Rwanda is experiencing low and very low levels of malaria test positivity rates, thought there are a few districts near the borders with Uganda, Tanzania and Burundi that have relatively higher transmission. Overall the country is strategizing how to move toward the pre-elimination phase on the pathway to malaria elimination. This is defined as a test positivity rate of less than 5% during the high transmission season.
It is important to distinguish between test positivity rate and prevalence rate. The most recent survey report that gives prevalence is the DHS 2010 with a rate of 1.4% in children below 5 years of age and 0.7% among women of reproductive age. During 2010 the health management information system shows that among those tested (microscopy or RDT) for malaria, 24% were positive. The population for test positivity reports is a much smaller group that is already suspected of having malaria. That said, 24% or the 2013 rate of 29% is still far from the 5% cut-off for pre-elimination status.
Rwanda still maintains a policy of universal coverage with insecticide treated nets (ITNs). Rwanda also has a policy that every pregnant woman should receive an ITN during her first antenatal care visit. Ideally in order to reach pre-elimination status, a country needs to sustain high coverage of malaria prevention and treatment interventions at an 80% level for several years.
The newly released preliminary results of the 2014-15 DHS provide an opportunity to examine achievements. The 2014-15 DHS found that 81% of households had at least one ITN, while 43% had achieved the universal coverage target of one ITN per two household members. These numbers remain basically unchanged from the 2013 Malaria Information Survey (83% and 43%), while the 2010 DHS found 82% of households had a net, but did not report on the indicator of one net per two people. In short, it appears that coverage levels have been maintained at a certain level.
DHS 2014-15 shows that 99% of pregnant women in Rwanda received antenatal care from a skilled provider. That means that basically all pregnant women should have received an ITN. 73% of pregnant women had slept under an ITN the night before they were surveyed, while 88% of all women of reproductive age slept under a net. 68% of children below the age of five years slept under an ITN the night before their household was surveyed, while 80% who lived in households that owned an ITN did so.
Indoor Residual Spraying (IRS) is focused on certain high transmission/burden districts. The preliminary 2014-15 DHS does not report on this and the 2013 MIS reports broadly by region, hence one sees coverage reports for IRS in the east (22%) and south (16%), where there is greater malaria burden, but this cannot be linked to specific districts that may have been targeted.
Rwanda also has a policy that all suspected malaria cases should be tested, whether with microscopy in health centers or rapid diagnostic tests by village health workers. It is only those persons testing positive for malaria who are supposed to be given malaria medicine.
DHS shows that 1439 children below five years of age (or 19% of the total) had fever in the two weeks prior to the survey. Of these 36% reported having a blood test performed, and 11% of those with fever received the approved artemisinin-based combination (ACT) therapy drug. The report does not indicate the actual test results of those receiving ACT.
As Rwanda strategized toward reaching malaria pre-elimination status it can consider ways of enhancing ITN use, not only among vulnerable groups like small children and pregnant women, but all members of the household. As prevalence drops, so does acquired immunity, putting adults at greater risk.
The universal coverage target of at least 1 net for every two people in a household must be maintained, especially since it is nearing three years since the last universal coverage distribution campaign. Either another campaign will be needed or efforts to strengthen delivery of nets to families through routine health services.
In addition prompt and appropriate treatment based on diagnostics can be strengthened. One would have expected more children with fever to have been tested for malaria that the DHS reports.
Internal and external support is needed. Rwanda has been on the verge of reaching malaria pre-elimination status several times in the past decade. Even though malaria is no longer the top cause of death, we should not reduce our efforts to create a malaria-free Rwanda.