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Chamberlin, Mary D., and Angela Lee. "A tale of two cohorts: Patients presenting for endoscopy in Kigali, Rwanda compared to an academic medical center in New Hampshire, U.S." Journal of Clinical Oncology 35, no. 15_suppl (2017): e18057-e18057. http://dx.doi.org/10.1200/jco.2017.35.15_suppl.e18057.
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e18057 Background: Gastric cancer is the third leading cause of cancer death worldwide. In Rwanda and East Africs in general, gastric cancer is common in young men and women to the point where the region is known as the "stomach cancer region." Previously reported molecular profiling of Rwandan gastric cancer specimens indicate a lower mutation burden than expected based on historic western-based data; the corresponding database of endoscopy results suggests lsrge differences in access to care. This study compares a US endoscopy database to one from the University of Rwanda, to highlight the disparities of care in low and middle income countries (LMIC’s) compared to higher income countries. Methods: Retrospective pathology, demographic and radiographic data was collected from 164 Rwandan patients who presented for endoscopy at the Kigali University Teaching Hospital and compared with a matching cohort of patients at Dartmouth-Hitchcock Medical Center , Lebanon, NH (DHMC). Results: Approximately 85% of the Rwandan endoscopy cohort presented with gastric cancer, whereas none was seen in the DHMC cohort; the latter group was older than the Rwandan cohort (62.3 vs. 58.6 years). The most common indication for endoscopy among the DHMC cohort was gastroesophageal reflux disease (GERD) or anemia (72%) while the Rwandan cohort most commonly presented with pain or vomiting (68%). A matched US gastric cancer cohort revealed that 63% of US cases of gastric cancer receive treatment with curative intent compared to 7.4% of Rwandan cases. Conclusions: The Rwandan cohort presented with more severe symptoms and was more likely to be diagnosed with gastric cancer than the DHMC patients yet less likely to receive treatment with curative intent. These results highlight the disparities of care in LMIC’s and the need for improving access to early detection and curative treatments.
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Taylor, S., R. Simango, Y. Ogbolu, R. Riel, D. J. Riedel, and E. Musabeyezu. "Hepatitis C Treatment Outcomes in Kigali, Rwanda." Annals of Global Health 82, no. 3 (2016): 562. http://dx.doi.org/10.1016/j.aogh.2016.04.510.
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Uwimana, A., I. Nhapi, U. G. Wali, Z. Hoko, and J. Kashaigili. "Sludge characterization at Kadahokwa water treatment plant, Rwanda." Water Supply 10, no. 5 (2010): 848–59. http://dx.doi.org/10.2166/ws.2010.377.
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A study was carried out to characterize the sludge produced at Kadahokwa Water Treatment Plant (KWTP) in Butare to assess the effectiveness of the sludge treatment and potential impacts of sludge disposal on the environment. Parameters analyzed were chromium, nickel, cadmium, lead, copper, zinc, iron, manganese, aluminium, total nitrogen, total phosphorus, potassium and cation exchange capacity (CEC). The results showed that 450±244.5 tons (dry weight) of sludge are produced annually. The concentrations of heavy metals in the sludge were below the standard limits for land application set by different countries. The high concentrations of nickel (42.3±2.5 ppm), chromium (29.9±6.2 ppm), cadmium (1.1±0.3 ppm) and lead (31.6±3.7 ppm) in the dried sludge posed a pollution risk for the wetland. The CEC was 28.4–33.3 cmol (+)/kg and pH was 6.50–7.45. It was concluded that the KWTP sludge is a poor source of total carbon, a moderate source of nutrients (NPK), and an important source of micronutrients, making it generally suitable for reuse for crop production. The CEC showed that the sludge could improve soil nutrient and water holding capacity. The higher concentration of aluminium (280 ppm) in the sludge creates an opportunity for recycling.
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Lansigan, Frederick, Cristiana A. Costa, Egide Mpanumusingo, et al. "A novel global health fellowship elective in oncology in Rwanda: A multi-faceted model in education." Journal of Clinical Oncology 35, no. 15_suppl (2017): e18086-e18086. http://dx.doi.org/10.1200/jco.2017.35.15_suppl.e18086.
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e18086 Background: Despite the rising burden of cancer, opportunities for global health education (GHE) at the fellowship level are lacking in hematology and oncology (HO). The Geisel School of Medicine at Dartmouth (GSMD) is pioneering a supervised one-month elective in Rwanda for HO fellows enrolled in U.S. programs. The goals are to expose fellows to a wider spectrum of disease states, improve clinical acumen, cultural sensitivity, and learn about health delivery in low-resource countries, while providing educational support for the local staff in a multidirectional learning paradigm. Methods: In partnership with the Rwandan Ministry of Health (MOH) and Partners in Health (PIH), GSMD created a one month elective rotation at the Butaro Cancer Center of Excellence (BCCOE) in Rwanda. HO Fellows with an interest in GHE apply to work in the outpatient clinic and inpatient wards in at BCCOE under direct supervision by GSMD faculty to provide input on cancer management including diagnosis, treatment, and chemotherapy administration. Fellows and attendings give lectures to hospital faculty and staff on topics requested by the leadership of BCCOE and participate in weekly telemedicine tumor boards. Fellows are evaluated using ACGME clinical competencies. Feedback from the Rwandan staff is obtained through customized evaluations. Results: The HO fellow gained exposure to advanced cancers including HIV-related malignancies, rare sarcomas and gestational trophoblastic disease, adhered to locally developed staging and treatment pathways, and gained confidence in guiding medical decisions. Fellows and faculty gave didactic presentations and provided bedside teaching. The local MOH and PIH staff gained new insight about approaches to management of complex disease states. This program promoted a multidirectional exchange of ideas related to patient care, disease states, and collaborative research projects. Conclusions: The institution of a global health fellowship elective in oncology has measurable benefits to HO fellows, cancer care providers in Rwanda and American faculty sub-specialists. This novel educational program will help to bridge the gap in global health disparities in a multifaceted approach.
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Rubagumya, Fidel, Ainhoa Costas-Chavarri, Achille Manirakiza, et al. "State of Cancer Control in Rwanda: Past, Present, and Future Opportunities." JCO Global Oncology, no. 6 (September 2020): 1171–77. http://dx.doi.org/10.1200/go.20.00281.
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Rwanda is a densely populated low-income country in East Africa. Previously considered a failed state after the genocide against the Tutsi in 1994, Rwanda has seen remarkable growth over the past 2 decades. Health care in Rwanda is predominantly delivered through public hospitals and is emerging in the private sector. More than 80% of patients are covered by community-based health insurance (Mutuelle de Santé). The cancer unit at the Rwanda Biomedical Center (a branch of the Ministry of Health) is responsible for setting and implementing cancer care policy. Rwanda has made progress with human papillomavirus (HPV) and hepatitis B vaccination. Recently, the cancer unit at the Rwanda Biomedical Center launched the country’s 5-year National Cancer Control Plan. Over the past decade, patients with cancer have been able to receive chemotherapy at Butaro Cancer Center, and recently, the Rwanda Cancer Center was launched with 2 linear accelerator radiotherapy machines, which greatly reduced the number of referrals for treatment abroad. Palliative care services are increasing in Rwanda. A cancer registry has now been strengthened, and more clinicians are becoming active in cancer research. Despite these advances, there is still substantial work to be done and there are many outstanding challenges, including the need to build capacity in cancer awareness among the general population (and shift toward earlier diagnosis), cancer care workforce (more in-country training programs are needed), and research.
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Francois, U., J. P. Balinda, M. Hagenimana, R. Samuel, E. Arielle, and M. A. Muhimpundu. "Scaling Up of Cervical Cancer Screening at Primary Health Care Level in Rwanda." Journal of Global Oncology 4, Supplement 2 (2018): 54s. http://dx.doi.org/10.1200/jgo.18.78700.
