Risk factors for transmission of Salmonella Typhi in Mahama refugee camp, Rwanda: a matched case-control study

Introduction: In early October 2015, the health facility in Mahama, a refugee camp for Burundians, began to record an increase in the incidence of a disease characterized by fever, chills and abdominal pain. The investigation of the outbreak confirmed Salmonella Typhi as the cause. A casecontrol study was conducted to identify risk factors for the disease. Methods: A retrospective matched case-control study was conducted between January and February 2016. Data were obtained through a survey of matched cases and controls, based on an epidemiological case definition and environmental assessment. Odd ratios were calculated to determine the risk factors associated with typhoid fever. Results: Overall, 260 cases and 770 controls were enrolled in the study. Findings from the multivariable logistic regression identified that having a family member who had been infected with S. Typhi in the last 3 months (OR 2.7; p < 0.001), poor awareness of typhoid fever (OR 1.6; p = 0.011), inconsistent hand washing after use of the latrine (OR 1.8; p = 0.003), eating food prepared at home (OR 2.8; p < 0.001) or at community market (OR 11.4; p = 0.005) were risk factors for typhoid fever transmission. Environmental assessments established the local sorghum beer and yoghurt were contaminated with yeast, aerobic flora, coliforms or Staphylococcus. Conclusion: These findings highlight the need of reinforcement of hygiene promotion, food safety regulations, hygiene education for beverage and food handlers in community market and intensification of environmental interventions to break the transmission of S.Typhi in Mahama

Knowledge, attitude and practice of hygiene and sanitation in a Burundian refugee camp: implications for control of a Salmonella typhi outbreak

Introduction: A Salmonella typhi outbreak was reported in a Burundian refugee camp in Rwanda in October 2015. Transmission persisted despite increased hygiene promotion activities and hand-washing facilities instituted to prevent and control the outbreak. A knowledge, attitude and practice (KAP) study was carried out to assess the effectiveness of ongoing typhoid fever preventive interventions.Methods: A cross-sectional survey was conducted in Mahama Refugee Camp of Kirehe District, Rwanda from January to February 2016. Data were obtained through administration of a structured KAP questionnaire. Descriptive, bivariate and multivariate analysis was performed using STATA software.Results: A total of 671 respondents comprising 264 (39.3%) males and 407 (60.7%) females were enrolled in the study. A comparison of hand washing practices before and after institution of prevention and control measures showed a 37% increase in the proportion of respondents who washed their hands before eating and after using the toilet (p < 0.001). About 52.8% of participants reported having heard about typhoid fever, however 25.9% had received health education. Only 34.6% and 38.6% of the respondents respectively knew how typhoid fever spreads and is prevented. Most respondents (98.2%) used pit latrines for disposal of feces. Long duration of stay in the camp, age over 35 years and being unemployed were statistically associated with poor hand washing practices. Conclusion: The findings of this study underline the need for bolstering up health education and hygiene promotion activities in Mahama and other refugee camp settings

Implementing One Health as an integrated approach to health in Rwanda

It is increasingly clear that resolution of complex global health problems requires interdisciplinary, intersectoral expertise and cooperation from governmental, non-governmental and educational agencies. ‘One Health’ refers to the collaboration of multiple disciplines and sectors working locally, nationally and globally to attain optimal health for people, animals and the environment. One Health offers the opportunity to acknowledge shared interests, set common goals, and drive toward team work to benefit the overall health of a nation. As in most countries, the health of Rwanda's people and economy are highly dependent on the health of the environment. Recently, Rwanda has developed a One Health strategic plan to meet its human, animal and environmental health challenges. This approach drives innovations that are important to solve both acute and chronic health problems and offers synergy across systems, resulting in improved communication, evidence-based solutions, development of a new generation of systems-thinkers, improved surveillance, decreased lag time in response, and improved health and economic savings. Several factors have enabled the One Health movement in Rwanda including an elaborate network of community health workers, existing rapid response teams, international academic partnerships willing to look more broadly than at a single disease or population, and relative equity between female and male health professionals. Barriers to implementing this strategy include competition over budget, poor communication, and the need for improved technology. Given the interconnectedness of our global community, it may be time for countries and their neighbours to follow Rwanda's lead and consider incorporating One Health principles into their national strategic health plans

Estimates of the burden of illnesses related to foodborne pathogens as from the syndromic surveillance data of 2013 in Rwanda

