Spatial distribution and temporal trends of tuberculosis case notifications, Uganda: a ten-year retrospective analysis (2013-2022).

BACKGROUND: Uganda has a high incidence and prevalence of tuberculosis (TB). Analysis of spatial and temporal distribution of TB is an important tool for supporting spatial decision-making, planning, and policy formulations; however, this information is not readily available in Uganda. We determined the spatial distribution and temporal trends of tuberculosis notifications in Uganda, 2013-2022. METHODS: We conducted a retrospective analysis of routinely-generated program data reported through the National TB and Leprosy Programme (NTLP) surveillance system. We abstracted data on all TB cases diagnosed from 2013 to 2022 by district and region. We drew choropleth maps for Uganda showing the TB case notification rates (CNR) per 100,000 and calculated the CNR using the cases per district as the numerator and individual district populations as the denominators. Population estimates were obtained from the 2014 National Population and Housing Census, and a national growth rate of 3% was used to estimate the annual population increase. RESULTS: Over the entire study period, 568,957 cases of TB were reported in Uganda. There was a 6% annual increase in TB CNR reported from 2013 (134/100,000) to 2022 (213/100,000) (p-value for trend p < 0.00001). Cases were reported from all 12 Ministry of Health regions during the entire period. The distribution of CNR was heterogeneous throughout the country and over time. Moroto, Napak and Kampala districts had consistently high CNR throughout the ten years. Kalangala district had lower CNR from 2013 to 2018 but high CNR from 2019 to 2022. Moroto region, in the northeast, had consistently high CNR while Mbale and Soroti regions in Eastern Uganda had the lowest CNR throughout the ten years. CONCLUSION: There was an overall increasing trend in TB CNR from 2013 to 2022. We recommend that the National TB program institutes intensified measures aided by more funding to mitigate and reverse the negative impacts of the COVID-19 pandemic on TB.

Wanda Blenska and the program of leprosy treatment in Uganda.

Wanda Blenska (1911-2014), a Polish physician, established a leprosy treatment center in the village of Buluba in Uganda in 1951, which lasted until 1993. Through her efforts, the village for lepers in Buluba, established in 1934, which had previously been a place of isolation conducted by the Little Sisters of St. Francis in Uganda, became such an important leprosy treatment and research center that eventually the facility was able to cooperate with similar centers in India and South Africa. It then became affiliated with research institutes in London and Amsterdam; the Borstel Research Institute near Hamburg, Germany; and the World Health Organization. Blenska developed a working relationship with the government of Uganda and contributed to changes in the government provision of health care for lepers by creating a network of leprosy treatment stations throughout the country. Through her efforts, public health education and leprosy prophylaxis became available for thousands of people, effectively changing the national attitude toward this disease. In 1994, one of the buildings of the St. Francis hospital complex in Buluba was named in her honor (The Wanda Blenska Training Centre).

Adherence to the MDR-TB intensive phase treatment protocol amongst individuals followed up at central and peripheral health care facilities in Uganda - a descriptive study.

BACKGROUND: Following initiation of MDR-TB treatment, patients have a choice to receive follow up DOT supervision at either the central initiating facility or at a peripheral facility. OBJECTIVES: We describe the adherence patterns of MDR-TB patients undergoing DOT supervision at the two health facility categories during intensive phase of treatment. METHODS: We used a retrospective cohort of patients initiated on MDR TB treatment at Mulago National Referral Hospital between 2014 and 2016. We extracted data from the National Tuberculosis and Leprosy Program records and analysed these using STATA V14. RESULT: Majority (84.01%) of the patients received their DOT supervision from the peripheral facilities. Males made up 62.1% of patients, and 91.2% had had their household contacts screened for MDR-TB. 26.5% of the patients on peripheral DOT supervision had good adherence to treatment protocol compared to 0% among patients on central initiating health facility DOT supervision. Among the patients with good adherence, 24.1% had contacts screened for MDR-TB as compared to 3.6% with poor adherence. CONCLUSION: More patients preferred MDR-TB DOT supervision at peripheral facilities, which had better adherence to the treatment protocol compared to the central initiating facility. Younger people and those with household contacts screened had better adherence to the treatment protocol, highlighting areas for targeted interventional programs for MDR-TB in resource limited settingsMore patients preferred MDR-TB DOT supervision at peripheral facilities, which had better adherence to the treatment protocol compared to the central initiating facility. Younger people and those with household contacts screened had better adherence to the treatment protocol, highlighting areas for targeted interventional programs for MDR-TB in resource limited settings.

