The effect of case management and vector-control interventions on space-time patterns of malaria incidence in Uganda.

BACKGROUND: Electronic reporting of routine health facility data in Uganda began with the adoption of the District Health Information Software System version 2 (DHIS2) in 2011. This has improved health facility reporting and overall data quality. In this study, the effects of case management with artemisinin-based combination therapy (ACT) and vector control interventions on space-time patterns of disease incidence were determined using DHIS2 data reported during 2013-2016. METHODS: Bayesian spatio-temporal negative binomial models were fitted on district-aggregated monthly malaria cases, reported by two age groups, defined by a cut-off age of 5 years. The effects of interventions were adjusted for socio-economic and climatic factors. Spatial and temporal correlations were taken into account by assuming a conditional autoregressive and a first-order autoregressive AR(1) process on district and monthly specific random effects, respectively. Fourier trigonometric functions were incorporated in the models to take into account seasonal fluctuations in malaria transmission. RESULTS: The temporal variation in incidence was similar in both age groups and depicted a steady decline up to February 2014, followed by an increase from March 2015 onwards. The trends were characterized by a strong bi-annual seasonal pattern with two peaks during May-July and September-December. Average monthly incidence in children < 5 years declined from 74.7 cases (95% CI 72.4-77.1) in 2013 to 49.4 (95% CI 42.9-55.8) per 1000 in 2015 and followed by an increase in 2016 of up to 51.3 (95% CI 42.9-55.8). In individuals ≥ 5 years, a decline in incidence from 2013 to 2015 was followed by an increase in 2016. A 100% increase in insecticide-treated nets (ITN) coverage was associated with a decline in incidence by 44% (95% BCI 28-59%). Similarly, a 100% increase in ACT coverage reduces incidence by 28% (95% BCI 11-45%) and 25% (95% BCI 20-28%) in children < 5 years and individuals ≥ 5 years, respectively. The ITN effect was not statistically important in older individuals. The space-time patterns of malaria incidence in children < 5 are similar to those of parasitaemia risk predicted from the malaria indicator survey of 2014-15. CONCLUSION: The decline in malaria incidence highlights the effectiveness of vector-control interventions and case management with ACT in Uganda. This calls for optimizing and sustaining interventions to achieve universal coverage and curb reverses in malaria decline.

Strengthening district-based health reporting through the district health management information software system: the Ugandan experience.

BACKGROUND: Untimely, incomplete and inaccurate data are common challenges in planning, monitoring and evaluation of health sector performance, and health service delivery in many sub-Saharan African settings. We document Uganda's experience in strengthening routine health data reporting through the roll-out of the District Health Management Information Software System version 2 (DHIS2). METHODS: DHIS2 was adopted at the national level in January 2011. The system was initially piloted in 4 districts, before it was rolled out to all the 112 districts by July 2012. As part of the roll-out process, 35 training workshops targeting 972 users were conducted throughout the country. Those trained included Records Assistants (168, 17.3%), District Health Officers (112, 11.5%), Health Management Information System Focal Persons (HMIS-FPs) (112, 11.5%), District Biostatisticians (107, 11%) and other health workers (473, 48.7%). To assess improvements in health reporting, we compared data on completeness and timeliness of outpatient and inpatient reporting for the period before (2011/12) and after (2012/13) the introduction of DHIS2. We reviewed data on the reporting of selected health service coverage indicators as a proxy for improved health reporting, and documented implementation challenges and lessons learned during the DHIS2 roll-out process. RESULTS: Completeness of outpatient reporting increased from 36.3% in 2011/12 to 85.3% in 2012/13 while timeliness of outpatient reporting increased from 22.4% to 77.6%. Similarly, completeness of inpatient reporting increased from 20.6% to 57.9% while timeliness of inpatient reporting increased from 22.5% to 75.6%. There was increased reporting on selected health coverage indicators (e.g. the reporting of one-year old children who were immunized with three doses of pentavelent vaccine increased from 57% in 2011/12 to 87% in 2012/13). Implementation challenges included limited access to computers and internet (34%), inadequate technical support (23%) and limited worker force (18%). CONCLUSION: Implementation of DHIS2 resulted in improved timeliness and completeness in reporting of routine outpatient, inpatient and health service usage data from the district to the national level. Continued onsite support supervision and mentorship and additional system/infrastructure enhancements, including internet connectivity, are needed to further enhance the performance of DHIS2.

