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1.
Trop Med Int Health ; 24(7): 879-887, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31066112

RESUMO

OBJECTIVE: To determine prevalent MDR-TB genotypes and describe treatment outcome and bacteriology conversion in MDR-TB patients. METHODS: Review of laboratory records of 173 MDR-TB patients from all over Rwanda who initiated treatment under programmatic management of MDR-TB (PMDT) between 2014 and 2015. Fifty available archived isolates were genotyped by mycobacterial interspersed repetitive units - variable number of tandem repeats (MIRU-VNTR) genotyping. RESULT: Of the 170 patients whose outcome was known, 114 (66.3%) were cured and 36 (21%) completed the treatment, giving a successful outcome (cured and completed) of 150 (87.3%) patients. Of 20 MDR-TB patients with unfavourable treatment outcome, 18 died, one failed and one defaulted/stopped treatment. Of the 18 patients who died, 11 (61%) were HIV-coinfected. The treatment outcome was successful for 93.9% among HIV negative and 81.8% among HIV-coinfected patients (P = 0.02). Sputum smear conversion occurred in 3, 46, 57 and 78 patients before 2, 3, 4 and 6 months, respectively, with median time of sputum smear and culture conversion at 3 months. The 44 MDR-TB isolates with MIRU-VNTR result, showed high genetic diversity with low clustering rate (9.09%) and Uganda II being the most prevalent sub-family lineage detected in 68.2% of isolates. Beijing family was the least common genotype detected (2.3%, 1 isolate). CONCLUSION: The high success rates for MDR-TB treatment achieved in Rwanda were comparable to outcomes observed in resource-rich settings with HIV being an independent risk factor for poor treatment outcome. High genetic diversity and low clustering rate reported here suggest that reactivation of previous disease plays an important role in the transmission of MDR-TB in Rwanda.

2.
Influenza Other Respir Viruses ; 12(1): 38-45, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-29197152

RESUMO

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.


Assuntos
Hospitalização , Influenza Humana/complicações , Influenza Humana/epidemiologia , Adolescente , Adulto , Idoso , Criança , Pré-Escolar , Humanos , Lactente , Vacinas contra Influenza/imunologia , Influenza Humana/prevenção & controle , Pessoa de Meia-Idade , Pandemias , Estudos Retrospectivos , Fatores de Risco , Ruanda/epidemiologia , Vigilância de Evento Sentinela , Adulto Jovem
3.
BMC Infect Dis ; 16(1): 660, 2016 11 08.
Artigo em Inglês | MEDLINE | ID: mdl-27825314

RESUMO

BACKGROUND: Tuberculosis control program of Rwanda is currently phasing in light emitting diode-fluorescent microscopy (LED-FM) as an alternative to Ziehl-Neelsen (ZN) smear microscopy. This, alongside the newly introduced Xpert (Cepheid, Sunnyvale, CA, USA) is expected to improve diagnosis of tuberculosis and detection of rifampicin resistance in patients at health facilities. We assessed the accuracy of smear microscopy and the incremental sensitivity of Xpert at tuberculosis laboratories in Rwanda. METHODS: This was a cross-sectional study involving four laboratories performing ZN and four laboratories performing LED-FM microscopy. The laboratories include four intermediate (ILs) and four peripheral (PLs) laboratories. After smear microscopy, the left-over of samples, of a single early-morning sputum from 648 participants, were tested using Xpert and mycobacterial culture as a reference standard. Sensitivity of each test was compared and the incremental sensitivity of Xpert after a negative smear was assessed. RESULTS: A total of 96 presumptive pulmonary tuberculosis participants were culture positive for M. tuberculosis. The overall sensitivity in PL of ZN was 55.1 % (40.2-69.3 %), LED-FM was 37 % (19.4-57.6 %) and Xpert was 77.6 % (66.6-86.4 %) whereas in ILs the same value for ZN was 58.3 % (27.7-84.8 %), LED-FM was 62.5 % (24.5-91.5 %) and Xpert was 90 (68.3-98.8 %). The sensitivity for all tests was significantly higher among HIV-negative individuals (all test p <0.05). The overall incremental sensitivity of Xpert over smear microscopy was 32.3 %; p < 0.0001. The incremental sensitivity of Xpert was statistically significant for both smear methods at PL (32.9 %; p = 0.001) but not at the ILs (30 %; p = 0.125) for both smear methods. CONCLUSIONS: Our study findings of the early implementation of the LED-FM did not reveal significant increment in sensitivity compared to the method being phased out (ZN). This study showed a significant incremental sensitivity for Xpert from both smear methods at peripheral centers where majority of TB patients are diagnosed. Overall our findings support the recommendation for Xpert as an initial diagnostic test in adults and children presumed to have TB.


