Effects of a large-scale distribution of water filters and natural draft rocket-style cookstoves on diarrhea and acute respiratory infection: A cluster-randomized controlled trial in Western Province, Rwanda.

BACKGROUND: Unsafe drinking water and household air pollution (HAP) are major causes of morbidity and mortality among children under 5 in low and middle-income countries. Household water filters and higher-efficiency biomass-burning cookstoves have been widely promoted to improve water quality and reduce fuel use, but there is limited evidence of their health effects when delivered programmatically at scale. METHODS AND FINDINGS: In a large-scale program in Western Province, Rwanda, water filters and portable biomass-burning natural draft rocket-style cookstoves were distributed between September and December 2014 and promoted to over 101,000 households in the poorest economic quartile in 72 (of 96) randomly selected sectors in Western Province. To assess the effects of the intervention, between August and December, 2014, we enrolled 1,582 households that included a child under 4 years from 174 randomly selected village-sized clusters, half from intervention sectors and half from nonintervention sectors. At baseline, 76% of households relied primarily on an improved source for drinking water (piped, borehole, protected spring/well, or rainwater) and over 99% cooked primarily on traditional biomass-burning stoves. We conducted follow-up at 3 time-points between February 2015 and March 2016 to assess reported diarrhea and acute respiratory infections (ARIs) among children <5 years in the preceding 7 days (primary outcomes) and patterns of intervention use, drinking water quality, and air quality. The intervention reduced the prevalence of reported child diarrhea by 29% (prevalence ratio [PR] 0.71, 95% confidence interval [CI] 0.59-0.87, p = 0.001) and reported child ARI by 25% (PR 0.75, 95% CI 0.60-0.93, p = 0.009). Overall, more than 62% of households were observed to have water in their filters at follow-up, while 65% reported using the intervention stove every day, and 55% reported using it primarily outdoors. Use of both the intervention filter and intervention stove decreased throughout follow-up, while reported traditional stove use increased. The intervention reduced the prevalence of households with detectable fecal contamination in drinking water samples by 38% (PR 0.62, 95% CI 0.57-0.68, p < 0.0001) but had no significant impact on 48-hour personal exposure to log-transformed fine particulate matter (PM2.5) concentrations among cooks (β = -0.089, p = 0.486) or children (β = -0.228, p = 0.127). The main limitations of this trial include the unblinded nature of the intervention, limited PM2.5 exposure measurement, and a reliance on reported intervention use and reported health outcomes. CONCLUSIONS: Our findings indicate that the intervention improved household drinking water quality and reduced caregiver-reported diarrhea among children <5 years. It also reduced caregiver-reported ARI despite no evidence of improved air quality. Further research is necessary to ascertain longer-term intervention use and benefits and to explore the potential synergistic effects between diarrhea and ARI. TRIAL REGISTRATION: Clinical Trials.gov NCT02239250

Uniting to address paediatric heart disease in Africa: Advocacy from Rwanda

Paediatric heart disease causes death or disability in 15 million children around the world each year – a fi gure staggeringly disproportionate to available and relevant international funding and support. Although 80% of the burden of cardiovascular disorders fall in low- and middleincome countries, poor countries have a very limited capacity to build a system of care to address heart disease, including prevention, care, control and research. In this article, authors who work in or with Rwanda’s public sector aim to describe the current state of heart disease among children, what is currently being done to manage care and future directions for the national programme. As the world turns its attention to non-communicable diseases and seeks to ensure that they fi nd a prominent place in the post-2015 development agenda, it is essential to ensure that children are not left behind

Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015 : a systematic analysis for the Global Burden of Disease Study 2015