Interactions between climatic changes and intervention effects on malaria spatio-temporal dynamics in Uganda.

BACKGROUND: Although malaria burden in Uganda has declined since 2009 following the scale-up of interventions, the disease is still the leading cause of hospitalization and death. Transmission remains high and is driven by suitable weather conditions. There is a real concern that intervention gains may be reversed by climatic changes in the country. In this study, we investigate the effects of climate on the spatio-temporal trends of malaria incidence in Uganda during 2013-2017. METHODS: Bayesian spatio-temporal negative binomial models were fitted on district-aggregated monthly malaria cases, reported by two age groups, defined by a cut-off age of 5 years. Weather data was obtained from remote sensing sources including rainfall, day land surface temperature (LSTD) and night land surface temperature (LSTN), Normalized Difference Vegetation Index (NDVI), altitude, land cover, and distance to water bodies. Spatial and temporal correlations were taken into account by assuming a conditional autoregressive and a first-order autoregressive process on district and monthly specific random effects, respectively. Fourier trigonometric functions modeled seasonal fluctuations in malaria transmission. The effects of climatic changes on the malaria incidence changes between 2013 and 2017 were estimated by modeling the difference in time varying climatic conditions at the two time points and adjusting for the effects of intervention coverage, socio-economic status and health seeking behavior. RESULTS: Malaria incidence declined steadily from 2013 to 2015 and then increased in 2016. The decrease was by over 38% and 20% in children <5 years and individuals ≥5 years, respectively. Temporal trends depict a strong bi-annual seasonal pattern with two peaks during April-June and October-December. The annual average of rainfall, LSTD and LSTN increased by 3.7 mm, 2.2 °C and 1.0 °C, respectively, between 2013 and 2017, whereas NDVI decreased by 6.8%. On the one hand, the increase in LSTD and decrease in NDVI were associated with a reduction in the incidence decline. On the other hand, malaria interventions and treatment seeking behavior had reverse effects, that were stronger compared to the effects of climatic changes. Important interactions between interventions with NDVI and LSTD suggest a varying impact of interventions on malaria burden in different climatic conditions. CONCLUSION: Climatic changes in Uganda during the last five years contributed to a favorable environment for malaria transmission, and had a detrimental effect on malaria reduction gains achieved through interventions scale-up efforts. The NMCP should create synergies with the National Meteorological Authority with an ultimate goal of developing a Malaria Early Warning System to mitigate adverse climatic change effects on malaria risk in the country.

Measuring health facility readiness and its effects on severe malaria outcomes in Uganda.

There is paucity of evidence for the role of health service delivery to the malaria decline in Uganda We developed a methodology to quantify health facility readiness and assessed its role on severe malaria outcomes among lower-level facilities (HCIIIs and HCIIs) in the country. Malaria data was extracted from the Health Management Information System (HMIS). General service and malaria-specific readiness indicators were obtained from the 2013 Uganda service delivery indicator survey. Multiple correspondence analysis (MCA) was used to construct a composite facility readiness score based on multiple factorial axes. Geostatistical models assessed the effect of facility readiness on malaria deaths and severe cases. Malaria readiness was achieved in one-quarter of the facilities. The composite readiness score explained 48% and 46% of the variation in the original indicators compared to 23% and 27%, explained by the first axis alone for HCIIIs and HCIIs, respectively. Mortality rate was 64% (IRR = 0.36, 95% BCI: 0.14-0.61) and 68% (IRR = 0.32, 95% BCI: 0.12-0.54) lower in the medium and high compared to low readiness groups, respectively. A composite readiness index is more informative and consistent than the one based on the first MCA factorial axis. In Uganda, higher facility readiness is associated with a reduced risk of severe malaria outcomes.

Conducting a Large Public Health Data Collection Project in Uganda: Methods, Tools, and Lessons Learned.

