21 research outputs found
Achieving High Coverage in Rwanda\u27s National Human Papillomavirus Vaccination Programme
Problem: Virtually all women who have cervical cancer are infected with the human papillomavirus (HPV). Of the 275000 women who die from cervical cancer every year, 88% live in developing countries. Two vaccines against the HPV have been approved. However, vaccine implementation in low-income countries tends to lag behind implementation in high-income countries by 15 to 20 years.
Approach: In 2011, Rwanda’s Ministry of Health partnered with Merck to offer the Gardasil HPV vaccine to all girls of appropriate age. The Ministry formed a “public–private community partnership” to ensure effective and equitable delivery.
Local setting: Thanks to a strong national focus on health systems strengthening, more than 90% of all Rwandan infants aged 12–23 months receive all basic immunizations recommended by the World Health Organization.
Relevant changes: In 2011, Rwanda’s HPV vaccination programme achieved 93.23% coverage after the first three-dose course of vaccination among girls in grade six. This was made possible through school-based vaccination and community involvement in identifying girls absent from or not enrolled in school. A nationwide sensitization campaign preceded delivery of the first dose.
Lessons learnt: Through a series of innovative partnerships, Rwanda reduced the historical two-decade gap in vaccine introduction between high- and low-income countries to just five years. High coverage rates were achieved due to a delivery strategy that built on Rwanda’s strong vaccination system and human resources framework. Following the GAVI Alliance’s decision to begin financing HPV vaccination, Rwanda’s example should motivate other countries to explore universal HPV vaccine coverage, although implementation must be tailored to the local context
Integration of Comprehensive Women’S Health Programmes into Health Systems: Cervical Cancer Prevention, Care and Control in Rwanda
PROBLEM: Although it is highly preventable and treatable, cervical cancer is the most common and most deadly cancer among women in Rwanda.
APPROACH: By mobilizing a diverse coalition of partnerships, Rwanda became the first country in Africa to develop and implement a national strategic plan for cervical cancer prevention, screening and treatment.
LOCAL SETTING: Rwanda - a small, landlocked nation in East Africa with a population of 10.4 million - is well positioned to tackle a number of high-burden noncommunicable diseases. The country\u27s integrated response to infectious diseases has resulted in steep declines in premature mortality over the past decade.
RELEVANT CHANGES: In 2011-2012, Rwanda vaccinated 227,246 girls with all three doses of the human papillomavirus (HPV) vaccine. Among eligible girls, three-dose coverage rates of 93.2% and 96.6% were achieved in 2011 and 2012, respectively. The country has also initiated nationwide screening and treatment programmes that are based on visual inspection of the cervix with acetic acid, testing for HPV DNA, cryotherapy, the loop electrosurgical excision procedure and various advanced treatment options.
LESSONS LEARNT: Low-income countries should begin to address cervical cancer by integrating prevention, screening and treatment into routine women\u27s health services. This requires political will, cross-sectoral collaboration and planning, innovative partnerships and robust monitoring and evaluation. With external support and adequate planning, high nationwide coverage rates for HPV vaccination and screening for cervical cancer can be achieved within a few years
Eff ect of pentavalent rotavirus vaccine introduction on hospital admissions for diarrhoea and rotavirus in children in Rwanda: a time-series analysis
Background In May, 2012, Rwanda became the fi rst low-income African country to introduce pentavalent rotavirus
vaccine into its routine national immunisation programme. Although the potential health benefi ts of rotavirus
vaccination are huge in low-income African countries that account for more than half the global deaths from
rotavirus, concerns remain about the performance of oral rotavirus vaccines in these challenging settings.
Methods We conducted a time-series analysis to examine trends in admissions to hospital for non-bloody diarrhoea in
children younger than 5 years in Rwanda between Jan 1, 2009, and Dec 31, 2014, using monthly discharge data from
the Health Management Information System. Additionally, we reviewed the registries in the paediatric wards at six
hospitals from 2009 to 2014 and abstracted the number of total admissions and admissions for diarrhoea in children
younger than 5 years by admission month and age group. We studied trends in admissions specifi c to rotavirus at one
hospital that had undertaken active rotavirus surveillance from 2011 to 2014. We assessed changes in rotavirus
epidemiology by use of data from eight active surveillance hospitals.
Findings Compared with the 2009–11 prevaccine baseline, hospital admissions for non-bloody diarrhoea captured by
the Health Management Information System fell by 17–29% from a pre-vaccine median of 4051 to 2881 in 2013 and
3371 in 2014, admissions for acute gastroenteritis captured in paediatric ward registries decreased by 48–49%, and
admissions specifi c to rotavirus captured by active surveillance fell by 61–70%. The greatest eff ect was recorded in
children age-eligible to be vaccinated, but we noted a decrease in the proportion of children with diarrhoea testing
positive for rotavirus in almost every age group.
