Date Published: September 27, 2017
Publisher: The American Society of Tropical Medicine and Hygiene
Author(s): Erin Eckert, Lia S. Florey, Jon Eric Tongren, S. René Salgado, Alphonse Rukundo, Jean Pierre Habimana, Emmanuel Hakizimana, Kaendi Munguti, Noella Umulisa, Monique Mulindahabi, Corine Karema.
The impressive decline in child mortality that occurred in Rwanda from 1996–2000 to 2006–2010 coincided with a period of rapid increase of malaria control interventions such as indoor residual spraying (IRS); insecticide-treated net (ITN) distribution and use, and improved malaria case management. The impact of these interventions was examined through ecological correlation analysis, and robust decomposition analysis of contextual factors on all-cause child mortality. Child mortality fell 61% during the evaluation period and prevalence of severe anemia in children 6–23 months declined 71% between 2005 and 2010. These changes in malaria morbidity and mortality occurred concurrently with a substantial increase in vector control activities. ITN use increased among children under five, from 4% to 70%. The IRS program began in 2007 and covered 1.3 million people in the highest burden districts by 2010. At the same time, diagnosis and treatment with an effective antimalarial expanded nationally, and included making services available to children under the age of 5 at the community level. The percentage of children under 5 who sought care for a fever increased from 26% in 2000 to 48% in 2010. Multivariable models of the change in child mortality between 2000 and 2010 using nationally representative data reveal the importance of increasing ITN ownership in explaining the observed mortality declines. Taken as a whole, the evidence supports the conclusion that malaria control interventions contributed to the observed decline in child mortality in Rwanda from 2000 to 2010, even in a context of improving socioeconomic, maternal, and child health conditions.
Rwanda is a small (26,338 km2), land-locked country in the Great Lakes region of eastern Africa, bordered by Uganda, Burundi, the Democratic Republic of the Congo, and Tanzania. It has a population of approximately 11.8 million, making it the most densely populated country in continental Africa.1 The entire population is at risk for malaria, including an estimated 2.2 million children less than 5 years of age and 443,000 pregnant women per year. Rwanda is divided into four malaria ecologic zones based on altitude, climate, level of transmission, and disease vector prevalence (Figure 1). Malaria is mesoendemic in the plains and epidemic prone in the high plateaus and hills. Malaria transmission occurs year round with two peaks (May–June, November–December) in the endemic zones. Other factors that influence malaria transmission include access to and use of health-care services, high population density, population movement (from areas of low to high transmission), irrigation schemes, and cross-border movements of people.
Vector control has long been one of the principal means of controlling malaria in Rwanda. In the 1990s, Rwanda began targeted distribution of bednets to pregnant women and children through antenatal clinics and vaccination campaigns. Long-lasting ITNs were introduced in 2006 and noninsecticidal nets banned in 2008.10
Rwanda was very successful at expanding the coverage of malaria-control interventions over the decade of the evaluation period. Bednet coverage increased exponentially such that 82% of households owned an ITN by 2010. IRS, which started later in the decade, covered a large portion of the population in the areas of high transmission by 2010. Similarly, the health sector improved its ability to detect malaria, through widespread use of RDTs, and to treat infections with an effective antimalarial.
Rwanda made dramatic progress in increasing population coverage of malaria prevention and treatment measures in the decade from 2000 to 2010. In this timeframe, Rwanda saw a substantial increase in bednet ownership, use among children under five, and sizeable gains in access to diagnosis and treatment of malaria. Over the same period, ACCM declined 61% and prevalence of severe anemia in children 6–23 months declined 71%. Larger declines in child mortality and severe anemia were observed in rural areas, where the burden of malaria is higher compared with urban areas. Multivariable models of the change in child mortality between the 2000 and 2010 DHS reveal the importance of increasing bed net ownership in explaining the observed mortality declines. Taken as a whole, the evidence supports the conclusion that malaria control interventions contributed to the observed decline in child mortality in Rwanda from 2000 to 2010, even in a context of improving socioeconomic, maternal, and child health conditions.