Spatial distribution and temporal trends of leprosy in Uganda, 2012-2016: a retrospective analysis of public health surveillance data.

BACKGROUND: Leprosy is a neglected disease that poses a significant challenge to public health in Uganda. The disease is endemic in Uganda, with 40% of the districts in the country affected in 2016, when 42 out of 112 districts notified the National Tuberculosis and Leprosy Program (NTLP) of at least one case of leprosy. We determined the spatial and temporal trends of leprosy in Uganda during 2012-2016 to inform control measures. METHODS: We analyzed quarterly leprosy case-finding data, reported from districts to the Uganda National Leprosy Surveillance system (managed by NTLP) during 2012-2016. We calculated new case detection by reporting district and administrative regions of treatment during this period. New case detection was defined as new leprosy cases diagnosed by the Uganda health services divided by regional population; population estimates were based on 2014 census data. We used logistic regression analysis in Epi-Info version 7.2.0 to determine temporal trends. Population estimates were based on 2014 census data. We used QGIS software to draw choropleth maps showing leprosy case detection rates, assumed to approximate the new case detection rates, per 100,000 population. RESULTS: During 2012-2016, there was 7% annual decrease in reported leprosy cases in Uganda each year (p = 0.0001), largely driven by declines in the eastern (14%/year, p = 0.0008) and central (11%/year, p = 0.03) regions. Declines in reported cases in the western (9%/year, p = 0.12) and northern (4%/year, p = 0.16) regions were not significant. The combined new case detection rates from 2012 to 2016 for the ten most-affected districts showed that 70% were from the northern region, 20% from the eastern, 10% from the western and 10% from the central regions. CONCLUSION: There was a decreasing trend in leprosy new case detection in Uganda during 2012-2016; however, the declining trends were not consistent in all regions. The Northern region consistently identified more leprosy cases compared to the other regions. We recommend evaluation of the leprosy surveillance system to ascertain the leprosy situation.

Explaining the successes and failures of tuberculosis treatment programs; a tale of two regions in rural eastern Uganda.

BACKGROUND: Optimally performing tuberculosis (TB) programs are characterized by treatment success rate (TSR) of at least 90%. In rural eastern Uganda, and elsewhere in sub Saharan Africa, TSR varies considerably across district TB programs and the reasons for the differences are unclear. This study explored factors associated with the low and high TSR across four districts in rural eastern Uganda. METHODS: We interviewed District TB and Leprosy Supervisors, Laboratory focal persons, and health facility TB focal persons from four districts in eastern Uganda as key informants. Interviews were audio recorded, transcribed verbatim, and imported into ATLAs.ti where thematic content analysis was performed and results were summarized into themes. RESULTS: The emerging themes were categorized as either facilitators of or barriers to treatment success. The emerging facilitators prevailing in the districts with high rates of treatment success were using data to make decisions and design interventions, continuous quality improvement, capacity building, and prioritization of better management of people with TB. The barriers common in districts with low rates of treatment success included lack of motivated and dedicated TB focal persons, scarce or no funding for implementing TB activities, and a poor implementation of community-based directly observed therapy short course. CONCLUSION: This study shows that several factors are associated with the differing rates of treatment success in rural eastern Uganda. These factors should be the focus for TB control programs in Uganda and similar settings in order to improve rates of treatment success.

Tuberculosis retreatment 'others' in comparison with classical retreatment cases; a retrospective cohort review.

