High Prevalence of Giardia duodenalis Assemblage B Infection and Association with Underweight in Rwandan Children

Giardia duodenalis is a protozoan parasite causing gastroenteritis. Although the parasite occurs worldwide, its regional prevalence varies considerably. Using PCR as a highly sensitive molecular diagnostic tool, we detected G. duodenalis in 60% of 583 children younger than five years in southern Rwanda. It was by far the most frequent intestinal parasite detected in this population. Importantly, two out of three infections would have been undetected if only the commonly used light microscopy had been applied. Genotyping revealed the presence of two distinct types of parasites, and only the infrequent subtype showed a weak association with gastrointestinal symptoms. However, G. duodenalis infection was associated with underweight and clinically assessed severe malnutrition. The data call for the establishment of more sensitive than light microscopy, yet simple diagnostic tools to identify infected children as well as for the consideration of abundant submicroscopic infections in evaluating the significance of G. duodenalis in high endemicity areas

Prevalence and risk factors of malaria among children in southern highland Rwanda

<p>Abstract</p> <p>Background</p> <p>Increased control has produced remarkable reductions of malaria in some parts of sub-Saharan Africa, including Rwanda. In the southern highlands, near the district capital of Butare (altitude, 1,768 m), a combined community-and facility-based survey on <it>Plasmodium </it>infection was conducted early in 2010.</p> <p>Methods</p> <p>A total of 749 children below five years of age were examined including 545 randomly selected from 24 villages, 103 attending the health centre in charge, and 101 at the referral district hospital. Clinical, parasitological, haematological, and socio-economic data were collected.</p> <p>Results</p> <p><it>Plasmodium falciparum </it>infection (mean multiplicity, 2.08) was identified by microscopy and PCR in 11.7% and 16.7%, respectively; 5.5% of the children had malaria. PCR-based <it>P. falciparum </it>prevalence ranged between 0 and 38.5% in the villages, and was 21.4% in the health centre, and 14.9% in the hospital. Independent predictors of infection included increasing age, low mid-upper arm circumference, absence of several household assets, reported recent intake of artemether-lumefantrine, and chloroquine in plasma, measured by ELISA. Self-reported bed net use (58%) reduced infection only in univariate analysis. In the communities, most infections were seemingly asymptomatic but anaemia was observed in 82% and 28% of children with and without parasitaemia, respectively, the effect increasing with parasite density, and significant also for submicroscopic infections.</p> <p>Conclusions</p> <p><it>Plasmodium falciparum </it>infection in the highlands surrounding Butare, Rwanda, is seen in one out of six children under five years of age. The abundance of seemingly asymptomatic infections in the community forms a reservoir for transmission in this epidemic-prone area. Risk factors suggestive of low socio-economic status and insufficient effectiveness of self-reported bed net use refer to areas of improvable intervention.</p

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

Moral Distress and Resilience Associated with Cancer Care Priority Setting in a Resource‐Limited Context

BackgroundMoral distress and burnout are highly prevalent among oncology clinicians. Research is needed to better understand how resource constraints and systemic inequalities contribute to moral distress in order to develop effective mitigation strategies. Oncology providers in low- and middle-income countries are well positioned to provide insight into the moral experience of cancer care priority setting and expertise to guide solutions.MethodsSemistructured interviews were conducted with a purposive sample of 22 oncology physicians, nurses, program leaders, and clinical advisors at a cancer center in Rwanda. Interviews were recorded, transcribed verbatim, and analyzed using the framework method.ResultsParticipants identified sources of moral distress at three levels of engagement with resource prioritization: witnessing program-level resource constraints drive cancer disparities, implementing priority setting decisions into care of individual patients, and communicating with patients directly about resource prioritization implications. They recommended individual and organizational-level interventions to foster resilience, such as communication skills training and mental health support for clinicians, interdisciplinary team building, fair procedures for priority setting, and collective advocacy for resource expansion and equity.ConclusionThis study adds to the current literature an in-depth examination of the impact of resource constraints and inequities on clinicians in a low-resource setting. Effective interventions are urgently needed to address moral distress, reduce clinician burnout, and promote well-being among a critical but strained oncology workforce. Collective advocacy is concomitantly needed to address the structural forces that constrain resources unevenly and perpetuate disparities in cancer care and outcomes.Implications for practiceFor many oncology clinicians worldwide, resource limitations constrain routine clinical practice and necessitate decisions about prioritizing cancer care. To the authors' knowledge, this study is the first in-depth analysis of how resource constraints and priority setting lead to moral distress among oncology clinicians in a low-resource setting. Effective individual and organizational interventions and collective advocacy for equity in cancer care are urgently needed to address moral distress and reduce clinician burnout among a strained global oncology workforce. Lessons from low-resource settings can be gleaned as high-income countries face growing needs to prioritize oncology resources