We report on the implementation experience of carrying out data collection and other activities for a public health evaluation study on whether U.S. President's Emergency Plan for AIDS Relief (PEPFAR) investment improved utilization of health services and health system strengthening in Uganda. The retrospective study period focused on the PEPFAR scale-up, from mid-2005 through mid-2011, a period of expansion of PEPFAR programing and health services. We visited 315 health care facilities in Uganda in 2011 and 2012 to collect routine health management information system data forms, as well as to conduct interviews with health system leaders. An earlier phase of this research project collected data from all 112 health district headquarters, reported elsewhere. This article describes the lessons learned from collecting data from health care facilities, project management, useful technologies, and mistakes. We used several new technologies to facilitate data collection, including portable document scanners, smartphones, and web-based data collection, along with older but reliable technologies such as car batteries for power, folding tables to create space, and letters of introduction from appropriate authorities to create entrée. Research in limited-resource settings requires an approach that values the skills and talents of local people, institutions and government agencies, and a tolerance for the unexpected. The development of personal relationships was key to the success of the project. We observed that capacity building activities were repaid many fold, especially in data management and technology.

District Health Officer Perceptions of PEPFAR's Influence on the Health System in Uganda, 2005-2011.

BACKGROUND: Vertically oriented global health initiatives (GHIs) addressing the HIV/AIDS epidemic, including the President's Emergency Plan for AIDS Relief (PEPFAR), have successfully contributed to reducing HIV/AIDS related morbidity and mortality. However, there is still debate about whether these disease-specific programs have improved or harmed health systems overall, especially with respect to non-HIV health needs. METHODS: As part of a larger evaluation of PEPFAR's effects on the health system between 2005-2011, we collected qualitative and quantitative data through semi-structured interviews with District Health Officers (DHOs) from all 112 districts in Uganda. We asked DHOs to share their perceptions about the ways in which HIV programs (largely PEPFAR in the Ugandan context) had helped and harmed the health system. We then identified key themes among their responses using qualitative content analysis. RESULTS: Ugandan DHOs said PEPFAR had generally helped the health system by improving training, integrating HIV and non-HIV care, and directly providing resources. To a lesser extent, DHOs said PEPFAR caused the health system to focus too narrowly on HIV/AIDS, increased workload for already overburdened staff, and encouraged doctors to leave public sector jobs for higher-paid positions with HIV/AIDS programs. CONCLUSION: Health system leaders in Uganda at the district level were appreciative of resources aimed at HIV they could often apply for broader purposes. As HIV infection becomes a chronic disease requiring strong health systems to manage sustained patient care over time, Uganda's weak health systems will require broad infrastructure improvements inconsistent with narrow vertical health programming.

The burden of tetanus in Uganda.

BACKGROUND: The successful scale-up of safe male circumcision (SMC) in Uganda has been hinged on client's safety and quality of services. However, after the recent three tetanus deaths after circumcision a review of all tetanus cases in one of the hospitals where the cases occurred was initiated. This was to ascertain the potential for an association between tetanus infection and circumcision. Routinely collected national data were also reviewed to determine the burden of tetanus in Uganda and contextualize these incidents. METHODS: A review of medical charts of tetanus cases identified from the inpatients registry at Masafu hospital, Busia district for the period 2009/2010-2013/2014. Data were abstracted from the inpatients registries, charts and HMIS annual reports, and a key informant interview conducted with the in-charge of the ward that treats tetanus patients. All quantitative data were captured in an electronic database. Routine facility data from the National District health Information Software-2 (DHIS-2) for all the 112 districts were also used. Descriptive analysis and Poisson regression models were used for statistical analysis using STATA version 13.0. RESULTS: Data from the routine DHIS-2 showed a high and increasing burden of tetanus from the emergency/out-patient department records over the 4 year period, highest among females aged 5+ years in all the regions. At the Masafa hospital, the chart review revealed a total of 25 tetanus cases and all were males. Nearly a third (32 %) was aged 7-15 years, with no evidence of circumcision apart from only one case. The rate of tetanus infection among male inpatients over the review period was 2-6 per 1000. The case fatality rate was nearly a half (47.4 %) with deaths occurring within 2 days after admission, and rates of patients' self-discharge against medical advice were high, 36.8 %. The most common tetanus entry wounds were due to road traffic accidents, followed by diabetic foot. Anti-tetanus serum was only not readily available. CONCLUSION: The burden of tetanus is increasing, especially among females aged 5+ years. Tetanus entry wounds among the inpatients in Masafa hospital were mostly due to road traffic accidents, and young males. The tetanus case fatality was very high (47.4 %) and so was patient requested discharge. There is a need to do more to protect the population against tetanus infection, especially among females, and males who need either initial or booster tetanus immunization as SMC is scaled up.