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Background: Rwanda is a high cervical cancer-burden country, with an age standardized rate (ASR) of cervical cancer incidence of 41.8 cases per 100,000 people in 2012. In the same year, cervical cancer mortality lay at 26.2 deaths per 100,000 people. Aim: To address this burden, Rwanda initiated the vision inspection with acetic acid (VIA) screening-based strategy in 2013 in line with WHO recommendations for low- and middle-income countries. The target audience of the program was set for women between the ages of 30 and 49 and remains today. Here, we describe the implementation status of the program at the primary health care level; health centers and district hospitals in Rwanda. Methods: Integrating into Rwanda's existing health system, the program was purposefully rooted in health centers, with a pathway designed for women who screen positive to be referred to the district hospital for cryotherapy or LEEP, according to the lesions' size. Nurses, midwives and medical officers from health centers and district hospitals are trained through a 10-day curriculum (5 days for theory and 5 days for practice) before initiating the provision of services to clients in routine care. Monitoring of the program is conducted through both quarterly, on-site mentorship and screening indicators that are integrated into Rwanda's Health Management Information System (HMIS), through which facilities report on monthly basis. Results: Since its initiation in August 2013, Rwanda's cervical cancer screening program has been established in 21 of 38 (55%) district hospitals and 256 health centers in their catchment area. Training has been an integral component as well, with at least two nurses/midwives trained at implementing health centers and a medical officer with two nurses/midwives trained on cervical cancer screening and the treatment of precancerous lesions at district hospital. In addition, district hospitals have been equipped with cryotherapy, LEEP, and colposcopy machines. Over this program's implementation three-and-a-half-year course, 38,000 women have been screened for cervical cancer. Conclusion: Using a simple VIA-based strategy, Rwanda has been able to swiftly and effectively increase the number of health facilities implementing cervical cancer screening program. Though additional innovative implementation strategies are still needed to proportionally increase women's screening coverage, these initial steps hold great promise in Rwanda's ability to effectively implement a sustainable cervical cancer screening program.
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Chemouni, Benjamin, and Assumpta Mugiraneza. "Ideology and interests in the Rwandan patriotic front: Singing the struggle in pre-genocide Rwanda." African Affairs 119, no. 474 (2019): 115–40. http://dx.doi.org/10.1093/afraf/adz017.
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Abstract In the study of African Politics, the analysis of political ideologies as a normative engine of political action seems to have receded in favour of a treatment of ideology as the support of actors in their pursuit of material interests. Rwanda is not an exception. The ideology of the ruling Rwandan Patriotic Front (RPF) has been predominantly analysed as a self-serving strategy geared towards the reinforcement of the party’s power. Such treatment of ideology prevents a full understanding of the RPF. This article argues that ideology should also be conceptualized as a matrix that can reshape material incentives and through which the RPF’s interests have emerged. To do so, the article analyses new sources of material, the songs of mobilization from RPF members and supporters composed before the Front took power during the genocide, to systematically delineate the RPF’s early ideology. The analysis centres on four main themes—Rwandan national unity, the RPF’s depiction of itself, its depiction of its enemy, and its relationship with the international community—and traces their influence on RPF interests in the post-genocide era. It reveals the surprisingly long-lasting power of ideas despite fast-changing material circumstances.
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Mazimpaka, Christian, Sabin Nsanzimana, Jenae Logan, Agnes Binagwaho, and Rex Wong. "Assessing the Magnitude and Risk Factors Associated With Undiagnosed Hypertension in Rural Rwanda." Journal of Management and Strategy 10, no. 2 (2019): 3. http://dx.doi.org/10.5430/jms.v10n2p3.
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Individuals living with hypertension are predisposed to higher risk of stroke, kidney diseases and heart failure. Approximately 9.4 million people worldwide die from complications related to hypertension every year. Hypertension is often known as the silent killer because many people do not develop any symptoms until they get very sick. Early screening is particularly important for better treatment outcomes yet it remains a challenge in many countries. Worldwide, approximately 50% of people are living with undiagnosed hypertension. In Rwanda, the rate of undiagnosed hypertension is unknown, and so are the associated risk factors in rural communities. A cross-sectional descriptive study was conducted to determine the rate and risk factors of undiagnosed hypertension among adults in a rural community in Rwanda. The proportion of people having undiagnosed hypertension was found to be high. Out of 155 study participants, 41.9% had undiagnosed hypertension, with slightly more men having hypertension (52.3%) than women (47.7%). More than 98% of respondents either did not know or knew wrong information about hypertension, and only 3% knew they should have regular checkups with physicians. Age (p=0.027) and alcohol consumption (p=0.014) were found to be statistically significantly associated with hypertension. Smoking and exercise were not found to be risk factors as most Rwandans living in the rural areas are physically active. Programs to promote hypertension awareness, encourage regular physical checkups, and reduce alcohol consumption are needed to improve diagnosis and control of hypertension in Rwanda. Community programs offering free regular blood pressure checks may also be helpful in identifying early hypertension. Larger scale studies of this kind should be conducted to understand whether results can be generalized to other areas of Rwanda.
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Karema, Corine, Mallika Imwong, Caterina I. Fanello, et al. "Molecular Correlates of High-Level Antifolate Resistance in Rwandan Children with Plasmodium falciparum Malaria." Antimicrobial Agents and Chemotherapy 54, no. 1 (2009): 477–83. http://dx.doi.org/10.1128/aac.00498-09.
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ABSTRACT Antifolate drugs have an important role in the treatment of malaria. Polymorphisms in the genes encoding the dihydrofolate reductase and dihydropteroate synthetase enzymes cause resistance to the antifol and sulfa drugs, respectively. Rwanda has the highest levels of antimalarial drug resistance in Africa. We correlated the efficacy of chlorproguanil-dapsone plus artesunate (CPG-DDS+A) and amodiaquine plus sulfadoxine-pyrimethamine (AQ+SP) in children with uncomplicated malaria caused by Plasmodium falciparum parasites with p fdhfr and p fdhps mutations, which are known to confer reduced drug susceptibility, in two areas of Rwanda. In the eastern province, where the cure rates were low, over 75% of isolates had three or more p fdhfr mutations and two or three p fdhps mutations and 11% had the p fdhfr 164-Leu polymorphism. In the western province, where the cure rates were significantly higher (P < 0.001), the prevalence of multiple resistance mutations was lower and the p fdhfr I164L polymorphism was not found. The risk of treatment failure following the administration of AQ+SP more than doubled for each additional p fdhfr resistance mutation (odds ratio [OR] = 2.4; 95% confidence interval [CI] = 1.01 to 5.55; P = 0.048) and each p fdhps mutation (OR = 2.1; 95% CI = 1.21 to 3.54; P = 0.008). The risk of failure following CPG-DDS+A treatment was 2.2 times higher (95% CI = 1.34 to 3.7) for each additional p fdhfr mutation, whereas there was no association with mutations in the p fdhps gene (P = 0.13). The p fdhfr 164-Leu polymorphism is prevalent in eastern Rwanda. Antimalarial treatments with currently available antifol-sulfa combinations are no longer effective in Rwanda because of high-level resistance.
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Ngabonziza, J.-C. S., Y. M. Habimana, T. Decroo, et al. "Reduction of diagnostic and treatment delays reduces rifampicin-resistant tuberculosis mortality in Rwanda." International Journal of Tuberculosis and Lung Disease 24, no. 3 (2020): 329–39. http://dx.doi.org/10.5588/ijtld.19.0298.
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SETTING: In 2005, in response to the increasing prevalence of rifampicin-resistant tuberculosis (RR-TB) and poor treatment outcomes, Rwanda initiated the programmatic management of RR-TB, including expanded access to systematic rifampicin drug susceptibility testing (DST) and standardised treatment.OBJECTIVE: To describe trends in diagnostic and treatment delays and estimate their effect on RR-TB mortality.DESIGN: Retrospective analysis of individual-level data including 748 (85.4%) of 876 patients diagnosed with RR-TB notified to the World Health Organization between 1 July 2005 and 31 December 2016 in Rwanda. Logistic regression was used to estimate the effect of diagnostic and therapeutic delays on RR-TB mortality.RESULTS: Between 2006 and 2016, the median diagnostic delay significantly decreased from 88 days to 1 day, and the therapeutic delay from 76 days to 3 days. Simultaneously, RR-TB mortality significantly decreased from 30.8% in 2006 to 6.9% in 2016. Total delay in starting multidrug-resistant TB (MDR-TB) treatment of more than 100 days was associated with more than two-fold higher odds for dying. When delays were long, empirical RR-TB treatment initiation was associated with a lower mortality.CONCLUSION: The reduction of diagnostic and treatment delays reduced RR-TB mortality. We anticipate that universal testing for RR-TB, short diagnostic and therapeutic delays and effective standardised MDR-TB treatment will further decrease RR-TB mortality in Rwanda.
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Korman, Rémi. "Mobilising the dead? The place of bones and corpses in the commemoration of the Tutsi genocide in Rwanda." Human Remains and Violence: An Interdisciplinary Journal 1, no. 2 (2015): 56–70. http://dx.doi.org/10.7227/hrv.1.2.6.
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Representations of Rwanda have been shaped by the display of bodies and bones at Tutsi genocide memorial sites. This phenomenon is most often only studied from the perspective of moral dimensions. This article aims in contrast to cover the issues related to the treatment of human remains in Rwanda for commemorative purposes from a historical perspective. To this end, it is based on the archives of the commissions in charge of genocide memory in Rwanda, as well as interviews with key memorial actors. This study shows the evolution of memorial practices since 1994 and the hypermateriality of bodies in their use as symbols, as well as their demobilisation for the purposes of reconciliation policies.
