Uganda Public Health Fellowship Program's Contributions to the National HIV and TB Programs, 2015-2020.

Despite remarkable progress in controlling HIV and TB, Uganda is one of the 30 high-burden TB/HIV countries. Approximately 53,000 Ugandans had a new HIV diagnosis in 2019, and approximately 88,000 Ugandans had a TB diagnosis in 2020. Fellows in the Uganda Public Health Fellowship Program (UPHFP) work directly with the Ministry of Health AIDS and TB Control Programs, the U.S. Centers for Disease Control and Prevention, UPHFP supervisors, and implementing partners to investigate and evaluate HIV-related and TB-related issues. These activities have contributed to the Uganda HIV and TB programs. UPHFP fellows complete projects in 7 competency domains, including outbreak investigations, surveillance evaluations, and data quality improvement. Priority HIV/AIDS/TB information gaps/topics are identified in consultation with key stakeholders, and fellows complete projects to guide program improvements and policy decisions. During 2015-2020, UPHFP fellows implemented 127 HIV and TB projects covering key program areas in AIDS and TB control programs, including care and treatment (16 projects), TB/HIV (18), prevention of mother-to-child HIV transmission (24), key and priority populations (9), pre-exposure and post-exposure prophylaxis (7), adolescent girls and young women (6), service delivery (13), and diagnosis of TB including drug-resistant TB and TB in high-risk groups (32). These projects have helped improve retention, quality of care, and treatment outcomes for people living with HIV, HIV and TB coinfected patients, and TB patients. They have also contributed to the decrease in pediatric TB and infant HIV positivity rates and improved service delivery for key populations. UPHFP results were disseminated to relevant stakeholders such as government departments, implementing partners, districts, and the general community and guided decision making. UPHFP has significantly improved HIV and TB control in Uganda. Other countries with similar programs could benefit from this approach and utilize program fellows to support HIV and TB control.

Large outbreak of Jimsonweed (Datura stramonium) poisoning due to consumption of contaminated humanitarian relief food: Uganda, March-April 2019.

BACKGROUND: Jimsonweed (Datura stramonium) contains toxic alkaloids that cause gastrointestinal and central nervous system symptoms when ingested. This can be lethal at high doses. The plant may grow together with leguminous crops, mixing with them during harvesting. On 13 March 2019, more than 200 case-patients were admitted to multiple health centres for acute gastrointestinal and neurologic symptoms. We investigated to determine the cause and magnitude of the outbreak and recommended evidence-based control and prevention measures. METHODS: We defined a suspected case as sudden onset of confusion, dizziness, convulsions, hallucinations, diarrhoea, or vomiting with no other medically plausible explanations in a resident of Napak or Amudat District from 1 March-30 April 2019. We reviewed medical records and canvassed all villages of the eight affected subcounties to identify cases. In a retrospective cohort study conducted in 17 villages that reported the earliest cases, we interviewed 211 residents about dietary history during 11-15 March. We used modified Poisson regression to assess suspected food exposures. Food samples underwent chemical (heavy metals, chemical contaminants, and toxins), proteomic, DNA, and microbiological testing in one national and three international laboratories. RESULTS: We identified 293 suspected cases; five (1.7%) died. Symptoms included confusion (62%), dizziness (38%), diarrhoea (22%), nausea/vomiting (18%), convulsions (12%), and hallucinations (8%). The outbreak started on 12 March, 2-12 h after Batch X of fortified corn-soy blend (CSB +) was distributed. In the retrospective cohort study, 66% of 134 persons who ate CSB + , compared with 2.2% of 75 who did not developed illness (RRadj = 22, 95% CI = 6.0-81). Samples of Batch X distributed 11-15 March contained 14 tropane alkaloids, including atropine (25-50 ppm) and scopolamine (1-10 ppm). Proteins of Solanaceae seeds and Jimsonweed DNA were identified. No other significant laboratory findings were observed. CONCLUSION: This was the largest documented outbreak caused by food contamination with tropane alkaloids. Implicated food was immediately withdrawn. Routine food safety and quality checks could prevent future outbreaks.

Community prevalence of Helicobacter pylori and dyspepsia and efficacy of triple therapy in a rural district of eastern Uganda.

Background: Helicobacter pylori (H. pylori) infection and chronic dyspepsia represent significant medical burdens in the developing world. An accurate assessment of the prevalence of chronic dyspepsia, as well as of the effectiveness of population-based screening and eradication of H. pylori are warranted. Objectives: We determined the prevalence of H. pylori and chronic dyspepsia within the general adult population in a region of eastern Uganda. Independent predictors of H. pylori infection were assessed. Finally, we evaluated the efficacy of standard triple therapy on H. pylori eradication. Methods: Of 400 randomly selected adult residents in eastern Uganda, 376 were administered a validated, chronic dyspepsia questionnaire and provided a stool sample for H. pylori testing. H. pylori-positive participants were given standard triple therapy and monitored for medication adherence. The efficacy of triple therapy on H. pylori eradication was determined by fecal antigen testing after treatment. Log-linear and logistic regression analyses identified predictors of H. pylori positivity and eradication failure. Results: H. pylori prevalence within the study population was 48%. The prevalence of chronic dyspepsia was 87%. The presence or severity of dyspepsia did not predict H. pylori infection. However, a higher level of education was an independent predictor of H. pylori infection. Standard triple therapy resulted in ∼90% eradication. Missing at least four doses of any of the triple therapy medications over the 14-day course predicted eradication failure. Conclusions: In our study population, chronic dyspepsia did not predict H. pylori infection, though clinical suspicion for this prevalent pathogen should nonetheless remain high. Population-based screening and adherence to triple therapy are effective at eradicating H. pylori within this region.

Survey on the prevalence of dyspepsia and practices of dyspepsia management in rural Eastern Uganda.

AIM: To investigate the current prevalence and management of dyspepsia in rural Eastern Uganda. METHODS: Residents older than 18 years of age across 95 study sites in Namutumba District, Eastern Uganda were surveyed. Each respondent was administered a questionnaire about dyspepsia and pertinent health-seeking behaviors. Health workers at 12 different clinics were also assessed on their competence in managing dyspepsia. Proportion-based analysis was used to determine self-reported outcome variables reported in this study, including: prevalence of dyspepsia; breakdown of symptoms; initial diagnosis location; management strategies; and appropriate medication usage. RESULTS: 397 residents (average age of 41.2 years) participated in this study (54.4% males, 45.6% females). 57.9% self-reported currently having dyspepsia, of average duration 4.5 years. Of this subset, 87% reported experiencing epigastric pain, and 42.2% believed that ulcers were "wounds in the stomach." Only 3% of respondents had heard of Helicobacter pylori (Hp). Respondents varied in their management of dyspepsia, with frequent eating (39.1%), doing nothing (23.9%), and taking Western medicine (20%) being the most common strategies. The diagnosis of "peptic ulcer disease" was made by a health worker in 64.3% of cases, and 27% of cases were self-diagnosed. Notably, 70.3% of diagnoses at formal health centers were based on clinical symptoms alone and only 22.7% of respondents received treatment according to Ugandan Ministry of Health guidelines. Among the 12 health care workers surveyed, 10 cited epigastric pain as a common symptom of "ulcer," although only two reported having heard of Hp. Only two out of 12 clinics had the capability to prescribe the triple therapy as treatment for presumed Hp. CONCLUSION: There is a high incidence of dyspepsia in Eastern Uganda, and current management strategies are poor and inconsistent, and may contribute to antibiotic resistance. Further studies are needed to investigate the causes of dyspepsia to guide appropriate management.