Did PEPFAR investments result in health system strengthening? A retrospective longitudinal study measuring non-HIV health service utilization at the district level.

OBJECTIVES : PEPFAR's initial rapid scale-up approach was largely a vertical effort focused fairly exclusively on AIDS. The purpose of our research was to identify spill-over health system effects, if any, of investments intended to stem the HIV epidemic over a 6-year period with evidence from Uganda. The test of whether there were health system expansions (aside from direct HIV programming) was evidence of increases in utilization of non-HIV services-such as outpatient visits, in-facility births or immunizations-that could be associated with varying levels of PEPFAR investments at the district level. METHODS : Uganda's Health Management Information System article-based records were available from mid-2005 onwards. We visited all 112 District Health offices to collect routine monthly reports (which contain data aggregated from monthly facility reports) and annual reports (which contain data aggregated from annual facility reports). Counts of individuals on anti-retroviral therapy (ART) at year-end served as our primary predictor variable. We grouped district-months into tertiles of high, medium or low PEPFAR investment based on their total reported number of patients on ART at the end of the year. We generated incidence-rate ratios, interpreted as the relative rate of the outcome measure in relation to the lowest investment PEPFAR tertile, holding constant control variables in the model. RESULTS : We found PEPFAR investment overall was associated with small declines in service volumes in several key areas of non-HIV care (outpatient care for young children, TB tests and in-facility deliveries), after adjusting for sanitation, elementary education and HIV prevalence. For example, districts with medium and high ART investment had 11% fewer outpatient visits for children aged 4 and younger compared with low investment districts, incidence rate ratio (IRR) of 0.89 for high investment compared with low (95% CI, 0.85-0.94) and IRR of 0.93 for medium compared with low (0.90-0.96). Similarly, 22% fewer TB sputum tests were performed in high investment districts compared with low investment, [IRR 0.78 (0.72-0.85)] and 13% fewer in medium compared with low, [IRR 0.88 (0.83-0.94)]. Districts with medium and high ART investment had 5% fewer in-facility deliveries compared with low investment districts [IRR 0.95 for high compared with low, (91-1.00) and 0.96 for medium compared with low (0.93-0.99)]. Although not statistically significant, the rate of maternal deaths in high investment district-months was 13% lower than observed in low investment districts. CONCLUSIONS : This study sought to understand whether PEPFAR, as a vertical programme, may have had a spill-over effect on the health system generally, as measured by utilization. Our conclusion is that it did not, at least not in Uganda.

Geographical information system and access to HIV testing, treatment and prevention of mother-to-child transmission in conflict affected Northern Uganda.

OBJECTIVES: Using Geographical Information System (GIS) as a tool to determine access to and gaps in providing HIV counselling and testing (VCT), treatment (ART) and mother-to-child transmission (PMTCT) services in conflict affected northern Uganda. METHODS: Cross-sectional data on availability and utilization, and geo-coordinates of health facilities providing VCT, PMTCT, and ART were collected in order to determine access. ArcView software produced maps showing locations of facilities and Internally Displaced Population(IDP) camps. FINDINGS: There were 167 health facilities located inside and outside 132 IDP camps with VCT, PMTCT and ART services provided in 32 (19.2%), 15 (9%) and 10 (6%) facilities respectively. There was uneven availability and utilization of services and resources among districts, camps and health facilities. Inadequate staff and stock-out of essential commodities were found in lower health facility levels. Provision of VCT was 100% of the HSSP II target at health centres IV and hospitals but 28% at HC III. For PMTCT and ART, only 42.9% and 20% of the respective targets were reached at the health centres IV. CONCLUSION: Access to VCT, PMTCT and ART services was geographically limited due to inadequacy and heterogeneous dispersion of these services among districts and camps. GIS mapping can be effective in identifying service delivery gaps and presenting complex data into simplistic results hence can be recommended in need assessments in conflict settings.