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Kazora, Amos Shyaka, and Khaldoon A. Mourad. "Assessing the Sustainability of Decentralized Wastewater Treatment Systems in Rwanda." Sustainability 10, no. 12 (2018): 4617. http://dx.doi.org/10.3390/su10124617.
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Kigali city, the capital of Rwanda, relies on decentralized, on-site, wastewater systems due to the absence of central sewerage systems and the limited finances to construct sustainable sanitation infrastructures. However, the city has increasingly shown failures in managing these on-site systems either at individual or collective levels. This study aims at assessing the sustainability of the operated collective public semicentralized sewage systems in Kigali city. To fully cover the sustainability assessment of such collective systems, the methods used were field observation, questionnaires, interviews, and laboratory tests. The study also reviewed the influence of national ruling sanitation legal instruments in addressing development, operation and management of such decentralized wastewater systems. The results showed that the sustainability levels of these systems were low in the technical, socioeconomic status, institutional, and legal dimensions. While the sustainability level was fair for the environmental quality. In conclusion, the research highlighted that the improved sanitation coverage does not mean coverage in terms of sewerage connection proportions for wastewater collection as these connections do not imply safe and sustainable treatment before being discharged into the environment.
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Bogaerts, J., W. Martinez Tello, L. Verbist, P. Piot, and J. Vandepitte. "Norfloxacin versus thiamphenicol for treatment of uncomplicated gonorrhea in Rwanda." Antimicrobial Agents and Chemotherapy 31, no. 3 (1987): 434–37. http://dx.doi.org/10.1128/aac.31.3.434.
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Hatungimana, Jean Claude, RT Srinivasan, and RR Vetukuri. "Assessment of the effects of liquid and granular fertilizers on maize yield in Rwanda." African Journal of Food, Agriculture, Nutrition and Development 21, no. 03 (2021): 17787–800. http://dx.doi.org/10.18697/ajfand.98.19670.
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Maize (Zea maysL.) is the most widely grown cereal in the world, accounting for 1,116.34 MT of production in 2019/2020.In Africa, this crop represented approximately 56% of the total cultivated area from 1990 to 2005. About 50% of the African population depends on maize as a staple food and source of carbohydrates, protein, iron, vitamin B, and minerals. Lately, maize has become a cash crop which contributes to the improvement of farmers' livelihoods. For example, the Strategic Plan for Agricultural Transformation (SPAT) III outlined that fertilizer availability in Rwandashouldincrease to55,000MT per year, whilefertilizeruseshouldincreasefrom30 kg/ha in 2013 to 45kg/ha for the 2017/18croppingseason. Only inorganic fertilizers are currently being used in maize production in Rwanda. This research was conducted to assess the effects of liquid(CBX: Complete Biological Extract) and granular fertilizers on maize crop yields in Rwanda. The study was conducted in the fields oftheRwanda Agriculture and Animal Resources Development Board(Rubona Station)during the 2018/2019cropping season. Analysis of variance (ANOVA) was used to determine whether differences between treatments were statistically significant, with the threshold for statistical significance set at p <0.05. Above ground biomass differed significantly between treatments,with maximum and minimum values of 11,475 kg and 7,850 kg, respectively, being observed. Furthermore, the harvest index differed significantly between treatments,with minimum and maximum values of 0.2136 and 0.33, respectively, being observed. Grain yield also differed significantly between treatments, with the highest value (3,053 kg/ha) observed for a treatment which applied liquid and granular fertilizer at equal proportions (treatment 8), and the lowest one was found in treatment 3 with 1,852 kg/ha. In this study, the gap between the lowest and highest grain yields was about 39.3%. In conclusion, the combination of organic liquid fertilizer and granular fertilizer can significantly increase the grain yield of maize in Rwanda.
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Mutagoma, Mwumvaneza, Malamba S. Samuel, Catherine Kayitesi, et al. "High HIV prevalence and associated risk factors among female sex workers in Rwanda." International Journal of STD & AIDS 28, no. 11 (2017): 1082–89. http://dx.doi.org/10.1177/0956462416688137.
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Human immunodeficiency virus (HIV) prevalence is often high among female sex workers (FSWs) in sub-Saharan Africa. Understanding the dynamics of HIV infection in this key population is critical to developing appropriate prevention strategies. We aimed to describe the prevalence and associated risk factors among a sample of FSWs in Rwanda from a survey conducted in 2010. A cross-sectional biological and behavioral survey was conducted among FSWs in Rwanda. Time–location sampling was used for participant recruitment from 4 to 18 February 2010. HIV testing was done using HIV rapid diagnostic tests (RDT) as per Rwandan national guidelines at the time of the survey. Elisa tests were simultaneously done on all samples tested HIV-positive on RDT. Proportions were used for sample description; multivariable logistic regression model was performed to analyze factors associated with HIV infection. Of 1338 women included in the study, 1112 consented to HIV testing, and the overall HIV prevalence was 51.0%. Sixty percent had been engaged in sex work for less than five years and 80% were street based. In multivariable logistic regression, HIV prevalence was higher in FSWs 25 years or older (adjusted odds ratio [aOR] = 1.83, 95% [confidence interval (CI): 1.42–2.37]), FSWs with consistent condom use in the last 30 days (aOR = 1.39, [95% CI: 1.05–1.82]), and FSWs experiencing at least one STI symptom in the last 12 months (aOR = 1.74 [95% CI: 1.34–2.26]). There was an inverse relationship between HIV prevalence and comprehensive HIV knowledge (aOR = 0.65, [95% CI: 0.48–0.88]). HIV prevalence was high among a sample of FSWs in Rwanda, and successful prevention strategies should focus on HIV education, treatment of sexually transmitted infections, and proper and consistent condom use using an outreach approach.
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Uwimana, Aline, Eric Legrand, Barbara H. Stokes, et al. "Emergence and clonal expansion of in vitro artemisinin-resistant Plasmodium falciparum kelch13 R561H mutant parasites in Rwanda." Nature Medicine 26, no. 10 (2020): 1602–8. http://dx.doi.org/10.1038/s41591-020-1005-2.
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Abstract Artemisinin resistance (delayed P. falciparum clearance following artemisinin-based combination therapy), is widespread across Southeast Asia but to date has not been reported in Africa1–4. Here we genotyped the P. falciparum K13 (Pfkelch13) propeller domain, mutations in which can mediate artemisinin resistance5,6, in pretreatment samples collected from recent dihydroarteminisin-piperaquine and artemether-lumefantrine efficacy trials in Rwanda7. While cure rates were >95% in both treatment arms, the Pfkelch13 R561H mutation was identified in 19 of 257 (7.4%) patients at Masaka. Phylogenetic analysis revealed the expansion of an indigenous R561H lineage. Gene editing confirmed that this mutation can drive artemisinin resistance in vitro. This study provides evidence for the de novo emergence of Pfkelch13-mediated artemisinin resistance in Rwanda, potentially compromising the continued success of antimalarial chemotherapy in Africa.
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Schleimer, Lauren E., Jean-Marie Vianney Dusengimana, John Butonzi, et al. "Barriers to Timely Surgery for Breast Cancer in Rwanda." Journal of Global Oncology 4, Supplement 1 (2018): 28s. http://dx.doi.org/10.1200/jgo.18.22000.
