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Article ; Online: Spatio-temporal dynamic of the COVID-19 epidemic and the impact of imported cases in Rwanda

Muhammed Semakula / François Niragire / Sabin Nsanzimana / Eric Remera / Christel Faes

BMC Public Health, Vol 23, Iss 1, Pp 1-

2023 Volume 13

Abstract: Abstract Introduction Africa was threatened by the coronavirus disease 2019 (COVID-19) due to the limited health care infrastructure. Rwanda has consistently used non-pharmaceutical strategies, such as lockdown, curfew, and enforcement of prevention ... ...

Abstract	Abstract Introduction Africa was threatened by the coronavirus disease 2019 (COVID-19) due to the limited health care infrastructure. Rwanda has consistently used non-pharmaceutical strategies, such as lockdown, curfew, and enforcement of prevention measures to control the spread of COVID-19. Despite the mitigation measures taken, the country has faced a series of outbreaks in 2020 and 2021. In this paper, we investigate the nature of epidemic phenomena in Rwanda and the impact of imported cases on the spread of COVID-19 using endemic-epidemic spatio-temporal models. Our study provides a framework for understanding the dynamics of the epidemic in Rwanda and monitoring its phenomena to inform public health decision-makers for timely and targeted interventions. Results The findings provide insights into the effects of lockdown and imported infections in Rwanda’s COVID-19 outbreaks. The findings showed that imported infections are dominated by locally transmitted cases. The high incidence was predominant in urban areas and at the borders of Rwanda with its neighboring countries. The inter-district spread of COVID-19 was very limited due to mitigation measures taken in Rwanda. Conclusion The study recommends using evidence-based decisions in the management of epidemics and integrating statistical models in the analytics component of the health information system.
Keywords	COVID-19 ; Spatio-temporal models ; Epidemiology ; Public aspects of medicine ; RA1-1270
Subject code	390
Language	English
Publishing date	2023-05-01T00:00:00Z
Publisher	BMC
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: The secondary transmission pattern of COVID-19 based on contact tracing in Rwanda

Sabin Nsanzimana / Muhammed Semakula / Christel Faes / Thierry Nyatanyi / Eric Remera / FranÇois Niragire / Angela Umutoni / Vedaste Ndahindwa / Edison Rwagasore

BMJ Global Health, Vol 6, Iss

2021 Volume 6

Abstract: Introduction COVID-19 has shown an exceptionally high spread rate across and within countries worldwide. Understanding the dynamics of such an infectious disease transmission is critical for devising strategies to control its spread. In particular, ... ...

Abstract	Introduction COVID-19 has shown an exceptionally high spread rate across and within countries worldwide. Understanding the dynamics of such an infectious disease transmission is critical for devising strategies to control its spread. In particular, Rwanda was one of the African countries that started COVID-19 preparedness early in January 2020, and a total lockdown was imposed when the country had only 18 COVID-19 confirmed cases known. Using intensive contact tracing, several infections were identified, with the majority of them being returning travellers and their close contacts. We used the contact tracing data in Rwanda for understanding the geographic patterns of COVID-19 to inform targeted interventions.Methods We estimated the attack rates and identified risk factors associated to COVID-19 spread. We used Bayesian disease mapping models to assess the spatial pattern of COVID-19 and to identify areas characterised by unusually high or low relative risk. In addition, we used multiple variable conditional logistic regression to assess the impact of the risk factors.Results The results showed that COVID-19 cases in Rwanda are localised mainly in the central regions and in the southwest of Rwanda and that some clusters occurred in the northeast of Rwanda. Relationship to the index case, being male and coworkers are the important risk factors for COVID-19 transmission in Rwanda.Conclusion The analysis of contact tracing data using spatial modelling allowed us to identify high-risk areas at subnational level in Rwanda. Estimating risk factors for infection with SARS-CoV-2 is vital in identifying the clusters in low spread of SARS-CoV-2 subnational level. It is imperative to understand the interactions between the index case and contacts to identify superspreaders, risk factors and high-risk places. The findings recommend that self-isolation at home in Rwanda should be reviewed to limit secondary cases from the same households and spatiotemporal analysis should be introduced in routine monitoring of COVID-19 in Rwanda for policy making decision on real time.
Keywords	Medicine (General) ; R5-920 ; Infectious and parasitic diseases ; RC109-216
Subject code	390
Language	English
Publishing date	2021-06-01T00:00:00Z
Publisher	BMJ Publishing Group
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: How early is too early? Challenges in ART initiation and engaging in HIV care under Treat All in Rwanda-A qualitative study.

