Stephen Rulisa
National University of Rwanda, Obstetrics and gynaecology, Faculty Member
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Background Cardiovascular diseases (CVD) are responsible for 17.9 million annual deaths globally, with a disproportionally high burden in sub-Saharan Africa (SSA). There is growing evidence of the use of citizen science and co-design... more
Background Cardiovascular diseases (CVD) are responsible for 17.9 million annual deaths globally, with a disproportionally high burden in sub-Saharan Africa (SSA). There is growing evidence of the use of citizen science and co-design approaches in developing interventions in different fields, but less so in the context of CVD prevention interventions in SSA. This paper reports on the outcomes of a multi-country collaborative project that employed a citizen science approach to explore, co-design, and implement CVD risk prevention and advocacy in SSA. Methods The study was implemented in rural and urban communities in Malawi, Ethiopia and Rwanda and urban South Africa, using citizen science and co-design approaches. Trained citizen scientists used a mobile app-based (EpiCollect) semi-structured survey questionnaire to collect data on CVD risk perceptions from participants purposively selected from two communities per country. Data collected per community included 100–150 photographs a...
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BackgroundEighty percent (80%) of global Non-Communicable Diseases attributed deaths occur in low- and middle-income countries (LMIC) with hypertension and diabetes being key contributors. The overall prevalence of hypertension was 15.3%... more
BackgroundEighty percent (80%) of global Non-Communicable Diseases attributed deaths occur in low- and middle-income countries (LMIC) with hypertension and diabetes being key contributors. The overall prevalence of hypertension was 15.3% the national prevalence of diabetes in rural and urban was 7.5 and 9.7%, respectively among 15–64 years. Hypertension represents a leading cause of death (43%) among hospitalized patients at the University teaching hospital of Kigali. This study aimed to identify ongoing population-level interventions targeting risk factors for diabetes and hypertension and to explore perceived barriers and facilitators for their implementation in Rwanda.MethodsThis situational analysis comprised a desk review, key informant interviews, and stakeholders' consultation. Ongoing population-level interventions were identified through searches of government websites, complemented by one-on-one consultations with 60 individuals nominated by their respective organizati...
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Background The literature has shown the relationship between maternal periodontitis and complications associated with pregnancy. Thus, prevalence estimates and risk factor identification for periodontitis during pregnancy in Rwanda are... more
Background The literature has shown the relationship between maternal periodontitis and complications associated with pregnancy. Thus, prevalence estimates and risk factor identification for periodontitis during pregnancy in Rwanda are paramount. Aim The aim of the current study was to determine the prevalence of periodontitis and identify related risk factors among pregnant women in Rwanda. Methods A cross sectional study was conducted to determine the prevalence of periodontal diseases in a convenience sample of 400 pregnant women in the Southern Province of Rwanda. A logistic regression analysis using a hierarchical approach was performed to assess the risk factors for periodontal disease. Socio demographic factors were put in the regression model first followed by a second step for other potential factors. Results The overall prevalence of periodontitis was 60.5%. Multivariable logistic regression showed that age OR=2.48 (95% CI. 1.18-5.22), education level OR=82.15 (95% CI. 8.2...
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Objective: Emergency Cesarean Section (ECS) improves maternal and neonatal outcomes but can be associated with complications including Surgical Site Infections (SSI). Prophylactic antibiotics reduce SSIs but inappropriate use increases... more
Objective: Emergency Cesarean Section (ECS) improves maternal and neonatal outcomes but can be associated with complications including Surgical Site Infections (SSI). Prophylactic antibiotics reduce SSIs but inappropriate use increases antibiotic resistance. The study aim was to assess single versus multiple-dose antibiotic prophylaxis for SSI prevention in a limited-resource setting. Methods: All patients undergoing ECS in a rural district hospital were assessed for eligibility from 2015 to 2016. Participants were randomized, Group A received one dose of 2 g Ampicillin 15 to 60 minutes before skin incision and Group B received 2 g prior to skin incision with additional 1g every 8 hours over 72 hours. Participants were followed for 30 days, Demographic and clinical data were collected by chart review and patient phone interviews were performed on Days 3, 7, 15 and 30. Results: Three hundred and one participants were analyzed (147 in Group A; 154 in Group B). There were 8 surgical si...