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Abstract 81 Purpose Surgery is the mainstay of treatment for nonmetastatic breast cancer. Little is known about the quality of breast surgical care in sub-Saharan Africa. Research at the Butaro Cancer Center of Excellence (BCCOE), Rwanda’s first public cancer center, has suggested that access to timely surgery is inadequate, but barriers have not been systematically examined. The aim of the current study was to gain an understanding of the barriers to breast cancer surgery among patients who were diagnosed at BCCOE by investigating delays and interruptions in care. Methods We used a standardized chart abstraction instrument to collect demographic, treatment, and outcome data as of November 2017 for all patients who were diagnosed with breast cancer at BCCOE in 2014 and 2015. We recorded all visits and treatments received until surgery, disease progression, or loss to follow-up for all patients with stage I to III breast cancer. Results During 2014 and 2015, 91 patients were diagnosed with stage I to III breast cancer and were treated with curative intent—67 patients (74%) underwent surgery, with 22 undergoing surgery at BCCOE and 45 elsewhere. Of the 24 patients with no surgery, 16 were lost to follow-up and eight experienced disease progression before surgical evaluation. Median time from diagnosis to surgery was 103 days (range, 30 to 826 days) for patients without neoadjuvant chemotherapy (NAC) and 268 days (range, 108 to 794 days) for patients with NAC. We defined surgical delays as > 120 days from diagnosis without NAC or > 365 days from diagnosis if NAC was administered. Of the 67 patients who had surgery, 26 patients (39%) experienced delays. When documented, reasons for delay included patient factors, such as social and/or financial issues (n = 5), seeking alternate treatment (n = 2), refusing referral to Kigali (n = 3), or any surgery (n = 1); system factors, such as surgeon nonavailability (n = 1); and changes in clinical status, such as pregnancy (n = 5), treatment-associated adverse events (n = 4), or the need for a second surgical opinion (n = 2). Unexplained failure to complete the initial surgical referral (n = 5) and missed NAC treatment appointments (n = 6) were frequent contributors. Some patients had multiple reasons for delay. For five patients, there was no documented explanation. Conclusion We observed high rates of loss to follow-up, surgical delays, and lapses in care at the point of surgical referral. Identification of the barriers to completing referrals could guide strategies for improving access to timely surgery. Efforts are needed to address social and financial barriers and explore patients’ refusals to undergo surgery. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST No COIs from the authors.
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Chankova, Slavea, Laurel Hatt, and Sabine Musange. "A community-based approach to promote household water treatment in Rwanda." Journal of Water and Health 10, no. 1 (2012): 116–29. http://dx.doi.org/10.2166/wh.2012.071.
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Treatment of drinking water at the household level is one of the most effective preventive interventions against diarrhea, a leading cause of illness and death among children in developing countries. A pilot project in two districts in Rwanda aimed to increase use of Sûr'Eau, a chlorine solution for drinking water treatment, through a partnership between community-based health insurance schemes and community health workers who promoted and distributed the product. Evaluation of the pilot, drawing on a difference-in-differences design and data from pre- and post-pilot household surveys of 4,780 households, showed that after 18 months of pilot implementation, knowledge and use of the product increased significantly in two pilot districts, but remained unchanged in a control district. The pilot was associated with a 40–42 percentage point increase in ever use, and 8–9 percentage points increase in use of Sûr'Eau at time of the survey (self-reported measures). Our data suggest that exposure to inter-personal communication on Sûr'Eau and hearing about the product at community meetings and health centers were associated with an increase in use.
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Tapela, Neo, Ignace Nzayisenga, Roshan Sethi, et al. "Treatment of Chronic Myeloid Leukemia in Rural Rwanda: Promising Early Outcomes." Journal of Global Oncology 2, no. 3 (2016): 129–37. http://dx.doi.org/10.1200/jgo.2015.001727.
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Purpose The burden of cancer is rising in low- and middle-income countries, yet cancer treatment requires resources that are often not available in these settings. Although management of chronic myeloid leukemia (CML) has been described in low- and middle-income countries, few programs involve patients treated in rural settings. We describe characteristics and early outcomes of patients treated for CML at rural district hospitals in Rwanda. Methods We conducted a retrospective review of patients with confirmed BCR-ABL–positive CML who were enrolled between July 1, 2009 and June 30, 2014. Types of data included patient demographics, diagnostic work up, treatment, clinical examination, laboratory testing, and death. Results Forty-three patients were included, with a maximum follow-up of 58 months. Of 31 patients who were imatinib-naïve at enrollment, 54.8% were men and the median age at diagnosis was 36.9 years (interquartile range: 29-42 years). Approximately two-thirds of patients (67.7%) were on the national public insurance scheme. The imatinib dose was reduced for 16 patients and discontinued for five. Thirty-two of the 43 patients continued to have normal blood counts at last follow-up. Four patients have died and four are lost to follow-up. Conclusion Our experience indicates that CML can be effectively managed in a resource-constrained rural setting, despite limited availability of on-site diagnostic resources or specialty oncology personnel. The importance of model public-private partnerships as a strategy to bring high-cost, life-saving treatment to people who do not have the ability to pay is also highlighted.
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Stulac, Sara, Richard B. Mark Munyaneza, Jeanne Chai, et al. "Initiating Childhood Cancer Treatment in Rural Rwanda: A Partnership-Based Approach." Pediatric Blood & Cancer 63, no. 5 (2016): 813–17. http://dx.doi.org/10.1002/pbc.25903.
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Dionne-Odom, J., E. Karita, W. Kilembe, et al. "Syphilis Treatment Response Among HIV-Discordant Couples in Zambia and Rwanda." Clinical Infectious Diseases 56, no. 12 (2013): 1829–37. http://dx.doi.org/10.1093/cid/cit146.
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Rubagumya, F., L. Greenberg, A. Manirakiza, et al. "Establishing a Childhood Cancer Survivorship Program in Rwanda." Journal of Global Oncology 4, Supplement 2 (2018): 87s. http://dx.doi.org/10.1200/jgo.18.30400.
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Background: Over 80% of children diagnosed with cancer survive in high-income countries (HICs). While the survival rate remains poor in low- and middle-income countries (LMICs) such as Rwanda, a growing number of children with cancer are surviving to adulthood. These children and young adults will face an increased risk of secondary cancers and late complications from their curative treatment. Cancer centers in HICs have established Long Term Survivorship (LTS) programs to cater for childhood cancer survivors and to capture these complications and/or recurrences at an early stage. They also address the more complex psychological and social aspects of surviving cancer in childhood. Aims: To develop an LTS program in Rwanda, initial training will take place in Botswana where a pediatric hematology-oncology (PHO) program was established at the national referral hospital, Princess Marina Hospital (PMH), in 2007. This training program will allow successful methods and lessons learned from the development of an LTS program in Botswana to establish a similar program in Rwanda with ongoing bidirectional collaboration. Methods: The Texas Children's Cancer and Hematology Centers (TXCH) Global Hematology-Oncology Pediatric Excellence (HOPE) program in Botswana is the only provider of PHO care in the country, provided at PMH, through a partnership with the Botswana government. The program has over 130 childhood cancer survivors in active follow-up. A one-month bench-marking visit will be conducted. During this period, Dr. Rubagumya will spend time with the medical director of the program learning how the LTS program was established and current operations. He will spend time with clinicians during consultations to understand the scope of tests requested, frequently asked questions across all parties: clinicians, survivors and/or caretakers and use of technology to aid in the management of LTS patients. Focused interviews of clinicians, patients, caregiver and administration will be conducted to further understand the challenges of the pediatric cancer survivors and the development of an LTS program in an LMIC face. Results: After this month visit, critical areas of knowledge transfer will include: how to set up a childhood cancer survivorship programs; methods for sustainable operation of a childhood cancer LTS program, and how to help childhood cancer survivors navigate health care systems. A similar model will be established in Rwanda. Long-term mentorship with Botswana colleagues will help to build Rwanda's first LTS. Conclusion: Survivors involved in dedicated LTS follow-up care have better health outcomes. This indicates the need for life long survivorship care. There is a dearth of data on how to establish and operate a childhood cancer LTS program in LMIC settings. Lessons learned through this program will guide us on how to set up such program in Rwanda.
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Stulac, Sara, Merab Nyishime, Jean Bosco Bigirimana, Alain N. Uwumugambi, Sara Chaffee, and Leslie E. Lehmann. "Partners In Health Generalist/Specialist Twinning: A Health Delivery Model Used in Treating Childhood Lymphoma in Rural Rwanda,." Blood 118, no. 21 (2011): 4222. http://dx.doi.org/10.1182/blood.v118.21.4222.4222.
