Plasmodium vivax Malaria in Duffy-Positive Patients in Rwanda.

Plasmodium vivax is the second-most common malaria pathogen globally, but is considered very rare in the predominantly Duffy-negative sub-Saharan African population. In 259 malaria patients from highland southern Rwanda, we assessed Plasmodium species and Duffy blood group status by polymerase chain reaction (PCR). Plasmodium falciparum, P. vivax, Plasmodium malariae, and Plasmodium ovale were seen in 90.7%, 8.1%, 11.6%, and 5.0%, respectively. Plasmodium vivax occurred more frequently as a monoinfection than in combination with P. falciparum. All P. vivax-infected individuals showed heterozygous Duffy positivity, whereas this was the case for only 3.1% of patients with P. falciparum monoinfection and malaria-negative control subjects (P < 0.01). Based on PCR diagnosis, P. vivax is not rare in southern Rwanda. All episodes of P. vivax were observed in heterozygous Duffy-positive patients, whereas elsewhere in Africa, P. vivax is also reported in Duffy-negative individuals. Refined mapping of Plasmodium species is required to establish control and elimination strategies including all malaria species.

Clients' satisfaction of maternity care at a public referral teaching hospital, in Rwanda: case of University Teaching Hospital of Butare (CHUB).

Introduction: maternal satisfaction is the key in health facilities utilization and so improving the birth outcome and reducing maternal morbidity and mortality. The main objective of this study was to assess women´s satisfaction with perinatal care provided in maternity at CHUB with its associated factors. Methods: a cross-sectional study was done at maternity of CHUB on clients´ satisfaction of maternity care. With a sample size of 422 mothers who were admitted for labor and delivery from July 1st to October 31st 2020. Data were collected using a structured questionnaire and client's satisfaction (eight questions (CSQ-8). Every respondent had to answer all questions under guidance of a data collector. Excel, Stata and SPSS were used for data entry and data analysis. Chi-squared and multivariate regressions were used for analysis of the association. Results: eighty-nine point thirty four (89.34%) percent of our respondents reported that services they received helped them to deal more effectively with their problems; and they were most satisfied with a mean score of 3.9 (97.5%) and least satisfied with the fact that they were not allowed to decide themselves in their management, with a mean score of 3.1 (77.5%). The overall satisfaction of our respondent's equals to the mean score is 28.4/32= 88.75%. Factors found to affect mothers´ satisfaction were respecting mother´s privacy & values and allowing them to take decision and consenting before procedure. Conclusion: the majority of mothers were satisfied with received services. Respecting patients´ privacy and allowing them to participate in decision-making were two factors associated with high satisfaction.

In Vitro Confirmation of Artemisinin Resistance in Plasmodium falciparum from Patient Isolates, Southern Rwanda, 2019.

Artemisinin resistance in Plasmodium falciparum is conferred by mutations in the kelch 13 (K13) gene. In Rwanda, K13 mutations have increased over the past decade, including mutations associated with delayed parasite clearance. We document artemisinin resistance in P. falciparum patient isolates from Rwanda carrying K13 R561H, A675V, and C469F mutations.

Experience of Rwanda on COVID-19 Case Management: From Uncertainties to the Era of Neutralizing Monoclonal Antibodies.

The management of COVID-19 in Rwanda has been dynamic, and the use of COVID-19 therapeutics has gradually been updated based on scientific discoveries. The treatment for COVID-19 remained patient-centered and entirely state-sponsored during the first and second waves. From the time of identification of the index case in March 2020 up to August 2021, three versions of the clinical management guidelines were developed, with the aim of ensuring that the COVID-19 patients treated in Rwanda were receiving care based on the most recent therapeutic discoveries. As the case load increased and imposed imminent heavy burdens on the healthcare system, a smooth transition was made to enable that the asymptomatic and mild COVID-19 cases could continue to be closely observed and managed while they remained in their homes. The care provided to patients requiring facility-based interventions mainly focused on the provision of anti-inflammatory drugs, anticoagulation, broad-spectrum antibiotic therapy, management of hyperglycemia and the provision of therapeutics with a direct antiviral effect such as favipiravir and neutralizing monoclonal antibodies. The time to viral clearance was observed to be shortest among eligible patients treated with neutralizing monoclonal antibodies (bamlanivimab). Moving forward, as we strive to continue detecting COVID-19 cases as early as possible, and promptly initiate supportive interventions, the use of neutralizing monoclonal antibodies constitutes an attractive and cost-effective therapeutic approach. If this approach is used strategically along with other measures in place (i.e., COVID-19 vaccine roll out, etc.), it will enable us to bring this global battle against the COVID-19 pandemic under full control and with a low case fatality rate.

