Trends in malaria cases, hospital admissions and deaths following scale-up of anti-malarial interventions, 2000–2010, Rwanda

Corine Karema 2 Maru W Aregawi 1 Alphonse Rukundo 2 Alain Kabayiza 2 Monique Mulindahabi 2 Ibrahima S Fall 0 Khoti Gausi 6 Ryan O Williams 1 Michael Lynch 1 Richard Cibulskis 1 Ngabo Fidele 4 Jean-Pierre Nyemazi 7 Daniel Ngamije 5 Irenee Umulisa 2 Robert Newman 1 Agnes Binagwaho 3 8 0 World Health Organization , Regional Office for Africa (AFRO), Brazzaville , Congo 1 World Health Organization, Global Malaria Programme , Geneva , Switzerland 2 Malaria and Other Parasitic Diseases Division (Rwanda Malaria Control Programme), Rwanda Biomedical Centre, Ministry of Health , Kigali , Rwanda 3 Ministry of Health , Rwanda, Kigali , Rwanda 4 Maternal and Child Health Unit, Ministry of Health- Rwanda , Kigali , Rwanda 5 Single Project Management Unit-GF Projects-Ministry of Health- Rwanda , Kigali , Rwanda 6 World Health Organization, Inter-Country Support Team for Southern and Eastern Africa , Regional Office for Africa (AFRO), Harare , Zimbabwe 7 Planning, M&E Coordination - Rwanda Biomedical Centre, Ministry of Health , Kigali , Rwanda 8 Department of Global Health and Social Medicine, Harvard Medical School , Boston , USA Background: To control malaria, the Rwandan government and its partners distributed insecticide-treated nets (ITN) and made artemisinin-based combination therapy (ACT) widely available from 2005 onwards. The impact of these interventions on malaria cases, admissions and deaths was assessed using data from district hospitals and household surveys. Methods: District records of ITN and ACT distribution were reviewed. Malaria and non-malaria indictors in 30 district hospitals were ascertained from surveillance records. Trends in cases, admissions and deaths for 2000 to 2010 were assessed by segmented log-linear regression, adjusting the effect size for time trends during the pre-intervention period, 2000-2005. Changes were estimated by comparing trends in post-intervention (2006-2010) with that of pre-intervention (2000-2005) period. All-cause deaths in children under-five in household surveys of 2005 and 2010 were also reviewed to corroborate with the trends of deaths observed in hospitals. Results: The proportion of the population potentially protected by ITN increased from nearly zero in 2005 to 38% in 2006, and 76% in 2010; no major health facility stock-outs of ACT were recorded following their introduction in 2006. In district hospitals, after falling during 2006-2008, confirmed malaria cases increased in 2009 coinciding with decreased potential ITN coverage and declined again in 2010 following an ITN distribution campaign. For all age groups, from the pre-intervention period, microscopically confirmed cases declined by 72%, (95% Confidence Interval [CI], 12-91%) in 2010, slide positivity rate declined 58%, (CI, 47%-68%), malaria inpatient cases declined 76% (CI, 49%-88%); and malaria deaths declined 47% (CI, 47%-81%). In children below five years of age, malaria inpatients decreased 82% (CI, 61%-92%) and malaria hospital deaths decreased 77% (CI, 40%-91%). Concurrently, outpatient cases, admissions and deaths due to non-malaria diseases in all age groups either increased or remained unchanged. Rainfall and temperature remained favourable for malaria transmission. The annual all-cause mortality in children under-five in household surveys declined from 152 per 1,000 live births during 2001-2005, to 76 per 1,000 live births in 2006-2010 (55% decline). The five-year cumulative number of all-cause deaths in hospital declined 28% (8,051 to 5,801) during the same period. Conclusions: A greater than 50% decline in confirmed malaria cases, admissions and deaths at district hospitals in Rwanda since 2005 followed a marked increase in ITN coverage and use of ACT. The decline occurred among both children under-five and in those five years and above, while hospital utilization increased and suitable conditions for malaria transmission persisted. Declines in malaria indicators in children under 5 years were more striking than in the older age groups. The resurgence in cases associated with decreased ITN coverage in 2009 highlights the need for sustained high levels of anti-malarial interventions in Rwanda and other malaria endemic countries. - Background Rwanda bordered by Uganda, Burundi, the Democratic Republic of Congo and Tanzania, has an areas of 26,000 sq km and a population of 11 million. Control of malaria, a major public health problem, is integrated into the overall health system through health posts, health centres, district hospitals and referral hospitals complemented by community based treatment using trained health workers. The country is divided into five provinces (North, South, East, West and Kigali) and 30 districts. Rwanda has two distinct malaria epidemiological strata: in two-thirds of the districts, malaria is characterized by seasonal peaks of transmission and in the remaining one-third of districts, malaria transmission is comparatively stable year-round. Before 2005, preventive interventions were limited to delivery of ITN to pregnant women and children under five through social marketing. In 2001, the country changed its first-line anti-malarial treatment policy from chloroquine to amodiaquine and sulphadoxine-pyrimethamine (AQ+SP), implemented during 2002 2005 countrywide; in 2006, the country shifted from AQ + SP to an ACT, artemetherlumefantrine. Rwanda developed its first comprehensive national malaria strategic plan for the period 20052010. Subsequently, the National Malaria Control Programme (NCMP), supported by the Global Fund to Fight HIV/ AIDS, Tuberculosis and Malaria, the President Malaria Initiative, and other development partners, scaled-up malaria control interventions, with insecticide-treated nets (ITN) and artemisinin-based combination therapy (ACT) as key interventions. In 2006 and 2007, over three million ITN were distributed through a mass distribution campaign targeting pregnant women and children below five years of age. During 20092011, over 6.1 million nets were delivered, with the goal of achieving universal coverage with a ratio of one net per two persons. In August 2007, the country implemented targeted indoor residual spraying (IRS) in selected sectors of the three districts of Kigali and later scaled-up to 32 sectors in 5 districts (Nyagatare, Bugesera, Nyanza, Gisagara and Kirehe). Starting in 2006, the country implemented the policy shift from AQ+SP to an ACT, Artemetherlumefantrine for the treatment of malaria cases in all public health facilities beginning in October 2006. In 2009, the country also implemented nationwide community case management of malaria by training and deploying community health workers (CHW) to test febrile cases using rapid diagnostic tests (RDT) and treat confirmed malaria cases with artemether-lumefantrine. Apart from use by CHWs, RDTs were also used in health centres and higher facilities as adjunct to microscopy in emergency cases, after working hours, when the microscopy (...truncated)