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Abstract Abstract 4222 In the developed world approximately 80% of children with lymphoma can be cured. As global health initiatives have broadened to address noncommunicable diseases the approach to cancer care for children in resource poor settings becomes of increasing concern. Traditional models of tertiary care provision will not be applicable as there is not an adequate number of existing pediatricians subspecializing in oncology to provide for the world's children. At Rwinkwavu, a Partners In Health (PIH) supported government district hospital in rural Rwanda, a small cohort of children with lymphoma have received therapy over the past 4 years using a unique approach to care delivery. Each case is managed by a team consisting of a Rwandan physician with no specialty training, a Rwandan nurse coordinator focused on oncology patients, a Rwanda-based US trained pediatrician and a US- based pediatric oncologist. Biopsies and radiologic staging studies were obtained in Rwanda but all pathologic diagnoses were made at Brigham and Women's Hospital, a Harvard teaching hospital, through a formal arrangement. A treatment plan for each patient was formulated with the consulting pediatric oncologist and a road map was generated. Chemotherapy was administered by nurses in the Rwinkwavu pediatric ward under the daily supervision of the local generalist and with the support of the pediatrician. Blood counts and broad spectrum antibiotics were available but blood cultures could not be performed. If radiation therapy was required patients were transported to Uganda for the treatments. Ten patients aged 3–15 (median age 9.5 years) have been treated using this approach. 5 (50%) have completed therapy - Hodgkin's Disease (HD) n =2, HIV-associated large cell lymphoma (HIV LCL) n =2, Burkitt's Lymphoma (BL) n=1. They received either CHOP (cyclophosphamide, adriamycin, vincristine, prednisone), n=3 or ABVD (adriamycin, bleomycin, vincristine, dacarbazine), n=1; 1 patient with Stage 1 Lymphocyte Predominant HD is being observed without adjuvant therapy after complete surgical excision. All 5 have no evidence of disease recurrence 4 months - 4 years following completion of therapy (median = 14 months). 2 patients are currently on therapy (recurrent HD, HIV LCL) and are in remission. 2 patients succumbed to treatment complications (HD- died from cardiomyopathy, BL- died from transverse myelopathy) and 1 patient (BL) died of progressive disease while receiving chemotherapy. We can not determine the number of pediatric patients with lymphoma who died before a diagnosis was made or before receiving appropriate therapy. In the developing world lymphoma is one of the most common oncologic diseases in children. These data suggest that chemotherapy can be administered with curative intent to a subset of these patients in the setting of a confirmed pathological diagnosis. This approach provides a platform for models of care that rely on local physicians acting in concert with trained consultants from the developed countries to deliver subspeciality care in resource poor settings. Disclosures: No relevant conflicts of interest to declare.
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O’Neil, Daniel S., Nancy L. Keating, Jean Marie V. Dusengimana, et al. "Quality of Breast Cancer Treatment at a Rural Cancer Center in Rwanda." Journal of Global Oncology, no. 4 (December 2018): 1–11. http://dx.doi.org/10.1200/jgo.2016.008672.
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Purpose As breast cancer incidence and mortality rise in sub-Saharan Africa, it is critical to identify strategies for delivery of high-quality breast cancer care in settings with limited resources and few oncology specialists. We investigated the quality of treatments received by a cohort of patients with breast cancer at Butaro Cancer Center of Excellence (BCCOE), Rwanda’s first public cancer center. Patients and Methods We reviewed medical records of all female patients diagnosed with invasive breast cancer at BCCOE between July 2012 and December 2013. We evaluated the provision of chemotherapy, endocrine therapy, surgery, and chemotherapy dose densities. We also applied modified international quality metrics and estimated overall survival using interval-censored analysis. Results Among 150 patients, 28 presented with early-stage, 64 with locally advanced, and 53 with metastatic disease. Among potentially curable patients (ie, those with early-stage or locally advanced disease), 74% received at least four cycles of chemotherapy and 63% received surgery. Among hormone receptor–positive patients, 83% received endocrine therapy within 1 year of diagnosis. Fifty-seven percent of potentially curable patients completed surgery and chemotherapy and initiated endocrine therapy if indicated within 1 year of biopsy. Radiotherapy was not available. At the end of follow-up, 62% of potentially curable patients were alive, 24% were dead, and 14% were lost to follow-up. Conclusion Appropriate delivery of chemotherapy and endocrine therapy for breast cancer is possible in rural sub-Saharan African even without oncologists based on site. Performing timely surgery and ensuring treatment completion were key challenges after the opening of BCCOE. Further investigation should examine persistent quality gaps and the relationship between treatment quality and survival.
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Park, Paul H., Cyprien Shyirambere, Fred Kateera, et al. "Implementing Cancer Care in Rwanda: Capacity Building for Treatment and Scale-Up." Sustainability 13, no. 13 (2021): 7216. http://dx.doi.org/10.3390/su13137216.
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Background: The majority of countries in sub-Saharan Africa are ill-prepared to address the rising burden of cancer. While some have been able to establish a single cancer referral center, few have been able to scale-up services nationally towards universal health coverage. The literature lacks a step-wise implementation approach for resource-limited countries to move beyond a single-facility implementation strategy and implement a national cancer strategy to expand effective coverage. Methods: We applied an implementation science framework, which describes a four-phase approach: Exploration, Preparation, Implementation, and Sustainment (EPIS). Through this framework, we describe Rwanda’s approach to establish not just a single cancer center, but a national cancer program. Results: By applying EPIS to Rwanda’s implementation approach, we analyzed and identified the implementation strategies and factors, which informed processes of each phase to establish foundational cancer delivery components, including trained staff, diagnostic technology, essential medicines, and medical informatics. These cancer delivery components allowed for the implementation of Rwanda’s first cancer center, while simultaneously serving as the nidus for capacity building of foundational components for future cancer centers. Conclusion: This “progressive scaling” approach ensured that initial investments in the country’s first cancer center was a step toward establishing future cancer centers in the country.
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Mathur, Poonam, Emily Comstock, Jean Damascene Makuza, et al. "Implementation of a unique hepatitis C care continuum model in Rwanda." Journal of Public Health 41, no. 2 (2018): e203-e208. http://dx.doi.org/10.1093/pubmed/fdy115.
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Abstract Background There has been an evolution in the treatment of chronic hepatitis C (HCV) due to highly effective direct-acting antivirals, however, restriction of treatment to medical specialists hinders escalation of HCV treatment. This is particularly true in resource-limited settings (RLS), which disproportionately represent the burden of HCV worldwide. The ASCEND study in Washington, DC, demonstrated that complete task-shifting can safely and effectively overcome a low provider-to-patient ratio and expand HCV treatment. However, this model has not been applied internationally to RLS. Method The validated ASCEND model was translated to an international clinical program in Kigali, Rwanda, aimed at training general medicine providers on HCV management and obtaining HCV prevalence data. Results The didactic training program administered to 11 new HCV providers in Rwanda increased provider’s knowledge about HCV management. Through the training program, 26% of patients seen during the follow-up period were screened for HCV and a prevalence estimate of 2% was ascertained. Of these patients, 30% were co-infected with hepatitis B. Conclusion The ASCEND paradigm can be successfully implemented in RLS to escalate HCV care, in a self-sustaining fashion that educates more providers about HCV management, while increasing the public’s awareness of HCV and access to treatment.
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Mather, William, Paul Hutchings, Sophie Budge, and Paul Jeffrey. "Association between water and sanitation service levels and soil-transmitted helminth infection risk factors: a cross-sectional study in rural Rwanda." Transactions of The Royal Society of Tropical Medicine and Hygiene 114, no. 5 (2020): 332–38. http://dx.doi.org/10.1093/trstmh/trz119.
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Abstract Background Soil-transmitted helminth (STH) infections are one of the most prevalent neglected tropical diseases in the world. Drug treatment is the preferred method for infection control yet reinfection occurs rapidly, so water and sanitation represent important complementary barriers to transmission. Methods A cross-sectional study was conducted to observe STH risk factors in rural Rwandan households in relation to the Sustainable Development Goal for water and sanitation service levels. Survey and observation data were collected from 270 households and 67 water sources in rural Rwanda and were processed in relation to broader risk factors identified from the literature for the role of water and sanitation in STH infection pathways. Results A significant association between higher water and sanitation service levels and lower STH infection risk profiles was found for both water and sanitation. However, variability existed within service level classifications. Conclusions Greater granularity within service level assessments is required to more precisely assess the efficacy of water and sanitation interventions in reducing STH infection risks.
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Bradshaw, Abigail, Lambert Mugabo, Alemayehu Gebremariam, Evan Thomas, and Laura MacDonald. "Integration of Household Water Filters with Community-Based Sanitation and Hygiene Promotion—A Process Evaluation and Assessment of Use among Households in Rwanda." Sustainability 13, no. 4 (2021): 1615. http://dx.doi.org/10.3390/su13041615.
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Unsafe drinking water contributes to diarrheal disease and is a major cause of morbidity and mortality in low-income contexts, especially among children under five years of age. Household-level water treatment interventions have previously been deployed in Rwanda to address microbial contamination of drinking water. In this paper, we describe an effort to integrate best practices regarding distribution and promotion of a household water filter with an on-going health behavior messaging program. We describe the implementation of this program and highlight key roles including the evaluators who secured overall funding and conducted a water quality and health impact trial, the promoters who were experts in the technology and behavioral messaging, and the implementers who were responsible for product distribution and education. In January 2019, 1023 LifeStraw Family 2.0 household water filters were distributed in 30 villages in the Rwamagana District of Rwanda. Approximately a year after distribution, 99.5% of filters were present in the household, and water was observed in 95.1% of filters. Compared to another recent water filter program in Rwanda, a lighter-touch engagement with households and supervision of data collection was observed, while also costing approximately twice per household compared to the predecessor program.