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<p><i>Source: MINITRACO/CGIS-NUR, 2001 and NISR 2006.</i></p
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Objective Malaria in pregnancy is associated with adverse perinatal outcomes. The objective was to compare outcomes of simple and severe malaria and to determine whether they vary by trimester or severity of infection. Methods Prospective... more
Objective Malaria in pregnancy is associated with adverse perinatal outcomes. The objective was to compare outcomes of simple and severe malaria and to determine whether they vary by trimester or severity of infection. Methods Prospective cohort study performed in 3 hospitals in Rwanda. Both hospitalized and non-hospitalized pregnant patients with confirmed malaria were enrolled and followed until 7 days postpartum. Demographic, clinical manifestations and perinatal outcomes were recorded. Results There were 446 pregnant women with confirmed malaria and outcome data; 361 (80.9%) had simple malaria. Severe malaria was more common as pregnancy progressed; out of 85 with severe malaria, 12.9%, 29.4% and 57.6% were in the 1st, 2nd and 3rd trimesters (p<0.0001). Overall, a normal term delivery occurred in 57.6%, with preterm delivery in 24.9% and abortion in 13.5%. Adverse perinatal outcomes increased with trimester of infection (p<0.0001). Eight of the 9 early neonatal deaths had ...
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15th Bethune Round Table Conference on International SurgeryCaustic soda for the manufacture of a local variety of soap — the cause of untold suffering in the lives of children in a developing countryBarriers to care and patterns of congenital malformations in Eastern Democratic Republic of Congo...more
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INTRODUCTION: Optimal management of pregnancy and delivery is dependent upon dating. In low resource settings, pregnancies are predominantly dated by LMP. Little is known about dating methods and their impact on outcomes in different... more
INTRODUCTION: Optimal management of pregnancy and delivery is dependent upon dating. In low resource settings, pregnancies are predominantly dated by LMP. Little is known about dating methods and their impact on outcomes in different geographic areas in Rwanda. This study compared pregnancy dating and its impact on perinatal management and outcomes. METHODS: We performed a retrospective study at the largest teaching hospital (KUTH) and a rural district hospital (Kibogora) in Rwanda. All patients with antenatal care and delivery at the studied institution between March 1 and September 30, 2017 were included. Methods of pregnancy dating were: certain LMP, uncertain LMP and ultrasound before 20 weeks. If the clinician intervened and acted to medically to delay or expedite delivery, management was “active” and if they were managed expectantly it was defined as “passive”. RESULTS: We enrolled 239 patients from urban (57.3%) and rural (42.7%) settings. Among urban women, 91.2% were certai...
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INTRODUCTION: Peritonitis is a rare complication after cesarean section. In cases where uterine necrosis is encountered, hysterectomy is usually performed, but there have been case reports of successful uterine debridement and... more
INTRODUCTION: Peritonitis is a rare complication after cesarean section. In cases where uterine necrosis is encountered, hysterectomy is usually performed, but there have been case reports of successful uterine debridement and conservation. However, data are limited. We present the largest series of successful uterine conservation among patients with uterine necrosis due to post-cesarean section peritonitis. METHODS: We performed a prospective observational cohort study at the University Teaching Hospital Kigali (CHUK) from January until August 2015. All patients admitted with the diagnosis of post-cesarean section peritonitis undergoing exploratory laparotomy at CHUK were enrolled. Patients were followed to either discharge or death. Study variables included demographic/clinical characteristics, admission vitals, intra-operative findings, and management. Patients with uterine necrosis at time of laparotomy who survived to discharge were included in the analysis. Data were analyzed using STATA version 14. RESULTS: Forty-two patients were included in the analysis—26 (62%) underwent subtotal hysterectomy and 16 (38%) had successful uterine conservation. There was no significant difference in age, parity, insurance, HIV-status, post-operative day on admission, antibiotic history, severe sepsis on admission, or length of hospitalization between the two groups. Fifteen patients with uterine conservation (94%) had less than 1 cm of necrosis at uterine incision compared to 1 (8%) in the hysterectomy group (P=.001). None of the patients with uterine conservation had a history of previous cesarean section compared to those undergoing hysterectomy (0% vs 31%; P=.014). CONCLUSION: Uterine conservation preserves fertility and is a safe alternative to hysterectomy in post-cesarean peritonitis patients with minimal uterine necrosis.
