Coronavirus disease-2019 morbidity and mortality among health care workers in Uganda.

Background: Health care workers (HCWs) are at increased risk of acquiring coronavirus disease 2019 (COVID-19). This study aimed to determine and compare the morbidity and mortality rates due to COVID-19 among the HCWs and the general population (non-HCWs). Methods: We conducted a retrospective chart review. We accessed electronic database of participants admitted at Mulago National Referral Hospital COVID-19 Treatment Unit (CTU) between March 2020 and September 2021. Participants with missing occupations were excluded. Results: Of 594 eligible participants, 6.4% (n = 38) were HCWs. Compared with non-HCWs, HCWs were much younger (48 versus 55 years, p = 0.020). The proportion of participants with severe disease (73.7% versus 77.6%, p = 0.442), who had not received COVID-19 vaccine (91.2% versus 94.7%, p = 0.423), mortality rate (44.7% versus 54.8%, p = 0.243) and the median length of hospitalization (6 versus 7 days, p = 0.913) were similar among HCWs and non-HCWs, respectively. A higher proportion of HCWs required oxygen therapy (24.3% versus 9.7%, p < 0.01). At admission, the presence of cough (p = 0.723), breathlessness (p = 0.722), fever (p = 0.19), sore throat (p = 0.133), comorbidities (p = 0.403) and headache (p = 0.162) were similar across groups. Rhinorrhoea was more common among HCWs (34.4% versus 16.6%, p = 0.017). Among HCWs, nurses had the highest morbidity (52.6%) and mortality (58.8%). Conclusion: The morbidity and mortality among HCWs in Uganda were substantial, with a low COVID-19 vaccination rate and a higher requirement for oxygen therapy despite a younger age.

Experiences and practices of key research team members in obtaining informed consent for pharmacogenetic research among people living with HIV: a qualitative study.

This study aimed to explore experiences and practices of key research team members in obtaining informed consent for pharmacogenetics research and to identify the approaches used for enhancing understanding during the consenting process. Data collection involved 15 qualitative, in-depth interviews with key researchers who were involved in obtaining informed consent from HIV infected individuals in Uganda for participation in pharmacogenetic clinical trials. The study explored two prominent themes: approaches used to convey information and enhance research participants' understanding and challenges faced during the consenting process. Several barriers and facilitators for obtaining consent were identified. Innovative and potentially effective consenting strategies were identified in this study that should be studied and independently verified.

Understanding of Critical Elements of Informed Consent in Genomic Research: A Case of a Paediatric HIV-TB Research Project in Uganda.

Several studies have reported inadequate comprehension of informed consent for genomic research. This study aimed to assess research participants' understanding of critical elements of informed consent for genomic research. A cross-sectional survey involving 123 parents/caregivers of children participating in a paediatric genomic TB/HIV study was conducted. Only 47.2% of the participants had adequate understanding of consent information. The mean objective (actual) and subjective (perceived) understanding scores were 78.7% and 91.7% respectively. Participants adequately understood most elements of consent however, some elements were poorly understood including foreseeable risks, protection of confidentiality and compensation for research related injury. Overall there was inadequate comprehension of critical elements of informed consent and there was dissonance between actual and perceived comprehension of informed consent.

Higher intensive care unit consultations for COVID-19 patients living with HIV compared to those without HIV coinfection in Uganda.

Coronavirus disease-2019 (COVID-19) is the leading cause of death worldwide from a single infectious agent. Whether or not HIV infection affects clinical outcomes in patients with COVID-19 remains inconclusive. This study aimed to compare the clinical outcomes of people living with HIV (PLWH) and non-HIV-infected patients hospitalized during the second wave of the COVID-19 pandemic in Uganda. We retrospectively retrieved data on patients with COVID-19 who were admitted to the Mulago National Referral Hospital in Uganda between April 2021 and mid-July 2021. We performed propensity-score-matching of 1:5 to compare outcomes in COVID-19 patients living with and those without HIV coinfection (controls). We included 31 PLWH and 155 non-HIV controls. The baseline characteristics were similar across groups (all p values > 0.05). PLWH had close to threefold higher odds of having ICU consultation compared to controls (odds ratio [OR]: 2.9, 95% CI: 1.2-6.9, p = 0.015). There was a trend toward having a severe or critical COVID-19 illness among PLWHIH compared to controls (OR: 1.9, 95% CI: 0.8-4.7, p = 0.164). Length of hospitalization was not significantly different between PLWH and non-HIV controls (6 days vs. 7 days, p = 0.184). Seven-day survival was 63% (95% CI: 42%-78%) among PLWH and 72% (95% CI: 61%-82%) among controls while 14-day survival was 50% (95% CI: 28%-69%) among PLWH and 65% (95% CI: 55%-73%) among controls (p = 0.280). There was another trend toward having 1.7-fold higher odds of mortality among PLWH compared to controls (OR: 1.7, 95% CI: 0.8-3.8, p = 0.181). Our data suggest that PLWH may be at an increased risk of severe or critical COVID-19 illness requiring ICU consultation. Further studies with larger sample sizes are recommended.

Effect of diabetes nutrition education on the dietary feeding practices and lifestyle of type 2 diabetic patients.

