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Schurer JM, Bayisenge U, Hakizimana D, Rafferty E. 'My feet cannot stand on their own': podoconiosis patient healthcare expenditures and income impacts in Rwanda. Trans R Soc Trop Med Hyg 2024:trae006. [PMID: 38456460 DOI: 10.1093/trstmh/trae006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 01/23/2024] [Accepted: 02/21/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND Podoconiosis is a progressive and debilitating form of tropical lymphoedema endemic to Rwanda. Although the physical and psychological consequences are well known, few studies have evaluated the financial burden of podoconiosis. METHODS This cross-sectional, quantitative study aimed to characterize direct treatment costs and impacts on annual earnings among individuals living with podoconiosis. Participants from two highly endemic districts were invited to complete a survey focused on health-seeking history, insurance status, out-of-pocket costs and income changes. Direct treatment costs included medical expenditures (consultation, diagnostics, medication) and non-medical expenditures (food, transportation, accommodation). RESULTS Overall, 226 adults (≥18 y of age) diagnosed with podoconiosis participated. Most had access to community-based health insurance (91.6%) but were unable to work (71.7%). Respondents sought care from health centres/posts (61.9%), hospitals (25.1%), traditional healers (5.8%) and/or community health workers (4.0%). On average, study participants paid US$32.50 (range US$0-779.23) annually, or 11.7% of their household salary, on podoconiosis treatments. CONCLUSIONS This study demonstrates the significant financial burden of podoconiosis on individuals and their communities. Increased attention on integrating podoconiosis management into primary care systems and testing cost-effective solutions is needed to protect those who are most vulnerable.
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Affiliation(s)
- Janna M Schurer
- Center for One Health, University of Global Health Equity, Butaro, Rwanda
- Department of Infectious Disease and Global Health, Cummings School of Veterinary Medicine at Tufts University, North Grafton, MA, USA
| | - Ursin Bayisenge
- Center for One Health, University of Global Health Equity, Butaro, Rwanda
- Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK
| | - Dieudonne Hakizimana
- Institute of Global Health, University of Global Health Equity, Kigali, Rwanda
- University of Washington, Department of Global Health, Seattle, WA, USA
| | - Ellen Rafferty
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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Hakizimana D, Shitu K, Rankin KC, Alemie GA, Walson J, Guthrie BL, Means AR. Optimising scale-up for public health impact: a multimethod implementation science research protocol to improve infant health outcomes in Ethiopia. BMJ Open 2023; 13:e075817. [PMID: 38011972 PMCID: PMC10685948 DOI: 10.1136/bmjopen-2023-075817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 10/30/2023] [Indexed: 11/29/2023] Open
Abstract
INTRODUCTION Child mortality rates remain high in sub-Saharan Africa, including Ethiopia. We are conducting a cluster randomised control trial in the Gondar zone of the Amhara region to determine the impact of pairing Orthodox priests with community health workers, known locally as the Health Development Army (HDA), on newborns' nutritional status, early illness identification and treatment, and vaccination completeness.Ensuring intervention efficacy with scientific rigour is essential, but there are often delays in adopting evidence into policy and programmes. Here, we present a protocol for conducting parallel implementation research alongside an efficacy study to understand intervention implementability and scalability. This will help develop a scale-up strategy for effective elements of the intervention to ensure rapid implementation at scale. METHODS AND ANALYSIS We will conduct a stakeholder analysis of key implementation stakeholders and readiness surveys to assess their readiness to scale up the intervention. We will conduct semistructured interviews and focus group discussions with stakeholders, including HDA members, health workers, Orthodox priests, and caregivers, to determine the core intervention elements that need to be scaled, barriers and facilitators to scaling up the intervention in diverse sociocultural settings, as well as the human and technical requirements for national and regional implementation. Finally, to determine the financial resources necessary for sustaining and scaling the intervention, we will conduct activity-based costing to estimate implementation costs from the provider's perspective. ETHICS AND DISSEMINATION The study received approval from the University of Gondar Institutional Review Board (approval no: VP/RTT/05/1030/2022) and the University of Washington Human Subjects Division (approval no: STUDY00015369). Participants will consent to participate. Results will be disseminated through workshops with stakeholders, local community meetings, presentations at local and international conferences, and journal publications. The study will provide evidence for factors to consider in developing a scale-up strategy to integrate the intervention into routine health system practices.
