By Henry Rosenbloom
Before the creation of Rwanda’s neglected tropical disease program in 2007, there had been little research on two debilitating parasites running rampant throughout the country: intestinal worms and schistosomiasis. But in 2019, the Rwandan government began financing 100% of the operational costs related to mass treatment campaigns that have successfully curtailed these parasitic infections.
Children with intestinal worms or schistosomiasis face a range of health challenges, from malnutrition and anemia to impaired cognitive and physical development. These infections lead to chronic fatigue, stunted growth, and a weakened immune system, leaving children vulnerable to other illnesses. The symptoms can keep children away from school, causing long term educational deficits.
“Children [with schistosomiasis] can have anemia as well as adults, and can be impacted by different morbidities that can affect different organs, like liver fibrosis, which can lead to death,” said Eugene Ruberanziza, Senior Director of Programs at the END Fund.
“If a kid has abdominal pain, they frequently cannot go to school and cannot go far in their education, impacting their future.”
Although the government knew that intestinal worm infections were the second leading cause of health center visits, there was minimal understanding of the total number of people suffering from these infections throughout the country.
Arivella and her little brother, Isaac James sit with their parents.
James Hategekimana was diagnosed with intestinal worms, causing him to become worryingly weak. His family lives near the tranquil shores of Lake Kivu in western Rwanda, an area that has been historically at high risk of both intestinal worms and schistosomiasis. James’ family caught on to his symptoms early, finding him treatment that allowed him to return to a pain-free life.
If James’ infection had happened a decade earlier, the outcome likely would have been different. In 2017, the Ministry of Health purchased the medication needed to ensure health facilities had the drugs for routine cases like James’.
Between 2007 and 2008, the country’s investment began with the arduous task of mapping the prevalence of intestinal worms and schistosomiasis. The results clearly showed that there was a heavy burden of both parasites in many areas of the country with prevalence of intestinal worm infection as high as 95% in many districts.
Not far behind, schistosomiasis ranged up to 69.5% across the surveyed schools. High-infection areas were localized around the many lakes and rice fields in Rwanda where snails live, the vectors for the disease.
After years of treatment through mass treatment campaigns, the government re-surveyed intestinal worms and schistosomiasis in 2014. The results, however, showed that schistosomiasis was more widespread throughout the country than previously believed with cases present in almost every district in areas surrounding perennial water bodies.
The progress was due to improved sampling methodology and, for schistosomiasis, a more sensitive rapid test called (CCA test). However, 9 million people still remain in need of treatment for parasitic worms in Rwanda.
9 million people are still in need of treatment for parasitic worms in Rwanda.
The findings necessitated a reinvigorated investment in treatment and prevention of the disease.
After more than ten years of support from the END Fund, Rwanda has substantially and sustainably reduced its dependence on investor funds because of its comprehensive commitment to schistosomiasis elimination.
“Rwanda is the first country to have a strong supply chain of (neglected tropical disease) drugs. This is because we integrated the supply chain into the existing system. And we came up with this innovative solution to owning 100 percent of the cost for mass drug administration. It is the first country in Africa to have this successful milestone,” said Jean Bosch, Acting Director for NTDs and Other Parasitic Diseases unit at the Rwanda Biomedical Centre (RBC).
Rwanda provides treatment for schistosomiasis at the community level to school aged children and adults living or working in areas that are at a high risk of the disease, ensuring that resources are effectively used. This differs from past campaigns that used to target just school aged children, the group considered to be at the highest risk of long term damage because of these parasites. This holistic approach ensures that the cycle of transmission can be stopped for good.
Communities are provided with information about the importance of drinking clean water, using proper sanitation, and practicing healthy hygiene habits to prevent infections.
“This comprehensive approach applied in Rwanda, like improving hygiene and resource commitment by the government, can be applied in other countries and they can reach elimination.”
– Mr. Ladislas Nshimiyimana, NTD Research Senior Officer, Rwanda Biomedical Centre.
In collaboration with the END Fund, the Ministry of Health is integrating mass drug administration (MDA) campaigns against schistosomiasis and intestinal worms, as well as WASH monitoring, into its new electronic national health information system (eCHIS). The integration of the MDA into the broader eCHIS toolkit of the Ministry of Health will better target the MDA and monitor its implementation in real time using designed dashboards.
These centralized tools help the government measure infections, evaluate treatment effectiveness, track drug supply and use, and digitize the reporting of activities conducted by community health workers, including MDAs.
As a result, schistosomiasis has reached a threshold of elimination as a public health problem, meaning prevalence has been reduced to below 1% of heavy intensity infections in 97% of surveyed villages according to remapping in 2020. This outcome follows years of effective treatment campaigns that were the result of Rwanda’s steadfast commitment to elimination.
Learn more about Rwanda’s blueprint for eliminating parasitic worms!