Background Improving survival and extending the longevity of life for all populations requires timely, robust evidence on local mortality levels and trends. The Global Burden of Disease 2015 Study (GBD 2015) provides a comprehensive assessment of all-cause and cause-specific mortality for 249 causes in 195 countries and territories from 1980 to 2015. These results informed an in-depth investigation of observed and expected mortality patterns based on sociodemographic measures. Methods We estimated all-cause mortality by age, sex, geography, and year using an improved analytical approach originally developed for GBD 2013 and GBD 2010. Improvements included refinements to the estimation of child and adult mortality and corresponding uncertainty, parameter selection for under-5 mortality synthesis by spatiotemporal Gaussian process regression, and sibling history data processing. We also expanded the database of vital registration, survey, and census data to 14 294 geography-year datapoints. For GBD 2015, eight causes, including Ebola virus disease, were added to the previous GBD cause list for mortality. We used six modelling approaches to assess cause-specific mortality, with the Cause of Death Ensemble Model (CODEm) generating estimates for most causes. We used a series of novel analyses to systematically quantify the drivers of trends in mortality across geographies. First, we assessed observed and expected levels and trends of cause-specific mortality as they relate to the Socio-demographic Index (SDI), a summary indicator derived from measures of income per capita, educational attainment, and fertility. Second, we examined factors affecting total mortality patterns through a series of counterfactual scenarios, testing the magnitude by which population growth, population age structures, and epidemiological changes contributed to shifts in mortality. Finally, we attributed changes in life expectancy to changes in cause of death. We documented each step of the GBD 2015 estimation processes, as well as data sources, in accordance with Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER). Findings Globally, life expectancy from birth increased from 61.7 years (95% uncertainty interval 61.4-61.9) in 1980 to 71.8 years (71.5-72.2) in 2015. Several countries in sub-Saharan Africa had very large gains in life expectancy from 2005 to 2015, rebounding from an era of exceedingly high loss of life due to HIV/AIDS. At the same time, many geographies saw life expectancy stagnate or decline, particularly for men and in countries with rising mortality from war or interpersonal violence. From 2005 to 2015, male life expectancy in Syria dropped by 11.3 years (3.7-17.4), to 62.6 years (56.5-70.2). Total deaths increased by 4.1% (2.6-5.6) from 2005 to 2015, rising to 55.8 million (54.9 million to 56.6 million) in 2015, but age-standardised death rates fell by 17.0% (15.8-18.1) during this time, underscoring changes in population growth and shifts in global age structures. The result was similar for non-communicable diseases (NCDs), with total deaths from these causes increasing by 14.1% (12.6-16.0) to 39.8 million (39.2 million to 40.5 million) in 2015, whereas age-standardised rates decreased by 13.1% (11.9-14.3). Globally, this mortality pattern emerged for several NCDs, including several types of cancer, ischaemic heart disease, cirrhosis, and Alzheimer's disease and other dementias. By contrast, both total deaths and age-standardised death rates due to communicable, maternal, neonatal, and nutritional conditions significantly declined from 2005 to 2015, gains largely attributable to decreases in mortality rates due to HIV/AIDS (42.1%, 39.1-44.6), malaria (43.1%, 34.7-51.8), neonatal preterm birth complications (29.8%, 24.8-34.9), and maternal disorders (29.1%, 19.3-37.1). Progress was slower for several causes, such as lower respiratory infections and nutritional deficiencies, whereas deaths increased for others, including dengue and drug use disorders. Age-standardised death rates due to injuries significantly declined from 2005 to 2015, yet interpersonal violence and war claimed increasingly more lives in some regions, particularly in the Middle East. In 2015, rotaviral enteritis (rotavirus) was the leading cause of under-5 deaths due to diarrhoea (146 000 deaths, 118 000-183 000) and pneumococcal pneumonia was the leading cause of under-5 deaths due to lower respiratory infections (393 000 deaths, 228 000-532 000), although pathogen-specific mortality varied by region. Globally, the effects of population growth, ageing, and changes in age-standardised death rates substantially differed by cause. Our analyses on the expected associations between cause-specific mortality and SDI show the regular shifts in cause of death composition and population age structure with rising SDI. Country patterns of premature mortality (measured as years of life lost [YLLs]) and how they differ from the level expected on the basis of SDI alone revealed distinct but highly heterogeneous patterns by region and country or territory. Ischaemic heart disease, stroke, and diabetes were among the leading causes of YLLs in most regions, but in many cases, intraregional results sharply diverged for ratios of observed and expected YLLs based on SDI. Communicable, maternal, neonatal, and nutritional diseases caused the most YLLs throughout sub-Saharan Africa, with observed YLLs far exceeding expected YLLs for countries in which malaria or HIV/AIDS remained the leading causes of early death. Interpretation At the global scale, age-specific mortality has steadily improved over the past 35 years; this pattern of general progress continued in the past decade. Progress has been faster in most countries than expected on the basis of development measured by the SDI. Against this background of progress, some countries have seen falls in life expectancy, and age-standardised death rates for some causes are increasing. Despite progress in reducing age-standardised death rates, population growth and ageing mean that the number of deaths from most non-communicable causes are increasing in most countries, putting increased demands on health systems. Copyright (C) The Author(s). Published by Elsevier Ltd.Peer reviewe

Malnutrition and child health in rural Rwanda: management of community based growth monitoring.

