Articles and Issues
COMPARATIVE STUDY OF THE PROFILE OF MORTALITY IN THE DEPARTMENT OF INTERNAL MEDICINE AT THE PRINCE REGENT CHARLES HOSPITAL (PRCH)
By Alexis NIZIGIYIMANA MD
Globally, WHO reported that cervical cancer affects over half a million women each year, and kills a quarter of a million. One woman dies of cervical cancer every two minutes, making it one of the greatest threats to women’s health(1). It is predominant among women aged 15 years and older reaching the peak between 45 and 65 years old, which ranked it the second most common female cancer in the 15±44year group (2). According to the 2014 Africa Cervical Cancer Multi-Indicator Incidence and Mortality Scorecard, out of the 20 countries globally with the highest incidence of cervical cancer, 16 are African countries (3).
There are proven approaches to reduce these disparities, including HPV vaccination to prevent cervical cancer. However, in many countries, and in many lower-resource areas within countries, implementation of HPV vaccination is limited, as is the availability of, and access to early detection programmes, cancer surgery, essential cancer medicines, radiotherapy, palliative care, as well as to support for those who survive, sometimes called “survivorship care”(4). In Burundi, Cervical cancer accounted for an annual estimated incidence of 1429 ICC cases and 108 deaths, corresponding to an annually age-standardized incidence and mortality rates of 49.3 and 39.3 per 100,000 women respectively (2). However, cervical cancer is preventable and curable, at low cost and low risk, when all adolescent girls were immunized against human papillomavirus (HPV), and screening to facilitate the timely detection of early precursor lesions in asymptomatic women is available together with appropriate diagnosis, treatment, and follow-up(5). In Burundi, the limited access to effective prevention measures as well as early detection and treatment services significantly reduces patients’ chances of survival (2). This paper is aiming at exploring the health system gaps responsible for the poor delivery of the cervical cancer prevention program in Burundi. Cervical cancer prevention policy
The cervical cancer prevention has received a little attention disproportionately to its global burden. Some asserts that the lack of local-level cervical cancer indicators in much of sub-Saharan Africa due to limitations in systematic reporting, cancer registries, and information collection, which may be difficult to raise cervical cancer as a priority issue if national actors are not aware of the scale of the problem in their home country(6).they also argue that the little attention attached to cervical cancer may be due to in part because of underrepresentation of women or structural bias against women’s health in national and global circles, while others framed cervical either as an NCD, which leads to it having to compete with a number of other health issues with this category or a women’s rights and women’s health, which moves it outside the epidemiological burden of cervical cancer to link it to a broader social priority of gender equality. However, these efforts seem to have provided limited changes in the conceptualization of cervical cancer on the global health agenda (6). Nevertheless, the International organization including GAVI, Foundations, United High-Level Meeting, African First ladies have continuously advocated to raise cervical cancer at a global level,and other support cervical cancer prevention programs (6).In recognition of this, the WHO Director-General made a global call for action on 19th May 2018 towards the elimination of cervical cancer (7). However, Burundi does not yet have any operational policy and cancer registry neither on cancer controls in general nor on cervical cancer, but the Ministry of Health (MOH) in Burundi, through its non-communicable diseases control programme “PNILMCNT” (Programme National Intégré de Lutte Contre fewer Maladies Chroniques non Transmissibles), has recently developed cancer national strategic plan 2016–2020, including cervical cancer control (2).
Cervical cancer screening and diagnosis
The cervical cancer is preventable through screening that allows for early detection and subsequent treatment of precancerous lesions caused by sexually transmitted infection with human papillomavirus (HPV). While most HPV infections clear spontaneously within 1 to 2 years, a persistent infection with one of approximately 15 oncogenic HPV genotypes may progress to pre-cancer which, if untreated, may become invasive cancer (8).
Since the last clinical guidelines for screening were developed, an increasing number of studies have been published that support the high sensitivity of human papillomavirus (HPV) DNA testing, relative to cytologic evaluation of cervical cells with a Pap test (cytology), for detecting high-grade cervical intraepithelial neoplasia (CIN) (8).
