310transition from malaria control surveillance to malaria elimination surveillance. References...
1
This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the Maternal and Child Survival Program and do not necessarily reflect the views of USAID or the United States Government. Toward Malaria Preelimination in Rwanda: Reactive Case Investigation in a Low-Endemic District Noella Umulisa 1 , Didier Uwizeye 1 , Angelique Mugirente 1 , Veneranda Umubyeyi 1 , Beata Mukarugwiro 1 , Stephen Mutwiwa 1 , Jean Pierre Habimana 2 , Corine Karema 3 , and Aimable Mbitumuremyi 2 1 Maternal and Child Survival Program/Jhpiego; 2 Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Centre; 3 Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute Introduction • Rwanda has been heralded as a success story in the fight against malaria. The country has reached near-universal coverage of long-lasting insecticidal nets, artemisinin- based combination therapy, rapid diagnostic tests, and targeted indoor residual spraying in three districts. • However, between 2012 and 2014, Rwanda grappled with an unprecedented rise in malaria cases, even with optimal coverage of both preventive and curative key malaria control interventions. 1 • This change can be attributed to an increase in temperature, rainfall, and resistance to insecticides in the country and in the region. 1 • Despite this setback, Rwanda aims to reach the preelimination phase by 2018 (slide positivity rate < 5%). 2 • In 2014, Rwanda initiated preelimination activities in six districts. • In 2015, two low-endemic districts of Rubavu and Gakenke started implementing preelimination activities with a focus on reactive case detection. • Reactive case detection involves screening and treating individuals living in close proximity to passively detected cases of malaria, also known as index cases. 3 • In Rwanda, index case detection (investigation) involves testing individuals with a rapid diagnostic test and treating those who test positive according to government protocols. • Reactive case detection is recommended by the World Health Organization because it is useful for capturing and treating asymptomatic infections, thereby further preventing the spread of the disease. 3 Test Positivity Rate in Six Preelimination Districts 310 Annual Trend in Malaria Cases in the Rubavu District Eight Districts Implementing Malaria Preelimination Strategies 2012–2015 Study’s Goals • This study evaluated the Rubavu district’s performance in investigating reactive cases. • We analyzed the malaria cases that the Rubavu district was notified of and investigated from January to December 2015. Methods • We retrieved Health Management Information System data from Rubavu health centers conducting malaria preelimination activities from January–December 2015 • We retrieved from Rwanda preelimination data base the numbers of confirmed and investigated cases in Rubavu district from January–December 2015 • Data were aggregated by health facility • Data were analysed using Excel 2013 and STATA Version 13 Results Between January and December 2015: • A total of 66 health care providers out of 165 clinical staff in the 11 health facilities of Rubavu District were trained on preelimination interventions. • 16,434 cases of malaria were detected and treated. • 2,917 (17.8%) index cases were investigated, and 4,943 individuals (1–2 contacts for each index case) living in proximity to index cases were tested using rapid diagnostic tests. • 508 (10.3%) individuals tested positive for malaria and were treated according to national guidelines. Proportion of Confirmed Malaria Cases at the Rubavu District Health Centers in 2015 Malaria Cases Investigated and Not Investigated in the Rubavu District in 2015 Burera Gakenke Musanze Ngorero Nyabihu Rubavu Y2013 Y2012 Y2014 Y2015 Y2016 Dist Avg 0.5 0.4 0.3 0.2 0.1 0.0 0 10,000 20,000 30,000 40,000 50,000 60,000 Y2016 Y2015 Y2014 Y2013 Y2012 53,836 16,449 1,941 574 460 Malaria Cases Discussion • Data show that the number of investigated cases is still lower than what is recommended in the national guidelines (to screen five individuals residing between 100–500 meters of every confirmed case). • Screening 75% of investigated cases is the national target; the 17.8% found in the Rubavu district falls significantly below this target. • The low rate could be due to the increase in malaria cases in Rwanda, which has placed a burden on health care providers and health facilities in areas like Rubavu that used to be low-endemic for malaria. • Data indicate a need to provide additional training to health care providers on screening investigations, so they adhere to national guidelines and conduct investigations more efficiently. • To reduce the national slide positivity rate to < 5% by 2018 will require a more aggressive strategy in low-transmission districts, which may include linking the vector control component to active case detection and treatment. Conclusions and Recommendations • In 2015, Rubavu