BACKGROUND: Many of the countries in sub-Saharan Africa are still largely dependent on microscopy as the mainstay for diagnosis of tuberculosis (TB) including patients with previous history of TB treatment. The available guidance in management of TB retreatment cases is focused on bacteriologically confirmed TB retreatment cases leaving out those classified as retreatment 'others'. Retreatment 'others' refer to all TB cases who were previously treated but with unknown outcome of that previous treatment or who have returned to treatment with bacteriologically negative pulmonary or extra-pulmonary TB. This study was conducted in 11 regional referral hospitals (RRHs) serving high burden TB districts in Uganda to determine the profile and treatment success of TB retreatment 'others' in comparison with the classical retreatment cases. METHODS: A retrospective cohort review of routinely collected National TB and Leprosy Program (NTLP) facility data from 1 January to 31 December 2010. This study uses the term classical retreatment cases to refer to a combined group of bacteriologically confirmed relapse, return after failure and return after loss to follow-up cases as a distinct group from retreatment 'others'. Distribution of categorical characteristics were compared using Chi-squared test for difference between proportions. The log likelihood ratio test was used to assess the independent contribution of type of retreatment, human immunodeficiency virus (HIV) status, age group and sex to the models. RESULTS: Of the 6244 TB cases registered at the study sites, 733 (11.7%) were retreatment cases. Retreatment 'others' constituted 45.5% of retreatment cases. Co-infection with HIV was higher among retreatment 'others' (70.9%) than classical retreatment cases (53.5%). Treatment was successful in 410 (56.2%) retreatment cases. Retreatment 'others' were associated with reduced odds of success (AOR = 0.44, 95% CI 0.22,0.88) compared to classical cases. Lost to follow up was the commonest adverse outcome (38% of adverse outcomes) in all retreatment cases. Type of retreatment case, HIV status, and age were independently associated with treatment success. CONCLUSION: TB retreatment 'others' constitute a significant proportion of retreatment cases, with higher HIV prevalence and worse treatment success. There is need to review the diagnosis and management of retreatment 'others'.

Incidence and predictors of mortality and the effect of tuberculosis immune reconstitution inflammatory syndrome in a cohort of TB/HIV patients commencing antiretroviral therapy.

BACKGROUND: Tuberculosis-HIV (TB-HIV) coinfection remains an important cause of mortality in antiretroviral therapy (ART) programs. In a cohort of TB-HIV-coinfected patients starting ART, we examined the incidence and predictors of early mortality. METHODS: Consecutive TB-HIV-coinfected patients eligible for ART were enrolled in a cohort study at the Mulago National Tuberculosis and Leprosy Program clinic in Kampala, Uganda. Predictors of mortality were assessed using Cox proportional hazards analysis. RESULTS: Three hundred and two patients [median CD4 count 53 cells/µL (interquartile range, 20-134)] were enrolled. Fifty-three patients died, 36 (68%) of these died within the first 6 months of TB diagnosis. Male sex [hazard (HR): 2.19; 95% confidence interval (CI): 1.19 to 4.03; P = 0.011], anergy to tuberculin skin test [HR: 2.59 (1.10 to 6.12); P = 0.030], a positive serum cryptococcal antigen result at enrollment (HR: 4.27; 95% CI: 1.50 to 12.13; P = 0.006) and no ART use (HR: 4.63; 95% CI: 2. 37 to 9.03; P < 0.001) were independent predictors of mortality by multivariate analysis. Six (10%) patients with TB immune reconstitution inflammatory syndrome died, and in most, an alternative contributing cause of death was identified. CONCLUSIONS: Mortality among these TB-HIV-coinfected patients was high particularly when presenting with advanced HIV disease and not starting ART, reinforcing the need for timely and joint treatment for both infections. Screening for a concomitant cryptococcal infection and antifungal treatment for patients with cryptococcal antigenemia may further improve clinical outcome.

Potential role of dermatologists and dermatological services in developing and sustaining the leprosy control referral system in resource constrained settings.