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Nwankwo, Chinenye Mercy, and Yasmin Umubyeyi Omar. "Factors associated with delays in seeking tuberculosis treatment among patients at Muhima district hospital, Rwanda." International Journal Of Community Medicine And Public Health 7, no. 8 (2020): 3183. http://dx.doi.org/10.18203/2394-6040.ijcmph20203398.
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Background: Few studies exist in Rwanda to establish the reasons behind delays in seeking treatment in the health institutions which further affected timely diagnosis and case detection. The study investigated factors associated with delays in seeking treatment among tuberculosis (TB) patients at Muhima District Hospital, Rwanda.Methods: The study adopted descriptive cross- sectional study of 49 smear-positive TB patients derived using proportion estimation of case registry (November 2016 to January 2017) newly- diagnosed patients, first and second months treatment. Systematic sampling technique used to select 60 TB patients from target population. Data collected by researcher and trained research assistant, using a close- ended questionnaire through a translation in local dialect.Results: About 49% (24) of the smear- positive TB patients experienced delayed in seeking treatment for more than 180 days (6 months). Also 53% (26) were within the 36-45 age-cohort, while majority 75.5% (37) of the respondents was male. About 57% (28) of the respondents have poor knowledge of TB transmission. Similarly, about 51% (25) were the results on the perception of taking anti- TB medication, while median time interval from onset of symptoms and initiation of treatments was 45 days, average 71 days between 15 -180 days.Conclusions: Statistically significant relationship exist between initial source of treatment using home remedies (p=0.0) and private insurance cover (p=0.0) in relation to delay, which further contributed to delay among majority. Recommendations of the study are strengthening medical services utilization, improving case detection, medical infrastructures and collaboration with non- formal healthcare practices.
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Deloron, Philippe, John D. Sexton, Laurent Bugilimfura, and Célestin Sezibera. "Amodiaquine and Sulfadoxine-Pyrimethamine as Treatment for Chloroquine-Resistant Plasmodium falciparum in Rwanda." American Journal of Tropical Medicine and Hygiene 38, no. 2 (1988): 244–48. http://dx.doi.org/10.4269/ajtmh.1988.38.244.
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Mukazayire, Marie-Jeanne, Védaste Minani, Christopher K. Ruffo, Elias Bizuru, Caroline Stévigny, and Pierre Duez. "Traditional phytotherapy remedies used in Southern Rwanda for the treatment of liver diseases." Journal of Ethnopharmacology 138, no. 2 (2011): 415–31. http://dx.doi.org/10.1016/j.jep.2011.09.025.
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Stone, Barbara, Lori Leyden, and Bert Fellows. "Energy Psychology Treatment for Orphan Heads of Households in Rwanda: An Observational Study." Energy Psychology Journal 2, no. 2 (2010): 33–40. http://dx.doi.org/10.9769/epj.2010.2.2.bs.ll.bf.
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Kayigamba, Felix R., Molly F. Franke, Mirjam I. Bakker, et al. "Discordant Treatment Responses to Combination Antiretroviral Therapy in Rwanda: A Prospective Cohort Study." PLOS ONE 11, no. 7 (2016): e0159446. http://dx.doi.org/10.1371/journal.pone.0159446.
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Nzayisenga, Ignace, Roanne Segal, Natalie Pritchett, et al. "Gestational Trophoblastic Neoplasia Treatment at the Butaro Cancer Center of Excellence in Rwanda." Journal of Global Oncology 2, no. 6 (2016): 365–74. http://dx.doi.org/10.1200/jgo.2015.002568.
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Purpose Gestational trophoblastic neoplasia (GTN) is a highly treatable disease, most often affecting young women of childbearing age. This study reviewed patients managed for GTN at the Butaro Cancer Center of Excellence (BCCOE) in Rwanda to determine initial program outcomes. Patients and Methods A retrospective medical record review was performed for 35 patients with GTN assessed or treated between May 1, 2012, and November 30, 2014. Stage, risk score, and low or high GTN risk category were based on International Federation of Gynecology and Obstetrics staging and the WHO scoring system and determined by beta human chorionic gonadotropin level, chest x-ray, and ultrasound per protocol guidelines for resource-limited settings. Pathology reports and computed tomography scans were assessed when possible. Treatment was based on a predetermined protocol stratified by risk status. Results Of the 35 patients (mean age, 32 years), 26 (74%) had high-risk and nine (26%) had low-risk disease. Nineteen patients (54%) had undergone dilation and curettage and 11 (31%) had undergone hysterectomy before evaluation at BCCOE. Pathology reports were available in 48% of the molar pregnancy surgical cases. Systemic chemotherapy was initiated in 30 of the initial 35 patients: 13 (43%) received single-agent oral methotrexate, 15 (50%) received EMACO (etoposide, methotrexate, dactinomycin, cyclophosphamide, and vincristine), and two (7%) received alternate regimens. Of the 13 patients initiating methotrexate, three had their treatment intensified to EMACO. Four patients experienced treatment delays because of medication stockouts. At a median follow-up of 7.8 months, the survival probability for low-risk patients was 1.00; for high-risk patients, it was 0.63. Conclusion This experience demonstrates the feasibility of GTN treatment in rural, resource-limited settings. GTN is a curable disease and can be treated following the BCCOE model of cancer care.
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Murindababisha, David, Vedaste Havugimana, Honorine Mutezinka, and Domithile Nimukuze. "Performance of Locally Produced Ceramic Pot Filters for Drinking Water Treatment in Rwanda." International Journal of Applied Chemistry 5, no. 3 (2018): 10–14. http://dx.doi.org/10.14445/23939133/ijac-v5i3p103.
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Lepage, P., J. Bogaerts, C. Van Goethem, D. G. Hitimana, and F. Nsengumuremyi. "Multiresistant Salmonella typhimurium systemic infection in Rwanda. Clinical features and treatment with cefotaxime." Journal of Antimicrobial Chemotherapy 26, suppl A (1990): 53–57. http://dx.doi.org/10.1093/jac/26.suppl_a.53.
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Dhont, N., S. Luchters, W. Ombelet, et al. "Gender differences and factors associated with treatment-seeking behaviour for infertility in Rwanda." Human Reproduction 25, no. 8 (2010): 2024–30. http://dx.doi.org/10.1093/humrep/deq161.
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Guzman, Andrea. "Case study: Reducing preventable maternal mortality in Rwandan healthcare facilities through improvements in WASH protocols." Journal of Patient Safety and Risk Management 23, no. 3 (2018): 129–34. http://dx.doi.org/10.1177/2516043518778117.
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Problem A lack of proper water, sanitation, and hygiene (WASH) infrastructure and poor hygiene practices reduce the preparedness and response of health care facilities (HCFs) in low-income countries to infection and disease outbreaks. According to a World Bank Service Provision Assessment conducted in 2007, only 28% of HCFs in Rwanda had water access throughout the year supplied by tap and 58% of HCFs provided functioning latrines. 1 This evaluation of services and infrastructure in HCFs in Rwanda indicates that targets for WASH in-country need to be enhanced. Objectives To present a case study of the causes and management of sepsis during delivery that led to the death of a 27-year-old woman, and propose a WASH protocol to be implemented in HCFs in Rwanda. Methods The state of WASH services used by staff, caregivers, and patients in HCFs was assessed in 2009 in national evaluations conducted by the Ministry of Infrastructure of Rwanda. Site selection was purposive, based on the presence of both water and power supply. Direct observation was used to assess water treatment, presence and condition of sanitation facilities and sterile equipment in the delivery room, provision of soap and water, gloves, alcohol-based hand rub, and WASH-related record keeping. Results All healthcare facilities met Ministry policies for water access, but WHO guidelines for environmental standards, including for water quality, were not fully satisfied. Conclusions The promotion and provision of low-cost technologies that enable improved WASH practices could help to reduce high rates of morbidity and mortality due to infection in low-income countries.
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Ross, Jonathan, Gad Murenzi, Sarah Hill, et al. "Reducing time to differentiated service delivery for newly diagnosed people living with HIV in Kigali, Rwanda: study protocol for a pilot, unblinded, randomised controlled study." BMJ Open 11, no. 4 (2021): e047443. http://dx.doi.org/10.1136/bmjopen-2020-047443.
