Background: Cesarean sections (c-sections), the most common surgical procedures performed worldwide, are essential in reducing maternal and neonatal deaths. There is a paucity of research studies on c-section care and outcomes in rural African settings. The objective of this study was to describe demographic characteristics, clinical management, and maternal and neonatal outcomes among women receiving c-sections at Kirehe District Hospital (KDH) in rural Rwanda. Methods: This retrospective cohort study included all women aged 18 y residing in KDH catchment area who delivered by c-section at KDH between April 1 and September 30, 2017. Demographic and clinical characteristics of these women and their newborns were collected using patient interviews and medical chart extraction. Descriptive analyses were performed, and frequency and percentages are reported. Results: Of the 621 women included in the study, 45.7% (n ¼ 284) were aged 25-34 y; 42.2% (n ¼ 262) were married; 67.5% (n ¼ 419) had primary education; and 75.7% (n ¼ 470) were farmers by occupation. Burundian refugees living in the nearby Mahama Refugee Camp comprised 13.7% (n ¼ 85) of the study population. The most common indication for csection was having undergone a c-section previously (31.9%, n ¼ 198), followed by acute fetal distress (30.8%, n ¼ 191). Among those with previous c-section as the sole indication for surgery, 85.4% presented as either urgent or emergent cases. Postoperatively, 67.7%

Individuals living with hypertension are predisposed to higher risk of stroke, kidney diseases and heart failure. Approximately 9.4 million people worldwide die from complications related to hypertension every year. Hypertension is often known as the silent killer because many people do not develop any symptoms until they get very sick. Early screening is particularly important for better treatment outcomes yet it remains a challenge in many countries. Worldwide, approximately 50% of people are living with undiagnosed hypertension. In Rwanda, the rate of undiagnosed hypertension is unknown, and so are the associated risk factors in rural communities. A cross-sectional descriptive study was conducted to determine the rate and risk factors of undiagnosed hypertension among adults in a rural community in Rwanda.  The proportion of people having undiagnosed hypertension was found to be high. Out of 155 study participants, 41.9% had undiagnosed hypertension, with slightly more men having hypertension (52.3%) than women (47.7%). More than 98% of respondents either did not know or knew wrong information about hypertension, and only 3% knew they should have regular checkups with physicians. Age (p=0.027) and alcohol consumption (p=0.014) were found to be statistically significantly associated with hypertension. Smoking and exercise were not found to be risk factors as most Rwandans living in the rural areas are physically active.  Programs to promote hypertension awareness, encourage regular physical checkups, and reduce alcohol consumption are needed to improve diagnosis and control of hypertension in Rwanda. Community programs offering free regular blood pressure checks may also be helpful in identifying early hypertension. Larger scale studies of this kind should be conducted to understand whether results can be generalized to other areas of Rwanda.

Background To eliminate hepatitis C, Rwanda is conducting national mass screenings and providing to people with chronic hepatitis C free access to Direct Acting Antivirals (DAAs). Until 2020, prescribers trained and authorized to initiate DAA treatment were based at district hospitals, and access to DAAs remains expensive and geographically difficult for rural patients. We implemented a mobile clinic to provide DAA treatment initiation at primary-level health facilities among people with chronic hepatitis C identified through mass screening campaigns in rural Kirehe and Kayonza districts. Methods The mobile clinic team was composed of one clinician authorized to manage hepatitis, one lab technician, and one driver. Eligible patients received same-day clinical consultations, counselling, laboratory tests and DAA initiation. Using clinical databases, registers, and program records, we compared the number of patients who initiated DAA treatment before and during the mobile clinic campaign. We assessed linkage to care during the mobile clinical campaign and assessed predictors of linkage to care. We also estimated the cost per patient of providing mobile services and the reduction in out-of-pocket costs associated with accessing DAA treatment through the mobile clinic rather than the standard of care. Results Prior to the mobile clinic, only 408 patients in Kirehe and Kayonza had been initiated on DAAs over a 25-month period. Between November 2019 and January 2020, out of 661 eligible patients with hepatitis C, 429 (64.9%) were linked to care through the mobile clinic. Having a telephone number and complete address recorded at screening were strongly associated with linkage to care. The cost per patient of the mobile clinic program was 29.36 USD, excluding government-provided DAAs. Providing patients with same-day laboratory tests and clinical consultation at primary-level health facilities reduced out-of-pocket expenses by 9.88 USD. Conclusion The mobile clinic was a feasible strategy for providing rapid treatment initiation among people chronically infected by hepatitis C, identified through a mass screening campaign. Compared to the standard of care, mobile clinics reached more patients in a much shorter time. This low-cost strategy also reduced out-of-pocket expenditures among patients. However, long-term, sustainable care would require decentralization to the primary health-centre level.