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Affiliation(s)
| | - Kegnie Shitu
- Department of Health Education and Behavioral Sciences, University of Gondar, Gondar, Ethiopia
| | - Katherine C Rankin
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Getahun A Alemie
- College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Judd Walson
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Brandon L Guthrie
- Department of Global Health/Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Arianna Rubin Means
- Department of Global Health, University of Washington, Seattle, Washington, USA
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Schurer JM, Admasu MT, Bonaventure M, Hakizimana D, Murara E, MacDonald LE, Rafferty E. "I sold my towel and shoes to pay the traditional healer": Care-seeking costs and productivity losses among snakebite victims in Eastern Province, Rwanda. PLoS Negl Trop Dis 2023; 17:e0011768. [PMID: 37983274 PMCID: PMC10695369 DOI: 10.1371/journal.pntd.0011768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 12/04/2023] [Accepted: 11/03/2023] [Indexed: 11/22/2023] Open
Abstract
Snakebite envenomation (SBE) is endemic to sub-Saharan Africa and generally over-represented in rural, remote, and impoverished agricultural communities. While poverty is an established risk factor, little research has been done to investigate the economic consequences of SBE. This cross-sectional, quantitative study aimed to measure out-of-pocket spending and lost income when a household member was bitten by a snake. In 2020, 732 snakebite survivors from Eastern Province (Rwanda) agreed to complete a survey administered by telephone. The survey focused on participant demographics, income, direct medical and non-medical costs, care-seeking decisions, and lost work during convalescence. Our results suggested that patients incurred the highest mean expenses when they sought care from hospitals (11 307 RWF or 12 USD) or traditional healers (5 836 RWF or 6 USD) but that the highest maximum cost was incurred from traditional healers (300 000 RWF or 313 USD). Across all victims, the total amount paid to traditional healers (3.4 million RWF or 3 537 USD) was 4.7 times higher than all other care providers combined. On average, families lost 111 814 RWF (117 USD) per snakebite in direct treatment costs and indirect productivity losses. Many victims sought care from traditional healers despite being eligible for free medical care. Altogether, this study serves as a reminder of the serious physical and financial consequences associated with SBE and provides justification for new investments into SBE prevention and care.
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Affiliation(s)
- Janna M. Schurer
- Center for One Health, University of Global Health Equity, Butaro, Rwanda
- Department of Infectious Disease and Global Health, Cummings School of Veterinary Medicine at Tufts University, North Grafton, Massachusetts, United States of America
| | | | - Mihigo Bonaventure
- Center for One Health, University of Global Health Equity, Butaro, Rwanda
| | - Dieudonne Hakizimana
- University of Washington, Department of Global Health, Seattle, Washington state, United States of America
| | - Elijah Murara
- Center for One Health, University of Global Health Equity, Butaro, Rwanda
| | | | - Ellen Rafferty
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
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Hakizimana D, Ntizimira C, Mbituyumuremyi A, Hakizimana E, Mahmoud H, Birindabagabo P, Musanabaganwa C, Gashumba D. The impact of Covid-19 on malaria services in three high endemic districts in Rwanda: a mixed-method study. Malar J 2022; 21:48. [PMID: 35164781 PMCID: PMC8845295 DOI: 10.1186/s12936-022-04071-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/30/2022] [Indexed: 11/10/2022] Open
Abstract
Background Rwanda has achieved impressive reductions in malaria morbidity and mortality over the past two decades. However, the disruption of essential services due to the current Covid-19 pandemic can lead to a reversal of these gains in malaria control unless targeted, evidence-based interventions are implemented to mitigate the impact of the pandemic. The extent to which malaria services have been disrupted has not been fully characterized. This study was conducted to assess the impact of Covid-19 on malaria services in Rwanda. Methods A mixed-methods study was conducted in three purposively selected districts in Rwanda. The quantitative data included malaria aggregated data reported at the health facility level and the community level. The data included the number of malaria tests, uncomplicated malaria cases, severe malaria cases, and malaria deaths. The qualitative data were collected using focus group discussions with community members and community health workers, as well as in-depth interviews with health care providers and staff working in the malaria programme. Interrupted time series analysis was conducted to compare changes in malaria presentations between the pre-Covid-19 period (January 2019 to February 2020) and Covid-19 period (from March 2020 to November 2020). The constant comparative method was used in qualitative thematic analysis. Results Compared to the pre-Covid-19 period, there was a monthly reduction in patients tested in health facilities of 4.32 per 1000 population and a monthly increase in patients tested in the community of 2.38 per 1000 population during the Covid-19 period. There was no change in the overall presentation rate for uncomplicated malaria. The was a monthly reduction in the proportion of severe malaria of 5.47 per 100,000 malaria cases. Additionally, although healthcare providers continued to provide malaria services, they were fearful that this would expose them and their families to Covid-19. Covid-19 mitigation measures limited the availability of transportation options for the community to seek care in health facilities and delayed the implementation of some key malaria interventions. The focus on Covid-19-related communication also reduced the amount of health information for other diseases provided to community members. Conclusion The Covid-19 pandemic resulted in patients increasingly seeking care in the community and poses challenges to maintaining delivery of malaria services in Rwanda. Interventions to mitigate these challenges should focus on strengthening programming for the community and home-based care models and integrating malaria messages into Covid-19-related communication. Additionally, implementation of the interrupted interventions should be timed and overlap with the malaria transmission season to mitigate Covid-19 consequences on malaria.
