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