Despite these above evidence-based cervical cancer prevention, Burundi has no national organized cervical cancer screening strategy in Burundi. Pap smear can only be done at the teaching hospital in Bujumbura, Roi Khaled, when gynecologists propose it to their clients and the latter are able to afford this service. Therefore, very few women are screened and few have heard about cervical cancer prevention. The only functional pathology laboratory in the country is hampered by frequent stock out of reagents, very old equipment, and insufficient personnel as there are only 2 pathologists and 3 cytotechnicians with only bench training (2). This could be explained by the financial resources constraint, while in 2015, 60.1% of allocated resources to the Ministry of Public Health consisted of foreign aid, contributions of donor Governments only represented 17% of health allocations in 2016, according to the Financial Laws of the Government of Burundi (11) .
HPV vaccine and treatment
Cervical cancer is largely preventable through public health interventions (HPV vaccination and screening with treatment of pre-cancerous lesions), and HPV vaccination of girls is among the few cancer-related so-called “Best Buys” or “very cost-effective strategies” according to the World Health Organization’s Global Action Plan for the Prevention and Control of Non communicable Diseases (2013-2020)(9).
Conversely, the price for three doses of HPV vaccine was estimated to be about $13·50 through GAVI Alliance procurement, $39 at the lowest non-GAVI public sector indicative price, and more than $300 in high-income countries (8). Burundi has no HPV vaccination program, but recently GAVI has been conducting a pilot HPV vaccine program in two health district of Burundi in 2017(10). Nevertheless ,regarding the price of HPV vaccine, the financial constraints could prevent
the government to scale up the cervical cancer prevention program across the country, as it is ranked fifth from bottom (184 of 188 countries) on UNDP’s Human Development index with most human development indicators being shockingly low, which ranks it to 132nd out of 157 countries in terms of progress toward meeting the Sustainable Development Goals (11). Also, the cervical cancer prevention could compete with other health issues as the government is facing a double burden of diseases (communicable and non-communicable diseases respectively 68% and 32% of total deaths)(12).
Concerning the access to cervical cancer treatment, the Burundian health system is still facing not only the lack of radiotherapy, chemotherapy and the palliative care but also the lack of oncologists across the country; the only treatment available is surgery(2).
Cervical cancer is the leading cause of women’s death worldwide, and the second cause of mortality among women in Burundi. This case study revealed gaps that faced the Burundian health system in tackling cervical cancer. We call upon the government to urgently develop a cervical cancer prevention program including HPV vaccination program, cervical cancer screening equipment, an educational program for health care providers on cervical cancer prevention. We also launch a call to the international community such as GAVI, IUCC, and others to support the government to implement the WHO recommendation for the cervical cancer program. And lastly, a vibrant call goes towards the Burundian women to do regular cervical cancer screening, where is possible.
1. Dr Tedros Adhanom Ghebreyesus, Director-General. cervical cancer:An NCD we can overcome ا .2018;(May):300.:https://www.who.int/reproductivehealth/DG_Call-to-Action.
2. Ndizeye Z, Vanden Broeck D, Vermandere H, Bogers JP, Van Geertruyden JP. Knowledge and practices of general practitioners at district hospitals towards cervical cancer prevention in Burundi, 2015: A cross-sectional study. Global Health. 2018;14(1):10–7.
3. Maseko FC, Chirwa ML, Muula AS. Health system challenges cc prevention Malawi. 2015;1:1–8.
4. Ginsburg O, Bray F, Coleman MP, Vanderpuye V, Eniu A, Kotha SR, et al. Health , equity , and women ’ s cancers 1 The global burden of women ’ s cancers : a grand challenge in. Lancet. 2016;6736(16):7–20.
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7. Organization WH. UN Joint Global Programme on Cervical Cancer Prevention and Control. 2016; WHO/NMH/NMA/16.96 © World Health Organization 2016.
8. Campos NG, Mvundura M, Jeronimo J, Holme F, Vodicka E, Kim JJ. Cost-effectiveness of HPV-based cervical cancer screening in the public health system in Nicaragua. BMJ Open. 2017;7(6).
9. Ginsberg GM, Edejer TTT, Lauer JA, Sepulveda C. Screening, prevention and treatment of cervical cancer-A global and regional generalized cost-effectiveness analysis. Vaccine. 2009;27(43):6060–79.