Assuntos
Microscopia de Fluorescência/métodos , Tuberculose Pulmonar/diagnóstico , Adolescente , Adulto , Estudos Transversais , Testes Diagnósticos de Rotina , Farmacorresistência Bacteriana , Feminino , Instalações de Saúde , Humanos , Laboratórios , Masculino , Pessoa de Meia-Idade , Mycobacterium tuberculosis/efeitos dos fármacos , Mycobacterium tuberculosis/patogenicidade , Rifampina/uso terapêutico , Ruanda , Sensibilidade e Especificidade , Escarro/microbiologia , Tuberculose Pulmonar/tratamento farmacológico , Tuberculose Pulmonar/microbiologia , Adulto Jovem
4.
PLoS One ; 11(9): e0163462, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27685783

RESUMO

BACKGROUND: The World Health Organization (WHO) 2010 guidelines for intensified tuberculosis (TB) case finding (ICF) among people living with HIV (PLHIV) includes a recommendation that PLHIV receive routine TB screening. Since 2005, the Rwandan Ministry of Health has been using a five-question screening tool. Our study objective was to assess the operating characteristics of the tool designed to identify PLHIV with presumptive TB as measured against a composite reference standard, including bacteriologically confirmed TB. METHODS: In a cross-sectional study, the TB screening tool was routinely administered at enrolment in outpatient HIV care and treatment services at seven public health facilities. From March to September 2011, study enrollees were examined for TB disease irrespective of TB screening outcome. The examination consisted of a chest radiograph (CXR), three sputum smears (SS), sputum culture (SC) and polymerase chain reaction line-probe assay (Hain test). PLHIV were classified as having "laboratory-confirmed TB" with positive results on SS for acid-fast bacilli, SC on Lowenstein-Jensen medium, or a Hain test. RESULTS: Overall, 1,767 patients were enrolled and screened of which; 1,017 (57.6%) were female, median age was 33 (IQR, 27-41), and median CD4+ cell count was 385 (IQR, 229-563) cells/mm3. Of the patients screened, 138 (7.8%) were diagnosed with TB of which; 125 (90.5%) were laboratory-confirmed pulmonary TB. Of 404 (22.9%) patients who screened positive and 1,363 (77.1%) who screened negative, 79 (19.5%) and 59 (4.3%), respectively, were diagnosed with TB. For laboratory-confirmed TB, the tool had a sensitivity of 54.4% (95% CI 45.3-63.3), specificity of 79.5% (95% CI 77.5-81.5), PPV of 16.8% and NPV of 95.8%. CONCLUSION: TB prevalence among PLHIV newly enrolling into HIV care and treatment was 65 times greater than the overall population prevalence. However, the performance of the tool was poorer than the predicted performance of the WHO recommended TB screening questions.

5.
PLoS One ; 10(4): e0124485, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25919759

RESUMO

INTRODUCTION: Data are limited regarding tuberculosis (TB) and latent TB infection prevalence in Rwandan health facilities. METHODS: We conducted a cross-sectional survey among healthcare workers (HCWs) in Kigali during 2010. We purposively selected the public referral hospital, both district hospitals, and randomly selected 7 of 17 health centers. School workers (SWs) from the nearest willing public schools served as a local reference group. We tested for latent TB infection (LTBI) using tuberculin skin testing (TST) and asked about past TB disease. We assessed risk of LTBI and past history of TB disease associated with hospital employment. Among HCWs, we assessed risk associated with facility type (district hospital, referral hospital, health center), work setting (inpatient, outpatient), and occupation. RESULTS: Age, gender, and HIV status was similar between the enrolled 1,131 HCWs and 381 SWs. LTBI was more prevalent among HCWs (62%) than SWs (39%). Adjusted odds of a positive TST result were 2.71 (95% CI 2.01-3.67) times greater among HCWs than SWs. Among HCWs, there was no detectable difference between prevalence of LTBI according to facility type, work setting, or occupation. CONCLUSION: HCWs are at greater risk of LTBI, regardless of facility type, work setting, or occupation. The current status of TB infection control practices should be evaluated in the entire workforce in all Rwandan healthcare facilities.


