Under-two child mortality according to maternal HIV status in Rwanda: assessing outcomes within the National PMTCT Program

Introduction: We sought to compare risk of death among children aged under-2 years born to HIV positive mother (HIV-exposed) and to HIV negative mother (HIV non-exposed), and identify determinants of under-2 mortality among the two groups in Rwanda. Methods: In a stratified, two-stage cluster sampling design, we selected mother-child pairs using national Antenatal Care (ANC) registers. Household interview with each mother was conducted to capture socio-demographic data and information related to pregnancy, delivery and post-partum. Data were censored at the date of child death. Using Cox proportional hazard model, we compared the hazard of death among HIV-exposed children and HIV nonexposed children. Results: Of 1,455 HIV-exposed children, 29 (2.0%; 95% CI: 1.3%-2.7%) died by 6 months compared to 18 children of the 1,565 HIV non-exposed children (1.2%; 95% CI: 0.6%-1.7%). By 9 months, cumulative risks of death were 3.0% (95%; CI: 2.2%-3.9%) and 1.3% (96%; CI: 0.7%-1.8%) among HIV-exposed and HIV non-exposed children, respectively. By 2 years, the hazard of death among HIVexposed children was more than 3 times higher (aHR:3.5; 95% CI: 1.8-6.9) among HIV-exposed versus non-exposed children. Risk of death by 9-24 months of age was 50% lower among mothers who attended 4 or more antenatal care (ANC) visits (aHR: 0.5, 95% CI: 0.3-0.9), and 26% lower among families who had more assets (aHR: 0.7, 95% CI: 0.5-1.0). Conclusion: Infant mortality was independent of perinatal HIV exposure among children by 6 months of age. However, HIV-exposed children were 3.5 times more likely to die by 2 years. Fewer antenatal visits, lower household assets and maternal HIV seropositive status were associated with increased mortality by 9-24 months.Key words: HIV, PMTCT, maternal HIV infection, infant mortality, child mortality, under-five mortality, Rwand

Trends in Malaria Cases, Hospital Admissions and Deaths Following Scale-Up of Anti-Malarial Interventions, 2000–2010, Rwanda

Background: To control malaria, the Rwandan government and its partners distributed insecticide-treated nets (ITN) and made artemisinin-based combination therapy (ACT) widely available from 2005 onwards. The impact of these interventions on malaria cases, admissions and deaths was assessed using data from district hospitals and household surveys. Methods: District records of ITN and ACT distribution were reviewed. Malaria and non-malaria indictors in 30 district hospitals were ascertained from surveillance records. Trends in cases, admissions and deaths for 2000 to 2010 were assessed by segmented log-linear regression, adjusting the effect size for time trends during the pre-intervention period, 2000–2005. Changes were estimated by comparing trends in post-intervention (2006–2010) with that of pre-intervention (2000–2005) period. All-cause deaths in children under-five in household surveys of 2005 and 2010 were also reviewed to corroborate with the trends of deaths observed in hospitals. Results: The proportion of the population potentially protected by ITN increased from nearly zero in 2005 to 38% in 2006, and 76% in 2010; no major health facility stock-outs of ACT were recorded following their introduction in 2006. In district hospitals, after falling during 2006–2008, confirmed malaria cases increased in 2009 coinciding with decreased potential ITN coverage and declined again in 2010 following an ITN distribution campaign. For all age groups, from the pre-intervention period, microscopically confirmed cases declined by 72%, (95% Confidence Interval [CI], 12-91%) in 2010, slide positivity rate declined 58%, (CI, 47%–68%), malaria inpatient cases declined 76% (CI, 49%–88%); and malaria deaths declined 47% (CI, 47%–81%). In children below five years of age, malaria inpatients decreased 82% (CI, 61%-92%) and malaria hospital deaths decreased 77% (CI, 40%–91%). Concurrently, outpatient cases, admissions and deaths due to non-malaria diseases in all age groups either increased or remained unchanged. Rainfall and temperature remained favourable for malaria transmission. The annual all-cause mortality in children under-five in household surveys declined from 152 per 1,000 live births during 2001–2005, to 76 per 1,000 live births in 2006–2010 (55% decline). The five-year cumulative number of all-cause deaths in hospital declined 28% (8,051 to 5,801) during the same period. Conclusions: A greater than 50% decline in confirmed malaria cases, admissions and deaths at district hospitals in Rwanda since 2005 followed a marked increase in ITN coverage and use of ACT. The decline occurred among both children under-five and in those five years and above, while hospital utilization increased and suitable conditions for malaria transmission persisted. Declines in malaria indicators in children under 5 years were more striking than in the older age groups. The resurgence in cases associated with decreased ITN coverage in 2009 highlights the need for sustained high levels of anti-malarial interventions in Rwanda and other malaria endemic countries

Evaluating Helping Babies Breathe: training for healthcare workers at hospitals in Rwanda.