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Research Interests: HIV medicine, Medicine, Cytology, Cervical Cancer, Clinical Sciences, and 3 moreGenotype, Snp, and Genotyping
Here we wanted to assess whether sexual risk behaviour differs dependent by human immunodeficiency virus (HIV) status by following 100 HIV− and 137 HIV+ women recruited at two university teaching hospitals in Rwanda. Women were tested for... more
Here we wanted to assess whether sexual risk behaviour differs dependent by human immunodeficiency virus (HIV) status by following 100 HIV− and 137 HIV+ women recruited at two university teaching hospitals in Rwanda. Women were tested for sexually transmitted infections (STIs; trichomoniasis, syphilis, hepatitis B and C) and for reproductive tract infections (RTIs; candidiasis, bacterial vaginosis (BV)) and were interviewed at baseline and 9 months later. BV was the most prevalent infection, while syphilis was the most common STI with a 9-month incidence of 10.9% in HIV+ women. Only 24.5% of women positive for any RTI/STI contacted their health facility and got treatment. More HIV− women than HIV+ women had had more than one sexual partner and never used condoms during the follow-up period. The use of condoms was affected neither by marital status nor by concomitant STIs besides HIV. Our data highlight the importance of public education regarding condom use to protect against STIs i...
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A total of 334 Nigerian, non-pregnant women, living in a high density, low-income urban area of Enugu, Nigeria, were interviewed on knowledge, attitude and practice of family planning. About 97.6% were found literate. Knowledge and... more
A total of 334 Nigerian, non-pregnant women, living in a high density, low-income urban area of Enugu, Nigeria, were interviewed on knowledge, attitude and practice of family planning. About 97.6% were found literate. Knowledge and approval of family planning was high, 81.7% and 86.2% respectively, but the practice of family planning was low, as only 20% of the women were on a family planning method. The commonest methods for both ever use and current use were safe period/Billings, condom, IUCD and injectables. The commonest source of family planning information was health workers, while the commonest single reason for non-practice of a method was rejection by the husband. It is concluded that despite their high level of education/literacy, with the attendant high knowledge and approval rate of family planning, the socio-cultural influence of men on their wives is a major stumbling block to the use of modern family planning in this part of Nigeria. Policy makers should, therefore, increase male involvement in family planning programs.
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Background In Rwanda, cardiovascular diseases (CVDs) ranked second of the most common cause of death in 2016. CVD risk score tools have been recommended to identify people at high risk for management. Objective To assess the... more
Background In Rwanda, cardiovascular diseases (CVDs) ranked second of the most common cause of death in 2016. CVD risk score tools have been recommended to identify people at high risk for management. Objective To assess the comparability of body mass index (BMI)-based and lipid-based CVD risk scores in Rwandan population. Methods Secondary analysis was conducted on 4185 study participants extracted from the dataset of Rwanda 2012-2013 non-communicable diseases risk factors survey. Individual CVD risk scores were calculated using both BMI-based and lipid-based algorithms, one at a time. Spearman rank’s coefficient and Cohen’s Kappa coefficient were used to compare the two tools. Results About 63.5% of participants were women. There was a significant positive correlation between BMI-based algorithm and lipid-based algorithm vis-à-vis a 10-year CVD risk prediction (Spearman rank correlation coefficients > 0.90, p<0.001) considering either men, women or overall study participant...