Jonathan Ross / Charles Ingabire / Francine Umwiza / Josephine Gasana / Athanase Munyaneza / Gad Murenzi / Sabin Nsanzimana / Eric Remera / Matthew J Akiyama / Kathryn M Anastos / Adebola Adedimeji

PLoS ONE, Vol 16, Iss 5, p e

2021 Volume 0251645

Abstract: Introduction HIV treatment guidelines recommend that all people living with HIV (PLWH) initiate antiretroviral therapy (ART) as soon as possible after diagnosis (Treat All). As Treat All is more widely implemented, an increasing proportion of PLWH are ... ...

Abstract	Introduction HIV treatment guidelines recommend that all people living with HIV (PLWH) initiate antiretroviral therapy (ART) as soon as possible after diagnosis (Treat All). As Treat All is more widely implemented, an increasing proportion of PLWH are likely to initiate ART when they are asymptomatic, and they may view the relative benefits and risks of ART differently than those initiating at more advanced disease stages. To date, patient perspectives of initiating care under Treat All in sub-Saharan Africa have not been well described. Methods From September 2018 to March 2019, we conducted individual, semi-structured, qualitative interviews with 37 patients receiving HIV care in two health centers in Kigali, Rwanda. Data were analyzed using a mixed deductive and inductive thematic analysis approach to describe perceived barriers to, facilitators of and acceptability of initiating and adhering to ART rapidly under Treat All. Results Of 37 participants, 27 were women and the median age was 31 years. Participants described feeling traumatized and overwhelmed by their HIV diagnosis, resulting in difficulty accepting their HIV status. Most were prescribed ART soon after diagnosis, yet fear of lifelong medication and severe side effects in the immediate period after initiating ART led to challenges adhering to therapy. Moreover, because many PLWH initiated ART while healthy, taking medications and attending appointments were visible signals of HIV status and highly stigmatizing. Nonetheless, many participants expressed enthusiasm for Treat All as a program that improved health as well as health equity. Conclusion For newly-diagnosed PLWH in Rwanda, initiating ART rapidly under Treat All presents logistical and emotional challenges despite the perceived benefits. Our findings suggest that optimizing early engagement in HIV care under Treat All requires early and ongoing intervention to reduce trauma and stigma, and promote both individual and community benefits of ART.
Keywords	Medicine ; R ; Science ; Q
Subject code	700
Language	English
Publishing date	2021-01-01T00:00:00Z
Publisher	Public Library of Science (PLoS)
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Recent infections among individuals with a new HIV diagnosis in Rwanda, 2018-2020.

Gallican N Rwibasira / Samuel S Malamba / Gentille Musengimana / Richard C M Nkunda / Jared Omolo / Eric Remera / Vedaste Masengesho / Valens Mbonitegeka / Tafadzwa Dzinamarira / Eugenie Kayirangwa / Placidie Mugwaneza

PLoS ONE, Vol 16, Iss 11, p e

2021 Volume 0259708

Abstract: Background Despite Rwanda's progress toward HIV epidemic control, 16.2% of HIV-positive individuals are unaware of their HIV positive status. Tailoring the public health strategy could help reach these individuals with new HIV infection and achieve ... ...