AIM: To evaluate the educational effectiveness of the Helping Babies Breathe programme. METHODS: Knowledge of trainees from two district hospitals and one tertiary referral hospital was evaluated before and after training in 2010. A postcourse practical skills evaluation was performed on a Neonatalie Newborn Simulator. Participants underwent a re-evaluation after 3 months. RESULTS: One hundred eighteen trainees completed the course. The percentages of correct answers on a written test significantly increased from 77 ± 15% to 91 ± 9% (p < 0.01) after training. The mean score obtained on a postcourse skill evaluation was 89 ± 9%; 64% of the trainees achieved passing scores. Retesting 3 months later showed that knowledge remained at the same level, while practical skills decreased to 83 ± 16%, and the pass rate dropped significantly to 43% (p < 0.01). CONCLUSION: Healthcare workers who participate in a Helping Babies Breathe programme can significantly improve their knowledge. While such knowledge is retained for at least 3 months, skills dropped to unsatisfactory levels in that period of time, indicating the need for retraining in the interim or the acquisition of practical experience by such healthcare workers

Factors associated with the non-use of insecticide-treated nets in Rwandan children

Background: Insecticide-treated bed nets (ITNs) are highly effective in reducing malaria burden when used properly. However, factors related to individuals, households and community may influence how ITNs are used for malaria control. The study examined influences exerted at these levels to determine if they are associated with ITN non-use among children under 5 years of age in Rwanda. Methods: Using data from the 2010 Rwanda Demographic Health Survey, the investigation was done on the factors associated with ITN non-use among children under 5 years. Descriptive statistics as well as univariate and multilevel logistic regression analyses were used to identify factors associated with ITN non-use. Results: Responses from a total of 6173 women aged 15–49 years living in 492 villages were included in the analysis. Risk factors for children not utilizing ITNs (25 %) included: (Odds ratio [95 % confidence interval]) households with more than five members (1.42 [1.23–1.63]), employed mother (1.33 [1.06–1.66]), and lower household altitude (1.36 [1.14–1.61]). Protective risk factors for ITN use included households with more than three nets (0.39 [0.33–0.47]), mothers who attended one to four visits at antenatal clinics during pregnancy (0.45 [0.29–0.69]), more than four antenatal clinic visits during pregnancy (0.39 [0.21–0.70]), mothers married or living with partner (0.43 [0.36–0.52]), mothers with any education level (0.77 [0.65–0.91]), and households with higher community wealth quintile (0.71 [0.59–0.84]). Conclusions: Rwanda has achieved high coverage of ITN use and proper use has contributed to a decline in malaria in Rwanda; however, maintaining universal ITN coverage is not enough to protect citizens from this disease. Risk factors related to ITN non-use at individual, household and community level include poverty, education, birth spacing, and antenatal clinic attendance. There is a need to address findings with strategies to mitigate the non-use of ITNs for effective malaria prevention in Rwanda

Rwanda (2012): TRaC Malaria Control Behavioral Tracking Survey

Rwanda is a small, land-locked country in the Great Lakes region of Eastern Africa, with the entire population at risk for malaria, including an estimated 1.8 million children under five and 450,000 pregnant women per year. During the last four years, Rwanda has made significant progress in scaling up malaria control interventions, including promoting insecticide treated bed nets (ITNs), indoor residual spraying (IRS), and prompt fever treatment. PSI's current activities in Rwanda include targeting LLINs delivery from the central level to the hea lth centers level, providing prepackaged malaria treatment in the public sector, and supporting BCC activities for IRS and ITN use. Funding for PSI Rwanda activities comes from USAID-BCSM and the Global Fund. The purpose of the current study is to provide an assessment of the key health behaviors associated with bednet use and prompt fever treatment and to evaluate which communication channels have the strongest impact with regards to malaria control activities. The population for this study is the general population, including pregnant women and mothers of children under five in all districts in Rwanda. Respondents of the survey were restricted to male or females aged 15-49 years old. In total, a sample size of 7,353 households was established using a stratified two-stage cluster sampling approach, aimed at collecting nationally representative data, proportional to province size. The questionaire included questions on the malaria health behaviors of interest (bed net ownership and use and fever treatment) as well as demographic variables and the opportunity, ability, and motivation (OAM) variables

Trends in burden and risk factors associated with childhood stunting in Rwanda from 2000 to 2015: Policy and program implications