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IntroductionCurrent HIV guidelines recommend differentiated service delivery (DSD) models that allow for fewer health centre visits for clinically stable people living with HIV (PLHIV). Newly diagnosed PLHIV may require more intensive care early in their treatment course, yet frequent appointments can be burdensome to patients and health systems. Determining the optimal parameters for defining clinical stability and transitioning to less frequent appointments could decrease patient burden and health system costs. The objectives of this pilot study are to explore the feasibility and acceptability of (1) reducing the time to DSD from 12 to 6 months after antiretroviral therapy (ART) initiation,and (2) reducing the number of suppressed viral loads required to enter DSD from two to one.Methods and analysesThe present study is a pilot, unblinded trial taking place in three health facilities in Kigali, Rwanda. Current Rwandan guidelines require PLHIV to be on ART for ≥12 months with two consecutive suppressed viral loads in order to transition to less frequent appointments. We will randomise 90 participants to one of three arms: entry into DSD at 6 months after one suppressed viral load (n=30), entry into DSD at 6 months after two suppressed viral loads (n=30) or current standard of care (n=30). We will measure feasibility and acceptability of this intervention; clinical outcomes include viral suppression at 12 months (primary outcome) and appointment attendance (secondary outcome).Ethics and disseminationThis clinical trial was approved by the institutional review board of Albert Einstein College of Medicine and by the Rwanda National Ethics Committee. Findings will be disseminated through conferences and peer-reviewed publications, as well as meetings with stakeholders.Trial registration numberNCT04567693.
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Roder-DeWan, Sanam, Neil Gupta, Daniel M. Kagabo, et al. "Four delays of child mortality in Rwanda: a mixed methods analysis of verbal social autopsies." BMJ Open 9, no. 5 (2019): e027435. http://dx.doi.org/10.1136/bmjopen-2018-027435.
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ObjectivesWe sought to understand healthcare-seeking patterns and delays in obtaining effective treatment for rural Rwandan children aged 1–5 years by analysing verbal and social autopsies (VSA). Factors in the home, related to transport and to quality of care in the formal health sector (FHS) were thought to contribute to delays.DesignWe collected quantitative and qualitative cross-sectional data using the validated 2012 WHO VSA tool. Descriptive statistics were performed. We inductively and deductively coded narratives using the three delays model, conducted thematic content analysis and used convergent mixed methods to synthesise findings.SettingThe study took place in the catchment areas of two rural district hospitals in Rwanda—Kirehe and Southern Kayonza. Participants were caregivers of children aged 1–5 years who died in our study area between March 2013 and February 2014.ResultsWe analysed 77 VSAs. Although 74% of children (n=57) had contact with the FHS before dying, most (59%, n=45) died at home. Many caregivers (44%, n=34) considered using traditional medicine and 23 (33%) actually did. Qualitative themes reflected difficulty recognising the need for care, the importance of traditional medicine, especially for ‘poisoning’ and poor perceived quality of care. We identified an additional delay—phase IV—which occurred after leaving formal healthcare facilities. These delays were associated with caregiver dissatisfaction or inability to adhere to care plans.ConclusionDelays in deciding to seek care (phase I) and receiving quality care in FHS (phase III) dominated these narratives; delays in reaching a facility (phase II) were rarely discussed. An unwillingness or inability toadhere to treatment plans after leaving facilities (phase IV) were an important additional delay. Improving quality of care, especially provider capacity to communicate danger signs/treatment plans and promote adherence in the presence of alternative explanatory models informed by traditional medicine, could help prevent childhood deaths.
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Riedel, David J., Kristen A. Stafford, Peter Memiah, et al. "Patient-level outcomes and virologic suppression rates in HIV-infected patients receiving antiretroviral therapy in Rwanda." International Journal of STD & AIDS 29, no. 9 (2018): 861–72. http://dx.doi.org/10.1177/0956462418761695.
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The Rwanda national HIV program has been successful at scaling up antiretroviral therapy (ART) to achieve universal access. The AIDSRelief Model of Care focuses on four key principles: (1) earlier initiation of ART; (2) use of durable, highly-potent, and sequence-friendly first-line ART regimens; (3) early detection of treatment failure; and (4) provision of community-based care and support to ensure optimal adherence and follow up/engagement in care. We conducted a retrospective cohort study of randomly-selected HIV-infected patients at AIDSRelief-supported sites using a stratified, random sample of 583 adults (>15 years) who initiated ART from 30 June 2008 to 1 February 2010. At ART initiation, the median patient age was 38 years, and 67% were female. The baseline median CD4+ cell count was 309 cells/mm3. Overall virologic suppression was 91%. Married/ever married status (adjusted prevalence odds ratio [aPOR] 3.75, 95% confidence interval [CI] 1.30–10.78) and self-reported adherence ≥95% in the past month (aPOR 2.76, 95% CI 1.00–7.62) were significantly associated with viral suppression in the multivariable model. Excellent virologic outcomes were achieved in Rwandan AIDSRelief sites utilizing the AIDSRelief Model of Care during the scale-up of ART in the country.
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Mukasahaha, D., F. Uwinkindi, L. Grant, et al. "Home-Based Care Practitioners: A Strategy for Continuum of Care for Very Ill Patient." Journal of Global Oncology 4, Supplement 2 (2018): 121s. http://dx.doi.org/10.1200/jgo.18.78800.
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Background: Rwanda Ministry of Health in collaboration with partners has initiated an innovative initiative named Home Based Care Practitioners (HBCPs) to respond to the burden of long-term hospitalization for end of life patients. Aim: The program aims at providing home-based care to accompany patients and their families in their home, reduce unnecessary pain and suffering for those with chronic or terminal conditions, provide counseling to the patients and their families, early diagnosis of NCDs and improve awareness on prevention of NCDs risk factors and effectively refer them to either health facilities or community-based resources that can be of further help. Methods: The HBCPs is implemented into phases; phase one has started with a pilot of 200 HBCPs in 100 cells surrounding nine provincial and referral hospitals of Rwanda; 2 practitioners for both gender in each cell, with a criteria of completion at least secondary school. They have undergone a training of 120 credits (900 hours), equivalent of four months for theory and two months of practice. After training they have been deployed into the community with a supervision of health centers in collaboration with hospitals and Rwanda Biomedical Center. Results: During the implementation period of 6 months, 1663 NCDs patients have been transferred from health facility (OPD) to HBCPs for routine follow-up, 482 palliative care patients have been reported on end of life care by HBCPs, there is a remarkable linkage between facilities and community care ensured by supervisory relationship between health services providers and home based care practitioners, long-term admission has reduced the cost for the family and the facility due to the discharge of care from hospital to home. Conclusion: In a limited setting of social and economic cost of providing frivolous care in an expensive hospital for chronic or terminal conditions that would be better managed through treatment or palliative care at home (or less acute setting) home based care effort can better meet the needs of Rwandans at the community level and has started to show the efficiency in providing quality care to people in need of palliative care.
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Hanappe, Maud, Lowell T. Nicholson, Shekinah N. C. Elmore, et al. "International Radiotherapy Referrals From Rural Rwanda: Implementation Processes and Early Clinical Outcomes." Journal of Global Oncology, no. 4 (December 2018): 1–12. http://dx.doi.org/10.1200/jgo.18.00089.
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Purpose Low- and middle-income countries disproportionately comprise 65% of cancer deaths. Cancer care delivery in resource-limited settings, especially low-income countries in sub-Saharan Africa, is exceedingly complex, requiring multiple modalities of diagnosis and treatment. Given the vast human, technical, and financial resources required, access to radiotherapy remains limited in sub-Saharan Africa. Through 2017, Rwanda has not had in-country radiotherapy services. The aim of this study was to describe the implementation and early outcomes of the radiotherapy referral program at the Butaro Cancer Centre of Excellence and to identify both successful pathways and barriers to care. Methods Butaro District Hospital is located in a rural area of the Northern Province and is home to the Butaro Cancer Centre of Excellence. We performed a retrospective study from routinely collected data of all patients with a diagnosis of cervical, head and neck, or rectal cancer between July 2012 and June 2015. Results Between 2012 and 2015, 580 patients were identified with these diagnoses and were potential candidates for radiation. Two hundred eight (36%) were referred for radiotherapy treatment in Uganda. Of those referred, 160 (77%) had cervical cancer, 31 (15%) had head and neck cancer, and 17 (8%) had rectal cancer. At the time of data collection, 101 radiotherapy patients (49%) were alive and had completed treatment with no evidence of recurrence, 11 (5%) were alive and continuing treatment, and 12 (6%) were alive and had completed treatment with evidence of recurrence. Conclusion This study demonstrates the feasibility of a rural cancer facility to successfully conduct out-of-country radiotherapy referrals with promising early outcomes. The results of this study also highlight the many challenges and lessons learned in providing comprehensive cancer care in resource-limited settings.
