria Contingency Plan in 2016 for enhanced strategies to reduce malaria burden, which were revised in 2017 based on extensive consultations involving international stakeholders and data analysis on impacts of implemented interventions.  

Between 2017 and 2020, malaria cases decreased 68%, from 725 to 231 per 1000 of the population at risk, while deaths decreased 3.6%, from 0.244 to 0.235 per 1000 of the population at risk.[2] Higher malaria incidence was observed in the southern districts, with concentrated pockets showing incidences greater than 450 cases per 1,000 people in 2020.[1] In 2020, Rwanda accounted for 1.2% of global malaria cases and deaths, and 5.3% of malaria cases in East and Southern Africa. [2] 

The MOPDD – a division within the Rwanda Biomedical Centre (RBC) under the Ministry of Health (MOH) – has developed the Rwanda Malaria Strategic Plan (MSP) covering the 2020–2024 period.[1] 

Case management 

Parenteral artesunate is the recommended treatment of severe malaria for all patients except for pregnant women during the first trimester who are recommended to receive intravenous quinine.[1]  The Rwanda national treatment guidelines were updated to include artesunate suppository indicated only as an initial (pre‐referral) intervention of severe malaria, recommended for use only in children six months to six years of age given that this management of severe malaria cases is restricted only to district, provincial and referral hospitals.[1] The MOPDD uses RapidSMS (transitioning to RapidPro) a rapid, secure short message service (SMS) system introduced in late 2018 for coordination of severe malaria case referral from community health workers (CHWs) to health facilities.[1] 

Prevention of malaria 

Rwanda has been distributing ITNs since 2006 with a view to reaching universal coverage. As part of the Extended Malaria Strategic Plan 2013–2020, the MOPDD conducted a mass campaign in 2016– 2017, which targeted all districts in the country including a top-up among the population that had not received ITNs from the 2015 distribution, to markedly increase ITN ownership.  

The Malaria Indicator Survey in  2017 showed ownership of one ITN per household at 84% and universal coverage (i.e., one ITN for every two persons) at 55%. Based on these findings, the MOPDD revised its policy on ITN distribution which previously had focused on sleeping spaces to be in line with WHO guidance (i.e., one net per 1.8 people).  During the most recent mass campaign in 2020, the country distributed standard and piperonyl butoxide (PBO) nets.[1] 

The Rwanda MSP 2020–2024 does not include drug-based prevention. Intermittent preventive treatment for pregnant women was discontinued in 2008 due to evidence of high-level resistance to sulfadoxine- pyrimethamine. Seasonal malaria chemoprevention and other drug-based preventive approaches are not recommended for Rwanda.[1]  

National treatment guidelines
Uncomplicated  malaria Treatment
First-line treatment artemether-lumefantrine (AL)
 Severe malaria Treatment
Strong IV Artesunate
Alternative IV Quinine

 

Pregnancy
Recommendation Prevention
Strong

Sulfadoxine-pyrimethamine
(intermittent preventive treatment)

Pregnancy
Recommendation Treatment
Uncomplicated oral quinine plus clindamycin (first trimester)
Uncomplicated AL (second and third trimesters)
Strong IV quinine (first trimester)