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Background In Rwanda, maternal community health workers (M-CHWs) are involved in the country’s overall health system. In maternal health, their role includes the provision of preventive and promotional health services at the community... more
Background In Rwanda, maternal community health workers (M-CHWs) are involved in the country’s overall health system. In maternal health, their role includes the provision of preventive and promotional health services at the community level. They provide services such as health education on maternal health wellbeing, advice and information on access and timely utilization of health facilities for prenatal, delivery and postpartum care. The contribution of M-CHWs in the health sector combined with other government initiatives led the country to achieving the fifth Millennium Development Goal (MDG) - target 5A- that aimed to improve maternal health through the reduction of maternal mortality ratio by 75% between 1990 and 2015). The objective of this study was to explore M-CHWs’ perceptions and experiences on access and provision of maternal health services. Methods We used a case study methodology, a qualitative research approach to explore M-CHWs’ experiences and perceptions on acces...
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Reducing barriers to use maternal health care is one of the critical components to improving maternal health. Rwanda is among the countries that have made tremendous efforts to reduce maternal mortality. However, the current maternal... more
Reducing barriers to use maternal health care is one of the critical components to improving maternal health. Rwanda is among the countries that have made tremendous efforts to reduce maternal mortality. However, the current maternal mortality ratio is still high which calls for further efforts to be considered. This study used a qualitative approach to understand mothers\u27 perceptions and experiences of using maternal health care in Rwanda. Using in-depth interviews and focus group discussions, data were collected in the Western and Eastern provinces of the country where forty-five women participated in the study from June to August 2014. This paper highlights perceptions of these participants regarding issues that contribute to suboptimal use of maternal health-care services. The geographical, financial, and social-cultural barriers that emerged in this study highlight the need to understand mothers\u27 experiences and perceptions when using maternal health care as Rwanda and ot...
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Additional file 1. Ethiopia Administrative and Public Health System overview (Example of country administrative structure and public health system)
Standard operating procedures (PREGACT study) for obstetric ultrasound for the assessment of embryos and foetuses during pregnancy. (PDF 165 kb)
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Background: The proportion of births attended by skilled health personnel is one of two indicators used to measure progress towards Millennium Development Goal 5, which aims for a 75 % reduction in global maternal mortality ratios by... more
Background: The proportion of births attended by skilled health personnel is one of two indicators used to measure progress towards Millennium Development Goal 5, which aims for a 75 % reduction in global maternal mortality ratios by 2015. Rwanda has one of the highest maternal mortality ratios in the world, estimated between 249–584 maternal deaths per 100,000 live births. The objectives of this study were to quantify secular trends in health facility delivery and to identify factors that affect the uptake of intrapartum healthcare services among women living in rural villages in Bugesera District, Eastern Province, Rwanda. Methods: Using census data and probability proportional to size cluster sampling methodology, 30 villages were selected for community-based, cross-sectional surveys of women aged 18–50 who had given birth in the previous three years. Complete obstetric histories and detailed demographic data were elicited from respondents using iPad technology. Geospatial coordi...
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OBJECTIVE: To evaluate the first 5 years of the Human Resources for Health Rwanda program from the program onset in the July 2012–2016 academic years, and its effects on access to care through examination of: 1) the number of trained... more
OBJECTIVE: To evaluate the first 5 years of the Human Resources for Health Rwanda program from the program onset in the July 2012–2016 academic years, and its effects on access to care through examination of: 1) the number of trained obstetrician–gynecologists (ob-gyns) who graduated from the University of Rwanda and the University of Rwanda-Human Resources for Health program and 2) a geospatial analysis of pregnant women's access to Rwandan public hospitals with trained ob-gyns. METHODS: We used GPS coordinates in this cross-sectional study to identify public (government) hospitals with ob-gyns in 2011 (before initiation of the program) compared with 2016 (year 5 of the program). We compared access to care for the years 2011 and 2016 through geocoding the proportion of pregnant women within 10 and 25 km from these hospitals and compared the travel time to these hospitals in the two time periods. We used a World Pop dataset of Rwandan pregnancies from 2015, ArcGIS for spatial op...