10. ICO Information Centre on HPV and Cancer (HPV Information Centre). Human Papillomavirus and Related Diseases Report Ecuador. HPV Inf Cent. 2015;:(60).
11. United Nations. Human development indices and indicators: 2018 statistical update. 2018; Available from: http://hdr.undp.org/sites/default/files/hdr2018_technical_notes.pdf
12. WHO cancer country profile 2014 :https://www.who.int/cancer/country-profiles/bdi_en.pdf?ua=1
NCDs, including cancer, diabetes, heart and lung diseases, constitute the major reason for mortality globally and accounted for 72% of all deaths in 2016 of which nearly half were people younger than 60 years (so-called premature deaths). Nearly 3/4 of NCD deaths and most premature deaths (82%) occur in low and middle income countries (LMICs). The human toll taken by NCDs should be reason enough for taking urgent action; but the economic impacts of inaction underscore that the world cannot afford to stand by and watch NCDs destroy lives, families and communities.
At the broader NCD level, these diseases together pose the fastest growing disease burden and a development challenge in East Africa in the coming decades. While mortality due to infectious diseases decreased by 10% from 2000 to 2012, the mortality due to NCDs rose from 21% in 2000 to 30% in 2012. The World Health Organisation (WHO) projects that by 2030 in Sub Saharan African (which includes East Africa), NCDs will overtake infectious disease as the main cause of death from the current 30% to 42%, if nothing is done to reverse this trend. Researchers have noted that the East African regions is already experiencing rapid epidemiologic, demographic, and nutritional transitions, which abet the NCD scourge. Worryingly, it has been noted that in developing countries like East Africa, NCDs are also creating social inequality as the risk factors and cost burden are shifting towards the poor. All these indicators reflect a need for urgent action on diabetes and other NCDs in the East African region. Additionally, it is projected that ‘proportional change in number of people
with diabetes between 2013 and 2035’ will be 133%, 166.9% and 123.5% for Kenya, Uganda and Tanzania respectively. If this is to be extrapolated to include other countries of East Africa like Burundi for which there was no data, it would mean that the region is to experience an average of 141.1% increase in the number of diabetes cases by 2035 if no urgent action is taken.
NCDs are increasing rapidly in Burundi’s neighbouring countries, and everything points to the fact that NCDs are also increasing rapidly in Burundi. Burundi did not conduct a WHOs STEPS Survey, designed to document the prevalence of NCDs and risk factors, why the available data on NCDs is even lower in Burundi than elsewhere. However, the few studies that have been conducted point clearly to the fact that NCDs are already widespread. According to the World Food Program, 32% of Burundi’s population is chronically food insecure. As a result, underweight levels are 25% .This is due to low agricultural productivity, land degradation due to overuse, and poor farming methods. Investments in improved data are needed to assist policy makers and political leaders in making better decisions to address NCDs.
The burden of infectious diseases like HIV/AIDS, Malaria and tuberculosis is still overwhelming in Burundi and with the increase of NCDs the country is challenged by a double disease burden.
There is currently no political attention paid to NCDs in Burundi and only very limited donor attention on the matter. Perhaps less surprisingly, knowledge about NCDs and their risk factors is very low or non-existent amongst the general population.
A pilot survey made by the government (following pressure from civil society organisations) found that 25.2 % had hypertension and 1 % had diabetes. It also found that 20 % of the population used tobacco and staggering 88 % are drinking alcohol (although the quantities are not clear).Dr Francois NDIKUMWENAYO recently conduct a cross-sectional study in 2018 among 739 patients living with NCDs. The study found the morbidity linked to NCDs accounted for 31.40%, the admission rate of PLWNCD in internal medicine represented 93.78% compared to other diseases, the main risks factors associated to NCDs were as following, tobacco accounted 20.43%, alcohol represented 78.62%, overweight was 20.03%,the case fatality rate accounted to 43.71%,the age specific-death represented 71.94% with an average age about 59.37 years old.
