Figure 2: Rwandan Government COVID-19 Response Infrastructure
The Rwanda Biomedical Centre (RBC) and the MOH, the nation’s central health implementation agencies, have collaborated to develop a six month National COVID-19 Preparedness and Response Plan.9This plan includes four phases of country response: pre-epidemic, sporadic cases dealing with limited numbers of imported cases from affected countries, cluster of cases responding to local transmission in a district, sector, or village and community transmission involving more than one cluster.9
During the preparation phase, incident management has concentrated on establishing a rapid response team (RRT) in districts and health units with 480 trained staff in addition to the creation of COVID-19 Standard Operating Procedures (SOPs).15 The SOPs guide the national response to COVID-19, including leadership structure, infection prevention, epidemiological surveillance, handling of clinical specimens, psychosocial support, case management, community mobilization, and managing misinformation. Importantly, the plan includes the critical step of forming a coordinated national COVID-19 Incident Management System and outlining the allocation of $73,471,760 USD to be utilized over the next 6 months.9
RBC recommendations for healthcare facilities include adequate triage, early recognition of PUIs with subsequent isolation, and ultimately transfer to a COVID-19 treatment center if necessary. They also discuss the need for PPE training and hand-washing stations at all health facilities’ points of entry.15 Their recommended criteria for discharge from COVID-19 treatment centers after 14 days includes three or more afebrile days, significant improvement in clinical condition, and two negative PCR tests more than 24 hours apart.15 Additionally, the RBC highlights the importance of patients receiving appropriate psychological counseling prior to discharge; the psychosocial team is informed once the first test has resulted in order to provide services without delaying discharge.15
The MOH and RBC have released guidelines for community health workers to implement contact tracing.15 They recommend a protocolized system of sharing information related to active cases through Rwanda’s Electronic Infectious Disease Surveillance and Response (eIDSR) and the National Reference Laboratory.15 As part of the response, the pre-established RBC toll-free community health hotline number was transitioned to a COVID-19 hotline and a dedicated WhatsApp™ number has been established for reporting suspected cases which will inform the district’s RRT to investigate.15Due to the importance of maintaining public trust and confidence during the pandemic, a Risk Communication and Community Engagement (RCCE) team was created to provide a unified source of COVID-19 related information through governmental websites and social media in order to combat misinformation.9 The SOP provides a stepwise process for discovering and combating potentially harmful misinformation through daily media review and a coordinated multi-media response.15 The RBC and MOH also outline an organized effort to address COVID-19 related psychological issues through interventions and mental health education specifically designed for health-care workers, patients, and the general population. The National Epidemic Prevention Control Coordination Committee (NEPCC) is tasked with carrying out the recommended psychological intervention to reduce psychological damage and encourage social stability.15The critical need for continued services to treat critical non-COVID-19 public health needs, including HIV, TB, malaria, and maternal health is emphasized. Of note, they plan to distribute 2-3 months of antiretroviral therapy for known HIV patients.9 They will also utilize trained community health workers to complete mass distribution of long-lasting insecticidal nets.9
Consistent communication and public engagement about COVID-19 has been ongoing since late January (Figure 3). Mass media campaigns have been heavily used to increase social awareness of the pandemic, a strategy that Rwanda has also previously employed effectively in its preparation for Ebola virus disease.16 Social media has played a prominent role, with the MOH, Prime Minister, RBC, and other government offices releasing official information on Twitter™, a medium that is already frequently used for public communication in Rwanda. The daily updates also contain reminders of hygiene and prevention practices and emphasize important new public health guidelines, which are usually first announced by the Prime Minister.17 Importantly, official Twitter accounts also promptly acknowledge and debunk inaccurate rumors circulating on social media.13
Local governance and stakeholders have been increasing public awareness for COVID-19 prevention using public and private media, as well as mobile sounds systems via drones equipped with speakers that describe COVID-19 symptoms. Prevention measures including hand washing and avoidance of handshake greetings have been promoted through this approach as well. Communication as part of the pandemic management has been strengthened and controlled by the communication cell of the COVID-19 Joint Task Force Coordination responsible for awareness and community engagement, media management, rumors management.9
The MOH first alerted the public to the presence of COVID-19 in Asia on 21 January.13 In the following week, the MOH released basic hygiene advice for the public and has since regularly posted updates on the nation’s COVID prevention and response measures.13 Initial infection control measures were implemented on 28 January, more than a month before Rwanda’s first confirmed case. These measures included temperature screening and symptom assessment of travelers at all national points of entry, as well as protocolized screening methods within communities and healthcare facilities.15 Beginning with the first case on 14 March, daily updates have been released about the number of new cases and their locations (identified in the first month as either a traveler, result of contact tracing, or case of community transmission), recoveries and deaths, currently active cases, and the number of tests conducted.13
After the first confirmed case, the MOH announced the closure of all schools until September 2020, places of worship, and nightclubs; the postponement of weddings and sporting events; and the use of 114 toll-free number to report suspected COVID symptoms.13In the following week, guidelines for controlling the quality and price for masks, sanitizers and food were released. All arriving and departing commercial flights were ceased for an initial period of 30 days, and mandatory 14-day quarantines were implemented for recent travelers.13 Due to the continued rise of cases, on 21 March the Office of the Prime Minister issued sweeping infection control measures to promote social distancing through various measures, including restrictions on non-essential travel between cities and public transportation, border closures, and non-essential business closures.17 These lockdown measures were extended through 3 May with enforcement provided by police officers regulating circulation within and between districts.17Government-coordinated relief efforts began in late March, with food distribution to vulnerable families identified by neighborhood leaders in order to address unemployment and food insecurity as a consequence of lockdown measures.18 On 18 April, the MOH also announced that masks would be compulsory in public, following changes in mask recommendations from the WHO.16 Following the discovery that cross-border truck drivers delivering essential goods were contributing to a sharp increase in cases on 24 April, protocols for prevention and testing for cargo transport workers at the borders were developed.17,19
From May to July, Rwanda gradually eased lockdown restrictions. In May, full lockdown ended and a curfew was instated; businesses and transport within Kigali resumed and hotels and restaurants were required to register all patrons to facilitate contact tracing.17In June, domestic travel and tourism recommenced in nearly all provinces.17 Places of worship began to reopen in July, and multiple random street testing campaigns have been executed in Kigali to verify the prevalence of COVID-19 following the easing of restrictions.17 International flights were resumed on August 1, with COVID-19 testing strictly required before and after arriving flights.17 Provinces and villages in Kigali in which new clusters of COVID are found are periodically placed back on lockdown, and testing continues in high risk populations and locations.13