1. Malaria in Rwanda.
A closer Look

2. International Response. Elimination Question? Rwanda’s Burden.
Contents.
Global Scale.
International Response.
Elimination Question?
Rwanda’s Burden.
National Malaria Control Program.
Our Work and the Role of PCVs.

3. The Global Scale.
Burden and distribution

4. 106 malaria-endemic countries. 3.3 billion people at risk.
Worldwide.
106 malaria-endemic countries. 3.3 billion people at risk.

5. 216 million cases of malaria.
Health Burden.
According to the WHO, there were approximately
216 million cases of malaria.
Malaria killed 655,000 people.
That was in 2010 alone.

6. Economic Burden. of Sub-Saharan Africa’s annual GDP,
Economists estimate that
malaria drains 1.3%
estimated at $13 billion.
Economic Burden.

7. impaired cognitive development. school age absenteeism
Education Burden.
Malaria in childhood can lead to
impaired cognitive development.
Malaria is the leading cause of
school age absenteeism
in Africa.

8. 91% of malaria deaths were in Africa. 86% were children.
Global distribution.
91% of malaria deaths were in Africa. 86% were children.

9. the international Response.
MDGs, RBM, and GF

10. Millennium Development Goals.
Malaria directly affects 6 MDGs.

11. Millennium Development Goals.
Malaria directly affects 6 MDGs.

12. Millennium Development Goals.
Malaria directly affects 6 MDGs.

13. UN Special Envoy for Malaria 109 malaria endemic-countries
Global partners.
Multilaterals
Donor Countries
Research & Academia
NGOs
Private Sector
Ex officio members
UN Special Envoy for Malaria
Foundations
Endemic countries
109 malaria endemic-countries
including Rwanda

14. UN Special Envoy for Malaria 109 malaria endemic-countries
Global partners.
Multilaterals
Donor Countries
Research & Academia
NGOs
Private Sector
Ex officio members
UN Special Envoy for Malaria
Foundations
Endemic countries
109 malaria endemic-countries
including Rwanda

15. Global Fund for AIDS, TB, and MALARIA.
2 billion US$ for malaria control and prevention
270 million ITNs distributed; 44 million dwellings sprayed; 260 million drug treatments delivered
The amount committed, while substantial, is still inadequate.

16. The Elimination Question?
Rwanda is moving towards Pre-Elimination by 2017

17. Era of Renewed optimism.
Roll Back Malaria
Global Fund
PMI
Bill and Melinda Gates Foundation Global Community Challenge
2007
2005
2002
1998

18. Melinda Gates, 2007.
“Any goal short of eradicating malaria is accepting malaria; it’s making peace with malaria; it’s rich countries saying: ‘We don’t need to eradicate malaria around the world as long as we’ve eliminated malaria in our own countries.’
That’s just unacceptable.”

19. What’s the difference? Eradication Elimination
Permanent reduction to zero of
worldwide incidence of malaria infection caused by a
specific agent, ex. a particular parasite species.
GLOBAL; FINAL
Interruption in a
defined geographical area of local mosquito-borne malaria
transmission, i.e. zero incidence of locally contracted cases.
REGIONAL; SUSTAINED

20. Global Malaria Action Plan.
Control
Pre-Elimination
Elimination
Prevent Reintroduction
Certified Malaria-Free

21. Elimination does not mean SOME;
Remember…
Elimination does not mean SOME;
it means NONE.

22. Rwanda’s Burden.
The reason we are here

23. Rwanda’s Burden.
227,015 malaria cases in deaths caused by malaria in children under five per 1,000 live births dying from all- causes every year. + the indeterminate burdens: strain on the health system, the economic costs and continuation of the poverty cycle, and the consequences for education.

24. Malaria Incidence By District.

25. Malaria Death Cases By District.

26. Cases by month in High burden districts.

27. Cases by month in High burden districts.

28. National Malaria Control Program.
Strategies, policies, and Success

29. Prevention Strategy. Integrated vector control management
Universal coverage of Long- Lasting Insecticide-treated Nets (LLINs)
Blanket Indoor Residual Spraying (IRS) in targeted high-burden districts
Integrated Information, Communication, Education (IEC) and Behavior Change Communication (BCC) Campaigns

30. Diagnosis and treatment Policy.
Integrated Community Case Management of Childhood Illnesses (ICCM/IMCI/C-IMCI)
All presumed malaria cases laboratory confirmed by microscopy or rapid diagnostic test
Treatment with Artemisinin-based Combination Therapy (ACT)

31. Annual Child mortality Rate.

32. Key Indicators between 2005 and 2010.
Incidence
Morbidity
Mortality
Test Positivity Rate
86%
87%
74%
71%

33. Major Interventions AND SPR.

34. Lesson learned: Gains are Fragile!

35. Sustained Malaria Control.

36. Our Work.
A partnership between PC, PMI, RFHP

37. Activity:
Support the implementation of C-IMCI related to malaria diagnosis and treatment

38. A few More Acronyms.
IMCI: Integrated Management of Childhood Illnesses
Aims to reduce illness, death and disability by targeting the most common and deadly childhood illnesses with integrated prevention and treatment
Case management at health centers, villages and households
ICCM: Integrated Community Case Management
Strategy enabling prevention, treatment, and referral of most common and deadly diseases
Case management at the community level
C-IMCI: Community Integrated Management of Childhood Illnesses
Integrated management of childhood illnesses

