The Center for Global Health Equity Funded Its First Dartmouth MPH Students for Global Health Activities Abroad

Ifrah Ahmed MPH‘23 and Hannah Adams MPH‘23, were the first MPH students funded by the Center for Global Health Equity to participate in a Co-designed Community-based (CCI) internship abroad. Under the leadership and guidance of Geisel faculty member Dr. Rebecca Laird MED‘01, MPH‘21, an internist and cardiologist, Ifrah and Hannah completed a CCI internship in Kigali, Rwanda, in March 2023. Dr. Laird’s longstanding work to bring cardiovascular disease care, education, and fellowship training to Rwanda allowed Ifrah and Hannah to create a CCI project entitled: “Primary Prevention of Rheumatic Heart Disease in Rwanda.” Their CCI was a proposal delivered to the Rwandan Ministry of Health focused on preventing Rheumatic Heart Disease (RHD) through the diagnosis and treatment of Strep A pharyngitis.

The World Health Organization characterizes RHD as an acquired heart condition that results in damaged heart valves caused by one or more occurrences of rheumatic fever - an autoimmune inflammatory response to strep throat. It’s the most common acquired heart disease in people under age 25, primarily in low- or middle-income countries, and claims nearly 300,000 lives each year.  RHD is preventable and can be treated with antibiotics. Ifrah and Hannah’s CCI was an exploration project into the local health systems and the challenges facing the prevention and management of RHD in Rwanda. Their project culminated in a final proposal on sustainable solutions to improve health outcomes, delivered to the Rwandan Ministry of Health.Following is a personal account of their time on the ground in Rwanda.

Hannah Adams & Ifrah Ahmed
Primary Prevention of Rheumatic Heart Disease in Rwanda

In Rwanda, the prevalence of RHD in 2011 was estimated at 6.8 per 1,000 children in the Gasabo district of Kigali (95% CI: 4.2-10.9 per 1000) - over ten times higher than the prevalence in the US and Europe.¹ A 2020 estimate of RHD prevalence among Rwandan adults was approximately 10 per 1,000, translating to over 130,000 Rwandans with symptomatic RHD leading to a high mortality rate of approximately 3-4 per 1,000, or over 50,000 Rwandans per year.²  Especially concerning are pregnant women with RHD, where the risk of perinatal maternal mortality is estimated at 34%, leaving a significant number of infants and children without a mother.³ Over the past few decades, incredible efforts in treating symptomatic RHD have been underway thanks to the initiatives of the Rwandan Ministry of Health along with cardiothoracic surgery teams from the US and Canada - but without primary prevention, RHD will remain a burden on Rwandan individuals, families, and society that incurs a significant emotional and financial toll.

Throughout our time in Rwanda, we had the opportunity to engage in activities related to the proposed initiative for the primary prevention of RHD. During our trip, we aimed to prioritize relationship-building activities with key stakeholders within Rwanda’s national cardiology programs and the Ministry of Health. Hence, we met with various individuals to gain insight into the current healthcare referral processes within Rwanda, the burden of rheumatic heart disease on the nation, and how an initiative like the one proposed, could be designed to suit the unique needs of Rwanda, among others.

While visiting Centre Hospitalier Universitaire de Kigali (CHUK), which is one of two referral hospitals within Rwanda, we met with the pediatric cardiologist and ethics committee chair to learn about the referral process within Rwanda. Before the trip, we needed clarity in understanding the process and timeline of how an individual with RHD from a rural village in Rwanda eventually sees one of the few cardiologists at either CHUK or King Faisal Hospital in Kigali. Although the project is focused on primary prevention, we needed to see the complete picture of this process to better understand the burden RHD places on patients, providers, and the Rwandan healthcare system. We also learned more about the Rwanda Institutional Review Board (RIB). Working with the RIB is essential if we are to return or other MPH students propose to perform a survey on general public knowledge regarding the link between strep throat and RHD in the future.

We also had an incredible opportunity to shadow a pediatric cardiologist, which helped us gain insight into the impact of RHD and other cardiovascular diseases on Rwandan children and their families. Additionally, shadowing and conversing with the adult cardiology residents throughout our trip helped us better understand how patients are commonly treated for RHD and other cardiovascular diseases within Rwanda.Furthermore, listening to physicians discuss the difficulties of, more often than not, having to treat late-stage disease due to the limited access to preventative specialty care was incredibly impactful and reinforced the importance of primary prevention for RHD. The Rwandan residents were able to provide critical guidance and support for our proposal. They helped us clarify the resources needed, which stakeholders to connect with, and the limitations of our proposal, among others. We are so grateful for the insight theses physicians provided throughout our trip.