General Health Services that pay due attention to the management of skin conditions are opportune for suspecting and diagnosing early leprosy. In many developing countries, patients with dermatological conditions can only access specialist services in the larger cities and university hospitals; unaffordable costs make the services even less accessible if they can only be provided in the private sector. The high profile of dermatologists in the health services, gives them the opportunity to facilitate the development and implementation of a referral system that includes leprosy. This potential benefit for leprosy control must be initiated by current National Leprosy Programme Managers through establishing formal relationships with the dermatologists and involving them and other partners in the re-designing of leprosy control strategies to keep them in tandem with changing epidemiological patterns, national policies and on -going health sector reforms. The same health service managers should avail of the opportunities from the dermatologists (both in public and private sectors) about the current knowledge on the management and control of leprosy.

Anti-tuberculosis drug resistance surveillance in Uganda 1996-1997.

SETTING: Drug resistance surveillance conducted by the National Tuberculosis and Leprosy Control Programme (NTLP) Uganda from 1996-1997 in collaboration with the Armauer Hansen Institute/German Leprosy Relief Association (GLRA), Germany, for the WHO/IUATLD Global Project on Anti-Tuberculosis Drug Resistance Surveillance. OBJECTIVE: To determine the prevalence of primary and acquired anti-tuberculosis drug resistance in Uganda. DESIGN: The survey area covered three GLRA-supported operational NTLP zones, corresponding to 50% of the Ugandan population. A representative random sampling of individual patients was chosen as sampling procedure. Altogether 586 smear-positive TB patients (537 new cases and 49 previously treated cases) were included in the survey. RESULTS: For primary resistance the results were as follows: isoniazid (H) 6.7%, rifampicin (R) 0.8%, ethambutol (E) 6.1%, streptomycin (S) 13.4%, thioacetazone (T) 3.2%, pyrazinamide (Z) 0%, multidrug resistance (MDR) 0.5%; for acquired resistance they were: H 37.8%, R 4.4%, S 22.2%, E 11.1%, T 20.0%, Z 0%, and MDR 4.4%. CONCLUSION: According to these data the NTLP Uganda has been effective in preventing high levels of primary drug resistance. If it is assumed that the sampling process reflects the distribution of new patients and previously treated patients in the study areas, the amount of acquired resistance (any resistance) in the community of smear-positive patients is approximately 5%. To further monitor programme performance the NTLP will embark on a nationwide survey in 1998/1999.

Tuberculosis chemotherapy and sputum conversion among HIV-seropositive and HIV-seronegative patients in south-eastern Uganda.

OBJECTIVE: To investigate if there is a difference in response to tuberculosis treatment between HIV seronegative and HIV seropositive patients following two months of intensive phase tuberculosis treatment. DESIGN: Prospective cohort study. SETTING: St. Francis Leprosy Centre, south-east Uganda. SUBJECTS: Four hundred fifty seven patients with never previously treated sputum smear-positive tuberculosis admitted during a two-year period in 1991/1993. INTERVENTION: Intensive phase treatment with streptomycin, isoniazid, rifampicin and pyrazinamide. MAIN OUTCOME MEASURES: Sputum conversion from a positive to a negative smear at eight weeks of treatment. RESULTS: HIV seropositivity prevalence was 28%. Among HIV seronegative patients, conversion to a negative smear status occurred in 76% persons compared to 78% in HIV seropositive patients. This difference was not statistically significant (OR = 0.9; 95% CI, 0.6-1.5). HIV seropositive patients, however, were more likely to die (p = 0.017). A high prevalence of resistance to isoniazid and streptomycin was found. Isoniazid resistance was more likely in HIV seronegative patients with M. tuberculosis strains compared to HIV seropositive persons (p < 0.005). Initial resistance to antituberculosis drugs did not have a significant effect on smear conversion. CONCLUSION: This study demonstrates that HIV-seropositive status is not a principal factor in delaying sputum conversion among patients receiving intensive phase tuberculosis treatment.

