The evaluation of a surgical task-sharing program in South Sudan

Background: Five billion people lack timely, affordable, and safe surgical services. Sub-Saharan Africa (SSA) is the region with the scarcest access to surgical care. The surgical workforce is crucial in closing this gap. In SSA, South Sudan has one of the lowest surgical workforce density. Task-sharing being a cost-effective training method, in 2019, the University of British Columbia collaborated with Médecins Sans Frontières to create the Essential Surgical Skills program and launched it in South Sudan. This study aims to evaluate this pilot program. Methods: This is a mixed-method prospective cohort study. Quantitative data include pre- and post-training outputs (number and types of surgeries, complication, re-operation, and mortality) and surgical proficiency of the trainees (quiz, Entrustable Professional Activity (EPA), and logbook data), and online survey for trainers. Semi-structured interviews were performed with trainees at the program completion. Results: Since July 2019, trainees performed 385 operations. The most common procedures were skin graft (14.8%), abscess drainage (9.61%), wound debridement and transverse laparotomy (7.79% each). 172 EPAs have been completed, out of which 136 (79%) showed that the trainee could independently perform the procedure. During the training, the operating room and surgical ward mortality remained similar to the pre-training phase. Furthermore, the surgical morbidity decreased from 25% to less than 5%. The pass rate for all quizzes was 100%. Interviews and survey showed that trainees’ surgical knowledge, interprofessional teamwork, trainers’ global insight on surgical training in Low- and Middle-Income Countries (LMICs), and patient care has improved. Also, the program empowered trainees, developed career path, and local acceptance and retention. The modules were relevant to community needs. Conclusions: This study casts light on the feasibility of training surgeons through a virtual platform in under-resourced regions. The COVID-19 global pandemic highlighted the need to make LMICs independent from fly-in trainers and traditional apprenticeship. Knowledge translation of this training platform’s evaluation will hopefully inform Ministries of Health and their partners to develop their National Surgical, Obstetric and Anesthesia Plans (NSOAPs). Furthermore, thanks to its scalability, both across levels of training and geography, it paves the way for virtual surgical education everywhere in the world.

Cancer care delivery innovations, experiences and challenges during the COVID-19 pandemic: The Rwanda experience

Globally, cancer is the second leading cause of mortality. In 2018, 9.6 million lives were lost to cancer of which over 70% occurred in low and middle-income countries (LMICs) where limited access to cancer care and overwhelming late disease presentations negatively impact cancer related survival and quality of life [1]. Moreover, globally, new cancer cases are expected to increase from 18.1 million in 2018 to 21.4 million by 2030 [2]. In settings of poor health care systems and impoverished communities, the scarcity of and limited access to diagnostic and treatment modalities negatively impacts health outcomes and undermines achievement of the universal health care coverage (UHC) targets.

Over the past 20 years, Rwanda has recorded gains in key health indicators including increased life expectancy (from 48.6 in 2000 to 67.4 in 2015); declines in maternal mortality (from 1071 in 2000 to 210 per 100 000 live births in 2015) [3]. Concurrently, impressive gains were registered in the control of infectious diseases such as HIV, tuberculosis and malaria [3]. However, little gains have been recorded for the management of non-communicable diseases (NCDs) where age-standardized NCD mortality rates slightly decreased from 894.9 to 548.6 deaths per 100 000 people from 2000 to 2016 [4,5]. Anecdotally, plausible hindrances to the prevention and control of NCDs in Rwanda include low community awareness, lack of trained providers, limited access to diagnostic services and treatment capacity for complicated cases

History and Current State of Global Neurosurgery in Sub-Saharan Africa

Archaeological sources reported traces of trepanation in ancient Egypt 3000 years ago, and Papyri of that time already described techniques for the treatment of head trauma (1). The history of modern neurosurgery in Sub-Saharan Africa (SSA) is recent, and there are two significant periods to be considered.

The first period can be called the pre-independence period. This period corresponded to the 1950s, when most African nations were still colonized. During this period, neurosurgical care was delivered by surgeons originally from European countries. For instance, in West Africa, the first neurosurgical operations were carried out in 1957 by a French military medical officer at the Hôpital Principal de Dakar. Later on, in 1972, the first neurosurgical care delivery was organized in “Côte d’Ivoire” under Drs. Courson and Cournil. During the same period, neurosurgery service delivery developed in English-speaking West African countries. In Ghana and Nigeria, the discipline was introduced by local neurosurgeons who had trained in Europe, namely Dr. Mustaffa in 1962 (Ghana) and Dr. Odeku 1969 (Nigeria) (2,3,5). In Southern and Eastern Africa, the specialty was initiated by Dr. P. Cliffort in Kenya and Dr. I. Bailey in Uganda. In Zimbabwe, Dr. Lawrence Levy was the first neurosurgeon to practice the discipline (2, 3).