Abstract	Background Despite Rwanda's progress toward HIV epidemic control, 16.2% of HIV-positive individuals are unaware of their HIV positive status. Tailoring the public health strategy could help reach these individuals with new HIV infection and achieve epidemic control. Recency testing is primarily for surveillance, monitoring, and evaluation but it's not for diagnostic purposes. However, it's important to know what proportion of the newly diagnosed are recent infections so that HIV prevention can be tailored to the profile of people who are recently infected. We therefore used available national data to characterize individuals with recent HIV infection in Rwanda to inform the epidemic response. Methods We included all national-level data for recency testing reported from October 2018 to June 2020. Eligible participants were adults (aged ≥15 years) who had a new HIV diagnosis, who self-reported being antiretroviral therapy (ART) naïve, and who had consented to recency testing. Numbers and proportions of recent HIV infections were estimated, and precision around these estimates was calculated with 95% confidence intervals (CI). Logistic regression was used to assess factors associated with being recently (within 12 months) infected with HIV. Results Of 7,785 eligible individuals with a new HIV-positive diagnosis, 475 (6.1%) met the criteria for RITA recent infection. The proportion of RITA recent infections among individuals with newly identified HIV was high among those aged 15-24 years (9.6%) and in men aged ≥65 years (10.3%) compared to other age groups; and were higher among women (6.7%) than men (5.1%). Of all recent cases, 68.8% were women, and 72.2% were aged 15-34 years. The Northern province had the fewest individuals with newly diagnosed HIV but had the highest proportion of recent infections (10.0%) compared to other provinces. Recent infections decreased by 19.6% per unit change in time (measured in months). Patients aged ≥25 years were less likely to have recent infection than those aged 15-24 years ...
Keywords	Medicine ; R ; Science ; Q
Subject code	310
Language	English
Publishing date	2021-01-01T00:00:00Z
Publisher	Public Library of Science (PLoS)
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: The impact of "Option B" on HIV transmission from mother to child in Rwanda

Monique Abimpaye / Catherine M Kirk / Hari S Iyer / Neil Gupta / Eric Remera / Placidie Mugwaneza / Michael R Law

PLoS ONE, Vol 13, Iss 2, p e

An interrupted time series analysis.

2018 Volume 0192910

Abstract: Nearly a quarter of a million children have acquired HIV, prompting the implementation of new protocols-Option B and B+-for treating HIV+ pregnant women. While efficacy has been demonstrated in randomized trials, there is limited real-world evidence on ... ...

Abstract	Nearly a quarter of a million children have acquired HIV, prompting the implementation of new protocols-Option B and B+-for treating HIV+ pregnant women. While efficacy has been demonstrated in randomized trials, there is limited real-world evidence on the impact of these changes. Using longitudinal, routinely collected data we assessed the impact of the adoption of WHO Option B in Rwanda on mother to infant transmission.We used interrupted time series analysis to evaluate the impact of Option B on mother-to-child HIV transmission in Rwanda. Our primary outcome was the proportion of HIV tests in infants with positive results at six weeks of age. We included data for 20 months before and 22 months after the 2010 policy change.Of the 15,830 HIV tests conducted during our study period, 392 tested positive. We found a significant decrease in both the level (-2.08 positive tests per 100 tests conducted, 95% CI: -2.71 to -1.45, p < 0.001) and trend (-0.11 positive tests per 100 tests conducted per month, 95% CI: -0.16 to -0.07, p < 0.001) of test positivity. This represents an estimated 297 fewer children born without HIV in the post-policy period or a 46% reduction in HIV transmission from mother to child.The adoption of Option B in Rwanda contributed to an immediate decrease in the rate of HIV transmission from mother to child. This suggests other countries may benefit from adopting these WHO guidelines.
Keywords	Medicine ; R ; Science ; Q
Subject code	306
Language	English
Publishing date	2018-01-01T00:00:00Z
Publisher	Public Library of Science (PLoS)
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Child mortality associated with maternal HIV status

Agnes Binagwaho / Sabin Nsanzimana / Edward J Mills / Frédérique Chammartin / Marie Paul Nisingizwe / Placidie Mugwaneza / Heiner Bucher / Nathan Ford / Muhammed Semakula / Eric Remera / Jamie Ian Forrest / Gerald E Smith / Samuel S Malamba / Jeanine U Condo / David J Riedel

BMJ Global Health, Vol 6, Iss

a retrospective analysis in Rwanda, 2005-2015

2021 Volume 5

Abstract: Introduction Child mortality remains highest in regions of the world most affected by HIV/AIDS. The aim of this study was to assess child mortality rates in relation to maternal HIV status from 2005 to 2015, the period of rapid HIV treatment scale-up in ... ...