En l’an 2000, les Nations Unies ont adopté les Objectifs du Millénaire pour le Développement avec comme premier objectif l’éradication de l’extrême pauvreté et de la faim. La relation synergique entre une bonne nutrition et le développement économique est aujourd’hui indiscutable. La malnutrition et la pauvreté sont deux problèmes interdépendants et qui partagent les mêmes causes. On estimait en 2008 que le retard de croissance staturale affectait 195 millions d’enfants de moins de cinq ans dans le monde en développement dont 90% en Afrique et en Asie. Cette forme de malnutrition est la plus importante au niveau mondial. Dans beaucoup de pays en Afrique subsaharienne et en Asie, presque un enfant sur deux en souffre. La malnutrition est le résultat d’une alimentation insuffisante, des maladies fréquentes sans accès aux services de santé de base ainsi que de l’insuffisance des soins et pratiques à l’égard des enfants. Assez souvent on ne remarque que les cas de malnutrition sévère alors que les cas légers ou modérés sont de loin plus nombreux. Les estimations les plus récentes montrent que les formes légères ou modérées de malnutrition contribuent à plus d’un tiers des décès enregistrés chez les enfants dans les pays en développement. <p>Les enfants survivants ont des conséquences à moyen/long terme qui comprennent une vulnérabilité accrue aux infections, une diminution des capacités intellectuelles et des capacités de production ainsi que des risques élevés de complications en cas d’accouchement pour les futures mères. L’intégration de la nutrition dans les stratégies de développement économique et de réduction de la pauvreté dans le cadre des OMDs témoigne que les pays en développement comprennent de plus en plus l’impact d’une bonne nutrition de la population sur le développement durable. <p>Cependant l’efficacité avec laquelle de telles stratégies se mettent en œuvre pour cibler les milieux ruraux qui sont les plus touchés par la malnutrition reste faible dans beaucoup de pays. Les efforts fournis ne semblent pas correspondre à l’ampleur du problème de malnutrition. De plus, dans beaucoup de ces pays, les conditions nécessaires à la réussite de ces stratégies ne sont pas réunies. Le contexte sociopolitique n’est pas souvent favorable et les capacités de mise en œuvre sont faibles. Par ailleurs les principaux décideurs politiques à tous les niveaux du système ne sont pas suffisamment sensibilisés sur l’ampleur du problème de la malnutrition. Pourtant il y a des interventions simples de lutte contre la malnutrition infantile qui ont prouvé leur efficacité et efficience et qui sont à la portée des pays pauvres. Les pratiques d’alimentation optimale du nourrisson et du jeune enfant comprenant la mise au sein des nouveaux-nés endéans l’heure qui suit l’accouchement, l’allaitement maternel exclusif pendant les 6 premiers mois, l’allaitement jusqu'à au moins deux ans et une bonne utilisation des aliments de complément constituent un bon exemple. Elles peuvent avoir un impact sur la survie des enfants en prévenant à elles seules jusqu’à 19% des décès survenant avant cinq ans dans les pays en développement. <p>Néanmoins de telles informations ne sont pas toujours connues par ceux qui auraient le pouvoir d’opérer les changements au niveau des communautés. L’objectif général de ce travail est de fournir les informations sur l’ampleur de la malnutrition chez les enfants en milieu rural au Rwanda et de documenter le processus de mise en oeuvre du suivi de la croissance à base communautaire, une des stratégies de promotion d’une bonne nutrition et d’une bonne santé des enfants.<p><p>METHODOLOGIE:<p>Le présent travail est basé sur une série d’études réalisées depuis l’année 2004 dans la zone de rayonnement de l’hôpital rural de Ruli au Rwanda. Il a regroupé les études suivantes:<p> \Doctorat en Sciences médicalesinfo:eu-repo/semantics/nonPublishe

Influence of malnutrition on childhood mortality in a rural hospital in Rwanda

info:eu-repo/semantics/publishe

Performance-based financing for better quality of services in Rwandan health centres: 3-year experience.

In 2005, the Ministry of Health in Rwanda, with the support of the Belgian Technical Cooperation, launched a strategy of performance-based financing (PBF) in a group of 74 health centres (HCs), covering 2-m inhabitants. In 2006, PBF was extended to an additional group of 85 HCs, thus reaching 3.8-m inhabitants. This study evaluates the effect of PBF on HC performance from 2005 to 2007. Composite indicators for measuring quantity and quality of services were developed and evaluated through monthly formative supervisions by qualified and well-trained district supervisors. The strategy was based on a fixed fee per quality-approved service. The entire budget spent on the implementation of PBF amounted to $0.25/cap/year, of which$0.20/cap/year for subsidies and an estimated $0.05/cap/year for administration, supervision and training. A positive effect on utilization rates was only seen for activities that were previously less well organized; in this case, growth monitoring services and institutional deliveries. The quality of services, defined as the compliance rate with national and international norms, rose considerably for all services in both groups. A sustained level of quality between 80% and 95% was reached within 18 months in the first group. A similar result was reached in the second group in 8 months