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Wanyana D, Wong R, Hakizimana D. Rapid assessment on the utilization of maternal and child health services during COVID-19 in Rwanda. Public Health Action 2021; 11:12-21. [PMID: 33777716 DOI: 10.5588/pha.20.0057] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 12/22/2020] [Indexed: 11/10/2022] Open
Abstract
SETTING All public health facilities in Rwanda, East Africa. OBJECTIVE To assess the change in the utilization of maternal and child health (MCH) services during the COVID-19 outbreak. DESIGN This was a cross-sectional quantitative study. RESULTS During the COVID-19 outbreak in Rwanda, the utilization of 15 MCH services in all four categories-antenatal care (ANC), deliveries, postnatal care (PNC) and vaccinations-significantly declined. The Northern and Western Provinces were affected the most, with significant decrease in respectively nine and 12 services. The Eastern Province showed no statistically significant utilization changes. Kigali was the only province with significant increase in the fourth PNC visits for babies and mothers, while the Southern Province showed significant increase in utilization of measles + rubella (MR) 1 vaccination. CONCLUSION Access and utilization of basic MCH services were considerably affected during the COVID-19 outbreak in Rwanda. This study highlighted the need for pre-emptive measures to avoid disruptions in MCH service delivery and routine health services during outbreaks. In order for the reductions in MCH service utilization to be reversed, targeted resources and active promotion of ANC, institutional deliveries and vaccinations need to be prioritized. Further studies on long-term impact and geographical variations are needed.
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Affiliation(s)
- D Wanyana
- Institute of Global Health, University of Global Health Equity, Kigali, Rwanda
| | - R Wong
- Institute of Global Health, University of Global Health Equity, Kigali, Rwanda.,School of Public Health, Yale University, New Haven, CT, USA
| | - D Hakizimana
- Institute of Global Health, University of Global Health Equity, Kigali, Rwanda
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Hakizimana D, Nisingizwe MP, Logan J, Wong R. Identifying risk factors of anemia among women of reproductive age in Rwanda - a cross-sectional study using secondary data from the Rwanda demographic and health survey 2014/2015. BMC Public Health 2019; 19:1662. [PMID: 31829161 PMCID: PMC6907339 DOI: 10.1186/s12889-019-8019-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 11/29/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Anemia among Women of Reproductive Age (WRA) continues to be among the major public health problems in many developing countries, including Rwanda, where it increased in prevalence between the 2015 and 2010 Rwanda Demographic and Health Survey (RDHS) reports. A thorough understanding of its risk factors is necessary to design better interventions. However, to the best of our knowledge, no study has been conducted in Rwanda on a nationally representative sample to assess factors associated with anemia among WRA. Accordingly, this study was conducted to address such gap. METHODS A quantitative, cross-sectional study was conducted using data from the RDHS 2014-2015. The study population consisted of 6680 WRA who were tested for anemia during the survey. Anemia was defined as having a hemoglobin level equal to or below 10.9 g/dl for a pregnant woman, and hemoglobin level equal to or below 11.9 g/dl for a non-pregnant woman. Pearson's chi-squared test and multiple logistic regression were conducted for bivariate and multivariable analysis, respectively. RESULTS The prevalence of anemia among WRA was 19.2% (95% CI: 18.0-20.5). Four factors were found to be associated with lower odds of anemia, including being obese (OR: 0.61, 95% CI: 0.40-0.91), being in the rich category (OR: 0.74, 95% CI: 0.63-0.87), sleeping under a mosquito net (OR: 0.85, 95% CI: 0.74-0.98), and using hormonal contraceptives (OR: 0.61, 95% CI: 0.50-0.73). Five factors were associated with higher odds of anemia, including being underweight (OR: 1.39, 95% CI: 1.09-1.78), using an intrauterine device (OR: 1.98, 95% CI: 1.05-3.75), being separated or widowed (OR: 1.35, 95% CI: 1.09-1.67), and living in the Southern province (OR: 1.45, 95% CI: 1.11-1.89) or in the Eastern province (OR: 1.41, 95% CI: 1.06-1.88). CONCLUSION Anemia continues to pose public health challenges; novel public health interventions should consider geographic variations in anemia risk, seek to improve women's economic statuses, and strengthen iron supplementation especially for Intrauterine device users. Additionally, given the association between anemia and malaria, interventions to prevent malaria should be enhanced.