Food related illnesses contribute significantly to the global burden of disease and the estimates of these illnesses are important to develop evidence based food safety policies. However estimating the burden of these illnesses is complex. There is paucity of input data, and developing and sustaining disease surveillance systems that provide the input data is resource-intensive. In most developing countries with relative peace, the initial, faster and cheaper kind of health data is generated through syndromic surveillance. In this study, we estimated the burden of food related clinical features and illnesses (watery diarrhea, bloody diarrhea, suspected cases of cholera and typhoid fever) by making use of various syndromic surveillance data sources in Rwanda. Data sources were the reported cases as by the notifiable surveillance system, an opinion survey with health care providers about the prevalence of clinical features related to foodborne pathogens and over the counter prescription of drugs associated with foodborne illnesses. Study findings indicate that for the year 2013, watery diarrhea occurred all year round as by the surveillance system data, resulting to an estimated 672 (95% credible interval [CrI] 424-932) DALY per million inhabitants, bloody diarrhea was seasonal coinciding with the rainy months and caused an estimated 213 (95% CrI 50-475) DALY per million, typhoid and cholera cases were sporadic with an estimated 73 (95% CrI 57-91) and 1 (95% CrI 0-2) DALY per million respectively. Our DALY estimates from the different data sources were in the same range for combined cases of watery diarrhea, bloody diarrhea and cholera, but significantly different for typhoid fever. The methodology applied in this study can be adopted in resource-scarce settings where most data is from syndromic surveillance (a common phenomenon in most developing countries) other than the desired integrated food chain and laboratory-based surveillance systems, to pave way for future improved estimates of the burden of foodborne illnesses

Near universal childhood vaccination rates in Rwanda: how was this achieved and can it be duplicated?

Background: According to data from the WHO Vaccine-Preventable Disease Monitoring System, Rwanda has achieved near universal childhood vaccination rates, with an overall national coverage rate for childhood immunisation of 98% in 2015. These rates are striking given the country's status as a post-conflict, post-genocide, and low-income country. In this study, we aimed to determine factors that contributed to the success of Rwanda's childhood immunisation programme. Methods: We used primary and secondary sources to identify such factors. Primary research was conducted in August, 2017, in Eastern Province, Northern Province, and the city of Kigali, Rwanda. We used snow-ball sampling to recruit interviewees. Semi-structured interviews were conducted with government, multilateral organisations, and non-governmental staff members involved in the planning and delivery of Rwanda's immunisation programme. Secondary sources included review of primary databases, grey literature, and peer-reviewed literature that was identified through searches in Google Scholar and PubMed for articles written in English and published since Jan 1, 2000, using combinations of the search terms “Rwanda”, “vaccination”, “immunisation”, and “programme”. Findings: 24 interviews were conducted and secondary data were analysed. Several factors have contributed to Rwanda's vaccination success. First, at the local level, an engaged cadre of community health workers sensitises communities on the importance of vaccinations and performs health surveillance duties. Second, an integrated health management information system guides vaccination procurement and distribution to support vaccine delivery at the local level. Third, at the governmental level, the vaccination programme is driven by strong political will to prioritise health. Fourth, implementation is sufficiently decentralised to the district and village level to tailor appropriate approaches for the local population. Fifth, the uniquely Rwandan practice of imihigo, which involves leaders at all levels of government (centrally and locally) signing performance contracts to achieve certain targets, enhances accountability and ownership. Finally, the Rwandan health system benefits from strong relationships with development partners and cross-over effects from global health initiatives, particularly in developing capacity for supply chain and cold chain management. Interpretation: Although cultural factors such as imihigo differentiate Rwanda from demographically comparable countries, the success of the Rwandan vaccine programme is multifactorial. These factors include strong, high-level political will, multilevel accountability, effective use of funding, partnership with development partners, integrated health information, and community-level data collection. Countries aiming to improve coverage may wish to study and emulate these factors. Funding: Mastercard Center for Inclusive Growth

Implementing One Health as an integrated approach to health in Rwanda.

It is increasingly clear that resolution of complex global health problems requires interdisciplinary, intersectoral expertise and cooperation from governmental, non-governmental and educational agencies. 'One Health' refers to the collaboration of multiple disciplines and sectors working locally, nationally and globally to attain optimal health for people, animals and the environment. One Health offers the opportunity to acknowledge shared interests, set common goals, and drive toward team work to benefit the overall health of a nation. As in most countries, the health of Rwanda's people and economy are highly dependent on the health of the environment. Recently, Rwanda has developed a One Health strategic plan to meet its human, animal and environmental health challenges. This approach drives innovations that are important to solve both acute and chronic health problems and offers synergy across systems, resulting in improved communication, evidence-based solutions, development of a new generation of systems-thinkers, improved surveillance, decreased lag time in response, and improved health and economic savings. Several factors have enabled the One Health movement in Rwanda including an elaborate network of community health workers, existing rapid response teams, international academic partnerships willing to look more broadly than at a single disease or population, and relative equity between female and male health professionals. Barriers to implementing this strategy include competition over budget, poor communication, and the need for improved technology. Given the interconnectedness of our global community, it may be time for countries and their neighbours to follow Rwanda's lead and consider incorporating One Health principles into their national strategic health plans