District had a slide positivity rate > 5%. • Only 17% of malaria cases were investigated, which is a low performance. • Critical challenges to the ambitious goal of malaria preelimination exist in the Rubavu district and other preelimination districts in Rwanda. • Reactive case investigation alone is not enough to stop the spread of malaria transmission and maintain a slide positivity rate < 5%. • Malaria control interventions need to be strengthened to decrease cases in Rubavu and Rwanda. • The preelimination activities and approach need to be restrategized. • To achieve malaria preelimination, link vector control component to reactive case detection and treatment. • Preelimination activities should be scaled to other low- transmission districts only when case-based surveillance response is optimized in Rubavu and the other four current preelimination districts. • Active case investigation could be improved by training and involving more health care providers such as community health workers who could reduce the burden on health center staff. • Additional support for case investigation activities and improved training can help achieve a higher coverage of individuals located near index cases. • Use evidence generated in Rubavu and other preelimination districts to inform policy development to transition from malaria control surveillance to malaria elimination surveillance. References 1 2016. Malaria contingency plan. 2 2016. The feasibility of malaria preelimination and elimination in Rwanda. 3 2013. WHO. Disease surveillance for malaria elimination. Geneva, World Health Organization, 2012 http://apps.who.int/iris/bitstream/10665/44852/1/9789241503334_eng.pdf?ua=1. Byahi Health Center staff in Rubavu testing a child during a reactive case detection. Investigation at Rubavu district at Gisenyi Health Center catchment area. Burera Gisagara Ngororero Rubavu Gakenke Nyagatare Nyabihu Musanze Added January 2015 Preelimination districts Bugeshi Busasamana Byahi Gacuball Gisenyi Karambo Kigufi Mudende Murara Nyakiriba Nyundo Average 55 178 1,978 515 1359 68 746 60 3,925 60 700 877 184 45 50 128 39 682 46 341 203 379 79 29 Cases confirmed at health facilities Investigated case Proportion of Investigated over Confirmed Malaria Cases 4,000 3,500 3,000 2,500 2,000 1,500 1,000 500 0 17.8% 2,917 82.2% 16,434 Malaria cases noninvestigated Cases investigated
Transcript of 310transition from malaria control surveillance to malaria elimination surveillance. References...
This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the Maternal and Child Survival Program and do not necessarily reflect the views of USAID or the
United States Government.
Toward Malaria Preelimination in Rwanda: Reactive Case Investigation in a Low-Endemic DistrictNoella Umulisa1, Didier Uwizeye1, Angelique Mugirente1, Veneranda Umubyeyi1, Beata Mukarugwiro1, Stephen Mutwiwa1, Jean Pierre Habimana2, Corine Karema3, and Aimable Mbitumuremyi21Maternal and Child Survival Program/Jhpiego; 2Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Centre; 3Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute
Introduction • Rwanda has been heralded as a success story in the fight
against malaria. The country has reached near-universal coverage of long-lasting insecticidal nets, artemisinin-based combination therapy, rapid diagnostic tests, and targeted indoor residual spraying in three districts.
• However, between 2012 and 2014, Rwanda grappled with an unprecedented rise in malaria cases, even with optimal coverage of both preventive and curative key malaria control interventions.1
• This change can be attributed to an increase in temperature, rainfall, and resistance to insecticides in the country and in the region.1
• Despite this setback, Rwanda aims to reach the preelimination phase by 2018 (slide positivity rate < 5%).2
• In 2014, Rwanda initiated preelimination activities in six districts.
• In 2015, two low-endemic districts of Rubavu and Gakenke started implementing preelimination activities with a focus on reactive case detection.
• Reactive case detection involves screening and treating individuals living in close proximity to passively detected cases of malaria, also known as index cases.3
• In Rwanda, index case detection (investigation) involves testing individuals with a rapid diagnostic test and treating those who test positive according to government protocols.
• Reactive case detection is recommended by the World Health Organization because it is useful for capturing and treating asymptomatic infections, thereby further preventing the spread of the disease.3
Test Positivity Rate in Six Preelimination Districts
310
Annual Trend in Malaria Cases in the Rubavu District
Eight Districts Implementing Malaria Preelimination Strategies 2012–2015
Study’s Goals • This study evaluated the Rubavu district’s performance in
investigating reactive cases.
• We analyzed the malaria cases that the Rubavu district was notified of and investigated from January to December 2015.
