Allison F Linden1, Rebecca Maine2, Bethany L Hedt-Gauthier3, Emmanual Kamanzi4, Gita Mody5, Georges Ntakiyiruta6, Grace Kansayisa7, Edmond Ntaganda8, Francine Niyonkuru8, Joel Mubiligi4, Tharcisse Mpunga9, John G Meara10, Robert Riviello5. 1. Georgetown University Hospital, Department of Surgery, Washington, DC, USA; Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA. Electronic address: alli.linden@gmail.com. 2. Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA; University of California San Francisco Medical Center, Department of Surgery, San Francisco, CA, USA. 3. Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA; Partners In Health, Kigali, Rwanda. 4. Partners In Health, Kigali, Rwanda. 5. Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA; Brigham and Women's Hospital, Department of Surgery, Boston, MA, USA; Brigham and Women's Hospital, Center for Surgery and Public Health, Boston, MA, USA. 6. University of Rwanda College of Medicine and Health Sciences, Department of Surgery, Kigali, Rwanda. 7. Rwanda Military Hospital, Kigali, Rwanda. 8. Centre Hospitalier Universitaire de Kigali (CHUK), Kigali, Rwanda. 9. Rwanda Ministry of Health, Butaro Hospital, Rwanda. 10. Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA; Boston Children's Hospital, Department of Plastic and Oral Surgery, Boston, MA, USA.
Abstract
BACKGROUND: In low-income and middle-income countries, surgical epidemiology is largely undefined at the population level, with operative logs and hospital records serving as a proxy. This study assesses the distribution of surgical conditions that contribute the largest burden of surgical disease in Burera District, in northern Rwanda. We hypothesise that our results would yield higher rates of surgical disease than current estimates (from 2006) for similar low-income countries, which are 295 per 100 000 people. METHODS: In March and May, 2012, we performed a cross-sectional study in Burera District, randomly sampling 30 villages with probability proportionate to size and randomly sampling 23 households within the selected villages. Six Rwandan surgical postgraduates and physicians conducted physical examinations on all eligible participants in sampled households. Participants were assessed for injuries or wounds, hernias, hydroceles, breast mass, neck mass, obstetric fistula, undescended testes, hypospadias, hydrocephalus, cleft lip or palate, and club foot. Ethical approval was obtained from Boston Children's Hospital (Boston, MA, USA) and the Rwandan National Ethics Committee (Kigali, Rwanda). Informed consent was obtained from all participants. FINDINGS: Of the 2165 examined individuals, the overall prevalence of any surgical condition was 12% (95% CI 9·2-14·9) or 12 009 per 100 000 people. Injuries or wounds accounted for 55% of the prevalence and hernias or hydroceles accounted for 40%, followed by neck mass (4·2%), undescended testes (1·9%), breast mass (1·2%), club foot (1%), hypospadias (0·6%), hydrocephalus (0·6%), cleft lip or palate (0%), and obstetric fistula (0%). When comparing study participant characteristics, no statistical difference in overall prevalence was noted when examining sex, wealth, education, and travel time to the nearest hospital. Total rates of surgically treatable disease yielded a statistically significant difference compared with current estimates (p<0·001). INTERPRETATION: Rates of surgically treatable disease are significantly higher than previous estimates in comparable low-income countries. The prevalence of surgically treatable disease is evenly distributed across demographic parameters. From these results, we conclude that strengthening the Rwandan health system's surgical capacity, particularly in rural areas, could have meaningful affect on the entire population. Further community-based surgical epidemiological studies are needed in low-income and middle-income countries to provide the best data available for health system planning. FUNDING: The Harvard Sheldon Traveling Fellowship.