Changing Pattern of Plasmodium falciparum pfmdr1 Gene Polymorphisms in Southern Rwanda.

Plasmodium falciparum multidrug resistance-1 gene (pfmdr1) polymorphisms associate with altered antimalarial susceptibility. Between 2010 and 2018/2019, we observed that the prevalence of the wild-type allele N86 and the wild-type combination NYD increased 10-fold (4% versus 40%) and more than 2-fold (18% versus 44%), respectively. Haplotypes other than NYD or NFD declined by up to >90%. Our molecular data suggest the pfmdr1 pattern shifted toward one associated with artemether-lumefantrine resistance.

Circulation of Extended-Spectrum Beta-Lactamase-Producing Escherichia coli of Pandemic Sequence Types 131, 648, and 410 Among Hospitalized Patients, Caregivers, and the Community in Rwanda.

Multi-drug resistant (MDR), gram-negative Enterobacteriaceae, such as Escherichia coli (E. coli) limit therapeutic options and increase morbidity, mortality, and treatment costs worldwide. They pose a serious burden on healthcare systems, especially in developing countries like Rwanda. Several studies have shown the effects caused by the global spread of extended-spectrum beta-lactamase (ESBL)-producing E. coli. However, limited data is available on transmission dynamics of these pathogens and the mobile elements they carry in the context of clinical and community locations in Sub-Saharan Africa. Here, we examined 120 ESBL-producing E. coli strains from patients hospitalized in the University Teaching Hospital of Butare (Rwanda), their attending caregivers as well as associated community members and livestock. Based on whole-genome analysis, the genetic diversification and phylogenetics were assessed. Moreover, the content of carried plasmids was characterized and investigated for putative transmission among strains, and for their potential role as drivers for the spread of antibiotic resistance. We show that among the 30 different sequence types (ST) detected were the pandemic clonal lineages ST131, ST648 and ST410, which combine high-level antimicrobial resistance with virulence. In addition to the frequently found resistance genes bla CTX-M-15 , tet(34), and aph(6)-Id, we identified csg genes, which are required for curli fiber synthesis and thus biofilm formation. Numerous strains harbored multiple virulence-associated genes (VAGs) including pap (P fimbriae adhesion cluster), fim (type I fimbriae) and chu (Chu heme uptake system). Furthermore, we found phylogenetic relationships among strains from patients and their caregivers or related community members and animals, which indicates transmission of pathogens. Also, we demonstrated the presence and potential transfer of identical/similar ESBL-plasmids in different strains from the Rwandan setting and when compared to an external plasmid. This study highlights the circulation of clinically relevant, pathogenic ESBL-producing E. coli among patients, caregivers and the community in Rwanda. Combining antimicrobial resistance with virulence in addition to the putative exchange of mobile genetic elements among bacterial pathogens poses a significant risk around the world.

Increase in Kelch 13 Polymorphisms in Plasmodium falciparum, Southern Rwanda.

Artemisinin resistance in Plasmodium falciparum is associated with nonsynonymous mutations in the Kelch 13 (K13) propeller domain. We found that 12.1% (8/66) of clinical P. falciparum isolates from Huye district, Rwanda, exhibited K13 mutations, including R561H, a validated resistance marker. K13 mutations appear to be increasing in this region.

