Systematic media review: A novel method to assess mass-trauma epidemiology in absence of databases—A pilot-study in Rwanda

Surge capacity refers to preparedness of health systems to face sudden patient inflows, such as mass-casualty incidents (MCI). To strengthen surge capacity, it is essential to understand MCI epidemiology, which is poorly studied in low- and middle-income countries lacking trauma databases. We propose a novel approach, the “systematic media review”, to analyze mass-trauma epidemiology; here piloted in Rwanda.

A systematic media review of non-academic publications of MCIs in Rwanda between January 1st, 2010, and September 1st, 2020 was conducted using NexisUni, an academic database for news, business, and legal sources previously used in sociolegal research. All articles identified by the search strategy were screened using eligibility criteria. Data were extracted in a RedCap form and analyzed using descriptive statistics.

Of 3187 articles identified, 247 met inclusion criteria. In total, 117 MCIs were described, of which 73 (62.4%) were road-traffic accidents, 23 (19.7%) natural hazards, 20 (17.1%) acts of violence/terrorism, and 1 (0.09%) boat collision. Of Rwanda’s 30 Districts, 29 were affected by mass-trauma, with the rural Western province most frequently affected. Road-traffic accidents was the leading MCI until 2017 when natural hazards became most common. The median number of injured persons per event was 11 (IQR 5–18), and median on-site deaths was 2 (IQR 1–6); with natural hazards having the highest median deaths (6 [IQR 2–18]).

In Rwanda, MCIs have decreased, although landslides/floods are increasing, preventing a decrease in trauma-related mortality. By training journalists in “mass-casualty reporting”, the potential of the “systematic media review” could be further enhanced, as a way to collect MCI data in settings without databases.

The True Costs of Cesarean Sections for Patients in Rural Rwanda: Accounting for Post-Discharge Expenses in Estimated Health Expenditures

Introduction: While it is recognized that there are costs associated with postoperative patient follow-up, risk assessments of catastrophic health expenditures (CHEs) due to surgery in sub-Saharan Africa rarely include expenses after discharge. We describe patient-level costs for cesarean section (c-section) and follow-up care up to postoperative day (POD) 30 and evaluate the contribution of follow-up to CHEs in rural Rwanda.

Methods: We interviewed women who delivered via c-section at Kirehe District Hospital between September 2019 and February 2020. Expenditure details were captured on an adapted surgical indicator financial survey tool and extracted from the hospital billing system. CHE was defined as health expenditure of ≥ 10% of annual household expenditure. We report the cost of c-section up to 30 days after discharge, the rate of CHE among c-section patients stratified by in-hospital costs and post-discharge follow-up costs, and the main contributors to c-section follow-up costs.

Results: Of the 479 participants in this study, 90% were classified as impoverished before surgery and an additional 6.4% were impoverished by the c-section. The median out-of-pocket costs up to POD30 was US$122.16 (IQR: $102.94, $148.11); 63% of these expenditures were attributed to post-discharge expenses or lost opportunity costs (US$77.50; IQR: $67.70, $95.60). To afford c-section care, 64.4% borrowed money and 18.4% sold possessions. The CHE rate was 27% when only considering direct and indirect costs up to the time of discharge and 77% when including the reported expenses up to POD30. Transportation and lost household wages were the largest contributors to post-discharge costs.

Conclusion: Costs associated with surgical follow-up are often neglected in financial risk calculations but contribute significantly to the risk of CHE in rural Rwanda. Insurance coverage for direct medical costs is insufficient to protect against CHE. Innovative follow-up solutions to reduce costs of patient transport and compensate for household lost wages need to be considered.

Functional recovery after cesarean delivery: a prospective cohort study in rural Rwanda

Women who deliver via cesarean section (c-section) experience short- and long-term complications that may affect their physical health and their ability to function normally. While physical health outcomes are routinely assessed and monitored, postpartum functional outcomes are not well understood from a patient’s perspective or characterized by clinicians. In Rwanda, 11% of rural women deliver via c-section. This study explores the functional recovery of rural Rwandan women after c-section and assesses factors that predict poor functionality at postoperative day (POD) 30.