PIP: A prospective cohort study was undertaken to investigate the response of HIV-seropositive and -seronegative patients at St. Francis Leprosy Center, southeastern Uganda, to tuberculosis chemotherapy. The study population included 457 patients without a history of prior tuberculosis therapy between 1991 and 1993. The subjects were exposed to an intensive phase therapy of rifampicin, streptomycin, isoniazid, and pyrazinamide. After the treatment, sputum culture and sensitivity tests were conducted. Findings showed that 77% of the patients who never received tuberculosis treatment in the past converted to a negative smear status after the 8-week treatment. There was no significant difference in sputum conversion rates between HIV-seropositive and -seronegative patients. The study also revealed that HIV seropositivity prevalence was 28%. Among HIV-seronegative patients, conversion to a negative smear status occurred in 76% compared to 78% HIV-seropositive patients. Moreover, a significant number of HIV-seronegative patients died during the initial course of the therapy. Also, a high prevalence of isoniazid and streptomycin resistance was noted; however, this result never affected the conversions of smears. In conclusion, the study clearly demonstrates that other factors outside the seropositive status may be the principal causes of the delay in sputum conversion among patients receiving intensive tuberculosis chemotherapy.

Leprosy and infection with the human immunodeficiency virus in Uganda; a case-control study.

Both leprosy and infection with the human immunodeficiency virus (HIV) are endemic in Uganda. Various speculations about a possible interaction between the two infections have been put forward but not confirmed. A case-control study involving 189 new leprosy patients and 481 matched controls, resident in eight Ugandan districts, was carried out to investigate if any relationship exists between leprosy and infection with HIV-1 in Uganda. Serum samples from 23 (12.2%) of the 189 leprosy patients tested positive for HIV-1 antibodies as compared to 88 (18.3%) of the 481 control sera. The two proportions of HIV seropositivity are not different statistically. A stratified analysis of the data by districts was done and showed a negative relationship between leprosy and HIV infection in the case of Rakai District (0.04 < odds ratio < 0.61, p = 0.002). It is recommended that studies seeking to observe the clinical progress of dually infected patients might help to reveal new knowledge about a possible relationship between HIV and leprosy and about the immunology of leprosy in general.

Hospital-based epidemiological study of reactions, Buluba Hospital, 1985-89.

A retrospective study of 256 reactional episodes, both reversal reaction and erythema nodosum leprosum (ENL), seen in Buluba Hospital over a 5-year period (1985-89) was made. Over 90% of these episodes were due to reversal reaction, with ENL being encountered infrequently. About 80% of reversal reactions occurred during chemotherapy but all the episodes of ENL occurred during this period. Over 70% of both reversal and ENL episodes presented with clinically apparent nerve and skin involvement. The need to assess the effect of multidrug therapy on the incidence of reactions and to develop more sensitive diagnostic tools to detect early neuritis is emphasized. It is also necessary to study those patients who develop recurrent reactional episodes.

Estudos de intervençäo sobre vacinaçäo BCG em hanseníase: uma análise comparativa / Trial studies about BCG vaccination against leprosy: a comparative analysis

De um total de 468 trabalhos publicados sobre BCG e Hanseníase, os autores selecionaram três trabalhos realizados em Uganda, Nova Guiné e Birmânia, para análise comaprativa. Foram estudados segundo populaçäo de referência; de estudo; critérios de participaçäo e locaçäo; programas oferecidos aos participantes e avaliaçäo. Encontrou-se uma eficácia que variou de 20 a 80 por cento. Diferenças metodológicas na escolha de populaçöes (referência/estudo) e/ou critérios (participaçäo/locaçäo/avaliaçäo) poderiam, entre outras causas, contribuir para explicar as diferentes eficácias encontradas

Angioid streaks in Uganda.

A study on the ophthalmoscopic appearance of angioid streaks and their suspected association with local and systemic diseases among ugandan Africans is presented. In all 40 eyes of 20 patients were studied and the results indicate an interesting association with certain diseases.