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Rapid diagnostic tests (RDTs) for histidine rich protein 2 (HRP2) are often used to determine whether persons with fever should be treated with anti-malarials. However, Plasmodium falciparum parasites with a deletion of the hrp2 gene... more
Rapid diagnostic tests (RDTs) for histidine rich protein 2 (HRP2) are often used to determine whether persons with fever should be treated with anti-malarials. However, Plasmodium falciparum parasites with a deletion of the hrp2 gene yield false-negative RDTs and there are concerns the sensitivity of HRP2-based RDTs may fall when the intensity of transmission decreases. This observational study enrolled 9226 patients at three health centres in Rwanda from April 2014 to April 2015. It then compared the sensitivity of RDTs based on HRP2 and the Plasmodium lactate dehydrogenase (pLDH) to microscopy (thick smears) for the diagnosis of malaria. PCR was used to determine whether deletions of the histidine-rich central repeat region of the hrp2 gene (exon 2) were associated with false-negative HRP2-based RDTs. In comparison to microscopy, the sensitivity and specificity of HRP2- and pLDH-based RDTs were 89.5 and 86.2% and 80.2 and 94.3%, respectively. When the results for both RDTs were co...
Research Interests: Parasitology, Medical Microbiology, Biology, Malaria, Adolescent, and 15 moreMedicine, Prospective studies, Humans, Child, Polymerase Chain Reaction, Infant, Middle Aged, Adult, Plasmodium falciparum, Diagnostic Test, Protozoan Proteins, Cross Sectional Studies, Diagnosis of malaria, Child preschool, and Malaria Falciparum
The fifth United Nations Millennium Development Goal aimed to improve maternal health, by reducing the maternal mortality ratio (MMR) by three quarters from 1990 to 2015 and achieving universal access to reproductive health by 2015. In... more
The fifth United Nations Millennium Development Goal aimed to improve maternal health, by reducing the maternal mortality ratio (MMR) by three quarters from 1990 to 2015 and achieving universal access to reproductive health by 2015. In 2010, the MMR had fallen from 400 to 210 maternal deaths per 100,000 live births worldwide. Recognizing that most countries have not met this target, it is timely that the global health community considers what interventions and policies can be impactful. Thomas, Meadows, and McQueen have elegantly examined this [1], hypothesizing that if low-income countries (LICs) increase their cesarean section (CS) rates, MMR will correspondingly decrease. From an obstetric point of view, the underlying premise is clear—hemorrhage and obstructed labor significantly contribute to maternal mortality, and timely CS can decrease maternal death. In support of this, the authors found a very low CS rate of 3.8 % among the 30 LICs, corresponding to a high MMR of 531 per 100,000 live births. The authors argue that if these countries increase their CS rates to WHOrecommended levels of 10–15 %, their MMR can potentially drop by 62.5 %. We congratulate the authors for these pertinent findings. Readers should nevertheless be cautious to view reducing CS rate as the ideal intervention to reduce MMR. When examining countries that already have the target rates of 10–15 % (see Table 1 [1]), one notes a wide range of MMR from 8 to 380 per 100,000 live births, suggesting several confounding factors in the association between CS rates and MMR. While the capability to perform CS indicates a certain level of surgical and anesthesia infrastructure and manpower [2, 3], it may not be the only factor influencing MMR. In a systematic analysis of maternal mortality for 181 countries from 1980 to 2008, Hogan et al. identified 4 factors strongly correlated to higher MMR: (1) higher total fertility rate, (2) lower gross domestic product (GDP) per head, (3) lower education, and (4) presence of HIV infection [4]. Additionally, it is important to remember that without appropriate infrastructure, manpower, and supplies for performing CS, maternal morbidity can also result from CS itself, such as bleeding and infection. A holistic and multi-faceted approach to reducing MMR will be most effective. Most women in the developed settings do not go into labor thinking there is a real possibility that they will die. Therefore, maternal mortality should not be the only metric we focus on in attaining the goal of improving maternal health. Reducing maternal morbidity should also be of foremost importance; one of the best surrogates will be the development of obstetric vesicovaginal fistulae, which most commonly results from prolonged obstructed labor, avertable with a timely CS. In fact, it has been estimated that 37 % of the 56.6 million disability-adjusted life years can be avertable by full coverage of quality obstetric surgery in lowand middle-income countries [5]. While the authors were unable to demonstrate the above with available data, improving the CS rate to 10–15 % can substantially decrease maternal morbidity and improve the quality of life for millions of women around the world. & Jeffrey J. Leow jeffrey.leow@mail.harvard.edu