Data were collected prospectively on POD 3, 11, and 30 from women delivering at Kirehe District Hospital between October 2019 and March 2020. Functionality was measured by self-reported overall health, energy level, mobility, self-care ability, and ability to perform usual activities. We computed composite mean scores with a maximum score of 4.0 and scores ≤ 2.0 reflected poor functionality. We assessed functionality with descriptive statistics and logistic regression.

Of 617 patients, 54.0%, 25.9%, and 26.8% reported poor functional status at POD3, POD11, and POD30, respectively. At POD30, the most self-reported poor functionality dimensions were poor or very poor overall health (48.1%), and inability to perform usual activities (15.6%). In the adjusted model, women whose surgery lasted 30–45 minutes had higher odds of poor functionality (aOR = 1.85, p = 0.01), as did women who experienced intraoperative complications (aOR = 4.12, p = 0.037). High income patients had incrementally lower significant odds of poor functionality (aOR = 0.62 for every US$100 increase in monthly income, p = 0.04).

We found a high proportion of poor functionality 30 days post-c-section and while surgery lasting > 30 minutes and experiencing intra-operative complications was associated with poor functionality, a reported higher income status was associated with lower odds of poor functionality. Functional status assessments, monitoring and support should be included in post-partum care for women who delivered via c-section. Effective risk mitigating intervention should be implemented to recover functionality after c-section, particularly among low-income women and those undergoing longer surgical procedures or those with intraoperative complications.

Context Specific Realities and Experiences of Nurses and Midwives in Basic Emergency Obstetric and Newborn Care Services in Two District Hospitals in Rwanda

In low and middle-income countries, nurses and midwives are the frontline healthcare workers in obstetric care. Insights into the experiences of these healthcare workers in managing obstetric care emergencies are critical for improving quality of care. This article presents such insights, from the nurses and midwives working in Rwandan district hospitals, who reflected on their experiences of managing the most common birth-related complications; postpartum hemorrhage (PPH) and newborn asphyxia. This is a qualitative part of a broader research about implementation of an mLearning and mHealth decision support tool (Safe Delivery Application), in basic emergency obstetric and newborn care services in Rwanda.

In this exploratory qualitative aspect of the research, the first author facilitated four focus group discussions with 26 nurses and midwives from two district hospitals in Rwanda. Each focus group discussion was made up of two parts. The first part focused on the participants’ reflections on the research results, while the second part explored their experiences of delivering obstetric care services in their respective district hospitals. The research results included: survey results reflecting their knowledge and skills of PPH management and of neonatal resuscitation (NR); and findings from a six-month record review of PPH management and NR outcomes, from the district hospitals under study. Data were analyzed using hybrid thematic analysis.

Nurses and midwives felt that the presented findings were a true reflection of the reality and offered diverse explanations for the results. The participants’ narratives of lived experiences of providing BEmONC services are presented under two broad themes: (1) self-reflections on their current practices and (2) contextual factors influencing the delivery of BEmONC services.

The insights of nurses and midwives regarding the management of birth related complications revealed multi-faceted factors that influence the quality of their obstetric care. Even though the study was focused on their management of PPH and NR, the resulting recommendations to improve quality of care could benefit the broader field of maternal and child health particularly in low and middle income countries.

Improving hand hygiene measures in low-resourced intensive care units: experience at the Kigali University Teaching Hospital in Rwanda

Background: Proper hand hygiene (HH) practices have been shown to reduce healthcare-acquired infections. Several potential challenges in low-income countries might limit the feasibility of effective HH, including preexisting knowledge gaps and staffing.

Aim: We sought to evaluate the feasibility of the implementation of effective HH practice at a teaching hospital in Rwanda.

Methods: We conducted a prospective quality improvement project in the intensive care unit (ICU) at the Kigali University Teaching Hospital. We collected data before and after an intervention focused on HH adherence as defined by the World Health Organization ‘5 Moments for Hand Hygiene’ and assuring availability of HH supplies. Pre-intervention data were collected throughout July 2019, and HH measures were implemented in August 2019. Post-implementation data were collected following a 3-month wash-in.