Flies from a tertiary hospital in Rwanda carry multidrug-resistant Gram-negative pathogens including extended-spectrum beta-lactamase-producing E. coli sequence type 131.

Multidrug-resistant gram-negative (MRGN) bacteria are a serious threat to global health. We used genomics to study MRGN obtained from houseflies in a tertiary Rwandan hospital. Our analysis revealed a high abundance of different MRGN including E. coli pathogenic lineage ST131 suggesting the important role of flies in disseminating highly virulent pathogens in clinical settings and beyond.

Co-infections with Plasmodium, Ascaris and Giardia among Rwandan schoolchildren.

OBJECTIVES: Co-infections with Plasmodium, Ascaris and Giardia are common in sub-Saharan Africa but epidemiological and clinical data are rare. We examined factors associated with co-infections and their clinical manifestation among Rwandan schoolchildren. METHODS: Schoolchildren aged 6-10 years attending 12 schools in Huye district, Rwanda, were recruited preceding routine deworming. Data on socioeconomic status (SES) and children's histories were obtained, and children were clinically and anthropometrically examined. Blood and stool samples were collected, and infections with Plasmodium, Ascaris and Giardia were determined by microscopy and PCR assays. RESULTS: Among 878 schoolchildren, Plasmodium, Ascaris and Giardia were present in 22%, 35% and 36%, respectively. Co-infections with two or more parasites were found in 24%; only one-third of the children did not harbour any of the parasites examined. Factors associated with parasite (co-)infections largely overlapped and reflected low SES, in addition to a few specific risk factors. Clinically, most children were asymptomatic but anaemia (38%), underweight (17%), and reported signs and symptoms in the preceding 2 weeks (46%) were common. Many of the reported and assessed signs and symptoms were associated with Plasmodium infection, and co-infection with Ascaris and/or Giardia did basically not modify the clinical picture. One exception was malnutrition, which was pronounced in Ascaris-Giardia co-infection vs. individual mono-infections. CONCLUSIONS: Parasitic co-infections are common in Rwandan schoolchildren, and are associated with a rather silent clinical manifestation that nevertheless may affect school performance and long-term development. School-based health interventions should target such co-infections in an integrated manner.

OBJECTIFS: Les coinfections par Plasmodium, Ascaris et Giardia sont courantes en Afrique subsaharienne, mais les données épidémiologiques et cliniques sont rares. Nous avons examiné les facteurs associés aux coinfections et leurs manifestations cliniques chez les écoliers rwandais. MÉTHODES: Des écoliers âgés de 6 à 10 ans fréquentant 12 écoles du district de Huye au Rwanda ont été recrutés avant le déparasitage de routine. Les données sur le statut socioéconomique (SSE) et les antécédents des enfants ont été obtenues et les enfants ont été examinés cliniquement et anthropométriquement. Des échantillons de sang et de selles ont été recueillis et les infections à Plasmodium, Ascaris et Giardia ont été déterminées par microscopie et par PCR. RÉSULTATS: sur 878 écoliers, Plasmodium, Ascaris et Giardia étaient présents chez 22%, 35% et 36%, respectivement. Des coinfections avec deux parasites ou plus ont été trouvées chez 24%; seul un tiers des enfants n'hébergeait aucun des parasites examinés. Les facteurs associés aux (co)infections parasitaires se chevauchaient largement et reflétaient un faible statut SSE, en plus de quelques facteurs de risque spécifiques. Sur le plan clinique, la plupart des enfants étaient asymptomatiques mais l'anémie (38%), l'insuffisance pondérale (17%) et les signes et symptômes rapportés au cours des deux semaines précédentes (46%) étaient fréquents. De nombreux signes et symptômes rapportés et évalués étaient associés à l'infection au Plasmodium et la coinfection par Ascaris et/ou Giardia n'a fondamentalement pas modifié le tableau clinique. Une exception était la malnutrition, qui était prononcée dans la coinfection Ascaris-Giardia par rapport aux mono-infections individuelles. CONCLUSIONS: Les coinfections parasitaires sont courantes chez les écoliers rwandais et sont associées à une manifestation clinique plutôt silencieuse qui peut néanmoins affecter les performances scolaires et le développement à long terme. Les interventions de santé en milieu scolaire devraient cibler ces coinfections de manière intégrée.