Methods • We retrieved Health Management Information System
data from Rubavu health centers conducting malaria preelimination activities from January–December 2015
• We retrieved from Rwanda preelimination data base the numbers of confirmed and investigated cases in Rubavu district from January–December 2015
• Data were aggregated by health facility
• Data were analysed using Excel 2013 and STATA Version 13
ResultsBetween January and December 2015:
• A total of 66 health care providers out of 165 clinical staff in the 11 health facilities of Rubavu District were trained on preelimination interventions.
• 16,434 cases of malaria were detected and treated.
• 2,917 (17.8%) index cases were investigated, and 4,943 individuals (1–2 contacts for each index case) living in proximity to index cases were tested using rapid diagnostic tests.
• 508 (10.3%) individuals tested positive for malaria and were treated according to national guidelines.
Proportion of Confirmed Malaria Cases at the Rubavu District Health Centers in 2015
Malaria Cases Investigated and Not Investigated in the Rubavu District in 2015
Burera Gakenke Musanze Ngorero Nyabihu Rubavu
Y2013Y2012 Y2014
Y2015Y2016Dist Avg
0.5
0.4
0.3
0.2
0.1
0.0
0
10,000
20,000
30,000
40,000
50,000
60,000
Y2016Y2015Y2014Y2013Y2012
53,836
16,449
1,941574460
Mal
aria
Cas
esDiscussion • Data show that the number of investigated cases is
still lower than what is recommended in the national guidelines (to screen five individuals residing between 100–500 meters of every confirmed case).
• Screening 75% of investigated cases is the national target; the 17.8% found in the Rubavu district falls significantly below this target.
• The low rate could be due to the increase in malaria cases in Rwanda, which has placed a burden on health care providers and health facilities in areas like Rubavu that used to be low-endemic for malaria.
• Data indicate a need to provide additional training to health care providers on screening investigations, so they adhere to national guidelines and conduct investigations more efficiently.
• To reduce the national slide positivity rate to < 5% by 2018 will require a more aggressive strategy in low-transmission districts, which may include linking the vector control component to active case detection and treatment.
Conclusions and Recommendations • In 2015, Rubavu District had a slide positivity rate > 5%.
• Only 17% of malaria cases were investigated, which is a low performance.
• Critical challenges to the ambitious goal of malaria preelimination exist in the Rubavu district and other preelimination districts in Rwanda.
• Reactive case investigation alone is not enough to stop the spread of malaria transmission and maintain a slide positivity rate < 5%.
• Malaria control interventions need to be strengthened to decrease cases in Rubavu and Rwanda.
• The preelimination activities and approach need to be restrategized.
• To achieve malaria preelimination, link vector control component to reactive case detection and treatment.
• Preelimination activities should be scaled to other low-transmission districts only when case-based surveillance response is optimized in Rubavu and the other four current preelimination districts.
• Active case investigation could be improved by training and involving more health care providers such as community health workers who could reduce the burden on health center staff.
• Additional support for case investigation activities and improved training can help achieve a higher coverage of individuals located near index cases.
• Use evidence generated in Rubavu and other preelimination districts to inform policy development to transition from malaria control surveillance to malaria elimination surveillance.
References12016. Malaria contingency plan.22016. The feasibility of malaria preelimination and elimination in Rwanda.32013. WHO. Disease surveillance for malaria elimination. Geneva, World Health Organization, 2012http://apps.who.int/iris/bitstream/10665/44852/1/9789241503334_eng.pdf?ua=1.
Byahi Health Center staff in Rubavu testing a child during a reactive case detection.
Investigation at Rubavu district at Gisenyi Health Center catchment area.
Burera
Gisagara
Ngororero
Rubavu Gakenke
Nyagatare
Nyabihu
Musanze
Added January 2015Preelimination districts
Buge
shi
Busas
aman
aBy
ahi
Gacub
all
Giseny
i
Karam
boKigu
fi
Muden
de
Murar
a
Nyakir
iba
Nyund
o
Avera
ge
55178
1,978
515
1359
68
746
60
3,925
60
700877
184455012839
682
46
341203
379
7929
Cases confirmed at health facilities Investigated case
Prop
orti
on o
f Inv
esti
gate
d ov
er C
onfir
med
Mal
aria
Cas
es 4,000
3,500
3,000
2,500
2,000
1,500
1,000
500
0
17.8%2,917
82.2%16,434
Malaria cases noninvestigatedCases investigated