Abstract	Introduction Child mortality remains highest in regions of the world most affected by HIV/AIDS. The aim of this study was to assess child mortality rates in relation to maternal HIV status from 2005 to 2015, the period of rapid HIV treatment scale-up in Rwanda.Methods We used data from the 2005, 2010 and 2015 Rwanda Demographic Health Surveys to derive under-2 mortality rates by survey year and mother’s HIV status and to build a multivariable logistic regression model to establish the association of independent predictors of under-2 mortality stratified by mother’s HIV status.Results In total, 12 010 live births were reported by mothers in the study period. Our findings show a higher mortality among children born to mothers with HIV compared with HIV negative mothers in 2005 (216.9 vs 100.7 per 1000 live births) and a significant reduction in mortality for both groups in 2015 (72.0 and 42.4 per 1000 live births, respectively). In the pooled reduced multivariable model, the odds of child mortality was higher among children born to mothers with HIV, (adjusted OR, AOR 2.09; 95% CI 1.57 to 2.78). The odds of child mortality were reduced in 2010 (AOR 0.69; 95% CI 0.59 to 0.81) and 2015 (AOR 0.35; 95% CI 0.28 to 0.44) compared with 2005. Other independent predictors of under-2 mortality included living in smaller families of 1–2 members (AOR 5.25; 95% CI 3.59 to 7.68), being twin (AOR 4.93; 95% CI 3.51 to 6.92) and being offspring from mothers not using contraceptives at the time of the survey (AOR 1.6; 95% CI 1.38 to 1.99). Higher education of mothers (completed primary school: (AOR 0.74; 95% CI 0.64 to 0.87) and secondary or higher education: (AOR 0.53; 95% CI 0.38 to 0.74)) was also associated with reduced child mortality.Conclusions This study shows an important decline in under-2 child mortality among children born to both mothers with and without HIV in Rwanda over a 10-year span.
Keywords	Medicine (General) ; R5-920 ; Infectious and parasitic diseases ; RC109-216
Subject code	310 ; 360
Language	English
Publishing date	2021-05-01T00:00:00Z
Publisher	BMJ Publishing Group
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Phased implementation of spaced clinic visits for stable HIV-positive patients in Rwanda to support Treat All

Sabin Nsanzimana / Eric Remera / Muhayimpundu Ribakare / Tracy Burns / Sibongile Dludlu / Edward J Mills / Jeanine Condo / Heiner C Bucher / Nathan Ford

Journal of the International AIDS Society , Vol 20, Iss S4, Pp 21-

2017 Volume 27

Abstract: Introduction: In 2016, Rwanda implemented “Treat All,” requiring the national HIV programme to increase antiretroviral (ART) treatment coverage to all people living with HIV. Approximately half of the 164,262 patients on ART have been on treatment for ... ...

Abstract	Introduction: In 2016, Rwanda implemented “Treat All,” requiring the national HIV programme to increase antiretroviral (ART) treatment coverage to all people living with HIV. Approximately half of the 164,262 patients on ART have been on treatment for more than five years, and long-term retention of patients in care is an increasing concern. To address these challenges, the Ministry of Health has introduced a differentiated service delivery approach to reduce the frequency of clinical visits and medication dispensing for eligible patients. This article draws on key policy documents and the views of technical experts involved in policy development to describe the process of implementation of differentiated service delivery in Rwanda. Discussion: Implementation of differentiated service delivery followed a phased approach to ensure that all steps are clearly defined and agreed by all partners. Key steps included: definition of scope, including defining which patients were eligible for transition to the new model; definition of the key model components; preparation for patient enrolment; considerations for special patient groups; engagement of implementing partners; securing political and financial support; forecasting drug supply; revision, dissemination and implementation of ART guidelines; and monitoring and evaluation. Conclusions: Based on the outcomes of the evaluation of the new service delivery model, the Ministry of Health will review and strategically reduce costs to the national HIV program and to the patient by exploring and implementing adjustments to the service delivery model.
Keywords	antiretroviral therapy ; differentiated care ; Rwanda ; stable patients ; Treat All ; Medicine ; R ; Political science ; J ; Social Sciences ; H
Subject code	360
Language	English
Publishing date	2017-07-01T00:00:00Z
Publisher	International AIDS Society
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: The role of community health workers and local leaders in reducing attrition among participant in the AIDS indicator survey and HIV incidence in a national cohort study in Rwanda

