Severe Acute Respiratory Illness Deaths in Sub-Saharan Africa and the Role of Influenza: A Case Series From 8 Countries.

BACKGROUND: Data on causes of death due to respiratory illness in Africa are limited. METHODS: From January to April 2013, 28 African countries were invited to participate in a review of severe acute respiratory illness (SARI)-associated deaths identified from influenza surveillance during 2009-2012. RESULTS: Twenty-three countries (82%) responded, 11 (48%) collect mortality data, and 8 provided data. Data were collected from 37 714 SARI cases, and 3091 (8.2%; range by country, 5.1%-25.9%) tested positive for influenza virus. There were 1073 deaths (2.8%; range by country, 0.1%-5.3%) reported, among which influenza virus was detected in 57 (5.3%). Case-fatality proportion (CFP) was higher among countries with systematic death reporting than among those with sporadic reporting. The influenza-associated CFP was 1.8% (57 of 3091), compared with 2.9% (1016 of 34 623) for influenza virus-negative cases (P < .001). Among 834 deaths (77.7%) tested for other respiratory pathogens, rhinovirus (107 [12.8%]), adenovirus (64 [6.0%]), respiratory syncytial virus (60 [5.6%]), and Streptococcus pneumoniae (57 [5.3%]) were most commonly identified. Among 1073 deaths, 402 (37.5%) involved people aged 0-4 years, 462 (43.1%) involved people aged 5-49 years, and 209 (19.5%) involved people aged ≥50 years. CONCLUSIONS: Few African countries systematically collect data on outcomes of people hospitalized with respiratory illness. Stronger surveillance for deaths due to respiratory illness may identify risk groups for targeted vaccine use and other prevention strategies.

Influenza sentinel surveillance in Rwanda, 2008-2010.

BACKGROUND: In 2008, Rwanda established an influenza sentinel surveillance (ISS) system to describe the epidemiology of influenza and monitor for the emergence of novel influenza A viruses. We report surveillance results from August 2008 to July 2010. METHODS: We conducted ISS by monitoring patients with influenza-like illness (ILI) and severe acute respiratory infection (SARI) at 6 hospitals. For each case, demographic and clinical data, 1 nasopharyngeal specimen, and 1 oropharyngeal specimen were collected. Specimens were tested by real-time reverse-transcription polymerase chain reaction for influenza A and B viruses at the National Reference Laboratory in Rwanda. RESULTS: A total of 1916 cases (945 ILI and 971 SARI) were identified. Of these, 29.2% (n = 276) of ILI and 10.4% (n = 101) of SARI cases tested positive for influenza. Of the total influenza-positive cases (n = 377), 71.8% (n = 271) were A(H1N1) pdm09, 5.6% (n = 21) influenza A(H1), 7.7% (n = 29) influenza A(H3), 1.6% (n = 6) influenza A (unsubtyped), and 13.3% (n = 50) influenza B. The percentage of positivity for influenza viruses was highest in October-November and February-March, during peaks in rainfall. CONCLUSIONS: The implementation of ISS enabled characterization of the epidemiology and seasonality of influenza in Rwanda for the first time. Future efforts should determine the population-based influenza burden to inform interventions such as targeted vaccination.

The national burden of influenza-associated severe acute respiratory illness hospitalization in Rwanda, 2012-2014.

BACKGROUND: Estimates of influenza-associated hospitalization are severely limited in low- and middle-income countries, especially in Africa. OBJECTIVES: To estimate the national number of influenza-associated severe acute respiratory illness (SARI) hospitalization in Rwanda. METHODS: We multiplied the influenza virus detection rate from influenza surveillance conducted at 6 sentinel hospitals by the national number of respiratory hospitalization obtained from passive surveillance after adjusting for underreporting and reclassification of any respiratory hospitalizations as SARI during 2012-2014. The population at risk was obtained from projections of the 2012 census. Bootstrapping was used for the calculation of confidence intervals (CI) to account for the uncertainty associated with all levels of adjustment. Rates were expressed per 100 000 population. A sensitivity analysis using a different estimation approach was also conducted. RESULTS: SARI cases accounted for 70.6% (9759/13 813) of respiratory admissions at selected hospitals: 77.2% (6783/8786) and 59.2% (2976/5028) among individuals aged <5 and ≥5 years, respectively. Overall, among SARI cases tested, the influenza virus detection rate was 6.3% (190/3022): 5.7% (127/2220) and 7.8% (63/802) among individuals aged <5 and ≥5 years, respectively. The estimated mean annual national number of influenza-associated SARI hospitalizations was 3663 (95% CI: 2930-4395-rate: 34.7; 95% CI: 25.4-47.7): 2637 (95% CI: 2110-3164-rate: 168.7; 95% CI: 135.0-202.4) among children aged <5 years and 1026 (95% CI: 821-1231-rate: 11.3; 95% CI: 9.0-13.6) among individuals aged ≥5 years. The estimates obtained from both approaches were not statistically different (overlapping CIs). CONCLUSIONS: The burden of influenza-associated SARI hospitalizations was substantial and was highest among children aged <5 years.

Seroprevalence of Rift Valley fever in cattle along the Akagera-Nyabarongo rivers, Rwanda.

