Forty-five-year-old Agnes Mukakigari recalls her family’s distressing lifestyle, marked by poor hygiene and sanitation, which led to frequent intestinal worm infections during her childhood.

Although her parents used local herbs like Umubirizi (bitter leaf) for relief, their efforts were in vain due to their lack of medical knowledge. The persistent worm infestations left Mukakigari malnourished with a swollen stomach.

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Now a laboratory technician and the eldest of five siblings, Mukakigari faced significant challenges early in life. Orphaned at 13, she became the primary caregiver for her younger siblings. Due to water scarcity, they often used dirty water for cooking or waited for rain to access clean water.

"Many people lost their lives to intestinal worm diseases due to a lack of awareness. There was widespread confusion, with some attributing these illnesses to witchcraft,” Mukakigari reflected.

Due to severe stomach pain, she walked three hours to the nearest hospital in Musanze District, where she was diagnosed with Ascariasis, a roundworm infection. Despite being prescribed Albendazole, the worms persisted.

After getting married in 2005 and giving birth to a son in 2006, Mukakigari’s stomach remained swollen. She sought traditional remedies but was advised by professional friends to visit another hospital. There, doctors discovered acidic water in her stomach, necessitating urgent surgery.

In 2006, Mukakigari, then 27, underwent successful surgery at Ruhengeri Hospital to remove the worms.

According to the 2008 National Prevalence Survey on Soil-Transmitted Helminths and Schistosomiasis in School-aged Children, 94.7 percent of children aged 5-15 were infected with intestinal worms.

"There was no awareness about intestinal worms or Neglected Tropical Diseases (NTDs). People didn’t bother washing their hands before handling food, drinking boiled water, washing vegetables thoroughly with clean water, or wiping wet utensils before using them. This triggered widespread intestinal worm infestations in the country,” Mukakigari explained.

Community Advocates

After her recovery in 2008, Mukakigari sought to raise awareness about the risks of intestinal worms and advocate for safe drinking water, sanitation, and hygiene (WASH). Her training at the Rwanda Biomedical Center (RBC) prepared her for this task. She gathered a team of four community advocates in Karwasa village, Musanze District, to educate others on essential sanitation and hygiene practices.

Clementine Ntawumenyumunsi, one of the initiative’s leaders, emphasised training breastfeeding mothers on proper hygiene.

"We teach people to wash and wipe utensils or leave them to dry under sunlight before using them to prevent bacteria growth,” she said.

"The impact of our efforts has been profoundly rewarding. Witnessing the community’s positive response and the reduction in intestinal worm cases is immensely satisfying,” Ntawumenyumunsi added.

Mukakigari’s WASH awareness initiative uses community platforms like Umuganda (community work) and local gatherings to disseminate crucial information on preventing intestinal worms. During these events, they stress the importance of regular hand washing, proper latrine covering, and other hygienic practices.

Elina Kawera, a resident of Karwasa Village, shared that the initiative has significantly benefited her.

"We were unacquainted with the condition, often confusing it with witchcraft. Since we are now well-informed about proper hygiene, there is a decrease in the prevalence of worm diseases in our area,” Kawera confirmed.

Although there has been improvement in hygiene practices, the community still faces challenges. Water scarcity remains an issue, with the entire population relying on one tank, and each 20-liter water jerry can cost Rwf20.

Musanze is one of the districts with a high prevalence of intestinal worms in Rwanda. The rate of intestinal worms has dropped significantly due to interventions, according to surveys conducted in 2008, 2015, and 2020.

According to the Ministry of Health (MoH), eight of the 20 diseases categorized by the World Health Organization (WHO) as NTDs affect thousands of people in Rwanda each year. Intestinal worms are among the most common NTDs, with a prevalence of 41 percent overall and 48 percent among adults.

Elimination of Intestinal Worms

Ladislas Nshimiyimana, an NTD Research Senior Officer at RBC, says that intestinal worms are prevalent across all districts, with some regions more affected than others.

Deworming, combined with improvements in water sanitation, hygiene, and awareness, has reduced the prevalence of intestinal worms among school-aged children from 66 percent in 2008 to 41 percent in 2020.

"Despite the high prevalence, the Ministry of Health, in collaboration with RBC, has instituted diverse interventions to reach WHO targets by 2030 and eliminate NTDs, including intestinal worms,” Nshimiyimana said.

"We have conducted different interventions, including increasing awareness, prevention, and treatment. The last mapping in 2020 was the impact mass mapping, but we have conducted others in 2008 and 2014, focusing on school-aged children,” he added.

Mass Albendazole administration in some endemic areas has helped reduce the burden.

"As a strategy, we administer this drug twice a year, integrated into Maternal and Child Health Week,” Nshimiyimana noted.

However, he stressed the need for a mindset change among the community to avoid using untreated human waste as fertilizer, which poses significant health risks.

RBC is researching to determine the efficacy of the drugs dispersed. In the meantime, "We have added Ivermectin, a drug recommended by WHO, to increase efficacy,” Nshimiyimana said.

Mukakigari’s initiative, though unregistered, aims to formalize as a Non-Governmental Organization to expand its reach and resources, further advancing public health through improved sanitation and hygiene practices.

"We hope that Mukakigari and her colleagues’ fight against deadly intestinal worms will soon be formalized to supplement the government&039;s efforts to eliminate these infectious diseases by 2030,” Nshimiyimana stressed.