title: Epidemiology of untreated non-obstetric surgical disease in Burera District, Rwanda: a cross-sectional survey.
abstract: BACKGROUND
  In low-income and middle-income countries, surgical epidemiology is largely undefined at the population level, with operative logs and hospital records serving as a proxy. This study assesses the distribution of surgical conditions that contribute the largest burden of surgical disease in Burera District, in northern Rwanda. We hypothesise that our results would yield higher rates of surgical disease than current estimates (from 2006) for similar low-income countries, which are 295 per 100 000 people.
  
  
  METHODS
  In March and May, 2012, we performed a cross-sectional study in Burera District, randomly sampling 30 villages with probability proportionate to size and randomly sampling 23 households within the selected villages. Six Rwandan surgical postgraduates and physicians conducted physical examinations on all eligible participants in sampled households. Participants were assessed for injuries or wounds, hernias, hydroceles, breast mass, neck mass, obstetric fistula, undescended testes, hypospadias, hydrocephalus, cleft lip or palate, and club foot. Ethical approval was obtained from Boston Children's Hospital (Boston, MA, USA) and the Rwandan National Ethics Committee (Kigali, Rwanda). Informed consent was obtained from all participants.
  
  
  RESULTS
  Of the 2165 examined individuals, the overall prevalence of any surgical condition was 12% (95% CI 9·2-14·9) or 12 009 per 100 000 people. Injuries or wounds accounted for 55% of the prevalence and hernias or hydroceles accounted for 40%, followed by neck mass (4·2%), undescended testes (1·9%), breast mass (1·2%), club foot (1%), hypospadias (0·6%), hydrocephalus (0·6%), cleft lip or palate (0%), and obstetric fistula (0%). When comparing study participant characteristics, no statistical difference in overall prevalence was noted when examining sex, wealth, education, and travel time to the nearest hospital. Total rates of surgically treatable disease yielded a statistically significant difference compared with current estimates (p<0·001).
  
  
  CONCLUSIONS
  Rates of surgically treatable disease are significantly higher than previous estimates in comparable low-income countries. The prevalence of surgically treatable disease is evenly distributed across demographic parameters. From these results, we conclude that strengthening the Rwandan health system's surgical capacity, particularly in rural areas, could have meaningful affect on the entire population. Further community-based surgical epidemiological studies are needed in low-income and middle-income countries to provide the best data available for health system planning.
  
  
  BACKGROUND
  The Harvard Sheldon Traveling Fellowship.
authors: Georgetown University Hospital, Department of Surgery, Washington, DC, USA; Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA. Electronic address: alli.linden@gmail.com.
authors: Allison F
authors: AF
authors: Linden
authors: Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA; University of California San Francisco Medical Center, Department of Surgery, San Francisco, CA, USA.
authors: Rebecca
authors: R
authors: Maine
authors: Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA; Partners In Health, Kigali, Rwanda.
authors: Bethany L
authors: BL
authors: Hedt-Gauthier
authors: Partners In Health, Kigali, Rwanda.
authors: Emmanual
authors: E
authors: Kamanzi
authors: Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA; Brigham and Women's Hospital, Department of Surgery, Boston, MA, USA; Brigham and Women's Hospital, Center for Surgery and Public Health, Boston, MA, USA.
authors: Gita
authors: G
authors: Mody
authors: University of Rwanda College of Medicine and Health Sciences, Department of Surgery, Kigali, Rwanda.
authors: Georges
authors: G
authors: Ntakiyiruta
authors: Rwanda Military Hospital, Kigali, Rwanda.
authors: Grace
authors: G
authors: Kansayisa
authors: Centre Hospitalier Universitaire de Kigali (CHUK), Kigali, Rwanda.
authors: Edmond
authors: E
authors: Ntaganda
authors: Centre Hospitalier Universitaire de Kigali (CHUK), Kigali, Rwanda.
authors: Francine
authors: F
authors: Niyonkuru
authors: Partners In Health, Kigali, Rwanda.
authors: Joel
authors: J
authors: Mubiligi
authors: Rwanda Ministry of Health, Butaro Hospital, Rwanda.
authors: Tharcisse
authors: T
authors: Mpunga
authors: Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA; Boston Children's Hospital, Department of Plastic and Oral Surgery, Boston, MA, USA.
authors: John G
authors: JG
authors: Meara
authors: Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA; Brigham and Women's Hospital, Department of Surgery, Boston, MA, USA; Brigham and Women's Hospital, Center for Surgery and Public Health, Boston, MA, USA.
authors: Robert
authors: R
authors: Riviello