Interpretation The number of admissions to hospital for diarrhoea and rotavirus in Rwanda fell substantially after
rotavirus vaccine implementation, including among older children age-ineligible for vaccination, suggesting indirect
protection through reduced transmission of rotavirus. These data highlight the benefi ts of routine vaccination against rotavirus in low-income settings
Human papillomavirus infection in Rwanda at the moment of implementation of a national HPV vaccination programme
Background: Cervical cancer is the most common female cancer in Rwanda that, in 2011, became the first African country to implement a national vaccination programme against human papillomavirus (HPV). Methods: To provide a robust baseline for future evaluations of vaccine effectiveness, cervical cell specimens were obtained from 2508 women aged 18–69 years from the general population in Kigali, Rwanda, during 2013/14. 20 % of women were HIV-positive. Samples were used for liquid-based cytology and HPV testing (44 types) with GP5+/6+ PCR. Results: HPV prevalence was 34 %, being highest (54 %) in women ≤19 years and decreasing to 20 % at age ≥50. Prevalence of high risk (HR) HPV and cytological abnormalities was 22 and 11 % respectively (including 2 % with high-grade squamous intraepithelial lesions, HSIL) decreasing with age. Age-standardised prevalence of HR HPV was 22 % (or 19 % among HIV-negative women), and HPV16 was the most common type. Prevalence of HPV and cytological abnormalities were significantly higher in HIV-positive than HIV-negative women, and the difference increased with age. Other significant risk factors for HPV positivity in multivariate analyses were high lifetime number of sexual partners, receiving cash for sex, and being a farmer. 40 % of women with HSIL were infected with HPV16/18 and there was no significant difference between HIV-positive and HIV-negative women. Conclusions: This study confirms Rwanda to be a setting of high prevalence of HPV and cervical disease that is worsened by HIV. These data will serve as a robust baseline for future evaluations of HPV vaccine programme effectiveness
The Economic Burden Attributable to a Child’s Inpatient Admission for Diarrheal Disease in Rwanda
Background: Diarrhea is one of the leading causes of childhood morbidity and mortality. Hospitalization for diarrhea can pose a significant burden to health systems and households. The objective of this study was to estimate the economic burden attributable to hospitalization for diarrhea among children less than five years old in Rwanda. These data can be used by decision-makers to assess the impact of interventions that reduce diarrhea morbidity, including rotavirus vaccine introduction. Methods: This was a prospective costing study where medical records and hospital bills for children admitted with diarrhea at three hospitals were collected to estimate resource use and costs. Hospital length of stay was calculated from medical records. Costs incurred during the hospitalization were abstracted from the hospital bills. Interviews with the child’s caregivers provided data to estimate household costs which included transport costs and lost income. The portion of medical costs borne by insurance and household were reported separately. Annual economic burden before and after rotavirus vaccine introduction was estimated by multiplying the reported number of diarrhea hospitalizations in public health centers and district hospitals by the estimated economic burden per hospitalization. All costs are presented in 2014 US44.22 ± 101, of which 65% was borne by the household. For households in the lowest income quintile, the household costs were 110% of their monthly income. The annual economic burden to Rwanda attributable to diarrhea hospitalizations ranged from 1.7 million before rotavirus vaccine introduction. Conclusion: Households often bear the largest share of the economic burden attributable to diarrhea hospitalization and the burden can be substantial, especially for households in the lowest income quintile
Human papillomavirus infection in Rwanda at the moment of implementation of a national HPV vaccination programme
Effectiveness of Pentavalent Rotavirus Vaccine under Conditions of Routine Use in Rwanda
Background. Rotavirus vaccine efficacy is lower in low-income countries than in high-income countries. Rwanda was one of the first low-income countries in sub-Saharan Africa to introduce rotavirus vaccine into its national immunization program. We sought to evaluate rotavirus vaccine effectiveness (VE) in this setting. Methods. VE was assessed using a case-control design. Cases and test-negative controls were children who presented with a diarrheal illness to 1 of 8 sentinel district hospitals and 10 associated health centers and had a stool specimen that tested positive (cases) or negative (controls) for rotavirus by enzyme immunoassay. Due to high vaccine coverage almost immediately after vaccine introduction, the analysis was restricted to children 7-18 weeks of age at time of rotavirus vaccine introduction. VE was calculated as (1 - odds ratio) × 100, where the odds ratio was the adjusted odds ratio for the rotavirus vaccination rate among case-patients compared with controls. Results. Forty-eight rotavirus-positive and 152 rotavirus-negative children were enrolled. Rotavirus-positive children were significantly less likely to have received rotavirus vaccine (33/44 [73%] unvaccinated) compared with rotavirus-negative children (81/136 [59%] unvaccinated) (P =. 002). A full 3-dose series was 75% (95% confidence interval [CI], 31%-91%) effective against rotavirus gastroenteritis requiring hospitalization or a health center visit and was 65% (95% CI, -80% to 93%) in children 6-11 months of age and 81% (95% CI, 25%-95%) in children ≥12 months of age. Conclusions. Rotavirus vaccine is effective in preventing rotavirus disease in Rwandan children who began their rotavirus vaccine series from 7 to 18 weeks of age. Protection from vaccination was sustained after the first year of life.SCOPUS: ar.jinfo:eu-repo/semantics/publishe