BACKGROUND: In low-income and middle-income countries, surgical epidemiology is largely undefined at the population level, with operative logs and hospital records serving as a proxy. This study assesses the distribution of surgical conditions that contribute the largest burden of surgical disease in Burera District, in northern Rwanda. We hypothesise that our results would yield higher rates of surgical disease than current estimates (from 2006) for similar low-income countries, which are 295 per 100 000 people. METHODS: In March and May, 2012, we performed a cross-sectional study in Burera District, randomly sampling 30 villages with probability proportionate to size and randomly sampling 23 households within the selected villages. Six Rwandan surgical postgraduates and physicians conducted physical examinations on all eligible participants in sampled households. Participants were assessed for injuries or wounds, hernias, hydroceles, breast mass, neck mass, obstetric fistula, undescended testes, hypospadias, hydrocephalus, cleft lip or palate, and club foot. Ethical approval was obtained from Boston Children's Hospital (Boston, MA, USA) and the Rwandan National Ethics Committee (Kigali, Rwanda). Informed consent was obtained from all participants. FINDINGS: Of the 2165 examined individuals, the overall prevalence of any surgical condition was 12% (95% CI 9·2-14·9) or 12 009 per 100 000 people. Injuries or wounds accounted for 55% of the prevalence and hernias or hydroceles accounted for 40%, followed by neck mass (4·2%), undescended testes (1·9%), breast mass (1·2%), club foot (1%), hypospadias (0·6%), hydrocephalus (0·6%), cleft lip or palate (0%), and obstetric fistula (0%). When comparing study participant characteristics, no statistical difference in overall prevalence was noted when examining sex, wealth, education, and travel time to the nearest hospital. Total rates of surgically treatable disease yielded a statistically significant difference compared with current estimates (p<0·001). INTERPRETATION: Rates of surgically treatable disease are significantly higher than previous estimates in comparable low-income countries. The prevalence of surgically treatable disease is evenly distributed across demographic parameters. From these results, we conclude that strengthening the Rwandan health system's surgical capacity, particularly in rural areas, could have meaningful affect on the entire population. Further community-based surgical epidemiological studies are needed in low-income and middle-income countries to provide the best data available for health system planning. FUNDING: The Harvard Sheldon Traveling Fellowship.
Authors: Corrado Cancedda; Phil Cotton; Joseph Shema; Stephen Rulisa; Robert Riviello; Lisa V Adams; Paul E Farmer; Jeanne N Kagwiza; Patrick Kyamanywa; Donatilla Mukamana; Chrispinus Mumena; David K Tumusiime; Lydie Mukashyaka; Esperance Ndenga; Theogene Twagirumugabe; Kaitesi B Mukara; Vincent Dusabejambo; Timothy D Walker; Emmy Nkusi; Lisa Bazzett-Matabele; Alex Butera; Belson Rugwizangoga; Jean Claude Kabayiza; Simon Kanyandekwe; Louise Kalisa; Faustin Ntirenganya; Jeffrey Dixson; Tanya Rogo; Natalie McCall; Mark Corden; Rex Wong; Madeleine Mukeshimana; Agnes Gatarayiha; Egide Kayonga Ntagungira; Attila Yaman; Juliet Musabeyezu; Anne Sliney; Tej Nuthulaganti; Meredith Kernan; Peter Okwi; Joseph Rhatigan; Jane Barrow; Kim Wilson; Adam C Levine; Rebecca Reece; Michael Koster; Rachel T Moresky; Jennifer E O'Flaherty; Paul E Palumbo; Rashna Ginwalla; Cynthia A Binanay; Nathan Thielman; Michael Relf; Rodney Wright; Mary Hill; Deborah Chyun; Robin T Klar; Linda L McCreary; Tonda L Hughes; Marik Moen; Valli Meeks; Beth Barrows; Marcel E Durieux; Craig D McClain; Amy Bunts; Forrest J Calland; Bethany Hedt-Gauthier; Danny Milner; Giuseppe Raviola; Stacy E Smith; Meenu Tuteja; Urania Magriples; Asghar Rastegar; Linda Arnold; Ira Magaziner; Agnes Binagwaho Journal: Int J Health Policy Manag Date: 2018-11-01