Cassava Brown Streak Disease (CBSD), which is caused by cassava brown streak virus (CBSV) and Ugandan cassava brown streak virus (UCBSV), represents one of the most devastating threats to cassava production in Africa, including in Rwanda where a dramatic epidemic in 2014 dropped cassava yield from 3.3 million to 900,000 tonnes (1). Studying viral genetic diversity at the genome level is essential in disease management, as it can provide valuable information on the origin and dynamics of epidemic events. To fill the current lack of genome-based diversity studies of UCBSV, we performed a nationwide survey of cassava ipomovirus genomic sequences in Rwanda by high-throughput sequencing (HTS) of pools of plants sampled from 130 cassava fields in thirteen cassava-producing districts, spanning seven agro-ecological zones with contrasting climatic conditions and different cassava cultivars. HTS allowed the assembly of a nearly complete consensus genome of UCBSV in twelve districts. The phylogenetic analysis revealed high homology between UCBSV genome sequences, with a maximum of 0.8 per cent divergence between genomes at the nucleotide level. An in-depth investigation based on Single Nucleotide Polymorphisms (SNPs) was conducted to explore the genome diversity beyond the consensus sequences. First, to ensure the validity of the result, a panel of SNPs was confirmed by independent reverse transcription polymerase chain reaction (RT-PCR) and Sanger sequencing. Furthermore, the combination of fixation index (FST) calculation and Principal Component Analysis (PCA) based on SNP patterns identified three different UCBSV haplotypes geographically clustered. The haplotype 2 (H2) was restricted to the central regions, where the NAROCAS 1 cultivar is predominantly farmed. RT-PCR and Sanger sequencing of individual NAROCAS1 plants confirmed their association with H2. Haplotype 1 was widely spread, with a 100 per cent occurrence in the Eastern region, while Haplotype 3 was only found in the Western region. These haplotypes\' associations with specific cultivars or regions would need further confirmation. Our results prove that a much more complex picture of genetic diversity can be deciphered beyond the consensus sequences, with practical implications on virus epidemiology, evolution, and disease management. Our methodology proposes a high-resolution analysis of genome diversity beyond the consensus between and within samples. It can be used at various scales, from individual plants to pooled samples of virus-infected plants. Our findings also showed how subtle genetic differences could be informative on the potential impact of agricultural practices, as the presence and frequency of a virus haplotype could be correlated with the dissemination and adoption of improved cultivars.

Background Developing a contextually appropriate curriculum is critical to train physicians who can address surgical challenges in sub-Saharan Africa. An innovative modified Delphi process was used to identify contextually optimized curricular content to meet sub-Saharan Africa and Rwanda\'s surgical needs. Methods Participants were surgeons from East, Central, Southern, and West Africa and general practitioners with surgical experience. Delphi participants excluded or prioritized surgical topic areas generated from extensive grey and formal literature review. Surgical educators first screened and condensed identified topics. Round 1 screened and prioritized identified topics, with a 75% consensus cut-off based on the content validity index and a prioritization score. Topics that reached consensus were screened again in round 2 and re-prioritized, following controlled feedback. Frequencies for aggregate prioritization scores, experts in agreement, item-level content validity index, universal agreement and scale-level content validity index based on the average method (S-CVI/Ave) using proportion relevance, and intra-class correlation (ICC) (based on a mean-rating, consistency, two-way mixed-effects model) were performed. We also used arithmetic mean values and modal frequency. Cronbach\'s Alpha was also calculated to ascertain reliability. Results were validated through a multi-institution consensus conference attended by Rwanda-based surgical specialists, general practitioners, medical students, surgical educators, and surgical association representatives using an inclusive, participatory, collaborative, agreement-seeking, and cooperative, a priori consensus decision-making model. Results Two-hundred and sixty-seven broad surgical content areas were identified through the initial round and presented to experts. In round 2, a total of 247 (92%) content areas reached 75% consensus among 31 experts. Topics that did not achieve consensus consisted broadly of small intestinal malignancies, rare hepatobiliary pathologies, and transplantation. In the final round, 99.6% of content areas reached 75% consensus among 31 experts. The highest prioritization was on wound healing, fluid and electrolyte management, and appendicitis, followed by metabolic response, infection, preoperative preparation, antibiotics, small bowel obstruction and perforation, breast infection, acute urinary retention, testicular torsion, hemorrhoids, and surgical ethics. Overall, the consistency and average agreement between panel experts was strong. ICC was 0.856 (95% CI: 0.83-0.87). Cronbach\'s Alpha for round 2 was very strong (0.985, 95% CI: 0.976-0.991) and higher than round 1, demonstrating strong reliability. All 246 topics from round 4 were verbally accepted by 40 participants in open forum discussions during the consensus conference. Conclusions A modified Delphi process and consensus were able to identify essential topics to be included within a highly contextualized, locally driven surgical clerkship curriculum delivered in rural Rwanda. Other contexts can use similar processes to develop relevant curricula.