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Pace, Lydia E., Lauren E. Schleimer, Cyprien Shyirambere, et al. "Identifying Breast Cancer Care Quality Measures for a Cancer Facility in Rural Sub-Saharan Africa: Results of a Systematic Literature Review and Modified Delphi Process." JCO Global Oncology, no. 6 (September 2020): 1446–54. http://dx.doi.org/10.1200/go.20.00186.
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PURPOSE The burden of cancer is growing in low- and middle-income countries (LMICs), including sub-Saharan Africa. Ensuring the delivery of high-quality cancer care in such regions is a pressing concern. There is a need for strategies to identify meaningful and relevant quality measures that are applicable to and usable for quality measurement and improvement in resource-constrained settings. METHODS To identify quality measures for breast cancer care at Butaro Cancer Center of Excellence (BCCOE) in Rwanda, we used a modified Delphi process engaging two panels of experts, one with expertise in breast cancer evidence and measures used in high-income countries and one with expertise in cancer care delivery in Rwanda. RESULTS Our systematic review of the literature yielded no publications describing breast cancer quality measures developed in a low-income country, but it did provide 40 quality measures, which we adapted for relevance to our setting. After two surveys, one conference call, and one in-person meeting, 17 measures were identified as relevant to pathology, staging and treatment planning, surgery, chemotherapy, endocrine therapy, palliative care, and retention in care. Successes of the process included participation by a diverse set of global experts and engagement of the BCCOE community in quality measurement and improvement. Anticipated challenges include the need to continually refine these measures as resources, protocols, and measurement capacity rapidly evolve in Rwanda. CONCLUSION A modified Delphi process engaging both global and local expertise was a promising strategy to identify quality measures for breast cancer in Rwanda. The process and resulting measures may also be relevant for other LMIC cancer facilities. Next steps include validation of these measures in a retrospective cohort of patients with breast cancer.
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Ford, K., S. Gunawardana, E. Manirambona, et al. "Investigating Wilms’ Tumours Worldwide: A Report of the OxPLORE Collaboration—A Cross-Sectional Observational Study." World Journal of Surgery 44, no. 1 (2019): 295–302. http://dx.doi.org/10.1007/s00268-019-05213-6.
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Abstract Background Childhood cancer is neglected within global health. Oxford Pediatrics Linking Oncology Research with Electives describes early outcomes following collaboration between low- and high-income paediatric surgery and oncology centres. The aim of this paper is twofold: to describe the development of a medical student-led research collaboration; and to report on the experience of Wilms’ tumour (WT). Methods This cross-sectional observational study is reported as per STROBE guidelines. Collaborating centres included three tertiary hospitals in Tanzania, Rwanda and the UK. Data were submitted by medical students following retrospective patient note review of 2 years using a standardised data collection tool. Primary outcome was survival (point of discharge/death). Results There were 104 patients with WT reported across all centres over the study period (Tanzania n = 71, Rwanda n = 26, UK n = 7). Survival was higher in the high-income institution [87% in Tanzania, 92% in Rwanda, 100% in the UK (X2 36.19, p < 0.0001)]. Given the short-term follow-up and retrospective study design, this likely underestimates the true discrepancy. Age at presentation was comparable at the two African sites but lower in the UK (one-way ANOVA, F = 0.2997, p = 0.74). Disease was more advanced in Tanzania at presentation (84% stage III–IV cf. 60% and 57% in Rwanda and UK, respectively, X2 7.57, p = 0.02). All patients had pre-operative chemotherapy, and a majority had nephrectomy. Post-operative morbidity was higher in lower resourced settings (X2 33.72, p < 0.0001). Methodology involving medical students and junior doctors proved time- and cost-effective. This collaboration was a valuable learning experience for students about global research networks. Conclusions This study demonstrates novel research methodology involving medical students collaborating across the global south and global north. The comparison of outcomes advocates, on an institutional level, for development in access to services and multidisciplinary treatment of WT.
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Jansen, Stefan, Ross White, Jemma Hogwood, et al. "The “treatment gap” in global mental health reconsidered: sociotherapy for collective trauma in Rwanda." European Journal of Psychotraumatology 6, no. 1 (2015): 28706. http://dx.doi.org/10.3402/ejpt.v6.28706.
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Sirbu, L., S. Ghosh, and D. Riedel. "Assessing Clinician Compliance with National Guidelines for Pediatric HIV Care and Treatment in Rwanda." Annals of Global Health 83, no. 1 (2017): 140. http://dx.doi.org/10.1016/j.aogh.2017.03.312.
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Park, Paul H., Sonya Davey, Alexandra E. Fehr, et al. "Patient Characteristics, Early Outcomes, and Implementation Lessons of Cervical Cancer Treatment Services in Rural Rwanda." Journal of Global Oncology, no. 4 (December 2018): 1–11. http://dx.doi.org/10.1200/jgo.18.00120.
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Purpose Low- and middle-income countries account for 86% of all cervical cancer cases and 88% of cervical cancer mortality globally. Successful management of cervical cancer requires resources that are scarce in sub-Saharan Africa, especially in rural settings. Here, we describe the early clinical outcomes and implementation lessons learned from the Rwanda Ministry of Health’s first national cancer referral center, the Butaro Cancer Center of Excellence (BCCOE). We hypothesize that those patients presenting at earlier stage and receiving treatment will have higher rates of being alive. Methods The implementation of cervical cancer services included developing partnerships, clinical protocols, pathology services, and tools for monitoring and evaluation. We conducted a retrospective study of patients with cervical cancer who presented at BCCOE between July 1, 2012, and June 30, 2015. Data were collected from the electronic medical record system and by manually reviewing medical records. Descriptive, bivariable and multivariable statistical analyses were conducted to describe patient demographics, disease profiles, treatment, and clinical outcomes. Results In all, 373 patients met the study inclusion criteria. The median age was 53 years (interquartile rage, 45 to 60 years), and 98% were residents of Rwanda. Eighty-nine percent of patients had a documented disease stage: 3% were stage I, 48% were stage II, 29% were stage III, and 8% were stage IV at presentation. Fifty percent of patients were planned to be treated with a curative intent, and 54% were referred to chemoradiotherapy in Uganda. Forty percent of patients who received chemoradiotherapy were in remission. Overall, 25% were lost to follow-up. Conclusion BCCOE illustrates the feasibility and challenges of implementing effective cervical cancer treatment services in a rural setting in a low-income country.
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Patrick, Munezero. "Treatment of Hepatitis B (HBV) and C Virus (HCV) and Challenges in the Treatment in Rwanda: Ruli District Hospital." TEXILA INTERNATIONAL JOURNAL OF PUBLIC HEALTH 8, no. 1 (2020): 90–105. http://dx.doi.org/10.21522/tijph.2013.08.01.art010.
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Habimana, Dominique Savio, Jean Claude Semuto Ngabonziza, Patrick Migambi, et al. "Predictors of Rifampicin-Resistant Tuberculosis Mortality among HIV-Coinfected Patients in Rwanda." American Journal of Tropical Medicine and Hygiene 105, no. 1 (2021): 47–53. http://dx.doi.org/10.4269/ajtmh.20-1361.
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Abstract.Tuberculosis (TB), including multidrug-resistant (MDR; i.e., resistant to at least rifampicin and isoniazid)/rifampicin-resistant (MDR/RR) TB, is the most important opportunistic infection among people living with HIV (PLHIV). In 2005, Rwanda launched the programmatic management of MDR/RR-TB. The shorter MDR/RR-TB treatment regimen (STR) has been implemented since 2014. We analyzed predictors of MDR/RR-TB mortality, including the effect of using the STR overall and among PLHIV. This retrospective study included data from patients diagnosed with RR-TB in Rwanda between July 2005 and December 2018. Multivariable logistic regression was used to assess predictors of mortality. Of 898 registered MDR/RR-TB patients, 861 (95.9%) were included in this analysis, of whom 360 (41.8%) were HIV coinfected. Overall, 86 (10%) patients died during MDR/RR-TB treatment. Mortality was higher among HIV-coinfected compared with HIV-negative TB patients (13.3% versus 7.6%). Among HIV-coinfected patients, patients aged ≥ 55 years (adjusted odds ratio = 5.89) and those with CD4 count ≤ 100 cells/mm3 (adjusted odds ratio = 3.77) had a higher likelihood of dying. Using either the standardized longer MDR/RR-TB treatment regimen or the STR was not correlated with mortality overall or among PLHIV. The STR was as effective as the long MDR/RR-TB regimen. In conclusion, older age and advanced HIV disease were strong predictors of MDR/RR-TB mortality. Therefore, special care for elderly and HIV-coinfected patients with ≤ 100 CD4 cells/mL might further reduce MDR/RR-TB mortality.