MAJOR DR VINCENT SUGIRA internal medicine specialist at Rwanda Military Hospital

Over the last few months, Rwanda has been experiencing an upsurge in malaria cases. Hospitals are increasingly taking in malaria patients with some reporting loss of lives.

Interestingly, Rwanda had registered remarkable success in dealing with malaria, so what could have gone wrong and what can be done to reverse the trend. To better understand the gravity of the situation, one has to critically look at the numbers.

In 2011, the Rwanda Military Hospital (RMH)-Kanombe where I work registered only 43 cases of malaria. Last year 453 patients were treated for Malaria with December alone registering142 cases.

As a tertiary referral hospital, RMH receives patients from urban and rural areas either referred or as primary visit. It serves different district hospitals of the country.

Why are we facing increased morbidity and mortality due to malaria after so many years of a well controlled and possible elimination of this disease?

Success in control of the disease was in part due to good policies by the leadership, proper implementation by health care service providers and the mobilisation of the grassroots communities and their subsequent support towards this cause.

For many observers, healthcare providers and the communities, the upsurge is due to ineffective mosquito nets, post-success complacency with decreased efforts in taking strict measures of prevention at different levels.

We need to address these issues at the level of prevention but we also need to do more research to be able to eradicate malaria and have better and lasting cure for malaria.

Malaria is a parasitic infection caused by one of the five species of plasmodium, namely falciparum, vivax, ovale, malariae and knowlesi. Plasmodium falciparum is predominant in sub-Saharan Africa and is associated with high rates of severe forms and complications such as; acute kidney injury, conscious alteration, convulsions, (cerebral malaria) respiratory distress, liver dysfunction, hypoglycemia and so on.

The plasmodium parasite is transmitted to a person via a bite of a female anopheles mosquito between dusk and dawn. Malaria is endemic throughout the tropics. The world Health Organisation (WHO) states that there were 198 million cases of symptomatic malaria cases worldwide in 2013.

In areas where transmission is low, full protective immunity is not acquired and symptomatic disease occurs at all ages with recurrence of any malaria transmission. As there is no non-human reservoirs for the human plasmodia, malaria can easily be eradicated with joint national and international efforts.

On the other hand, people coming from endemic regions can import malaria causing recurrence of symptomatic cases. That is why following successful elimination, ongoing rigorous surveillance is needed to identify those imported cases which must be detected, treated to prevent resurgence of endemic infection.

The WHO defines control of malaria as reduction of disease incidence and prevalence to levels that do not pose a threat to public health that are acceptable to a community, elimination as reduction of incidence and transmission to zero in humans in a defined geographic area. Eradication is a global elimination of human disease.

In all steps a surveillance system that could detect, respond to and report malaria cases and infections is essential. It is important to note that a breakdown in malaria control and prevention services can intensify epidemic conditions.

Strategies to disrupt malaria transmission include effective deployment of anti-malarial drugs, personal mosquito protection, mosquito vector control, and research (including vaccine development).

Optimal malaria control leading to elimination and ultimately eradication requires:

1. Effective human, parasitological and entomological surveillance at health facilities and in communities.

2. An understanding of local anopheline ecology (including breeding, biting , and resting habits).

3. Administrative, managerial, supervisory and operational capacity (including trained leaders and staff).

4. An ongoing monitoring and evaluation system for deployment and use of drugs, long lasting insecticidal nets (LLINS), indoor residual spraying (IRS) and environmental modifications.

5. Sustained high level, long term national and international commitment.

For now, we have to immediately go down to the grassroots communities and sensitize the public using the help of the ever efficient community health workers (Abajyanama b'ubuzima).

The community health workers should teach the basics in Malaria prevention. Households need to know to use mosquito nets for every family member, clean the compound and cut grass and bushes to eliminate breeding grounds for the mosquitoes.

For those who carry out night duties such as guards and security personnel, they should use insect repellents to keep them protected while on duty.

Malaria symptoms include fever, headache, nausea, vomiting, myalgia and artralgia. In the event that one demonstrates any of the symptoms, they should immediately visit the nearest health centre or hospital for rapid test as per national and WHO guidelines.

The healthcare facilities should endeavour to decrease the waiting time for such patients as early detection of Malaria increases the chance of speedy recovery and protects the patients from severity of the disease.

It is important to note that there are patients that show the symptoms of malaria but the blood smears come out negative.

In my opinion as a physician, when a patient has a clinical picture of malaria without any obvious alternative diagnosis, irrespective of a negative blood smear, they should be treated as malaria.

This will limit the progression of malaria to its severe state in false negatives as we noticed in the past for some patients.

The confirmation of the disease is always required to ensure we do not entirely depend on a presumptive treatment, which may have effects.

The recommended prescription for simple malaria is coartem and artesunate for severe forms of the disease.

These medications have proven to be effective when compared to other antimalarial drugs. In their absence or contraindication to the drugs, medical personnel can prescribe quinine or arthemeter.

From our experience at the Rwanda Military Hospital-Kanombe, acting quickly and closely observing patients for any symptoms of severity of the disease has turned out to be an excellent strategy for successfully treating patients.

The battle against malaria is one we can win. Through close collaboration and sharing of experiences amongst medical facilities in the country and in the region, we can come up with a winning strategy to control, eliminate and eventually eradicate Malaria from Rwanda.

The writer is an internal medicine specialist at Rwanda Military Hospital-Kanombe.

sugirav@gmail.com