Background: Standardised neonatal referral forms (NRFs) facilitate effective communication between healthcare providers and ensure continuity of care between facilities, which are essential for patient safety. We sought to determine the essential data items, or core clinical information (CCI), that should be conveyed for neonatal inter-hospital transfer in resource-limited settings (Rounds 1 to 3) and to create an NRF suitable for our setting (Round 4). Methods: We conducted an international, four-round, modified Delphi-consensus study. Round-1 was a literature and internet search to identify existing NRFs. In Round-2 and -3, participants were Rwandan clinicians and international paediatric healthcare practitioners who had worked in Rwanda in the five years before the study. These participants evaluated the draft items and proposed additional items to be included in an NRF. Round-4 focused on creating the NRF and used five focus groups of Rwandan general practitioners at district hospitals. Results: We identified 16 pre-existing NRFs containing 125 individual items. Of these, 91 items met the pre-defined consensus criteria for inclusion in Round-2. Only 33 items were present in more than 50% of the 16 NRFs, confirming the need for this consensus study. In Round-2, participants proposed 12 new items, six of which met the pre-defined consensus criteria. In Round-3, participants scored items for importance, and 57 items met the final consensus criteria. In Round-4, 29 general practitioners took part in five focus groups; a total of 16 modifications were utilised to finalise the NRF. Conclusions: We generated a novel, robust, NRF that may be readily employed in resource-limited settings to communicate the essential clinical information to accompany a neonate requiring inter-hospital transfer.

BACKGROUND: The management of severe burns and pediatric burns requires an organized system of care delivery, which includes referral guidelines. In Rwanda, the burn unit at the University Teaching Hospital of Kigali (CHUK) is the only dedicated burn unit in the country and admits patients of all ages referred from the other provinces. However, since there are no official referral guidelines, it is unknown whether patients with burns are appropriately referred. This study aims to analyze referral patterns among burn patients admitted at the CHUK burn unit and their adherence to the referral criteria listed by the American Burn Association (ABA), comparing patients transferred to the burn unit from facilities within Kigali and those referred from facilities outside Kigali.
METHODS: This retrospective study included all patients with acute burns admitted to the CHUK burn unit with data available on the province of origin from 2005 to 2019. Patients with burns younger than 16 y were defined as pediatric burns, as per the CHUK routines. Characteristics of all burns referred from a facility within Kigali (Pat-K) and facilities outside Kigali (Pat-O) were compared using Fisher\'s exact test for categorical variables or Wilcoxon rank-sum test for continuous variables. The adherence to ABA referral criteria was assessed for variables with available data, which were total burnt surface area %, burn thickness, cause of burn, and age.
RESULTS: The study population consisted of 1093 patients, of which 1064 had data regarding if they were referred from other facilities to CHUK. Overall, the median age was 3 y (2-16 y), with Pat-O being older than Pat-K (P < 0.001). Scalds were the dominant cause of injury in both groups; flame was more common among Pat-O than among Pat-K (in 25.5% versus 10.6%, P < 0.01). Burns of larger size and depth were more common among Pat-O, as compared to the Pat-K group [median total burnt surface area % = 19% versus 15.5%, respectively (P < 0.001); presence of full-thickness burns = 55.6% versus 29.7 %, respectively (P < 0.001)]. Hospitalization was longer and in-hospital mortality higher in Pat-O than in Pat-K [LOS = 42 d (interquartile range 11-164) versus 28 d (interquartile range 9-132), P < 0.05; in-hospital mortality = 18.9% versus 10.1%, P < 0.001]. Among Pat-O, 85% had characteristics that mirrored one or more of the analyzed ABA criteria.
CONCLUSIONS: Although there are no clear guidelines, referral patterns indicate that patients are being appropriately referred for specialized burn care in Rwanda. Compared to patients from Kigali, rural patients had larger and more severe injuries, needed more surgical interventions, and had worse outcomes. Most of referred patients matched criteria listed among international referral guidelines. However, the statement of national referral criteria is essential to improve timely access to adequate care.

