Persistence of Malaria in Pregnancy as Rwanda Targets PreElimination

William Brieger1, Corine Karema2, Beata Mukarugwiro1, Aline Uwimana2, Rachel Favero1, Irenee Umulisa2
1. 2. Maternal and Child Health Integrated Program (MCHIP), Jhpiego Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Center, Ministry of Health

Background
Malaria is decreasing in Rwanda, and the country is preparing for pre-elimination. The 2010 Demographic and Health Surveys (DHS) showed:

Only 1.4% of children were rapid diagnostic test positive (RDT+) Only 0.7% of women were RDT+

Malaria has dropped to the 8th reason for outpatient attendance, but pockets of disease remain.

Progress Over Time

Declining incidence (health center laboratory reports):
86% decline between 2005 and 2011

Declining morbidity:
87% decline in outpatient cases between 2005

and 2011

Declining mortality:
74% decline in inpatient deaths between 2005

and 2011

Declining Test Positivity Rate (health centers):

71% decline between 2005 and 2011
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Performance Review: Current Malaria in Pregnancy (MIP) Strategies

In 2008, Rwanda discontinued the use of intermittent preventive treatment in pregnancy (IPTp) based on studies that showed sulfadoxine-pyrimethamine (SP) therapeutic failures and increasing resistanceat 65% in some areas. There has been a strong focus on providing long-lasting insecticide-treated nets (LLINs) during antenatal care (ANC) and through community mobilization: 72% of pregnant women use LLINs (2010 DHS). Use of ANC laboratory testing of suspected malaria and treatment with artemisinin-based combination therapies (ACTs) is another strategy in place. Community maternal health agents follow pregnant women and refer if malaria is suspected. Is this enough to reach pre-elimination?
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Approaching Elimination Needs a Special Strategy

Components:
Epidemiological surveillance, including case

detection Entomological surveillance Focused control

What is needed for MIP?

We must first learn about nature and extent of

problem.
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Study Design and Methods

Prevalence at time of first ANC visit in current pregnancy Two districts each with relatively high, moderate and low cases Rapid diagnostic test (RDT), microscopy and polymerase chain reaction (PCR) assay Existing ANC staff trained Ethical review
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Six Health Centers and ~670 Clients per Study District

High Moderate Low

Overview of the ANC Clients

A total of 4,037 participants in the six districts were recruited during ANC registration. 81% of their families owned a LLIN, but only 74% slept under a net the previous night. 53% were having their first or second pregnancy. 87% were under 35 years of age. 3.3% were HIV-positive (test is normal part of ANC).
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RDT, PCR and Microscopy Prevalence

18% 18% 16% 16% 14% 14% 12% 12% 10% 10% 8% 8% 6% 6% 4% 4% 2% 2% 0% 0%

Malaria Test Results for P. falciparum by District Malaria Test Results for P. falciparum by District
15.4% 15.4%

Percent Positive Percent Positive

9.8% 9.8%

9.5% 9.5% 6.3% 6.3%

4.0% 4.0% 2.8%

1.7% 1.7%

3.1% 3.1% 2.8%

0.0% 0.0% 0.0% 0.0%

Gakenke Gakenke

0.0% 0.0% 0.0% 0.0%

1.3% 1.3% 0.7%

2.7% 2.7%
0.6% 0.3% 0.6% 0.3%

0.0% 0.7% 0.0%

Gisagara Gisagara

Karongi Kicukiro Karongi Kicukiro District

District

Nyagatare Ruhango Nyagatare Ruhango

% PCR % RDT % Microscopy % PCR % RDT % Microscopy

Positive Predictive Value (PPV)

Compared to

Test

Test

PPV

RDT

PCR

69%

Micro

PCR

81%

Micro

RDT

84%

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LLIN Use and Malaria Positivity

9 Percentage/Prevalence 8 7 6 5 4 3 2 1 0 PCR No Net
11 1.9% 1.2% 2.8% 4.9% 4.8% 8.5%

RDT Used Net

Microscopy

Anemia/Hemocue Results and Test Positivity

13.0 12.5 12.0 11.5 11.1 11.0 10.5 10.0 Microscopy Positive
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12.7

12.7

12.7

11.8 11.4

RDT Negative

PCR

Other Factors Tested but Not Associated with Test Results

Age Parity HIV status

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Implications for Action

Geographically-targeted interventions Intermittent screening and treatment at ANC Community health workers:
Agent de Sant Maternelle Intensified LLIN promotion

Surveillance:
Passive Active Borders (highest prevalence

districts on borders)
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MURAKOZE CYANE
Thank You

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