Mwumvaneza Mutagoma / Dieudonné Sebuhoro / Jean Pierre Nyemazi / Edward J. Mills / Jamie I. Forrest / Eric Remera / Augustin Murindabigwi / Mouhamed Semakula / Sabin Nsanzimana

BMC Public Health, Vol 18, Iss 1, Pp 1-

2018 Volume 6

Abstract: Abstract Background Retention of participants in longitudinal prospective surveys can challenging for population health researchers. Community health workers (CHWs) may help reduce attrition. Methods We used data came from a longitudinal prospective ... ...

Abstract	Abstract Background Retention of participants in longitudinal prospective surveys can challenging for population health researchers. Community health workers (CHWs) may help reduce attrition. Methods We used data came from a longitudinal prospective household-based survey targeting women and men in Rwanda, collected between June 2013 and December 2014. The sample was drawn from a population that included all residents of all 30 districts, 416 sectors, and 14,837 villages in Rwanda. The outcome measure was time to loss-to-follow-up. Follow up visits occurred at three, six and nine, and 12 months. A Cox proportional hazards model was constructed to identify factors independently associated with time to loss-to-follow-up. Results Overall, 14,222 respondents consented to be interviewed at baseline. At the end of 12 months of follow up, 13,728 were revisited and consented to participate at 12 months of follow up. The overall attrition rate was 8.0%. A majority of those lost (54.3%) were less than 25 years of age, male (55.1%), not living in union (67.3%), had no education level or had primary education level (71.4%), or were in the highest wealth index (54.2%). Compared to illiterate, secondary education was negatively associated with attrition. Conclusion The Rwanda AIDS indicator and HIV incidence survey recorded a very high retention of participants after 12 months. CHWs and local leaders played a major role to reduce attrition rate and identifying factors associated with loss-to-follow-up can help CHWs strengthen the quality of longitudinal survey data.
Keywords	Community health workers ; Attrition ; Public aspects of medicine ; RA1-1270
Subject code	360
Language	English
Publishing date	2018-03-01T00:00:00Z
Publisher	BMC
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Use of trained scent dogs for detection of COVID-19 and evidence of cost-saving

Leon Mutesa / Gashegu Misbah / Eric Remera / Hans Ebbers / Esther Schalke / Patrick Tuyisenge / Reuben Sindayiheba / Clement Igiraneza / Jeanine Uwimana / Diane Mbabazi / Epimaque Kayonga / Michel Twagiramungu / Denyse Mugwaneza / Leandre Ishema / Yvan Butera / Clarisse Musanabaganwa / Edson Rwagasore / Friederike Twele / Sebastian Meller /

Albert Tuyishime / Robert Rutayisire / Marilyn Milumbu Murindahabi / Lindsay A. Wilson / Noella Bigirimana / Holger A. Volk / Vedaste Ndahindwa / Benoit Kayijuka / Edward J. Mills / Claude Mambo Muvunyi / Sabin Nsanzimana

Frontiers in Medicine, Vol

2022 Volume 9

Abstract: BackgroundOne of the lessons learned from the coronavirus disease 2019 (COVID-19) pandemic is the importance of early, flexible, and rapidly deployable disease detection methods. Currently, diagnosis of COVID-19 requires the collection of oro/ ... ...