The second period of Sub-saharan African neurosurgery started after the independence and showed greater involvement of African neurosurgeons. This period began in the 1970s, and among the local neurosurgeons, Drs. Mélaine Kouamé Kangah, Vincent Ba Zézé, and G Dechambenoit contributed significantly to the growth of neurosurgery in Ivory Coast. Similarly, Drs. Mamadou Guèye, Seydou B Badiane, and Y Sakho were pioneers in Senegal. Dr. Kazadi Kalangu did the same in Zimbabwe, while Dr. S Sanoussi and Dr. Wandja pioneered neurosurgery in Niger and Cameroon (2,3). In Burkina Faso, Dr. Abel Kabre, after his training in Dakar in the 80s, has successfully developed its specialty.

Cross-sectional survey of treatments and outcomes among injured adult patients in Kigali, Rwanda

Introduction
Traumatic injuries and their resulting mortality and disability impose a disproportionate burden on sub-Saharan countries like Rwanda. An important facet of addressing injury burdens is to comprehend injury patterns and aetiologies of trauma. This study is a cross-sectional analysis of injuries, treatments and outcomes at the University Teaching Hospital-Kigali (CHUK).

Methods
A random sample of Emergency Centre (EC) injury patients presenting during August 2015 through July 2016 was accrued. Patients were excluded if they had non-traumatic illness. Data included demographics, clinical presentation, injury type(s), mechanism of injury, and EC disposition. Descriptive statics were utilised to explore characteristics of the population.

Results
A random sample of 786 trauma patients met inclusion criteria and were analysed. The median age was 28 (IQR 6–50) years and 69.4% were male. Of all trauma patients 49.4% presented secondary to road traffic injuries (RTIs), 23.9% due to falls, 10.9% due to penetrating trauma. Craniofacial trauma was the most frequent traumatic injury location at 36.3%. Lower limb trauma and upper limb trauma constituted 35.8% and 27.1% of all injuries. Admission was required in 68.2% of cases, 23.3% were admitted to the orthopaedic service with the second highest admission to the surgical service (19.2%). Of those admitted to the hospital, the median LOS was 6 days (IQR 3–14), in the subset of patients requiring operative intervention, the median LOS was also 6 days (IQR 3–16). Death occurred in 5.5% of admitted patients in the hospital.

Conclusion
The traumatic injury burden is borne more proportionally by young males in Kigali, Rwanda. Blunt trauma accounts for a majority of trauma patient presentations; of these RTIs constitute nearly half the injury mechanisms. These findings suggest that this population has substantial injury burdens and prevention and care interventions focused in this demographic group could provide positive impacts in the study setting.

Occurrence of surgical site infection and adherence to chemoprophylaxis protocol in orthopaedics at Univerity Teaching Hospital of Kigali, Rwanda

Background: Surgical Site Infections (SSIs) are among preventable but devastating complications in trauma and orthopaedic surgery. This study was conducted to determine the prevalence of SSIs and assess adherence to antibiotic prophylaxis protocol in the Trauma and Orthopaedic Unit at the University Teaching Hospital of Kigali (CHUK).

Objective: To assess how the orthopaedic practice at University Teaching Hospital of Kigali (CHUK) adheres to the standard protocols of antibiotic prophylaxis and to what extent the orthopaedic SSI occurs at CHUK.

Design: This was a retrospective study.

Methods: Patients who underwent any major trauma or orthopaedic procedure from 1st October 2015 to 31st December 2015 were included. The patient’s clinical records were reviewed to analyze the perioperative antibiotic use and track infectious complications within 90 days post-surgery. Percentages, means and ranges were used to describe the general characteristics and the outcome of interest.

Results: One hundred and thirty two patients with the mean age of 34.9 years were included in the study. Males accounted for 62.8% with a male to female ratio of 1.8/1. Emergencies and elective cases were accounting respectively for 90.1% and 9.8%. SSIs occurred in eight patients accounting for 6.06%. Ceftriaxone was predominantly used at 60.6% of all cases. The recommended chemoprophylaxis administration interval of 60 to 30 minutes prior to skin incision was respected in only 31.7% of cases. A single dose of chemoprophylaxis was given in 89.4% of cases.

Conclusion: The study noted significant deviations from internationally accepted standards of SSI chemoprophylaxis. Therefore, CHUK would be recommended to develop and implement evidencebased protocols for antibiotic prophylaxis in trauma and orthopaedics, to minimize SSI and ensure antibiotic stewardship.