Amélioration de la gestion d'un programme de suivi de la croissance à base communautaire des enfants en milieu rural au Rwanda

Background: In order to improve the management of a community based nutrition program in the catchment area of Ruli District Hospital in Rwanda, we carried out a nutrition survey to determine the risk factors for childhood malnutrition in the area. Identifying the groups of children at risk of malnutrition and their risk factors allows the community nutrition workers to target the children who require close monitoring, and assists in the development of key messages for educational nutrition training. Methods: The prevalence of the three forms of malnutrition was estimated by using the Z-scores height for age, weight for age and weight for height with NCHS/OMS/2000 reference. Logistic regression was performed to identify the risk factors for malnutrition. Results: Our findings show that children from 12-35 months of age are at greatest risk of malnutrition. Risk factors for wasting include: low monthly income of the household, concurrent illness of the child and a household that does not practice breeding. Risk factors for underweight include: child being greater than 12 months of age, mother of the child being pregnant and history of malnutrition in the household. Finally, risk factors for stunting include the absence of a mosquito net in the household, an insufficient number of working adults in the household, the child being greater than 12 months of age and a household managed by a man alone or by an orphan. Conclusion: Community based growth monitoring must focus its attention on the children from nine to 35 months of age. Children less than nine months of age are generally followed by the health centers through the immunization program, and the older children are generally followed in the child minder schools that need to be promoted in all the cells. Community messages must focus on the identified risk factors of malnutrition, and a positive deviance approach must be introduced in the entire zone. © 2010 Elsevier Masson SAS.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Fiabilité des mesures anthropométriques dans le suivi de la croissance à base communautaire des enfants en milieu rural au Rwanda

Background: In Rwanda, the community-based growth-monitoring program is implemented via volunteer community nutrition workers. These volunteers are recruited from within their communities, and receive basic training prior to providing services. Utilizing local volunteers improves access to basic nutrition services, and allows the local health jurisdictions to use qualified health care staff more efficiently. In addition to concerns raised in regards to the accountability of unpaid workers, some question the relevance of the data that is collected. We carried out a nutritional survey in the catchment area of Ruli District Hospital to evaluate the reliability of the community nutrition workers' measurements of anthropometric standards collected within the growth-monitoring framework. Methods: A nutritional survey was recently organized in the catchment area of the hospital in December 2006. The prevalence rates of malnutrition from the survey were compared with those from the existing community-based growth-monitoring program. Z-test was used to compare the prevalence rate of underweight from the survey with the prevalence rate determined by data collected from community nutrition workers. The concordance of children classified with moderate and severe underweight in each data set was determined by the coefficient Kappa of Cohen. Results: Our findings show that the recent survey reported an overall underweight prevalence rate of 27.2%. Community data calculated a prevalence rate of 28.8% for the same population. The difference is not statistically significant (P=0.294). Of 724 children evaluated, the survey and the community were in agreement in regards to 454 children classified in the category of good nutritional status, 143 children classified in moderate underweight and 11 children classified in the severe underweight category. The Kappa of Cohen coefficient of 0.636 indicates strong concordance between data sets. Conclusion: Anthropometric measurements provided by the community are reliable. Information gathered from the community can be used for epidemiologic monitoring of malnutrition. To ensure continued reliability, health centers must provide sufficient and permanent training to community nutrition workers. In addition, continued access to essential materials used for measuring nutritional status and maintenance of these materials will be crucial to the program's ongoing success. © 2010 Elsevier Masson SAS.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Transforming South–South Technical Support to Fight Noncommunicable Diseases

At the UN High-Level Meeting on non-communicable diseases (NCD) in September 2011, each member state was challenged to create a multisectoral national policy and plan for the prevention and control of non-communicable disease by 2013. Few low-income countries, however, currently have such plans. Their governments are likely to turn for assistance in drafting and implementation to multilateral agencies and Contract Technical Support Organizations recommended by development partners. Yet because many NCD seen in the lowest-income countries differ significantly from those prevalent elsewhere, existing providers of external technical support may lack the necessary experience to support strategic planning for NCD interventions in these settings. This article reviews currently available mechanisms of technical support for health sector planning. It places them in the broader historical context of post- World War II international development assistance and the more recent campaigns for horizontal “South-South” cooperation and aid effectiveness. It proposes bilateral technical assistance by low income-countries themselves as the natural evolution of development assistance in health. Such programs, it argues, may be able to improve the quality of technical support to low-income countries for strategic planning in the NCD area while directing resources to the regions where they are most needed