Background: Rwanda has made substantial economic progress over the past two decades. However, evidence suggests that malnutrition among children remains high in spite of this progress. This study aims to examine trends and potential risk factors associated with childhood stunting from 2000 to 2015 in Rwanda. Methods: Data for this study come from the 2000 to 2015 Rwanda's Demographic and Health Surveys (DHS), a cross-sectional, population-based survey that is conducted every 5 years. Following prior work, we define stunting based on age and weight as reported in the DHS. We assess the overall prevalence of stunting among children under the age of 5 in Rwanda and then conduct bivariate analyses across a range of policy-relevant demographic, socioeconomic, and health variables. We then incorporate key variables in a multivariable analysis to identify those factors that are independently associated with stunting. Results: The prevalence of stunting among children under the age of 5 in Rwanda declined from 2000 (47.4%) to 2015 (38.3%), though rates were relatively stagnant between 2000 and 2010. Factors associated with higher rates of stunting included living in the lowest wealth quintile, having a mother with limited education, having a mother that smoked, being of the male sex, and being of low-birth weight. Conclusions: Though overall stunting rates have improved nationally, these gains have been uneven. Furthering ongoing national policies to address these disparities while also working to reduce the overall risk of malnutrition will be necessary for Rwanda to reach its overall economic and health equity goals.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Impact evaluation of malaria control interventions on morbidity and all-cause child mortality in Rwanda, 2000-2010

The impressive decline in child mortality that occurred in Rwanda from 1996-2000 to 2006-2010 coincided with a period of rapid increase of malaria control interventions such as indoor residual spraying (IRS); insecticide-treated net (ITN) distribution and use, and improved malaria case management. The impact of these interventions was examined through ecological correlation analysis, and robust decomposition analysis of contextual factors on all-cause child mortality. Child mortality fell 61% during the evaluation period and prevalence of severe anemia in children 6-23 months declined 71% between 2005 and 2010. These changes in malaria morbidity and mortality occurred concurrently with a substantial increase in vector control activities. ITN use increased among children under five, from 4% to 70%. The IRS program began in 2007 and covered 1.3 million people in the highest burden districts by 2010. At the same time, diagnosis and treatment with an effective antimalarial expanded nationally, and included making services available to children under the age of 5 at the community level. The percentage of children under 5 who sought care for a fever increased from 26% in 2000 to 48% in 2010. Multivariable models of the change in child mortality between 2000 and 2010 using nationally representative data reveal the importance of increasing ITN ownership in explaining the observed mortality declines. Taken as a whole, the evidence supports the conclusion that malaria control interventions contributed to the observed decline in child mortality in Rwanda from 2000 to 2010, even in a context of improving socioeconomic, maternal, and child health conditions

Trends in malaria cases, hospital admissions and deaths following scale-up of anti-malarial interventions, 2000–2010, Rwanda

Abstract Background To control malaria, the Rwandan government and its partners distributed insecticide-treated nets (ITN) and made artemisinin-based combination therapy (ACT) widely available from 2005 onwards. The impact of these interventions on malaria cases, admissions and deaths was assessed using data from district hospitals and household surveys. Methods District records of ITN and ACT distribution were reviewed. Malaria and non-malaria indictors in 30 district hospitals were ascertained from surveillance records. Trends in cases, admissions and deaths for 2000 to 2010 were assessed by segmented log-linear regression, adjusting the effect size for time trends during the pre-intervention period, 2000–2005. Changes were estimated by comparing trends in post-intervention (2006–2010) with that of pre-intervention (2000–2005) period. All-cause deaths in children under-five in household surveys of 2005 and 2010 were also reviewed to corroborate with the trends of deaths observed in hospitals. Results The proportion of the population potentially protected by ITN increased from nearly zero in 2005 to 38% in 2006, and 76% in 2010; no major health facility stock-outs of ACT were recorded following their introduction in 2006. In district hospitals, after falling during 2006–2008, confirmed malaria cases increased in 2009 coinciding with decreased potential ITN coverage and declined again in 2010 following an ITN distribution campaign. For all age groups, from the pre-intervention period, microscopically confirmed cases declined by 72%, (95% Confidence Interval [CI], 12-91%) in 2010, slide positivity rate declined 58%, (CI, 47%–68%), malaria inpatient cases declined 76% (CI, 49%–88%); and malaria deaths declined 47% (CI, 47%–81%). In children below five years of age, malaria inpatients decreased 82% (CI, 61%-92%) and malaria hospital deaths decreased 77% (CI, 40%–91%). Concurrently, outpatient cases, admissions and deaths due to non-malaria diseases in all age groups either increased or remained unchanged. Rainfall and temperature remained favourable for malaria transmission. The annual all-cause mortality in children under-five in household surveys declined from 152 per 1,000 live births during 2001–2005, to 76 per 1,000 live births in 2006–2010 (55% decline). The five-year cumulative number of all-cause deaths in hospital declined 28% (8,051 to 5,801) during the same period. Conclusions A greater than 50% decline in confirmed malaria cases, admissions and deaths at district hospitals in Rwanda since 2005 followed a marked increase in ITN coverage and use of ACT. The decline occurred among both children under-five and in those five years and above, while hospital utilization increased and suitable conditions for malaria transmission persisted. Declines in malaria indicators in children under 5 years were more striking than in the older age groups. The resurgence in cases associated with decreased ITN coverage in 2009 highlights the need for sustained high levels of anti-malarial interventions in Rwanda and other malaria endemic countries.</p