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Affiliation(s)
- Dieudonne Hakizimana
- Department of Global Health Delivery, University of Global Health Equity, Kigali, Rwanda.
| | - Marie Paul Nisingizwe
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Jenae Logan
- Department of Global Health Delivery, University of Global Health Equity, Kigali, Rwanda
| | - Rex Wong
- Department of Global Health Delivery, University of Global Health Equity, Kigali, Rwanda.,School of Public Health, Yale University, New Haven, CT, USA
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Uwimana A, Penkunas MJ, Nisingizwe MP, Uyizeye D, Hakizimana D, Musanabaganwa C, Musabyimana JP, Ngwije A, Turate I, Mbituyumuremyi A, Murindahabi M, Condo J. Expanding home-based management of malaria to all age groups in Rwanda: analysis of acceptability and facility-level time-series data. Trans R Soc Trop Med Hyg 2019; 112:513-521. [PMID: 30184186 DOI: 10.1093/trstmh/try093] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 08/01/2018] [Indexed: 11/14/2022] Open
Abstract
Background In response to a resurgence of malaria in Rwanda, home-based management (HBM) was expanded to enable community-health workers (CHWs) to provide malaria treatment to patients of all ages. We assessed the effect of the expanded HBM program on malaria case presentations at health facilities. Methods Services provided by CHWs and health facility presentations among individuals >5 y of age were considered. Presentations to CHWs were analyzed descriptively to assess acceptability and segmented regression modeling using facility-level data was employed to compare changes between the pre- and postintervention periods for intervention and control districts. Results Individuals >5 y of age readily accessed malaria diagnosis and treatment services from CHWs. Severe and uncomplicated malaria increased in the postintervention period for both the intervention and control districts. Presentations for uncomplicated malaria increased in the intervention and control districts to a similar degree. Severe cases increased to a greater degree in the intervention districts immediately after HBM was expanded compared with controls, but the monthly rate of increase was lower in the intervention districts. Conclusions Services were shifted to CHWs, as demonstrated by the number of individuals treated through the expanded program. The rate of severe malaria increased immediately after implementation within intervention districts relative to controls, potentially because of enhanced case-finding. The rate of increase in severe cases was lower in the intervention districts comparatively, likely due to expedited treatment.
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Affiliation(s)
- Aline Uwimana
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Center, Kigali, Rwanda
| | - Michael J Penkunas
- Demand-Driven Evaluations for Decisions, Clinton Health Access Initiative, Kigali, Rwanda
| | - Marie Paul Nisingizwe
- Demand-Driven Evaluations for Decisions, Clinton Health Access Initiative, Kigali, Rwanda
| | - Didier Uyizeye
- Maternal and Child Survival Program, United States Agency for International Development, Kigali, Rwanda
| | - Dieudonne Hakizimana
- Demand-Driven Evaluations for Decisions, Clinton Health Access Initiative, Kigali, Rwanda
| | | | | | - Alida Ngwije
- Demand-Driven Evaluations for Decisions, Clinton Health Access Initiative, Kigali, Rwanda
| | - Innocent Turate
- Institute of HIV/AIDs Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | | | - Monique Murindahabi
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Center, Kigali, Rwanda
| | - Jeanine Condo
- Office of the Director General, Rwanda Biomedical Center, Kigali, Rwanda
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Schurer JM, Nishimwe A, Hakizimana D, Li H, Huang Y, Musabyimana JP, Tuyishime E, MacDonald LE. A One Health systematic review of diagnostic tools for Echinococcus multilocularis surveillance: Towards equity in global detection. Food Waterborne Parasitol 2019; 15:e00048. [PMID: 32095619 PMCID: PMC7034026 DOI: 10.1016/j.fawpar.2019.e00048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 03/14/2019] [Accepted: 03/15/2019] [Indexed: 12/16/2022] Open
Abstract