Abstract	BackgroundOne of the lessons learned from the coronavirus disease 2019 (COVID-19) pandemic is the importance of early, flexible, and rapidly deployable disease detection methods. Currently, diagnosis of COVID-19 requires the collection of oro/nasopharyngal swabs, nasal turbinate, anterior nares and saliva but as the pandemic continues, disease detection methods that can identify infected individuals earlier and more quickly will be crucial for slowing the spread of the virus. Previous studies have indicated that dogs can be trained to identify volatile organic compounds (VOCs) produced during respiratory infections. We sought to determine whether this approach could be applied for detection of COVID-19 in Rwanda and measured its cost-saving.MethodsOver a period of 5 months, four dogs were trained to detect VOCs in sweat samples collected from human subjects confirmed positive or negative for COVID-19 by reverse transcription polymerase chain reaction (RT-PCR) testing. Dogs were trained using a detection dog training system (DDTS) and in vivo diagnosis. Samples were collected from 5,253 participants using a cotton pad swiped in the underarm to collect sweat samples. Statistical analysis was conducted using R statistical software.FindingsFrom August to September 2021 during the Delta wave, the sensitivity of the dogs’ COVID-19 detection ranged from 75.0 to 89.9% for the lowest- and highest-performing dogs, respectively. Specificity ranged from 96.1 to 98.4%, respectively. In the second phase coinciding with the Omicron wave (January–March 2022), the sensitivity decreased substantially from 36.6 to 41.5%, while specificity remained above 95% for all four dogs. The sensitivity and specificity by any positive sample detected by at least one dog was 83.9, 95% CI: 75.8–90.2 and 94.9%; 95% CI: 93.9–95.8, respectively. The use of scent detection dogs was also found to be cost-saving compared to antigen rapid diagnostic tests, based on a marginal cost of approximately $14,000 USD for testing of the 5,253 samples which ...
Keywords	COVID-19 ; SARS-CoV-2 ; volatile organic compounds (VOCs) ; scent dogs ; RT-PCR ; cost-saving ; Medicine (General) ; R5-920
Subject code	630
Language	English
Publishing date	2022-12-01T00:00:00Z
Publisher	Frontiers Media S.A.
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Life expectancy among HIV-positive patients in Rwanda

Sabin Nsanzimana, MD / Eric Remera, MSc / Steve Kanters, MSc / Keith Chan, MSc / Jamie I Forrest, MPH / Nathan Ford, PhD / Jeanine Condo, MD / Agnes Binagwaho, MD / Dr. Edward J Mills, PhD

The Lancet Global Health, Vol 3, Iss 3, Pp e169-e

a retrospective observational cohort study

2015 Volume 177

Abstract: Background: Rwanda has achieved substantial progress in scaling up of antiretroviral therapy. We aimed to assess the effect of increased access to antiretroviral therapy on life expectancy among HIV-positive patients in two distinct periods of lower and ... ...

Abstract	Background: Rwanda has achieved substantial progress in scaling up of antiretroviral therapy. We aimed to assess the effect of increased access to antiretroviral therapy on life expectancy among HIV-positive patients in two distinct periods of lower and higher antiretroviral therapy coverage (1997–2007 and 2008–11). Methods: In a retrospective observational cohort study, we collected clinical and demographic data for all HIV-positive patients enrolled in care at 110 health facilities across all five provinces of Rwanda. We included patients aged 15 years or older with a known enrolment date between 1997 and 2014. We constructed abridged life tables from age-specific mortality rates and life expectancy stratified by sex, CD4 cell count, and WHO disease stage at enrolment in care and initiation of antiretroviral therapy. Findings: We included 72 061 patients in this study, contributing 213 983 person-years of follow-up. The crude mortality rate was 33·4 deaths per 1000 person-years (95% CI 32·7–34·2). Life expectancy for the overall cohort was 25·6 additional years (95% CI 25·1–26·1) at 20 years of age and 23·3 additional years (95% CI 22·9–23·7) at 35 years of age. Life expectancy at 20 years of age in the period of 1997–2007 was 20·4 additional years (95% CI 19·5–21·3); for the period of 2008–11, life expectancy had increased to 25·6 additional years (95% CI 24·8–26·4). Individuals enrolling in care with CD4 cell counts of 500 cells per μL or more, and with WHO disease stage I, had the highest life expectancies. Interpretation: This study adds to the growing body of evidence showing the benefit to HIV-positive patients of early enrolment in care and initiation of antiretroviral therapy. Funding: Bill & Melinda Gates Foundation.
Keywords	Public aspects of medicine ; RA1-1270
Subject code	616
Language	English
Publishing date	2015-03-01T00:00:00Z
Publisher	Elsevier
Document type	Article ; Online
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