Comment on "The optimal timing of post-treatment sampling for the assessment of anthelminthic drug efficacy against Ascaris infections in humans".

A recent publication by Levecke et al. (Int. J. Parasitol, 2018, 8, 67-69) provides important insights into the kinetics of worm expulsion from humans following treatment with albendazole. This is an important aspect of determining the optimal time-point for post treatment sampling to examine anthelmintic drug efficacy. The authors conclude that for the determination of drug efficacy against Ascaris, samples should be taken not before day 14 and recommend a period between days 14 and 21. Using this recommendation, they conclude that previous data (Krücken et al., 2017; Int. J. Parasitol, 7, 262-271) showing a reduction of egg shedding by 75.4% in schoolchildren in Rwanda and our conclusions from these data should be interpreted with caution. In reply to this, we would like to indicate that the very low efficacy of 0% in one school and 52-56% in three other schools, while the drug was fully efficient in other schools, cannot simply be explained by the time point of sampling. Moreover, there was no correlation between the sampling day and albendazole efficacy. We would also like to indicate that we very carefully interpreted our data and, for example, nowhere claimed that we found anthelmintic resistance. Rather, we stated that our data indicated that benzimidazole resistance may be suspected in the study population. We strongly agree that the data presented by Levecke et al. suggests that recommendations for efficacy testing of anthelmintic drugs should be revised.

Reduced efficacy of albendazole against Ascaris lumbricoides in Rwandan schoolchildren.

Control of human soil-transmitted helminths (STHs) relies on preventive chemotherapy of schoolchildren applying the benzimidazoles (BZ) albendazole or mebendazole. Anthelmintic resistance (AR) is a common problem in nematodes of veterinary importance but for human STHs, information on drug efficacy is limited and routine monitoring is rarely implemented. Herein, the efficacy of single dose albendazole (400 mg) was evaluated in 12 schools in the Huye district of Rwanda where Ascaris is the predominant STH. Ascaris eggs were detected by wet mount microscopy and the Mini-FLOTAC method to assess cure rate (CR) and faecal egg count reduction (FECR). Blood and faecal samples were analysed for co-infections with Plasmodium sp. and Giardia duodenalis, respectively. Ascaris positive samples collected before and after treatment were analysed for putatively BZ-resistance associated ß-tubulin gene single nucleotide polymorphisms. The overall CR was 69.9% by Mini-FLOTAC and 88.6% by wet mount microscopy. The FECR was 75.4% and the 95% calculated confidence intervals were 50.4-87.8% using sample variance, 55.4-88.8% by bootstrapping, and 75.0-75.7% applying a Markov Chain Monte Carlo Bayesian approach. FECR varied widely between 0 and 96.8% for individual schools. No putative BZ-resistance associated polymorphisms were found in the four Ascaris ß-tubulin isotype genes examined. Since FECRs <95% indicate reduced efficacy, these findings raise the suspicion of BZ resistance. In the absence of respective molecular evidence, heritable AR in the local Ascaris populations cannot be formally proven. However, since FECRs <95% indicate reduced efficacy, BZ resistance may be suspected which would be alarming and calls for further analyses and routine monitoring in preventive chemotherapy programs.

Intense pre-admission carriage and further acquisition of ESBL-producing Enterobacteriaceae among patients and their caregivers in a tertiary hospital in Rwanda.