Cost of Providing Quality Cancer Care at the Butaro Cancer Center of Excellence in Rwanda

Purpose: The cost of providing cancer care in low-income countries remains largely unknown, which creates a significant barrier to effective planning and resource allocation. This study examines the cost of providing comprehensive cancer care at the Butaro Cancer Center of Excellence (BCCOE) in Rwanda. Methods: A retrospective costing analysis was conducted from the provider perspective by using secondary data from the administrative systems of the BCCOE. We identified the start-up funds necessary to begin initial implementation and determined the fiscal year 2013-2014 operating cost of the cancer program, including capital expenditures and fixed and variable costs. Results: A total of $556,105 US dollars was assessed as necessary start-up funding to implement the program. The annual operating cost of the cancer program was found to be$957,203 US dollars. Radiotherapy, labor, and chemotherapy were the most significant cost drivers. Radiotherapy services, which require sending patients out of country because there are no radiation units in Rwanda, comprised 25% of program costs, labor accounted for 21%, and chemotherapy, supportive medications, and consumables accounted for 15%. Overhead, training, computed tomography scans, surgeries, blood products, pathology, and social services accounted for less than 10% of the total. Conclusion: This study is one of the first to examine operating costs for implementing a cancer center in a low-income country. Having a strong commitment to cancer care, adapting clinical protocols to the local setting, shifting tasks, and creating collaborative partnerships make it possible for BCCOE to provide quality cancer care at a fraction of the cost seen in middle- and high-income countries, which has saved many lives and improved survival. Not all therapies, though, were available because of limited financial resources

Impact of facilitating continued accessibility to cancer care during COVID-19 lockdown on perceived wellbeing of cancer patients at a rural cancer center in Rwanda.

During the COVID-19 pandemic in Rwanda, Partners In Health Inshuti Mu Buzima collaborated with the Butaro Cancer Center of Excellence (BCCOE) to mitigate disruptions to cancer care by providing patients with free transportation to treatment sites and medication delivery at patients' local health facilities. We assessed the relationship between facilitated access to care and self-reported wellbeing outcomes. This cross-sectional telephone survey included cancer patients enrolled at BCCOE in March 2020. We used linear regression to compare six dimensions of quality of life (EORTC QLQ-C30), depression (PHQ-9), anxiety (GAD-7), and financial toxicity (COST) among patients who did and did not receive facilitated access to care. We also assessed access to cancer care and whether patient wellbeing and its association with facilitated access to care differed by socioeconomic status. Of 214 respondents, 34.6% received facilitated access to care. Facilitated patients were more likely to have breast cancer and be on chemotherapy. Facilitation was significantly associated with more frequent in-person clinical encounters, improved perceived quality of cancer care, and reduced transportation-related barriers. Facilitated patients had significantly better global health status (β = 9.14, 95% CI: 2.3, 16.0, p <0.01) and less financial toxicity (β = 2.62, 95% CI: 0.2,5.0, p = 0.03). However, over half of patients reported missing or delaying appointment. Patient wellbeing was low overall and differed by patient socioeconomic status, with poor patients consistently showing worse outcomes. Socioeconomic status did not modify the association between facilitated access to care and wellbeing indicators. Further, facilitation did not lead to equitable wellbeing outcomes between richer and poorer patients. Facilitated access to care during COVID-19 pandemic was associated with some improvements in access to cancer care and patient wellbeing. However, cancer patients still experienced substantial disruptions to care and reported low overall levels of wellbeing, with socioeconomic disparities persisting despite facilitated access to care. Implementing more robust, equity-minded facilitation and better patient outreach programs during health emergencies may promote better care and strengthen patient care overall and effect better patients' outcomes