NCD is a public health health challenge in Burundi and requires a multi-sectoral and a holistic approach to tackle them. This paper explores the implication of civil society organization in prevention and control of NCD in Burundi. Dr Alexis NIZIGIYIMANA ,who is working as the program manager at Burundi NCD Alliance(BNCDA), highlights the activities and solutions over a period of 2 years working in BNCDA .From this, The Burundi NCD Alliance (BNCDA) was established in 2015 (the original members being Burundi Asthma Association, Diabetes Association, Epilepsy Association and Cancer Association). As part of The East African NCD Alliance Sustainability Project.
Furthermore, BNCDA received financial and technical support from DNCDA and EANCDA to develop its constitution, action plan and broadening the membership base. As result, the membership recruitment activities were successful and the following member associations have now joined BNCDA: Burundi Heart Foundation, Burundi Mental Health Support, Burundi Tobacco Initiative and Unhealthy Diet, Burundi Action against Obesity, Christian initiative against Trauma Association and Burundian Medical Student Association. They also succeeded to recruit 20,000 individual members and around 500 young people living with diabetes from 2015 up to 2018. BNCDA has more than 100 active volunteers, including medical students, psychologists, economists, medical doctors, and lecturers at University, who volunteer their time to support BNCDA’s activities.
This start made it possible for BNCDA to get a CISU support to implement the Capacity for citizen driven advocacy for prevention of NCDs project in Burundi. This project trained board members and the project manager on governance and other relevant topics. Furthermore, 50 volunteers were recruited and trained and then led a number of NCD outreaches and community dialogues with people living with NCD activities. Other successes were massive media attention and engagement of MPs in the NCD movement and collaboration with Ministry of Health (MoH). The project entailed collection and publishing of patient stories and voices as well as screening of 1000 people in two rural provinces where 10.9% was diagnosed with diabetes and referred to the district hospitals. The current project supports 30 community dialogue meetings across the country, where 300 PLWNCD, neighbours, family members, friends and caregivers shared the stories and experiences perception and recommendations about NCD prevention and controls and access to essential medicine.
Additionally, this project succeeded to launch a NCD Media Forum (NMF), which is a group of medical doctors, medical students, bloggers and journalists committed to prevent and to control of NCDs , which is aiming to reach the large population to get access to health information on NCDs .
In conclusion, the chronic diseases is obviously becoming a global health issues particularly in developing countries including Burundi, which requires an urgent action ,partnership and global response with a multi-sectoral approach to address them. BNCDA, Government, NCD Media Forum, NGO, public and private sector should work together, and leverage on existing national health partnership including international agencies given their great resource.
We are grateful to the BNCDA, DNCDA, MoH and EANCDA for your support.
Authors: Dr Alexis Nizigiyimana, Anicet Ntisumbwa.
 The Lancet 2018, Bertram, Sweeny, Lauer, et al. Investing in NCDs: an estimation of the return on investment for prevention and treatment services.
 The cost of continued underinvestment in the fight against NCDS has been estimated at USD 47 trillion in lost GDP globally from 2011-2025 (world economic forum 2011, Bloom, Cafiero et.al. the global economic burden of NCDs),
 WHO, 2015 progress monitor
 Katende et al, 2015; Yonga et al, 2015
 Engelgau et al, 2011; WHO, 2010
 Guariguata et al, 2014
 WFP CFSVA
The morbi-mortality of people who inject drugs in Burundi: a prospective study of 2 years from 2016-2018.
The prevalence of HIV in Burundi is 1.3% of the general population and 10, 2% among PWID.PWID have a risk of morbi- mortality because they are not well integrated in healthcare system. For the first time, addressing this risk of PWID was included in the national strategic plan because of a strong advocacy of civil society but few interventions have been implemented.
Objective: To determine the number of people who died or became inactive due to using drugs and the contributing factors.
Methodology: A prospective study was performed for all registered drug users whether injected or not attending Jeunesse au Clair Medical drop- in center (DIC).
Results: In our study, 13 drug users registered in our DIC died, of which 80% of them died of overdose and 20% died due to associated co-morbidities such as tuberculosis and HIV;95% of drug users who attend the center presented with insomnia and can sleep no more than one 1hour a day ;68% had cutaneous infections and recurrent, antibiotic resistant infections , 53% of the patients have malaria, two women had miscarriages , 25% were students who dropped out school , 18 of drug users were HIV positive and six faced road traffic accidents.