Assuntos
Pessoal de Saúde/estatística & dados numéricos , Tuberculose Latente/epidemiologia , Adulto , Idoso , Feminino , Instalações de Saúde , Humanos , Tuberculose Latente/diagnóstico , Masculino , Pessoa de Meia-Idade , Razão de Chances , Fatores de Risco , Ruanda/epidemiologia , Instituições Acadêmicas , Teste Tuberculínico , Adulto Jovem
6.
Lancet ; 384(9940): 371-5, 2014 Jul 26.
Artigo em Inglês | MEDLINE | ID: mdl-24703831

RESUMO

Two decades ago, the genocide against the Tutsis in Rwanda led to the deaths of 1 million people, and the displacement of millions more. Injury and trauma were followed by the effects of a devastated health system and economy. In the years that followed, a new course set by a new government set into motion equity-oriented national policies focusing on social cohesion and people-centred development. Premature mortality rates have fallen precipitously in recent years, and life expectancy has doubled since the mid-1990s. Here we reflect on the lessons learned in rebuilding Rwanda's health sector during the past two decades, as the country now prepares itself to take on new challenges in health-care delivery.


Assuntos
Assistência à Saúde/organização & administração , Criança , Mortalidade da Criança , Genocídio , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Infecções por HIV/terapia , Política de Saúde , Humanos , Ruanda/epidemiologia , Tuberculose Pulmonar/mortalidade , Guerra
7.
J Acquir Immune Defic Syndr ; 66(2): e45-9, 2014 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-24562350

RESUMO

BACKGROUND: Tuberculosis (TB) is the leading cause of morbidity and mortality among people living with HIV (PLHIV) in sub-Saharan Africa. Early TB detection and treatment is key to saving lives of PLHIV. Rwanda began implementing intensified TB case finding (ICF) in 2005 in line with World Health Organization policy on TB/HIV collaborative activities. We aimed to describe trends of ICF in PLHIV newly enrolled into HIV clinics. METHODS: We used routinely collected program data on ICF from facility-based pre-antiretroviral therapy/antiretroviral therapy registers in Rwandan HIV clinics from 2006 to 2011. Semiannual, active data collection for PLHIV newly enrolled into HIV care included proportion screened for TB, proportion screened positive, and percentage with active TB and started anti-TB drugs. RESULTS: The number of health facilities reporting TB screening indicators increased 16-fold, from 20 facilities in the first semester of 2006 to 328 facilities by the end of 2011. The proportion of patients screened increased progressively from 77% of newly enrolled patients in first semester of 2006 to 94% at the end of 2011 (P < 0.001). The proportion of patients who screened positive decreased over time, from 23% in the first semester of 2006 to 10% at the end of 2011 (P < 0.001). The proportion of active TB cases remained relatively constant over time at 2.2%. CONCLUSIONS: Rwanda has increased the proportion of newly enrolled PLHIV screened for TB using a simple screening protocol. Countries with limited resources but high HIV and TB disease prevalence should implement ICF as part of their integrated HIV-TB treatment programs.


Assuntos
Infecções por HIV/microbiologia , Programas de Rastreamento , Sistema de Registros , Tuberculose/diagnóstico , Antirreumáticos/uso terapêutico , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Humanos , Ruanda/epidemiologia , Tuberculose/tratamento farmacológico , Tuberculose/epidemiologia , Organização Mundial da Saúde
8.
Global Health ; 9: 37, 2013 Aug 30.
Artigo em Inglês | MEDLINE | ID: mdl-24119388

RESUMO

The notion of "reverse innovation"--that some insights from low-income countries might offer transferable lessons for wealthier contexts--is increasingly common in the global health and business strategy literature. Yet the perspectives of researchers and policymakers in settings where these innovations are developed have been largely absent from the discussion to date. In this Commentary, we present examples of programmatic, technological, and research-based innovations from Rwanda, and offer reflections on how the global health community might leverage innovative partnerships for shared learning and improved health outcomes in all countries.