Results: In total, 902 HH observations were performed to assess pre-intervention adherence and 903 observations post-intervention adherence. Overall, HH adherence increased from 25% (222 of 902 moments) before intervention to 75% (677 of 903 moments) after intervention (P < 0.001). Improvement was seen among all health professionals (nurses: 19–74%, residents: 23–74%, consultants: 29–76%). Conclusions: Effective HH measures are feasible in an ICU in a low-income country. Ensuring availability of supplies and training appears key to effective HH practices.

Procedural fairness for radiotherapy priority setting in a low resource context

Radiotherapy is an essential component of cancer treatment, yet many countries do not have adequate capacity to serve their populations. This mismatch between demand and supply creates the need for priority setting. There is no widely accepted system to guide patient prioritization for radiotherapy in a low resource context. In the absence of consensus on allocation principles, fair procedures for priority setting should be established. Research is needed to understand what elements of procedural fairness are important to decision makers in diverse settings, assess the feasibility of implementing fair procedures for priority setting in low resource contexts, and improve these processes. This study presents the views of decision makers engaged in everyday radiotherapy priority setting at a cancer center in Rwanda. Semi-structured interviews with 22 oncology physicians, nurses, program leaders, and advisors were conducted. Participants evaluated actual radiotherapy priority setting procedures at the program (meso) and patient (micro) levels, reporting facilitators, barriers, and recommendations. We discuss our findings in relation to the leading Accountability for Reasonableness (AFR) framework. Participants emphasized procedural elements that facilitate adherence to normative principles, such as objective criteria that maximize lives saved. They ascribed fairness to AFR’s substantive requirement of relevance more than transparency, appeals, and enforcement. They identified several challenges unresolved by AFR, such as conflicting relevant rationales and unintended consequences of publicity and appeals. Implementing fair procedure itself is resource intensive, a paradox that calls for innovative, context-appropriate solutions. Finally, socioeconomic and structural barriers to care that undermine procedural fairness must be addressed.

Strategies for Improving Quality and Safety in Global Health: Lessons From Nontechnical Skills for Surgery Implementation in Rwanda

In 2015 the Lancet Commission on Global Surgery published its report “Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development,”1 helping to galvanize a global movement to increase access to safe, timely, and affordable surgical and anesthesia care with an emphasis on equity. A goal of the movement is to enable the benefits of these efforts to be reaped most by impoverished and marginalized populations. The authors laid out 5 key messages, including the great number of operations required annually (approximately 143 million), especially among the poorest third of the world’s population, which receives only 6% of the operations. The commission called on nations to track and report on 6 metrics related to surgical care. Two of these metrics—surgeon, anesthetist, and obstetric (SAO) density (the number of specialist surgical, anesthetic, and obstetric providers per 100,000 population) and surgical volume (number of operations performed in operating rooms annually per 100,000 population)—are measurements …

Strengthening Antimicrobial Resistance Diagnostic Capacity in Rural Rwanda: A Feasibility Assessment

Introduction: Antimicrobial resistance (AMR) is a global public health threat. Worse still, there is a paucity of data from low- and middle-income countries to inform rational antibiotic use.

Objective: Assess the feasibility of setting up microbiology capacity for AMR testing and estimate the cost of setting up microbiology testing capacity at rural district hospitals in Rwanda.

Methods: Laboratory needs assessments were conducted, and based on identified equipment gaps, appropriate requisitions were processed. Laboratory technicians were trained on microbiology testing processes and open wound samples were collected and cultured at the district hospital (DH) laboratories before being transported to the National Reference Laboratory (NRL) for bacterial identification and antibiotic susceptibility testing. Quality control (QC) assessments were performed at the DHs and NRL. We then estimated the cost of three scenarios for implementing a decentralized microbiology diagnostic testing system.

Results:There was an eight-month delay from the completion of the laboratory needs assessments to the initiation of sample collection due to the regional unavailability of appropriate supplies and equipment. When comparing study samples processed by study laboratory technicians and QC samples processed by other laboratory staff, there was 85.0% test result concordance for samples testing at the DHs and 90.0% concordance at the NRL. The cost for essential equipment and supplies for the three DHs was $245,871. The estimated costs for processing 600 samples ranged from $29,500 to $92,590.