39. Primary Causes of Child Mortality.
In Rwanda, the primary causes are:
Malaria
Diarrhea
Pneumonia
Malnutrition

40. Coverage of Core Interventions.

41. Secondary Causes.
The secondary causes of child mortality in Rwanda are:
Lack of immediate care
Being far from health center
Delays in seeking treatment
Inadequate treatment from caregivers
Inability to diagnose and treat illnesses

42. Secondary Causes. Lack of appropriate care at the community level
The secondary causes of child mortality in Rwanda are:
Lack of immediate care
Being far from health center
Delays in seeking treatment
Inadequate treatment from caregivers
Inability to diagnose and treat illnesses
Lack of appropriate care at the community level

43. main illnesses children community level..
To achieve its global commitment and national
priorities, Rwanda must treat the
main illnesses
affecting
children
at the
community level..

44. National Community Health Policy.
In each village, there are 4 CHWs:
2 CHWs (1 male/1 female) compose the Binome
1 Maternal and Child Health
1 Social Affairs
Village

45. National Community Health Policy.
In each village, there are 4 CHWs:
2 CHWs (1 male/1 female) compose the Binome
1 Maternal and Child Health
1 Social Affairs
Village

46. CHW Binome Responsibilities.
1. Case management for children under five years old at the community level (C-IMCI)
Referral of children with danger signs to health center
Treatment of simple confirmed cases of malaria, diarrhea, and pneumonia
Checking for severe and moderate malnutrition
Promotion of family health practices and disease prevention
2. Participating in outreach activities organized by the health center
Village

47. Training for CHWs.
The CHW binome receives training on C-ICMI with refresher trainings as needed
Training contains 8 lessons:
National Community Health Policy
Materials and Tools Used by the CHW
Individual Sick Child Recording Form
Community IMCI Register
Referral and Counter-Referral Form for a Child
Drug Management
Supervision Forms for CHW Activities
Monthly Activity Report for CHWs

48. Algorithm for treatment.

49. Algorithm For Fever.

50. Role Of PCVs in C-IMCI.
CHW binome
PCV
PCVs have a role working with CHWs to encourage proper treatment and disease prevention.

51. Activity:
Support improvement in the quality and timeliness of CHW-reported malaria data to SISCom

52. Health Information Systems.

53. SISCom Data Flow.

54. Monthly Activities report.
The Monthly Activities Report is composed of 9 parts:
Treating Sick Children: Lines 1-7
Nutrition, Vaccination, and Nutritional Supplement: Lines 8-14
Missing
Maternal Health and Community-Based Nutrition: Lines15-26
Family Planning: Lines 27-29
Mortality: Lines 30-33
Disease Follow-Up: Lines 34-38
Supervision and Meetings/IEC Participation: Lines
Payments
Drugs and Supplies A. B. D. E. F. J. G. H. I.

55. Monthly Activities report: Fever.
CHWs calculate:
Number of sick children under 5 years old seen by the CHW (Total/Treated/Referred (directly or after treatment))
Cases 6-59 months with fever/malaria presenting within 24 hours (Total/Treated)
Cases 6-59 months with fever/malaria presenting after 24 hours (Total/Treated)
Number of RDTs carried out (Total/Positive/Negative/Invalid) A.

56. Sources of Information.
Individual Sick Child Recording Form
C-IMCI Register

57. Role of PCVs in SISCom.
1. Retrospective review of SISCom data compared to health center and CHW data collected by PCVs. 2. Organize training-of-trainers for PCVs to provide training to CHWs on data collection and reporting. 3. Analyze and relay feedback on SISCom to health centers where PCVs are placed to encourage data use in decision-making. 4. Maintain and disseminate process documentation to support further rollout of data quality training. 5. Perform post-assessment to identify improvements in data quality and timeliness of reporting on malaria at the community level.

58. Activity:
Reinforce the active surveillance of LLIN usage and longevity

59. LLIN Tracking Study. Indicators:
Survivorship: the number of nets hanging in study households
Durability: the condition of the nets in study households
Bio-efficacy: the effectiveness of insecticide on nets in the study households

60. At 18 months, the percent survivorship was estimated to be in the range of 71-81%.

61. Durability Measurement Tool.

62. Durability Calculation.
Proportional Hole Index
(1 x # of Size 1) + (23 x # of Size 2) + (196 x # of Size 3) + (574 x # of Size 4)
1.6 cm²
36 cm²
306 cm²
900 cm²

63. Durability Analysis. New 0 PHI Good <64 PHI Replace >768 PHI
Serviceable

64. Durability.

65. Bio-Efficacy.

66. The longevity of nets in Rwanda is only 1.5 years!
Conclusion:
The longevity of nets in
Rwanda is only 1.5 years!

67. Lesson learned: Gains are Fragile!

68. Research Question.
What behavioral aspects determine the durability and bio-efficacy of nets and contribute to LLIN loss? .

69. Role of PCVs in LLIN Survey.
1. Develop a Rapid Survey Tool for PCVs to assess LLIN loss by households on a quarterly basis. 2. Conduct ToT for PCVs in application of the survey tool and LLIN activities 3. Maintain and provide process documentation to support further roll out of LLIN surveillance.

70. First Malaria Survey.
Results are coming!

71. Contact your Malaria Volunteers
START STOMPING!
Contact your Malaria Volunteers
for more resources.
Murakoze!