The factors that most heavily contributed to the morbi-mortality were: heroin use which contributed to 80% of deaths and morbidity, lack support from family or other partners, absence of emergency care or comprehensive package to deliver appropriate care, HIV, tuberculosis, unemployment and poverty.
Conclusion: In order to better manage the health of drug users in Burundi, whether drugs are injected or not need, there must be a comprehensive package of care as recommended by World Health Organization in a specific and equipped center which will reduce morbi-mortality among this population.
Recommendations: A comprehensive package of care supported by ministry of health and donors included ,but not limited to; policies to reduce stigma which increase access to healthcare, opioid substance therapy (OST) and needle syringe exchange program is key to reducing morbi-mortality among drug users in Burundi.
Key words: Morbi-mortality, PWID, contributing factors, Burundi
Author: Dr HARAGIRIMANA, E. Jeunesse au Clair Médical. ABS
Living with diabetes is very difficult in Burundi. Most of the population is poor, so it is difficult to get medicines and equipment. The average income of one type 1 patient is 100 USD and they can spend the average of 30 USD per month for medicines only. This does not include the cost of appointments and other types of care. When you live in rural zones, it is even worse. It is hard to get regular insulin and when you get it, you face the problem of not having a refrigerator to keep the insulin cool.
When I was doing my training at Kabezi district hospital here in Burundi, I remember seeing a teen die because he was unable to get insulin. He was hospitalized for a while, but when he went home he was unable to get insulin or any equipment to control his blood glucose. Another lady spent three months in hospital and couldn’t attend the educational class. Her diabetes was not stable and there was no one in her village to educate her about diabetes. People with diabetes are obliged to go to a health center at least 5km away to get their insulin and do some tests. Many cannot afford the costs of that.
During a conversation with a type 1 patient, she told me how she has problems to get access to medicines, and the environment in which she works is not healthy. She is in public service and works like others but there is no system to secure her, and because she has diabetes she faces many disadvantages in the workplace. Another patient told me, ‘‘it was hard as a teen to adapt myself to school activities as I was different to others’’. Many tell me that the way neighbors look them has changed after they learned about their diabetes.
With the health system in Burundi, the government provides insulin for free to people under the age of 25, but the distribution center is located in only one place. When I was in rural areas, I could see that hospitals do not have the resources to treat and follow up with patients so that they avoid complications.
Adelard Kakunze conducted a cross-sectional study in 2017 of a group composed of 92 children and adolescents living with type 1 diabetes at the MUSAGA Health Center. He found that the prevalence of type 1 diabetes is 3.54%. The average age of patients is 18.8 years and the average age at diagnosis is 16.4 years. At diagnosis, 52.2% of patients demonstrated the cardinal signs and symptoms, with 26.5% presenting with ketoacidosis. Only 4 patients (4.3%) had been diagnosed in a primary health center.
All of the patients in the study were on insulin, with the majority receiving a treatment regimen of 2 injections per day (90.2%). 74.6% of patients were on a diet versus 12.0% who were doing physical activity. Only 34.8% of patients had a glucometer and only 29.3% were self-monitoring blood glucose on a daily basis. Additionally, 64.1% of patients had never had their HbA1c tested.
Most of the patients were educated on insulin therapy, but they were less educated about their disease and complications. Few had any idea about the goals of their treatment.
Other difficulties encountered in the management of type 1 diabetes by the MUSAGA Health Center were the lack of training of the nursing staff about diabetes, as well as the absence of equipment, especially for the laboratory.
Type 1 patients in Burundi do not have a good life. They rarely receive support. The last time there was an educational program it was done in 2012. There are no associations and they feel that they need support to create one. With their network, they could organize themselves and make a plan about how to reach someone who cannot afford insulin. There is also potential for patients to do advocacy. They could request the government to provide insulin for free to everyone, as it is for HIV/AIDs.
There are no data for the whole country and few studies have been carried out. Complementary studies are needed to assess the complete package that a type 1 diabetic needs, whether in rural or urban areas, and to define policies that will enhance their lives.
Author: Egide Haragirimana,MD