A cost comparison of introducing and delivering pneumococcal, rotavirus and human papillomavirus vaccines in Rwanda
Background: Detailed cost evaluations of delivery of new vaccines such as pneumococcal conjugate, human papillomavirus (HPV), and rotavirus vaccines in low and middle-income countries are scarce. This paper differs from others by comparing the costs of introducing multiple vaccines in a single country and then assessing the financial and economic impact at the time and implications for the future. The objective of the analysis was to understand the introduction and delivery cost per dose or per child of the three new vaccines in Rwanda to inform domestic and external financial resource mobilization. Methods: Start-up, recurrent, and capital costs from a government perspective were collected in 2012. Since pneumococcal conjugate and HPV vaccines had already been introduced, cost data for those vaccines were collected retrospectively while prospective (projected) costing was done for rotavirus vaccine. Results: The financial unit cost per fully immunized child (or girl for HPV vaccine) of delivering 3 doses of each vaccine (without costs related to vaccine procurement) was 0.54 for pneumococcal (Prevnar®) vaccine in pre-filled syringes, and $10.23 for HPV (Gardasil ®) vaccine. The financial delivery costs of Prevnar® and RotaTeq® were similar since both were delivered using existing health system infrastructure to deliver infant vaccines at health centers. The total financial cost of delivering Gardasil® was higher than those of the two infant vaccines due to greater resource requirements associated with creating a new vaccine delivery system in for a new target population of 12-year-old girls who have not previously been served by the existing routine infant immunization program. Conclusion: The analysis indicates that service delivery strategies have an important influence on costs of introducing new vaccines and costs per girl reached with HPV vaccine are higher than the other two vaccines because of its delivery strategy. Documented information on financial commitments for new vaccines, particularly from government sources, is a useful input into country policy dialogue on sustainable financing and co-financing of new vaccines, as well as for policy decisions by donors such as Gavi, the Vaccine Alliance.SCOPUS: ar.jinfo:eu-repo/semantics/publishe
Effectiveness of Pentavalent Rotavirus Vaccine Under Conditions of Routine Use in Rwanda
Can routinely collected national data on childhood morbidity and mortality from diarrhea be used to monitor health impact of rotavirus vaccination in Africa? Examination of pre-vaccine baseline data from Rwanda.
BACKGROUND: As rotavirus vaccine is introduced into routine childhood immunization programs in Africa, understanding its impact on diarrheal disease burden is important. The objective of this analysis was to determine whether routinely collected health information on national diarrhea hospitalizations, in-hospital deaths and outpatient visits would be useful to monitor rotavirus vaccine impact. METHODS: We analyzed data for all-cause, nonbloody diarrheal disease among children <5 years of age from the routine health management information system (HMIS) in Rwanda from January 2008 through December 2011. We described trends in absolute numbers of inpatient admissions, in-hospital deaths and outpatient visits by year, age and setting. RESULTS: All-cause, nonbloody diarrheal hospitalizations and outpatient visits among children <5 years of age in Rwanda from 2008 to 2011 peaked during the June to August dry season, coinciding with the rotavirus season. The bulk of the diarrheal disease burden occurred in children <1 year of age. Health centers provided many care to children with diarrhea including 60-72% of hospitalizations and 97-99% of outpatient visits. Many in-hospital diarrheal deaths (84%) occurred in district hospitals. DISCUSSION: Given the stable and consistent trends and the prominent seasonality consistent with that of rotavirus, HMIS data should provide a useful baseline to monitor rotavirus vaccine impact on the overall diarrheal disease burden in Rwanda. Active, sentinel surveillance for rotavirus diarrhea will help interpret changes in diarrheal disease trends following vaccine introduction. Other countries planning rotavirus vaccine introduction should explore the availability and quality of their HMIS data. © 2013 Lippincott Williams and Wilkins.SCOPUS: ar.jinfo:eu-repo/semantics/publishe