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INTRODUCTION: Antimicrobial resistance (AMR) is one of the most serious global health threats today, particularly in the developing world. AMR limits the number of antibiotics available to treat severe illnesses like sepsis. Abdominal... more
INTRODUCTION: Antimicrobial resistance (AMR) is one of the most serious global health threats today, particularly in the developing world. AMR limits the number of antibiotics available to treat severe illnesses like sepsis. Abdominal sepsis due to post-partum infections, such as post-cesarean section peritonitis, is being encountered with considerable frequency at the main referral hospital in Kigali, Rwanda and is associated with a mortality rate of 25%. Understanding resistance patterns of bacterial isolates can help tailor initial therapy in these high-risk patients. METHODS: We performed a prospective study at the University Teaching Hospital Kigali (CHUK) from January until September 2015. All patients admitted with the diagnosis of post-cesarean section peritonitis undergoing exploratory laparotomy at CHUK were enrolled. We evaluated the antibiotic sensitivity patterns of bacterial pathogens cultured from peritoneal fluid of patients at time of initial laparotomy. RESULTS: Culture results were available for 29 patients. Twenty-two samples (76%) had gram-negative bacterial isolates and 7 (24%) had no growth. No gram-positive bacteria were isolated. Escherichia coli and Klebsiella were isolated from 31% and 34% of specimens, respectively. The overall resistance rates were 88% to ampicillin; 76% to amoxicillin-clavulanate; 71% to co-trimoxazole; 54%, 58%, and 63% to ceftazidime, ceftriaxone, and cefotaxime, respectively; 58% to gentamicin, 56% to amikacin, and 32% to ciprofloxacin. Only imipenem retained sensitivity to all isolates. CONCLUSION: Antimicrobial resistance rates are alarmingly high among patients presenting with abdominal sepsis from post-cesarean section peritonitis, limiting first-line antibiotic choices. This could lead to increased morbidity and mortality in this high-risk population.
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To evaluate the long-term retention of skills gained by rural physicians who completed a postpartum hemorrhage simulation-training program. A quasi-experimental pre-post intervention study enrolled a convenience sample of generalist... more
To evaluate the long-term retention of skills gained by rural physicians who completed a postpartum hemorrhage simulation-training program. A quasi-experimental pre-post intervention study enrolled a convenience sample of generalist physicians in rural Rwanda. Participants underwent initial simulation training including pre- and post-training testing in February 2012. Simulation drills to assess skill retention were conducted in March 2014. Participants were scored based on their communication, evaluation, and management skills. Median scores and inter-quartile ranges were calculated and the Wilcoxon signed-rank sum test was used to compare the pre-training, post-training, and retention scores. Physician confidence was assessed using a survey. In total, 11 physicians were enrolled; eight were available for the 2-year skill-retention evaluation. Significant improvements were observed when comparing participants&amp;amp;amp;amp;amp;amp;amp;amp;#39; pre-training and post-training communication (P=0.03), evaluation (P=0.05), and management (P=0.02) scores, and there were no changes between participants&amp;amp;amp;amp;amp;amp;amp;amp;#39; post-training and 2-year communication (P&amp;amp;amp;amp;amp;amp;amp;amp;gt;0.99), evaluation (P=0.16), and management (P=0.46) scores. There were no differences in the self-reported confidence measures across the duration of the study. Simulation training is an effective method for teaching postpartum hemorrhage-management skills to generalist physicians in rural areas and skills are retained for at least 2 years. Further studies could determine the optimal time intervals for refresher training.