Andersen’s utilization model for cataract surgical rate and empirical evidence from economically-developing areas

Abstract
Background
Un-operated cataract is the leading cause of vision loss worldwide, responsible for 33% of visual impairment, and half of global blindness. The study aimed to build a fast evaluation method utilizing Andersen’s utilization framework and identify predictors of cataract surgical rate in sub-Saharan Africa and China.

Methods
The study was a cross-over ecological epidemiology study with a total of 19 countries in sub-Saharan Africa, and 31 provinces in China. Information was extracted from public data and published studies. Linear regression and structural equation modeling with Bootstrap were used to analyze predictors of CSR and their pathways to impact in sub-Saharan Africa and China separately.

Results
Cataract surgical resources in sub-Saharan Africa were linearly correlated with CSR (β = 0.74, 95% CI: 0.09, 0.91), while GDP/P didn’t impact cataract surgical resources (β = 0.29, 95% CI: − 0.12, 0.75). In China, residents’ average ability to pay was confirmed as the mediator between GDP/P and CSR (p = 0.32, RMSEA = 0.07; βCSR-paying = 0.77, 95% CI: 0.25, 0.90; βpaying-GDP/P = 0.89, 95% CI: 0.82, 0.93).

Conclusions
In sub-Saharan Africa, CSR is determined by health care provision. Local economic development may not directly influence CSR. Therefore, international assistance aimed to providing free cataract surgery directly is crucial. In China, CSR is determined principally by health care demand (ability to pay). To increase CSR in underserved areas of China, ability to pay must be enhanced through social insurance, and reduced surgical fees.

Predicting mortality in adults with suspected infection in a Rwandan hospital: an evaluation of the adapted MEWS, qSOFA and UVA scores

Rationale: Mortality prediction scores are increasingly being evaluated in low and middle income countries (LMICs) for research comparisons, quality improvement and clinical decision-making. The modified early warning score (MEWS), quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA), and Universal Vital Assessment (UVA) score use variables that are feasible to obtain, and have demonstrated potential to predict mortality in LMIC cohorts.

Objective: To determine the predictive capacity of adapted MEWS, qSOFA and UVA in a Rwandan hospital.

Design, setting, participants and outcome measures: We prospectively collected data on all adult patients admitted to a tertiary hospital in Rwanda with suspected infection over 7 months. We calculated an adapted MEWS, qSOFA and UVA score for each participant. The predictive capacity of each score was assessed including sensitivity, specificity, positive and negative predictive value, OR, area under the receiver operating curve (AUROC) and performance by underlying risk quartile.

Results: We screened 19 178 patient days, and enrolled 647 unique patients. Median age was 35 years, and in-hospital mortality was 18.1%. The proportion of data missing for each variable ranged from 0% to 11.7%. The sensitivities and specificities of the scores were: adapted MEWS >4, 50.4% and 74.9%, respectively; qSOFA >2, 24.8% and 90.4%, respectively; and UVA >4, 28.2% and 91.1%, respectively. The scores as continuous variables demonstrated the following AUROCs: adapted MEWS 0.69 (95% CI 0.64 to 0.74), qSOFA 0.65 (95% CI 0.60 to 0.70), and UVA 0.71 (95% CI 0.66 to 0.76); there was no statistically significant difference between the discriminative capacities of the scores.

Conclusion: Three scores demonstrated a modest ability to predict mortality in a prospective study of inpatients with suspected infection at a Rwandan tertiary hospital. Careful consideration must be given to their adequacy before using them in research comparisons, quality improvement or clinical decision-making.

Health System Factors That Influence Treatment Delay in Women With Breast Cancer in Sub-saharan Africa: A Systematic Review

Abstract
Background
Breast cancer patients in sub-Saharan Africa experience long delays between their first presentation to a health care facility and the start of cancer treatment. The role of the health system in the increasing delay in treatment has not been widely investigated. This review aimed to identify existing information on health system factors that influence treatment delays in women with breast cancer in sub-Saharan Africa to contribute to the reorientation of health policies in the region.
Methods
PubMed, ScienceDirect, African Journals Online, Mendeley, ResearchGate and Google Scholar were searched to identify relevant studies published between 2010 and July 2020. We performed a qualitative synthesis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyse (PRISMA) statement. Related health system factors were extracted and classified according to the World Health Organization’s six health system building blocks. The quality of qualitative and quantitative studies was assessed by using the Critical Appraisal Skills Program quality-assessment tool and the National Institute of Health Quality Assessment Tool, respectively. In addition, we used the Confidence in the Evidence from Reviews of Qualitative Research tool to assess the evidence for each qualitative finding.
Results
From 14,184 identified studies, this systematic review included 28 articles. We identified a total of 36 barriers and 8 facilitators that may influence treatment delay in women with breast cancer. The principal health system factors identified were mainly related to human resources and service delivery, particularly difficulty accessing health care, diagnostic errors, poor management, and treatment cost.
Conclusion
The present review shows that treatment delay among women with breast cancer in sub-Saharan Africa is influenced by many related health system factors. Policymakers in sub-Saharan Africa need to tackle the financial accessibility to breast cancer treatment by adequate universal health coverage policies and reinforce the clinical competencies for health workers to ensure timely diagnosis and appropriate care for women with breast cancer in this region

