Rwanda confronts a surprising surge in malaria

After years of progress in reducing malaria cases, Rwanda is confronting a surprising resurgence and signs of treatment resistance that have forced officials to revisit vaccine intervention the country once declined.

Rwanda had recorded steady declines in malaria infections for nearly a decade, with cases falling from nearly five million in 2016, to just 430,000 in 2023 — about a 90 per cent reduction — according to figures from the Rwanda Biomedical Centre (RBC).

But these gains are now under threat, says Aimable Mbituyumuremyi, division manager for malaria and other parasitic diseases at the RBC, Rwanda’s health implementation agency.

In 2024, malaria cases rose by more than 45 per cent in one year, reaching 620,000.

Rwanda had previously opted out of receiving malaria vaccines during the first phase of distribution by the World Health Organization (WHO) and GAVI in 2023, confident in its consistent progress in reducing malaria over the last decade.

“But now, we’re experiencing a surge in the disease,” Mbituyumuremyi said in an interview with SciDev.Net.

“We’re considering using vaccines since all other measures have yet to work and malaria cases are increasing.”

The rise in cases began unexpectedly in January 2024, a time when malaria incidence usually declines, according to Mbituyumuremyi.

It’s the first time we have experienced an increase in malaria cases in Rwanda since 2016.

We’re alarmed that it’s not just a slight increment, but a significant one.”

Aimable Mbituyumuremyi, division manager for malaria and other parasitic diseases at the RBC

According to Mbituyumuremyi, the number of annual deaths fell from 650 in 2016 to 67 in 2023, and more than two dozen districts entered the malaria pre-elimination phase.

He said between January and October 2024, the country recorded 620,000 malaria cases, an increase of nearly 200,000 compared to the same period in 2023.

October alone accounted for 112,000 of those cases, with almost 90 per cent of them (about 100,000) concentrated in just 15 of Rwanda’s 30 districts.

“At this time, we never expected such a burden because we were in the pre-elimination phase,” Mbituyumuremyi explained.

“We anticipated a progressive decrease, not even a slight increase.”

So far 17 African countries have rolled out the malaria vaccine with support from the World Health Organization and Gavi, the Vaccine Alliance.

“Now, we would like that consideration to be extended to us as well,” Mbituyumuremyi  added, referring to the distribution of vaccines.

Rwanda’s malaria resurgence comes despite investments in most malaria-prone districts.

Mbituyumuremyi tells SciDev.Net that Rwanda has invested heavily in existing control strategies, such as indoor residual spraying and mosquito net distribution.

He says the country has spent more than US$1.5 million per district on indoor spraying in a dozen districts.

Drug resistance

The RBC says several factors have contributed to the new surge in cases. These include growing mosquito resistance to drugs, shifting mosquito behaviour, and environmental changes that increase breeding sites.

Preliminary data shown to SciDev.Net by the RBC indicates that the effectiveness of the artemisinin drug is diminishing due to resistance.

Additionally, Mbituyumuremyi says mosquitoes are increasingly biting outdoors rather than indoors, raising the risk for people spending time outside at night.

Mbituyumuremyi also expressed concerns over the possible spread of the disease between countries.

“Preliminary investigations indicate that nearly all the most affected sectors are in the cross-border communities of Nyagatare, Gisagara, and Bugesera,” he said.

To combat drug resistance, Rwanda has started using alternative treatments.

“Since the end of last year, we have been receiving new anti-malaria drugs. While Coartem is being used less frequently, it has not been completely phased out. We are implementing a multiple first-line treatment strategy,” he explained.

Despite the setback, Rwanda still aims to be malaria-free by 2030.

Health officials are re-evaluating the country’s strategy, including the possible adoption of vaccines as part of a broader response.