Despite increasing cesarean rates in Africa, there remain extensive gaps in the standard provision of care after cesarean birth. We present recommendations for discharge instructions to be provided to women following cesarean delivery in Rwanda, particularly rural Rwanda, and with consideration of adaptable guidelines for sub-Saharan Africa, to support recovery during the postpartum period. These guidelines were developed by a Technical Advisory Group comprised of clinical, program, policy, and research experts with extensive knowledge of cesarean care in Africa. The final instructions delineate between normal and abnormal recovery symptoms and advise when to seek care. The instructions align with global postpartum care guidelines, with additional emphasis on care practices more common in the region and address barriers that women delivering via cesarean may encounter in Africa. The recommended timeline of postpartum visits and visit activities reflect the World Health Organization protocols and provide additional activities to support women who give birth via cesarean. These guidelines aim to standardize communication with women at the time of discharge after cesarean birth in Africa, with the goal of improved confidence and clinical outcomes among these individuals.

An emergency triage, assessment and treatment plus admission care (ETAT+) intervention was implemented in Rwandan district hospitals to improve hospital care for severely ill infants and children. Many interventions are rarely implemented with perfect fidelity under real-world conditions. Thus, evaluations of the real-world experiences of implementing ETAT+ are important in terms of identifying potential barriers to successful implementation. This study explored the perspectives of Rwandan healthcare workers (HCWs) on the relevance of ETAT+ and documented potential barriers to its successful implementation.
HCWs enrolled in the ETAT+ training were asked, immediately after the training, their perspective regarding (i) relevance of the ETAT+ training to Rwandan district hospitals; (ii) if attending the training would bring about change in their work; and (iii) challenges that they encountered during the training, as well as those they anticipated to hamper their ability to translate the knowledge and skills learned in the ETAT+ training into practice in order to improve care for severely ill infants and children in their hospitals. They wrote their perspectives in French, Kinyarwanda, or English and sometimes a mixture of all these languages that are official in the post-genocide Rwanda. Their notes were translated to (if not already in) English and transcribed, and transcripts were analyzed using thematic content analysis.
One hundred seventy-one HCWs were included in our analysis. Nearly all these HCWs stated that the training was highly relevant to the district hospitals and that it aligned with their work expectation. However, some midwives believed that the \"neonatal resuscitation and feeding\" components of the training were more relevant to them than other components. Many HCWs anticipated to change practice by initiating a triage system in their hospital and by using job aids including guidelines for prescription and feeding. Most of the challenges stemmed from the mode of the ETAT+ training delivery (e.g., language barriers, intense training schedule); while others were more related to uptake of guidelines in the district hospitals (e.g., staff turnover, reluctance to change, limited resources, conflicting protocols).
This study highlights potential challenges to successful implementation of the ETAT+ clinical practice guidelines in order to improve quality of hospital care in Rwandan district hospitals. Understanding these challenges, especially from HCWs perspective, can guide efforts to improve uptake of clinical practice guidelines including ETAT+ in Rwanda.