Echinococcus multilocularis is a zoonotic cestode of canid definitive hosts that is emerging as a parasite of medical and veterinary concern in regions of North America, Europe and Asia. Infection with the metacestode stage (alveolar echinococcosis - AE) is life-threatening, especially for patients who reside in low resource countries and lack access to modern diagnostic tests and treatments. The overall objectives of this One Health review were to systematically describe the diagnostic tests currently employed in endemic countries to detect E. multilocularis in people, canids and the environment, and to report the test characteristics of new diagnostic techniques for population surveillance. In this systematic review of English and Chinese language databases, we identified 92 primary records of E. multilocularis surveillance in canids (N = 75), humans (N = 20) and/or the environment (food, soil; N = 3) and 12 grey literature records that reported E. multilocularis surveillance or health systems protocols between 2008 and 2018. Surveillance for E. multilocularis was conducted using a broad range of combined morphological, molecular, immunological and imaging techniques. Nine studies reporting diagnostic evaluations for cestode or metacestode detection were identified, including studies on copro-antigen ELISA, copro-PCR, intestinal examination, Western Blot, magnetic capture RT-PCR and immunochromatography. Our dataset includes prevalence estimates for E. multilocularis in canids, people, or environment in 27 of the 43 endemic countries and reports data gaps in surveillance, laboratory methods, and diagnostic sensitivity. International consensus on gold standard diagnostic techniques and harmonization of human, canid and environmental surveillance data across political boundaries are needed to comprehensively assess the global burden and distribution of this parasite.
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Affiliation(s)
- Janna M. Schurer
- Cummings School of Veterinary Medicine at Tufts University, 200 Westboro Rd, North Grafton 01536, USA
- University of Global Health Equity, KG 7 Ave, 5th Floor, PO Box 6955, Kigali, Rwanda
| | - Arlene Nishimwe
- University of Global Health Equity, KG 7 Ave, 5th Floor, PO Box 6955, Kigali, Rwanda
| | - Dieudonne Hakizimana
- University of Global Health Equity, KG 7 Ave, 5th Floor, PO Box 6955, Kigali, Rwanda
| | - Huan Li
- College of Veterinary Medicine, China Agricultural University, Beijing 100193, China
| | - Yu Huang
- College of Veterinary Medicine, China Agricultural University, Beijing 100193, China
| | | | - Eugene Tuyishime
- University of Global Health Equity, KG 7 Ave, 5th Floor, PO Box 6955, Kigali, Rwanda
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Uwimana A, Penkunas MJ, Nisingizwe MP, Warsame M, Umulisa N, Uyizeye D, Musanabaganwa C, Munyaneza T, Ntagwabira E, Hakizimana D, Muvunyi CM, Kayobotsi C, Kabera M, Murindahabi M, Mbituyumuremyi A. Efficacy of artemether–lumefantrine versus dihydroartemisinin–piperaquine for the treatment of uncomplicated malaria among children in Rwanda: an open-label, randomized controlled trial. Trans R Soc Trop Med Hyg 2019; 113:312-319. [DOI: 10.1093/trstmh/trz009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 01/09/2019] [Accepted: 03/06/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Aline Uwimana
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Center, Kigali, Rwanda
| | - Michael J Penkunas
- Demand-Driven Evaluations for Decisions, Clinton Health Access Initiative, Kigali, Rwanda
| | - Marie Paul Nisingizwe
- Demand-Driven Evaluations for Decisions, Clinton Health Access Initiative, Kigali, Rwanda
| | - Marian Warsame
- Global Malaria Programme, World Health Organization, Geneva, Switzerland
| | - Noella Umulisa
- Maternal and Child Survival Program, United States Agency for International Development, Kigali, Rwanda
| | - Didier Uyizeye
- Maternal and Child Survival Program, United States Agency for International Development, Kigali, Rwanda
| | | | | | | | - Dieudonne Hakizimana
- Demand-Driven Evaluations for Decisions, Clinton Health Access Initiative, Kigali, Rwanda
| | | | - Claver Kayobotsi
- Single Project Implementation Unit, Rwanda Biomedical Center, Kigali, Rwanda
| | - Michee Kabera
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Center, Kigali, Rwanda
| | - Monique Murindahabi
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Center, Kigali, Rwanda
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