OBJECTIVES: To assess the presence and risk factors of intestinal carriage of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) among patients admitted to the University Teaching Hospital of Butare and among their attending caregivers, and to analyse the acquisition of ESBL-PE carriage during hospital stay and associated factors. METHODS: We screened 392 patients and their attending caregivers at admission and discharge for ESBL-PE carriage. Bacterial species were determined using the API-20E system, and antimicrobial susceptibility testing was performed by agar disc diffusion. Data on socio-economic status, diet, behaviour, household assets, livestock and hospital procedures were collected. RESULTS: At admission, 50% of the patients showed intestinal ESBL-PE carriage (Escherichia coli, 51%; Klebsiella pneumoniae, 39%; Enterobacter cloacae, 19%) as did 37% of their caregivers. Co-resistance was common but no carbapenem resistance was detected. At discharge, the proportion of ESBL-PE-colonised patients increased to 65% (caregivers, 47%) with almost complete carriage in paediatric patients (93%). The acquisition rate among initially non-colonised patients was 55% (or, 71/1000 patient days). Independent predictors of admission carriage included a colonised caregiver, prior antibiotic intake, egg consumption and neglecting to boil drinking water, whereas being a paediatric patient, undergoing surgery and male gender predicted acquisition during hospitalisation. CONCLUSIONS: Abundant admission carriage of ESBL-PE and a high acquisition rate in a Rwandan university hospital point to potential intrahospital transmission and community dissemination. Caregivers are an additional source of possible spread. Risk factors of colonisation such as diet and water source need to be tackled to prevent the further emergence and spread of ESBL-PE.

Asymptomatic only at first sight: malaria infection among schoolchildren in highland Rwanda.

BACKGROUND: Plasmodium infection and malaria in school children are increasingly recognized as a relevant public health problem, but data on actual prevalence and health consequences are insufficient. The present study from highland southern Rwanda aimed at estimating infection prevalence among children attending school, at identifying associated factors and at assessing the clinical consequences of these infections. METHODS: In a survey including 12 schools in the Huye district of Rwanda, 1089 children aged 6-10 years were clinically and anthropometrically examined, malaria parasites were diagnosed by microscopy and PCR, haemoglobin concentrations were measured, and socio-economic and behavioural parameters as well as medical histories were obtained. RESULTS: Upon examination, the vast majority of children was asymptomatic (fever 2.7%). Plasmodium infection was detected in 22.4% (Plasmodium falciparum, 18.8%); 41% of these were submicroscopic. Independent predictors of infection included low altitude, higher age, preceding antimalarial treatment, and absence of electricity or a bicycle in the household. Plasmodium infection was associated with anaemia (mean haemoglobin difference of -1.2 g/dL; 95% CI, -0.8 to -1.5 g/dL), fever, underweight, clinically assessed malnutrition and histories of fever, tiredness, weakness, poor appetite, abdominal pain, and vomiting. With the exception of underweight, these conditions were also increased at submicroscopic infection. CONCLUSION: Malaria infection is frequent among children attending school in southern highland Rwanda. Although seemingly asymptomatic in the vast majority of cases, infection is associated with a number of non-specific symptoms in the children´s histories, in addition to the impact on anaemia. This argues for improved malaria surveillance and control activities among school children.

Artemisinin Resistance-Associated K13 Polymorphisms of Plasmodium falciparum in Southern Rwanda, 2010-2015.

Emerging artemisinin resistance is a threat to global malaria control. Mutations in the Plasmodium falciparum Kelch 13 (K13) propeller domain confer artemisinin resistance and constitute molecular markers for its detection and monitoring. We sequenced 222 P. falciparum isolates obtained from community children in the Huye District of southern Rwanda in 2010, 2014, and 2015 to investigate the presence of K13 polymorphisms. No polymorphisms were observed in 2010 but they were present in 2.5% and 4.5% in 2014 and 2015, respectively. In 2015, two isolates showed candidate K13 resistance mutations (P574L and A675V), which are common in southeast Asia and associated with delayed parasite clearance. K13 polymorphisms in southern Rwanda are infrequent but include variants associated with artemisinin resistance. Establishing correlations with local treatment response and in vitro resistance assays are needed in addition to further monitoring K13 polymorphisms in the study area.