Background: To eliminate hepatitis C, Rwanda is conducting national mass screenings and providing hepatitis C patients with free access to Direct Acting Antivirals (DAAs). Until 2020, all prescribers trained and authorized to initiate DAA treatment were based at District Hospitals, and access to DAAs remains expensive and geographically difficult for rural patients. We designed and implemented a mobile hepatitis clinic to provide DAA treatment initiation at primary-level health facilities among hepatitis C patients identified through mass screening campaigns in rural Kirehe and Kayonza districts. Methods: The mobile clinic team was composed of one clinician trained and authorized to manage hepatitis, one lab technician, and one driver. Eligible patients received same-day clinical consultations, counselling, laboratory tests and DAA initiation. Using clinical databases, registers, and program records, we compared the number of patients who initiated DAA treatment before and during the mobile clinic campaign. We assessed linkage to care during the mobile clinical campaign and assessed predictors of linkage to care. We also estimated the cost per patient of providing mobile services and the reduction in out-of-pocket costs associated with accessing DAA treatment through the mobile clinic rather than the standard of care.Results: Prior to the mobile clinic, only 408 patients in Kirehe and Kayonza had been initiated on DAAs over a 25-month period. Between November 2019 and January 2020, out of 661 eligible patients with chronic hepatitis C, 429 (64.9%) were linked to care through the mobile clinic. Having a telephone number and complete address recorded at screening were strongly associated with linkage to care. The cost per patient of the mobile clinic program was 29.36 USD, excluding government-provided DAAs. Providing patients with same-day laboratory tests and clinical consultation at primary-level health facilities reduced out-of-pocket expenses by 9.88 USD. Conclusion: The mobile clinic model was a feasible strategy for providing rapid treatment initiation among hepatitis C patients identified through a mass screening campaign. Compared to the standard of care, mobile clinics reached more patients in a much shorter time. This low-cost strategy also reduced out-of-pocket expenditures among patients. However, long-term, sustainable care would require decentralization to the primary health-center level.

Introduction: Antimicrobial resistance (AMR) is a global public health threat. Worse still, there is a paucity of data from low- and middle-income countries to inform rational antibiotic use. Objective: Assess the feasibility of setting up microbiology capacity for AMR testing and estimate the cost of setting up microbiology testing capacity at rural district hospitals in Rwanda. Methods: Laboratory needs assessments were conducted, and based on identified equipment gaps, appropriate requisitions were processed. Laboratory technicians were trained on microbiology testing processes and open wound samples were collected and cultured at the district hospital (DH) laboratories before being transported to the National Reference Laboratory (NRL) for bacterial identification and antibiotic susceptibility testing. Quality control (QC) assessments were performed at the DHs and NRL. We then estimated the cost of three scenarios for implementing a decentralized microbiology diagnostic testing system. Results: There was an eight-month delay from the completion of the laboratory needs assessments to the initiation of sample collection due to the regional unavailability of appropriate supplies and equipment. When comparing study samples processed by study laboratory technicians and QC samples processed by other laboratory staff, there was 85.0% test result concordance for samples testing at the DHs and 90.0% concordance at the NRL. The cost for essential equipment and supplies for the three DHs was $245,871. The estimated costs for processing 600 samples ranged from $29,500 to $92,590. Conclusion: There are major gaps in equipment and supply availability needed to conduct basic microbiology assays at rural DHs. Despite these challenges, we demonstrated that it is feasible to establish microbiological testing capacity in Rwandan DHs. Building microbiological testing capacity is essential for improving clinical care, informing rational antibiotics use, and ultimately, contributing to the establishment of robust national antimicrobial stewardship programs in rural Rwanda and comparable settings.

Background The coronavirus disease 2019 (COVID-19) misinformation and inadequate access to hygiene and sanitation amenities could hamper efforts to contain COVID-19 spread in resource-limited settings. In this study, we describe knowledge of COVID-19 symptoms and preventive measures, sources of information, and access to adequate handwashing among patients with chronic diseases in three Rwandan rural districts during the onset of COVID-19 in Rwanda. Methods This was a cross-sectional survey conducted among patients who were enrolled in the HIV/AIDS, non-communicable diseases, mental health, oncology, and pediatric development programs at health facilities in Kayonza, Kirehe and Burera districts. The study sample was randomly selected and stratified by district and clinical program. Telephone-based data collection occurred between 23 April and 11 May 2020. Primary caregivers responded to the survey when the selected patient was a child under age 18 or severely ill. We defined good knowledge of COVID-19 symptoms and preventive measures as knowing that a dry cough and fever were common symptoms and social distancing or staying home and regular handwashing could prevent COVID-19 infection. Access to adequate handwashing was defined as living in a household with a handwashing station and regular access to clean water and soap. We used Fisher’s exact tests and logistic regression to measure associations between the source of information and good knowledge about COVID-19 and between socio-economic characteristics and access to adequate handwashing. Results In total, 150 patients and 70 caregivers responded to the survey. Forty-eight (22.3%) respondents had no formal education. Sources of COVID-19 information included mass media (86.8%), local government leaders (27.3%), healthcare workers (15.9%) and social media (6.8%). Twenty-seven percent (n=59) of respondents had good knowledge of COVID-19 symptoms and preventive measures. In the adjusted analysis, getting information from news media was associated with having good knowledge about COVID-19 (adjusted odds ratio, aOR: 5.46; 95% CI: 1.43-20.75]. Seventy-nine (35.9%) respondents reported access to adequate handwashing at home, with access varying significantly by the district in favour of Kayonza (61.3%). Conclusions COVID-19-related knowledge and access to adequate handwashing were low among patients with chronic diseases at the beginning of the pandemic in Rwanda. Efforts to mitigate COVID-19 spread among chronic care populations may include investment in targeted COVID-19-related education and access to adequate handwashing.