Assuntos
Comportamento Cooperativo , Assistência à Saúde , Países Desenvolvidos , Países em Desenvolvimento , Difusão de Inovações , Saúde Global , Disseminação de Informação , Humanos , Ruanda
9.
PLoS One ; 8(9): e73501, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-24066053

RESUMO

BACKGROUND: Adherence to treatment and sputum smear conversion after 2 months of treatment are thought to be important for successful outcome of tuberculosis (TB) treatment. METHODS: Retrospective cohort study of new adult TB patients diagnosed in the first quarter of 2007 at 48 clinics in Rwanda. Data were abstracted from TB registers and individual treatment charts. Logistic regression analysis was done to examine associations between baseline demographic and clinical factors and three outcomes adherence, sputum smear conversion at two months, and death. RESULTS: Out of 725 eligible patients the treatment chart was retrieved for 581 (80%). Fifty-six (10%) of these patients took <90% of doses (defined as poor adherence). Baseline demographic characteristics were not associated with adherence to TB treatment, but adherence was lower among HIV patients not taking antiretroviral therapy (ART); p = 0.03). Sputum smear results around 2 months after start of treatment were available for 220 of 311 initially sputum-smear-positive pulmonary TB (PTB+) patients (71%); 175 (80%) had achieved sputum smear conversion. In multivariable analysis, baseline sputum smear grade (odds ratio [OR] = 2.7, 95% Confidence interval [CI] 1.1-6.6 comparing smear 3+ against 1+) and HIV infection (OR 3.0, 95%CI 1.3-6.7) were independent predictors for non-conversion at 2 months. Sixty-nine of 574 patients (12%) with known TB treatment outcomes had died. Besides other known determinants, poor adherence had an independent, strong effect on mortality (OR 3.4, 95%CI 1.4-7.8). CONCLUSION: HIV infection is an important independent predictor of failure of sputum smear conversion at 2 months among PTB+ patients. Poor adherence to TB treatment is an important independent determinant of mortality.


Assuntos
Escarro/microbiologia , Tuberculose Pulmonar/tratamento farmacológico , Tuberculose Pulmonar/mortalidade , Adolescente , Adulto , Antituberculosos/uso terapêutico , Intervalos de Confiança , Feminino , Infecções por HIV/complicações , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Ruanda , Adulto Jovem
12.
J Acquir Immune Defic Syndr ; 60 Suppl 3: S136-44, 2012 Aug 15.
Artigo em Inglês | MEDLINE | ID: mdl-22797735

RESUMO

The US President's Emergency Plan for AIDS Relief (PEPFAR) has supported a comprehensive package of care in which interventions to address HIV-related tuberculosis (TB) have received increased funding and support in recent years. PEPFAR's TB/HIV programming is based on the World Health Organization's 12-point policy for collaborative TB/HIV activities, which are integrated into PEPFAR annual guidance. PEPFAR implementing partners have provided crucial support to TB/HIV collaboration, and as a result, PEPFAR-supported countries in sub-Saharan Africa have made significant gains in HIV testing and counseling of TB patients and linkages to HIV care and treatment, intensified TB case finding, and TB infection control. PEPFAR's support of TB/HIV integration has also included significant investment in health systems, including improved laboratory services and educating and enlarging the workforce. The scale-up of antiretroviral therapy along with support of programs to increase HIV counseling and testing and improve linkage and retention in HIV care may have considerable impact on TB morbidity and mortality, if used synergistically with isoniazid preventive therapy, intensified case finding, and infection control. Issues to be addressed by future programming include accelerating implementation of isoniazid preventive therapy, increasing access and ensuring appropriate use of new TB diagnostics, supporting early initiation of antiretroviral therapy for HIV-infected TB patients, and strengthening systems to monitor and evaluate program implementation.


Assuntos
Infecções Oportunistas Relacionadas com a AIDS/tratamento farmacológico , Síndrome de Imunodeficiência Adquirida/complicações , Síndrome de Imunodeficiência Adquirida/tratamento farmacológico , Controle de Doenças Transmissíveis/organização & administração , Saúde Global , Tuberculose/complicações , Tuberculose/tratamento farmacológico , Infecções Oportunistas Relacionadas com a AIDS/diagnóstico , Síndrome de Imunodeficiência Adquirida/diagnóstico , África ao Sul do Saara/epidemiologia , Controle de Doenças Transmissíveis/métodos , Controle de Doenças Transmissíveis/tendências , Países em Desenvolvimento , Humanos , Cooperação Internacional , Programas Nacionais de Saúde/organização & administração , Programas Nacionais de Saúde/tendências , Parcerias Público-Privadas/organização & administração , Parcerias Público-Privadas/tendências , Tuberculose/diagnóstico , Estados Unidos
13.
BMC Res Notes ; 5: 357, 2012 Jul 16.
Artigo em Inglês | MEDLINE | ID: mdl-22800438