Rift Valley fever (RVF) virus is caused by a zoonotic arbovirus that is endemic to eastern and southern Africa. It has also been reported in West and North Africa, Madagascar and the Arabian Peninsula. The virus is transmitted by mosquitoes, but people can also become infected while handling blood or other body fluids of animals and humans with RVF. In 2007, there was a large outbreak of RVF in Kenya, Tanzania, Sudan and Somalia. Outbreaks were also reported in South Africa in 2008-2011. The epidemiology of RVF and factors for disease occurrence in Rwanda are neither clear nor documented. Therefore, we conducted a crosssectional study from December 2012 to March 2013 to generate baseline information on RVF in cattle. Purposive sampling of cattle (n = 595) was done in six districts, and serum samples were screened with competitive enzyme-linked immunosorbent assay (ELISA). We performed a statistical analysis on the generated data, and risk factors associated with RVF seroprevalence were determined by a simple logistic regression. Overall, RVF seroprevalence was 16.8% (95% confidence interval [CI] [13.8% - 20.0%]). The highest seroprevalence was recorded in Kirehe district (36.9%) followed by Ngoma (22.3%), and the least was recorded in Nyagatare (7.9%). RVF was more likely to occur in adult cattle (19.9% [odds ratio {OR} = 1.88, 95% CI {0.98-3.61}]) compared to young cattle (10.5% [OR = 0.47, 95% CI {0.26-0.83}]). Pure exotic or cross-breeds were significantly exposed to RVF virus (seroprevalence 22.9% [OR = 4.26, 95% CI {1.82-9.99}]) in comparison to 14.1% (OR = 0.55, 95% CI [0.35-0.86]) in local breeds. Sex differences were not statistically significant. These findings indicated that cattle have been exposed to RVF virus in six districts in Rwanda with a significant risk in adult, exotic or cross-breeds in Kirehe district.

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.

Bovine tuberculosis in Rwanda: Prevalence and economic impact evaluation by meat inspection at Société des Abattoirs de Nyabugogo-Nyabugogo Abattoir, Kigali.

Despite the significant public health burden of bovine tuberculosis (bTB) in Rwanda, the prevalence of bTB is poorly documented. This study was conducted to estimate the prevalence of bTB in cattle using gross examination of granulomatous lesions, to identify mycobacteria species in suspected samples, and to evaluate the economic impact of meat condemnation based on bTB-like lesions in the meat industry in Rwanda. Routine meat inspection was conducted at Société des Abattoirs de Nyabugogo (SABAN)-Nyabugogo Abattoir. Tissue samples including 31 lymph nodes, 3 lungs and 2 livers were obtained from cattle of different ages with gross tuberculous lesions. Mycobacterium bovis was identified using microscopy with Kinyoun staining and isolation of mycobacterial species in culture on Löwenstein-Jensen and Colestos media, further identified using biochemical tests. Our findings, based on culture and postmortem results, show that the prevalence of bTB is 0.5%(0.587*148/16753), with an overall gross tuberculous lesion prevalence of 0.9% (148/16753). The presence of lesions were higher in cattle aged 2 years and older (1.6% vs. 0.6%, p < 0.05) and higher in females than in males (1.4% vs. 0.6%, p < 0.05). Of the 36 samples tested, 26 (72.2%) were positive by microscopic examination with Kinyoun staining while M. bovis was culture-confirmed in 21 (58.7%) cases. Bovine tuberculosis caused condemnation of 1683.5 kg of meat, resulting in an estimated loss of $4810. Our findings indicate that the prevalence of bTB in Rwanda is significant, and that bTB is a major cause of meat condemnation requiring continued implementation of surveillance and control measures. Furthermore, the results from this study also show important variations in sensitivity of the different tests that were used to determine the prevalence of bTB in cattle in Rwanda.

2009 pandemic influenza A (H1N1) virus outbreak and response--Rwanda, October, 2009-May, 2010.

BACKGROUND: In October 2009, the first case of pandemic influenza A(H1N1)pdm09 (pH1N1) was confirmed in Kigali, Rwanda and countrywide dissemination occurred within several weeks. We describe clinical and epidemiological characteristics of this epidemic. METHODS: From October 2009 through May 2010, we undertook epidemiologic investigations and response to pH1N1. Respiratory specimens were collected from all patients meeting the WHO case definition for pH1N1, which were tested using CDC's real time RT-PCR protocol at the Rwandan National Reference Laboratory (NRL). Following documented viral transmission in the community, testing focused on clinically severe and high-risk group suspect cases. RESULTS: From October 9, 2009 through May 31, 2010, NRL tested 2,045 specimens. In total, 26% (n = 532) of specimens tested influenza positive; of these 96% (n = 510) were influenza A and 4% (n = 22) were influenza B. Of cases testing influenza A positive, 96.8% (n = 494), 3% (n = 15), and 0.2% (n = 1) were A(H1N1)pdm09, Seasonal A(H3) and Seasonal A(non-subtyped), respectively. Among laboratory-confirmed cases, 263 (53.2%) were children <15 years and 275 (52%) were female. In total, 58 (12%) cases were hospitalized with mean duration of hospitalization of 5 days (Range: 2-15 days). All cases recovered and there were no deaths. Overall, 339 (68%) confirmed cases received oseltamivir in any setting. Among all positive cases, 26.9% (143/532) were among groups known to be at high risk of influenza-associated complications, including age <5 years 23% (122/532), asthma 0.8% (4/532), cardiac disease 1.5% (8/532), pregnancy 0.6% (3/532), diabetes mellitus 0.4% (2/532), and chronic malnutrition 0.8% (4/532). CONCLUSIONS: Rwanda experienced a PH1N1 outbreak which was epidemiologically similar to PH1N1 outbreaks in the region. Unlike seasonal influenza, children <15 years were the most affected by pH1N1. Lessons learned from the outbreak response included the need to strengthen integrated disease surveillance, develop laboratory contingency plans, and evaluate the influenza sentinel surveillance system.