Ethical dilemmas in prioritizing patients for scarce radiotherapy resources

BackgroundRadiotherapy is an essential component of cancer treatment, yet many countries do not have adequate capacity to serve all patients who would benefit from it. Allocation systems are needed to guide patient prioritization for radiotherapy in resource-limited contexts. These systems should be informed by allocation principles deemed relevant to stakeholders. This study explores the ethical dilemmas and views of decision-makers engaged in real-world prioritization of scarce radiotherapy resources at a cancer center in Rwanda in order to identify relevant principles.MethodsSemi-structured interviews were conducted with a purposive sample of 22 oncology clinicians, program leaders, and clinical advisors. Interviews explored the factors considered by decision-makers when prioritizing patients for radiotherapy. The framework method of thematic analysis was used to characterize these factors. Bioethical analysis was then applied to determine their underlying normative principles.ResultsParticipants considered both clinical and non-clinical factors relevant to patient prioritization for radiotherapy. They widely agreed that disease curability should be the primary overarching driver of prioritization, with the goal of saving the most lives. However, they described tension between curability and competing factors including age, palliative benefit, and waiting time. They were divided about the role that non-clinical factors such as social value should play, and agreed that poverty should not be a barrier.ConclusionsMultiple competing principles create tension with the agreed upon overarching goal of maximizing lives saved, including another utilitarian approach of maximizing life-years saved as well as non-utilitarian principles, such as egalitarianism, prioritarianism, and deontology. Clinical guidelines for patient prioritization for radiotherapy can combine multiple principles into a single allocation system to a significant extent. However, conflicting views about the role that social factors should play, and the dynamic nature of resource availability, highlight the need for ongoing work to evaluate and refine priority setting systems based on stakeholder views

Implementing Cancer Care in Rwanda: Capacity Building for Treatment and Scale-Up

Background: The majority of countries in sub-Saharan Africa are ill-prepared to address the rising burden of cancer. While some have been able to establish a single cancer referral center, few have been able to scale-up services nationally towards universal health coverage. The literature lacks a step-wise implementation approach for resource-limited countries to move beyond a single-facility implementation strategy and implement a national cancer strategy to expand effective coverage. Methods: We applied an implementation science framework, which describes a four-phase approach: Exploration, Preparation, Implementation, and Sustainment (EPIS). Through this framework, we describe Rwanda’s approach to establish not just a single cancer center, but a national cancer program. Results: By applying EPIS to Rwanda’s implementation approach, we analyzed and identified the implementation strategies and factors, which informed processes of each phase to establish foundational cancer delivery components, including trained staff, diagnostic technology, essential medicines, and medical informatics. These cancer delivery components allowed for the implementation of Rwanda’s first cancer center, while simultaneously serving as the nidus for capacity building of foundational components for future cancer centers. Conclusion: This “progressive scaling” approach ensured that initial investments in the country’s first cancer center was a step toward establishing future cancer centers in the country

Validating the Children’s Depression Inventory in the context of Rwanda

Background: Depression is often co-morbid with chronic conditions, and when combined with HIV it can increase progression and reduce survival. A brief and accurate screening tool for depression among children living with HIV is necessary to increase access to mental health care and improve HIV-related outcomes in the long-term. Methods: A validation study was conducted, comparing the Children’s Depression Inventory (CDI) with a structured clinical assessment as the gold standard among children living with HIV ages 7-14 years in Rwanda. The response rate was 87 % and the analysis was performed among 100 study participants. Results: Twenty-five percent of children had a diagnosis of depression based on the clinical interview. Sensitivity of the CDI ranged from 44 to 76 % and specificity was 92 to 100 % for cut-off scores from 5 to 9. The area under the curve (AUC) for receiver operating characteristic analysis, an estimate of overall accuracy, was 0.87 (95 % confidence interval: 0.77 – 0.97). Conclusions: The significant prevalence of depression among children living with HIV in Rwanda reflects a critical need to advance mental health care in this population. Although overall accuracy of the CDI is reasonable in this context, further research needs to be done to develop a more sensitive measure of depression in this vulnerable population. Development of a highly sensitive screening measure will be a fundamental step towards improving access to mental health care among children living with HIV, potentially improving health outcomes and quality of life in the long-term as this vulnerable population transitions into adulthood