BACKGROUND: Initiation of antiretroviral therapy (ART) in the advanced stages of HIV infection remains a major challenge in sub-Saharan Africa. This study was conducted to better understand barriers and enablers to timely ART initiation in Rwanda where ART coverage is high and national ART eligibility guidelines first expanded in 2007-2008.
METHODS: Using data on 6326 patients (≥15 years) at five Rwandan clinics, we assessed trends and correlates of CD4 cell count at ART initiation and the proportion initiating ART with advanced HIV disease (CD4 <200 cells/μl or WHO stage IV).
RESULTS: Out of 6326 patients, 4486 enrolling in HIV care initiated ART with median CD4 cell count of 211 cells/μl [interquartile range: 131-300]. Median CD4 cell counts at ART initiation increased from 183 cells/μl in 2007 to 293 cells/μl in 2011-2012, and the proportion with advanced HIV disease decreased from 66.2 to 29.4%. Factors associated with a higher odds of advanced HIV disease at ART initiation were male sex [adjusted odds ratios (AOR) = 1.7; 95% confidence interval (CI): 1.3-2.1] and older age (AOR46-55+vs.<25 = 2.3; 95% CI: 1.2-4.3). Among those initiating ART more than 1 year after enrollment in care, those who had a gap in care of 12 or more months prior to ART initiation had higher odds of advanced HIV disease (AOR = 5.2; 95% CI: 1.2-21.1).
CONCLUSIONS: Marked improvements in the median CD4 cell count at ART initiation and proportion initiating ART with advanced HIV disease were observed following the expansion of ART eligibility criteria in Rwanda. However, sex disparities in late treatment initiation persisted through 2011-2012, and appeared to be driven by later diagnosis and/or delayed linkage to care among men.

The aim of this study was to obtain data on susceptibility patterns of pathogens responsible for both community and hospital urinary tract infections (UTIs); and analyzed risk factors for infection caused by ciprofloxacin-resistant Escherichia coli and extended-spectrum β-lactamase (ESBL)-producing strains in Rwanda. Of 1,012 urine cultures prospectively studied, a total of 196 (19.3%) yielded significant growth of a single organism. The most common isolate (60.7%) was Escherichia coli. The antibiotics commonly used in UTIs are less effective except Fosfomycin-trometamol and imipinem. The use of ciprofloxacin in the previous 6 months (odds ratio [OR] = 7.59 [1.75-32.74]), use of other antibiotics in the previous 6 months (OR = 1.02 [1.02-2.34]), and production of ESBL (OR = 19.32 [2.62-142.16]) were found to be associated with ciprofloxacin resistance among the E. coli isolates. Risk factors for ESBL positivity were the use of ciprofloxacin and third-generation cephalosporin in the preceding 6 months (OR = 3.05 [1.42-6.58] and OR = 9.78 [2.71-35.25], respectively); and being an inpatient (OR = 2.27 [1.79-2.89]). Fosfomycin-trometamol could be included as a reasonable alternative for the therapy of uncomplicated UTI in Rwanda.

Units deployed on humanitarian aid may have little experience of the most appropriate interventions which can be expected to produce the most favourable population outcomes. Guidelines produced by UNICEF and the International Dispensary Association (IDA) can be used as a basis for planning. These guidelines were previously untested in Rwanda. This report focuses on iron and folate supplementation for pregnant women suggested by the IDA. The high levels of anaemia in pregnancy would suggest that supplementation is appropriate. However, before fully embracing the full set of recommendations, further field testing would be sensible.