Conclusion: There are major gaps in equipment and supply availability needed to conduct basic microbiology assays at rural DHs. Despite these challenges, we demonstrated that it is feasible to establish microbiological testing capacity in Rwandan DHs. Building microbiological testing capacity is essential for improving clinical care, informing rational antibiotics use, and ultimately, contributing to the establishment of robust national antimicrobial stewardship programs in rural Rwanda and comparable settings

Surgical Site Infections and Antimicrobial Resistance After Cesarean Section Delivery in Rural Rwanda

Background: As the volume of surgical cases in low- and middle-income countries (LMICs) increases, surgical-site infections (SSIs) are becoming more prevalent with anecdotal evidence of antimicrobial resistance (AMR), despite a paucity of data on resistance patterns.

Objectives: As a primary objective, this prospective study aimed to describe the epidemiology of SSIs and the associated AMR among women who delivered by cesarean at a rural Rwandan hospital. As secondary objectives, this study also assessed patient demographics, pre- and post-operative antibiotic use, and SSI treatment.

Methods: Women who underwent cesarean deliveries at Kirehe District Hospital between September 23rd, 2019, and March 16th, 2020, were enrolled prospectively. On postoperative day (POD) 11 (+/− 3 days), their wounds were examined. When an SSI was diagnosed, a wound swab was collected and sent to the Rwandan National Reference Laboratory for culturing and antibiotic susceptibility testing.

Findings: Nine hundred thirty women were enrolled, of whom 795 (85.5%) returned for the POD 11 clinic visit. 45 (5.7%) of the 795 were diagnosed with SSI and swabs were collected from 44 of these 45 women. From these 44 swabs, 57 potential pathogens were isolated. The most prevalent bacteria were coagulase-negative staphylococci (n = 12/57, 20.3% of all isolates), and Acinetobacter baumannii complex (n = 9/57, 15.2%). 68.4% (n = 39) of isolates were gram negative; 86.7% if excluding coagulase-negative staphylococci. No gram-negative pathogens isolated were susceptible to ampicillin, and the vast majority demonstrated intermediate susceptibility or resistance to ceftriaxone (92.1%) and cefepime (84.6%).

Conclusions: Bacterial isolates from SSI swab cultures in rural Rwanda predominantly consisted of gram-negative pathogens and were largely resistant to commonly used antibiotics. This raises concerns about the effectiveness of antibiotics currently used for surgical prophylaxis and treatment and may guide the appropriate selection of treatment of SSIs in rural Rwanda and comparable settings.

Surgical Management and Outcomes of Wilms Tumor in Rwanda: A Retrospective Study of Patients Operated on at the University Teaching Hospital of Kigali-Rwanda

BACKGROUND: Wilms tumor is the most common renal tumor in children and accounts for 6-8% of all childhood malignancies and has a variable survival rate worldwide. The aim of this study was to describe the surgical management and outcomes of care for Wilms tumor patients operated at the University Teaching Hospital of Kigali (CHUK).
METHODS: This is a retrospective chart review conducted at CHUK in Rwanda. It includes all children who had a confirmed Wilms tumor diagnosis operated from July 2012 to June 2016. Patient’s demographics, staging, surgical management, and outcomes were analyzed.
RESULTS: A total of 58 patients diagnosed with Wilms tumor were identified. 52.6% were female. The median age was four years, interquartile range (IQR): 1-10 years. The majority of the children were stage II (39.7%) and the minority being stage V (5.2%). Treatment offered was in accordance with the Societe Internationale d’ Oncologie Pediatrique (SIOP) protocol; 91.2% of patients received four weeks of preoperative chemotherapy and a median of 15 weeks postoperative chemotherapy (IQR: 8,26). The resection rate was 100% for those with unilateral tumors. The spillage rate was 15.8%. At the time of the study, the mortality rate was 19.3%, recurrence was 7%, and 12.3% were lost to follow-up.
CONCLUSION: The introduction of a single national protocol for treating Wilms tumor in Rwanda with a dedicated management team, including the surgical and pediatric oncology services, has led to early outcomes approaching the ones in high-income countries, but efforts also need to include earlier detection of this tumor.