Cervical cancer in Sub‐Saharan Africa: a multinational population‐based cohort study on patterns and guideline adherence of care

Abstract
Background
Cervical cancer (CC) is the most common female cancer in many countries of sub‐Saharan Africa (SSA). We assessed treatment guideline adherence and its association with overall survival (OS).

Methods
Our observational study covered nine population‐based cancer registries in eight countries: Benin, Ethiopia, Ivory Coast, Kenya, Mali, Mozambique, Uganda, and Zimbabwe. Random samples of 44‐125 patients diagnosed 2010‐2016 were selected in each. Cancer‐directed therapy (CDT) was evaluated for degree of adherence to National Comprehensive Cancer Network (USA) Guidelines.

Results
Of 632 patients, 15.8% received CDT with curative potential: 5.2% guideline‐adherent, 2.4% with minor and 8.2% major deviations. CDT was not documented or without curative potential in 22%; 15.7% were diagnosed FIGO IV disease. Adherence was not assessed in 46.9% (no stage or follow‐up documented 11.9%) or records not traced (35.1%). The largest share of guideline‐adherent CDT was observed in Nairobi (49%), the smallest in Maputo (4%). In FIGO I‐III patients (n=190), minor and major guideline deviations were associated with impaired OS: hazard rate ratio (HRR) 1.73, 95% confidence interval (CI) 0.36‐8.37; and HRR 1.97, CI 0.59‐6.56 respectively. CDT without curative potential (HRR 3.88, CI 1.19‐12.71) and no CDT (HRR 9.43, CI 3.03‐29.33) showed substantially worse survival.

Conclusion
We found only one in six cervical cancer patients in SSA received CDT with curative potential. At least one‐fifth and possibly up to two thirds of women never accessed CDT, despite curable disease, resulting in impaired OS. Investments into more radiotherapy, chemotherapy, and surgical training could change the fatal outcomes of man

A Situational Analysis of the Specialist Anaesthesia Workforce of East, Central and Southern Africa

Background: An accurate account of the distribution of qualied anaesthesiologists in East, Central and Southern Africa has been lacking with most of the current publications being estimates of headline gures. As university training programmes, and more recently the College of Anaesthesiologists of East, Central and Southern Africa (CANECSA), work to scale up the anaesthesiology workforce, it is crucial to understand the scope of the need by carrying out an extensive survey. This is key to informing policymakers and stakeholders for tackling the problem of human resources for anaesthesia.

Methods: The anaesthesiologist distribution in the eight CANECSA member countries was determined using a combination existing databases and collection of new data from sources such as CANECSA records, national medical council registers, national anaesthesiology society records, as well as data validation through direct and indirect contact with the anaesthesiologists. Data collation and analysis was performed using Microsoft Excel Spreadsheets and SPSS by assessing relevant frequencies and crosstabulations. Data was stored in a cloud-based database managed by CANECSA.

Results: 411 qualified anaesthesiologists were identied within the CANECSA member countries, a rate of 0.21 anaesthesiologists per 100,000 population compared to 333 (0.17 anaesthesiologists per 100,000 population) reported by the World Federation of Societies of Anaesthesiology (WFSA) in 2015/2016. Newly quantified details on the distribution of anesthesiologists in the region include: the majority (89.5%) of anaesthesiologists perform clinical work and most (69.3%) are based in the main commercial cities of their countries of practice; only about one third (35.5%) are female; the majority are employed by government institutions (61.6%) and medical-training institutions (59.4%); and almost half (49.2%) of anaesthesiologists whose age was recorded ranged from 30 to 39 years.

Conclusion: The numbers of anaesthesiologists in CANECSA member countries are still far below all international recommendations constituting only about 5% of the minimum recommended figures for LMICs. Anaesthesiologist are highly concentrated in the major cities of the region, with few in provincial and rural areas. Nonetheless, all trends suggest huge opportunities for advancing training of more
anaesthesiologists through collaborative efforts.