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

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.

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.

Association between volume resuscitation & mortality among injured patients at a tertiary care hospital in Kigali, Rwanda

Background
Injuries cause significant morbidity and mortality in sub-Saharan African countries such as Rwanda. These burdens may be compounded by limited access to intravenous (IV) resuscitation fluids such as crystalloids and blood products. This study evaluates the association between emergency department (ED) intravenous volume resuscitation and mortality outcomes in adult trauma patients treated at the University Teaching Hospital-Kigali (UTH- K).

Methods
Data were abstracted using a structured protocol for a random sample of ED patients treated during periods from 2012 to 2016. Patients under 15 years of age were excluded. Data collected included demographics, clinical aspects, types of IV fluid resuscitation provided and outcomes. The primary outcome was facility-based mortality. Descriptive statistics were used to explore characteristics of the population. Kampala Trauma Scores (KTS) were used to control for injury severity. Magnitudes of effects were quantified using multivariable regression models adjusted for gender, KTS, time period, clinical interventions, presence of head injury and transfer to a tertiary care centre to yield adjusted odds ratios (aOR) with 95% confidence intervals (CI).

Results
From the random sample of 3609 cases, 991 trauma patients were analysed. The median age was 32 [IQR 26, 46] years and 74.3% were male. ED volume resuscitation was given to 50.1% of patients with 43.5% receiving crystalloid and 6.4% receiving crystalloid and packed red blood cell (PRBC) transfusions. The median KTS score was 13 [IQR 12, 13]. In multivariable regression, mortality likelihood was increased in those who received crystalloid (aOR = 4.31, 95%CI 1.24, 15.05, p = 0.022) and PRBC plus crystalloid (aOR = 9.97, 95%CI 2.15,46.17, p = 0.003) as compared to trauma patients not treated with IV resuscitation fluids.

Conclusions
Injured ED patients treated with volume resuscitation had higher mortality, which may be due to unmeasured confounding or therapies provided. Further studies on fluid resuscitation in trauma populations in resource-limited settings are needed.

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

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.

Recording patient data in burn unit logbooks in Rwanda – who and what are we missing?

Systematic data collection in high-income countries has demonstrated a decreasing burn morbidity and mortality, whereas lack of data from low- and middle-income countries hinder a global overview of burn epidemiology. In low- and middle-income countries, dedicated burn registries are few. Instead, burn data are often recorded in logbooks or as one variable in trauma registries, where incomplete or inconsistently recorded information is a known challenge. The University Teaching Hospital of Kigali hosts the only dedicated burn unit in Rwanda and has collected data on patients admitted for acute burn care in logbooks since 2005. This study aimed to assess the data registered between January 2005 and December 2019, to evaluate the extent of missing data, and to identify possible factors associated with “missingness”. All data were analyzed using descriptive statistics, Fisher’s exact test, and Wilcoxon Rank Sum test. In this study, 1,093 acute burn patients were included and 64.2% of them had incomplete data. Data completeness improved significantly over time. The most commonly missing variables were whether the patient was referred from another facility and information regarding whether any surgical intervention was performed. Missing data on burn mechanism, burn degree, and surgical treatment were associated with in-hospital mortality. In conclusion, missing data is frequent for acute burn patients in Rwanda, although improvements have been seen over time. As Rwanda and other low- and middle-income countries strive to improve burn care, ensuring data completeness will be essential for the ability to accurately assess the quality of care, and hence improve it.

Factors Associated with Loss to Follow-up among Cervical Cancer Patients in Rwanda

Background:
Cervical cancer is among the most common cancers affecting women globally. Where treatment is available in low- and middle-income countries, many women become lost to follow-up (LTFU) at various points of care.

Objective:
This study assessed predictors of LTFU among cervical cancer patients in rural Rwanda.

Methods:
We conducted a retrospective study of cervical cancer patients enrolled at Butaro Cancer Center of Excellence (BCCOE) between 2012 and 2017 who were either alive and in care or LTFU at 12 months after enrollment. Patients are considered early LTFU if they did not return to clinic after the first visit and late LTFU if they did not return to clinic after the second visit. We conducted two multivariable logistic regressions to determine predictors of early and late LTFU.

Findings:
Of 652 patients in the program, 312 women met inclusion criteria, of whom 47 (15.1%) were early LTFU, 78 (25.0%) were late LTFU and 187 (59.9%) were alive and in care. In adjusted analyses, patients with no documented disease stage at presentation were more likely to be early LTFU vs. patients with stage 1 and 2 when controlling for other factors (aOR: 14.93, 95% CI 6.12–36.43). Patients who travel long distances (aOR: 2.25, 95% CI 1.11, 4.53), with palliative care as type of treatment received (aOR: 6.65, CI 2.28, 19.40) and patients with missing treatment (aOR: 7.99, CI 3.56, 17.97) were more likely to be late LTFU when controlling for other factors. Patients with ECOG status of 2 and higher were less likely to be late LTFU (aOR: 0.26, 95% CI 0.08, 0.85).

Conclusion:
Different factors were associated with early and later LTFU. Enhanced patient education, mechanisms to facilitate diagnosis at early stages of disease, and strategies that improve patient tracking and follow-up may reduce LTFU and improve patient retention.

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

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.

Delivery Mode for Prolonged, Obstructed Labour Resulting in Obstetric Fistula: A Retrospective Review of 4396 Women in East and Central Africa

Objective: To evaluate the mode of delivery and stillbirth rates over time among women with obstetric fistula.

Design: Retrospective record review.

Setting: Tanzania, Uganda, Kenya, Malawi, Rwanda, Somalia, South Sudan, Zambia and Ethiopia.

Population: A total of 4396 women presenting with obstetric fistulas for repair who delivered previously in facilities between 1990 and 2014.

Methods: Retrospective review of trends and associations between mode of delivery and stillbirth, focusing on caesarean section (CS), assisted vaginal deliveries and spontaneous vaginal deliveries.

Main outcome measures: Mode of delivery, stillbirth.

Results: Out of 4396 women with fistula, 3695 (84.1%) delivered a stillborn baby. Among mothers with fistula giving birth to a stillborn baby, the CS rate (overall 54.8%, 2027/3695) rose from 45% (162/361) in 1990-94 to 64% (331/514) in 2010-14. This increase occurred at the expense of assisted vaginal delivery (overall 18.3%, 676/3695), which declined from 32% (115/361) to 6% (31/514).

Conclusions: In Eastern and Central Africa, CS is increasingly performed on women with obstructed labour whose babies have already died in utero. Contrary to international recommendations, alternatives such as vacuum extraction, forceps and destructive delivery are decreasingly used. Unless uterine rupture is suspected, CS should be avoided in obstructed labour with intrauterine fetal death to avoid complications related to CS scars in subsequent pregnancies. Increasingly, women with obstetric fistula add a history of unnecessary CS to their already grim experiences of prolonged, obstructed labour and stillbirth.