Background: Neonatal hypothermia is a common source of morbidity and mortality in low resource settings. We developed the Dream Warmer, a low cost, re-usable non-electric infant warmer to prevent and treat hypothermia. Methods: We conducted a cluster-randomized stepped-wedge trial. The primary aim was to assess the effect on overall euthermia rates of introducing the warmer compared to standard of care in rural Rwandan hospitals. The secondary aims were to assess effects of warmer introduction on mortality, as well as the safety and feasibility of the warmer. Ten district hospitals participated in the study from November 19th 2019 to July 15th 2020. Patients were eligible to use the warmer if they were 1) hypothermic (temp < 36 ¢ 5°C) or 2) or at risk of hypothermia (weight < 2 ¢ 5 kg or estimated post menstrual age < 35 weeks) when Kangaroo Mother Care was not available. An encounter was defined as the data from an individual infant on a single day. Trial of a Non Electric Infant Warmer for Prevention and Treatment of Hypothermia in Rwanda [NCT03890211]. Findings: Over the study period, 3179 patients were enrolled across the ten neonatal wards, yielding 12,748 encounters; 464 unique infants used the warmer 892 times, 79% eligible due to hypothermia. Because of limited study nurse resources, the warmer was used in only 18% of eligible encounters. Despite this low rate of warmer use, the rate of euthermia rose from 51% (95% CI 50À52%) of encounters pre-intervention to 67% (66À68%) postintervention; p < 0 ¢ 0001. Among the encounters in which the warmer was used, only 11% (9À13%) remained hypothermic. While mortality rates pre-and post-intervention did not change, mortality rate among those who used the warmer was significantly lower than among those who did not (0 ¢ 9% vs 2 ¢ 8%, p = 0 ¢ 01). Use of the warmer did not affect hyperthermia rates. There were no safety concerns or instances of incorrect warmer use. Interpretation: Introduction of the warmer increased rates of euthermia with no associated safety concerns.

Background Traditional medicine is commonly used in low- and middle-income countries (LMICs). Little is known about the use of traditional medicine among women undergoing cesarean section (c-section) and the association to surgical site infections (SSIs) in LMICs. In this study, we describe peripartum use of traditional medicines and the risk of SSIs among women delivering via c-section in rural Rwanda.Methods This prospective cohort study enrolled women who underwent c-section at Kirehe District Hospital in rural Rwanda between September 2019 and February 2020. We collected self-reported data regarding traditional medicine use before and during pregnancy and after discharge up to postoperative day (POD) 11. On POD 11 (+/- 3 days), the women returned to the hospital for a study follow-up visit. We used Fisher’s exact test to assess the relationship between sociodemographic characteristics and traditional medicine use, and logistic regression to determine the association between traditional medicine use and SSI development while controlling for confounders. Results Of the 841 women enrolled in this study, 45 (5.4%) reported using traditional medicine to get pregnant. Nearly 39% used traditional medicine during pregnancy; the majority (96.9%) for a pregnancy-related reason. Only four women (0.5%) reported traditional medicine use between c-section and the POD 11 study visit. Of the 775 women who responded at all time-points, 341 (44.0%) reported using traditional medicine at some point during pregnancy or c-section recovery. No demographic characteristics were significantly associated with traditional medicine use (p>0.05), except for smoking (p=0.048) and alcohol consumption (p=0.010). Both traditional medicine use during pregnancy (p=0.04, aOR=2.0, 95% CI: 1.05, 3.85) and at any time point (p=0.04, aOR=2.0, 95% CI: 1.04, 3.83) were associated with development of SSI.Conclusions Traditional medicine use among c-section patients was high in the peripartum period, particularly during pregnancy, and was significantly associated with SSI. Knowing patterns of traditional medicine use during the peripartum period can help providers collaborate with traditional healers and give appropriate, culturally-sensitive pregnancy and postoperative care and counseling to patients.