RESUMO

BACKGROUND: In Rwanda tuberculosis (TB) is one of the major health problems. To contribute to an improved performance of the Rwandan National TB Control Program, we conducted a study with the following objectives: (1) to assess the completion rate of sputum smear examinations at the end of the intensive phase of TB treatment; (2) to assess the sputum conversion rate (SCR); (3) to assess associations between smear completion rate or SCR with key health facility characteristics. METHODS: TB registers in 89 health facilities in five provinces were reviewed. Data of new and retreatment smear-positive pulmonary TB (PTB+) cases registered between January and June 2006 were included in the study. Data on key characteristics of the selected health facilities were also collected. RESULTS: Among 1509 new PTB + cases, 32 (2.1%) had died by 2 months, and 178 (11.8%) had been transferred-out. Among the remaining 1299 patients, a smear examination at month 2 was done in 1039 (smear completion rate 80.0%). Among these 1039, 852 (82.0%) had become smear-negative. The smear completion rate and SCR varied considerably between health facilities. A high number of new PTB cases at a health facility was the only significant predictor of a low completion rate, while the only independent factor associated with low sputum conversion rates was rural (vs. urban) location of the health facility. CONCLUSIONS: In Rwanda, too few patients get a smear examination after 2 months of TB treatment; the SCR among those with smear results was adequate at 82%. A high number of new TB patients at a health facility was a significant predictor of a low completion rate. The national TB control program should design strategies to improve completion rates.


Assuntos
Antituberculosos/uso terapêutico , Escarro/microbiologia , Tuberculose Pulmonar/tratamento farmacológico , Tuberculose Pulmonar/prevenção & controle , Antituberculosos/farmacologia , Instalações de Saúde , Humanos , Retratamento , Ruanda/epidemiologia , Escarro/efeitos dos fármacos , Resultado do Tratamento , Tuberculose Pulmonar/epidemiologia
14.
BMC Public Health ; 11: 550, 2011 Jul 11.
Artigo em Inglês | MEDLINE | ID: mdl-21745385

RESUMO

BACKGROUND: In 2005, Rwanda drafted a national TB/HIV policy and began scaling-up collaborative TB/HIV activities. Prior to the scale-up, we evaluated existing TB/HIV practices, possible barriers to policy and programmatic implementation, and patient treatment outcomes. We then used our evaluation data as a baseline for evaluating the national scale-up of collaborative TB/HIV activities from 2005 through 2009. METHODS: Our baseline evaluation included a cross-sectional evaluation of 23/161 TB clinics. We conducted structured interviews with patients and clinic staff and reviewed TB registers and patient records to assess HIV testing practices, provision of HIV care and treatment for people with TB that tested positive for HIV, and patients' TB treatment outcomes. Following our baseline evaluation, we used nationally representative TB/HIV surveillance data to monitor the scale-up of collaborative TB/HIV activities RESULTS: Of 207 patients interviewed, 76% were offered HIV testing, 99% accepted, and 49% reported positive test results. Of 40 staff interviewed, 68% reported offering HIV testing to >50% of patients. From 2005-2009, scaled-up TB/HIV activities resulted in increased HIV testing of patients with TB (69% to 97%) and provision of cotrimoxazole (15% to 92%) and antiretroviral therapy (13% to 49%) for patients with TB disease and HIV infection (TB/HIV). The risk of death among patients with TB/HIV relative to patients with TB not infected with HIV declined from 2005 (RR = 6.1, 95%CI 2.6, 14.0) to 2007 (RR = 1.8, 95%CI 1.68, 1.94). CONCLUSIONS: Our baseline evaluation highlighted that staff and patients were receptive to HIV testing. However, expanded access to testing, care, and treatment was needed based on the proportion of patients with TB having unknown HIV status and the high rate of HIV infection and poorer TB treatment outcomes for patients with TB/HIV. Following our evaluation, scale-up of TB/HIV services resulted in almost all patients with TB knowing their HIV status. Scale-up also resulted in dramatic increases in the uptake of lifesaving HIV care and treatment coinciding with a decline in the risk of death among patients with TB/HIV.


Assuntos
Comportamento Cooperativo , Assistência à Saúde/estatística & dados numéricos , Infecções por HIV , Tuberculose , Adulto , Estudos Transversais , Feminino , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Política de Saúde , Acesso aos Serviços de Saúde , Humanos , Entrevistas como Assunto , Masculino , Programas de Rastreamento/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde , Vigilância da População , Sistema de Registros , Ruanda/epidemiologia , Tuberculose/tratamento farmacológico , Tuberculose/epidemiologia
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