Our visits to the local hospital and community clinic in the Nyamirambo district of Kigali were enlightening. While speaking to nurses at both locations, we learned more about the referral process, what providers oversee the district hospital such as this, and how community health workers (CHWs) connect patients to the community health centers and district-level hospitals. Throughout our time there, we gained a more in-depth understanding of how CHWs are trained. Given that a key aspect of the primary prevention initiative involves training CHWs to identify cases of strep throat and potential acute rheumatic fever/RHD, this was crucial information that was not available elsewhere. It was clear that there needs to be active training focused on steps to the primary prevention care for RHD.  We also visited with Team Heart to gain a better understanding of any community outreach programs that focus on primary prevention or RHD. Unfortunately, we found out that there is no primary prevention service being conducted by Team Heart, except on World Heart Day, where they go into the community to talk about RHD and pass out information about it.

Our experience in Rwanda is supported by the literature, though perhaps underestimates the burden of RHD. Inpatient hospitalizations in cardiology have a high burden of RHD patients. Patients face a diminished quality of life, have high medical costs, and need trained specialist care. For those cases that are selected, valve replacement surgery is lifesaving. Currently, the majority cannot undergo surgery either because of late presentation, severity of disease, comorbidities, or lack of sufficient resources. End-of-life care for those with RHD can typically involve multiple hospitalizations for heart failure, stabilization in the ICU, and specialized care from nursing, critical-care and cardiology staff. Especially concerning are the young women with RHD who risk their lives to have children, all too often die from complications related to their valve disease.³

Launching a primary prevention strategy to educate, diagnose, and treat Strep A pharyngitis will no doubt not only reduce the costly downstream impact of Acute Rheumatic Fever (ARF) and RHD but, most importantly, save Rwandan lives.⁴ Here we outline a 3-pronged approach for primary prevention that centers around diagnosis and treatment in the established network of Community Health Centers in Rwanda:

1. Education:

• Highlight the importance of treating Strep Pharyngitis as it leads to RHD.
• Raise community awareness of new options to diagnose and treat Strep Pharyngitis.
• Provide proven clinical algorithms for community health centers to follow.
• Train healthcare workers on how to perform rapid Strep testing.

2. Diagnosis:

• Provide low-cost highly specific Rapid Antigen Detection Tests (RADTs) for Streptococcus A bacteria.
• Provide training on performance of Rapid Strep Tests.

3) Treatment:

• Prescribe antibiotics (penicillin or amoxicillin) to treat Strep throat infections.
• Stress the importance of finishing the entire course of antibiotics.

During our trip, we constructed a proposal integrating the information we learned. With the guidance of Dr. Laird and Dr. Muvunyi Bienvenu, a Rwandan Cardiology Fellow, the proposal was finalized and submitted to the Rwandan Ministry of Health. Our trip to Rwanda was insightful and helped us better understand the local health system and the challenges facing the prevention and management of RHD. We are committed to finding sustainable solutions to address this problem and improve the health outcomes of the local community. We are also determined to find ways to fund our project and make it a reality.

Read personal blogs by Hannah (blog) and Ifrah (blog) about their activities in Rwanda on the Gastroenterology Rising (GI Rising) webpage. GI Rising is a non-profit organization associated with the gastroenterology section at Dartmouth-Hitchcock Medical Center that partners with Rwandan medical professionals to educate the next generation of providers in gastroenterology and hepatology to help reduce the burden of gastrointestinal and liver diseases. Dr. Laird is a member of GI Rising and supports the yearly endoscopy week in Rwanda.

1. Prevalence of rheumatic valvular heart disease in Rwandan school children: echocardiographic evaluation using the World Heart Federation criteria. J Mucumbitsi, B Bulwer, L Mutesa, V Ndahindwa, M Semakula, E Rusingiza, P Arya, S Breakey, C Patton-Bolman, E L Kaplan
2. Mucumbitsi J, Scholtz W, Nel G, Fourie JM, Scarlatescu O. Rwanda Country Report. Cardiovasc J Afr. 2020;31(4 Suppl):S27-S34. doi:10.5830/CVJA-2020-034
3. Diao M Kane A Ndiaye MB Mbaye A Bodian M Dia MM Sarr M Kane A Monsuez J-J Ba SA. Pregnancy in women with heart disease in Sub-Saharan Africa. Arch Cardiovasc Dis.2011;104:370–374.
4. RHD Action Report. https://rhdaction.org/sites/default/files/RHD%20Action%20Report_0.pdf. Accessed April 19, 2023.

POSTED 9/17/2024 AT 11:29 AM IN #alumni #global health #internship