BACKGROUND: Type 2 diabetes mellitus (T2DM) is one of the most common global diseases of public concern. In developing countries like Uganda, dietary habits and sedentary lifestyle are the major factors for rapidly rising incidence of DM. Therefore, awareness about diabetes dietary practices and life style are paramount in the control of the disease. METHODOLOGY: One hundred type 2 diabetic patients were randomly selected and divided into two groups of intervention and control (50 patients in each group) to participate in the study. The intervention consisted of two educational sessions each for 30 min with various learning segments. A conversation map for type 2 diabetes, 24-h dietary recall and glycemic load tables were used. Data were collected using a pre-tested questionnaire before intervention and on monthly basis for a period of four months of intervention. Data were entered and analyzed using SPSS software version 21. RESULTS: There was a significant (p < 0.001) increase in water, vegetables, fruits, and number of meals intake per day coupled with quitting alcohol, soda, and beer among the intervention group. On the other hand, it was revealed that meat and milk consumption significantly reduced by 81.6 and 82.4% respectively among the intervention group. At the end of study period, milk, meat, vegetable, beer, soda, cigarettes intake, and duration of physical activity increased among the control group. CONCLUSIONS: Nutrition education improves dietary feeding practices and lifestyle among type 2 diabetes patients within four months of intervention.

High Mortality During the Second Wave of the Coronavirus Disease 2019 (COVID-19) Pandemic in Uganda: Experience From a National Referral COVID-19 Treatment Unit.

BACKGROUND: We evaluated clinical outcomes of patients hospitalized with coronavirus disease 2019 (COVID-19) in the second wave of the pandemic in a national COVID-19 treatment unit (CTU) in Uganda. METHODS: We conducted a retrospective cohort study of COVID-19 patients hospitalized at the Mulago National Referral Hospital CTU between May 1 and July 11, 2021. We performed Kaplan-Meier analysis to evaluate all-cause in-hospital mortality. RESULTS: Of the 477 participants, 247 (52%) were female, 15 (3%) had received at least 1 dose of the COVID-19 vaccine, and 223 (46%) had at least 1 comorbidity. The median age was 52 (interquartile range, 41-65) years. More than 80% of the patients presented with severe (19%, n=91) or critical (66%, n=315) COVID-19 illness. Overall, 174 (37%) patients died. Predictors of all-cause in-hospital mortality were as follows; age ≥50 years (adjusted odds ratio [aOR], 1.9; 95% confidence interval [CI], 1.2-3.2; P=.011), oxygen saturation at admission of ≥92% (aOR, 0.97; 95% CI, 0.91-0.95; P<.001), and admission pulse rate of ≥100 beats per minute (aOR, 1.01; 95% CI, 1.00-1.02; P=.042). The risk of death was 1.4-fold higher in female participants compared with their male counterparts (hazards ratio, 1.4; 95% CI, 1.0-2.0; P=.025). CONCLUSIONS: In this cohort, where the majority of the patients presented with severe or critical illness, more than one third of the patients hospitalized with COVID-19 at a national CTU died of the illness.

COVID-19, HIV-Associated Cryptococcal Meningitis, Disseminated Tuberculosis and Acute Ischaemic Stroke: A Fatal Foursome.

BACKGROUND: Several viral, bacterial and fungal co-infections have been associated with increased morbidity and mortality among patients with COVID-19. We report a fatal case of severe COVID-19 pneumonia in a patient with a recent diagnosis of advanced HIV disease complicated by cryptococcal meningitis, disseminated tuberculosis and acute ischemic stroke. CASE PRESENTATION: A 37-year-old Ugandan woman was diagnosed with HIV infection 8 days prior to her referral to our center. She was antiretroviral naïve. Her chief complaints were worsening cough, difficulty in breathing, fever and altered mental status for 3 days with a background of a 1-month history of coughing with associated drenching night sweats and weight loss. The reverse transcriptase-polymerase chain reaction for SARS-CoV-2 of her nasopharyngeal swab sample was positive. Chest radiograph demonstrated military pattern involvement of both lungs. The serum and cerebrospinal fluid cryptococcal antigen tests were positive. Urine lipoarabinomannan and sputum GeneXpert were positive for Mycobacterium tuberculosis. Computed tomography of the brain showed a large acute ischemic infarct in the territory of the right middle cerebral artery. Regardless of the initiation of treatment, that is, fluconazole 1200 mg once daily, enoxaparin 60 mg, intravenous (IV) dexamethasone 6 mg once daily, oral fluconazole 1200 mg once daily, IV piperacillin/tazobactam 4.5 g three times daily and oxygen therapy, the patient passed on within 36 hours of admission. CONCLUSION: Co-infections worsen COVID-19 outcomes.

COVID-19 vaccine acceptance among high-risk populations in Uganda.

BACKGROUND: Immunization is an important strategy for controlling the COVID-19 pandemic. COVID-19 vaccination was recently launched in Uganda, with prioritization to healthcare workers and high-risk individuals. In this study, we aimed to determine the acceptability of COVID-19 vaccine among persons at high risk of COVID-19 morbidity and mortality in Uganda. METHODS: Between 29 March and 14 April 2021, we conducted a cross-sectional survey consecutively recruiting persons at high risk of severe COVID-19 (diabetes mellitus, HIV and cardiovascular disease) attending Kiruddu National Referral Hospital outpatient clinics. A trained research nurse administered a semi-structured questionnaire assessing demographics, COVID-19 vaccine related attitudes and acceptability. Descriptive statistics, bivariate and multivariable analyses were performed using STATA 16. RESULTS: A total of 317 participants with a mean age 51.5 ± 14.1 years were recruited. Of this, 184 (60.5%) were female. Overall, 216 (70.1%) participants were willing to accept the COVID-19 vaccine. The odds of willingness to accept COVID-19 vaccination were four times greater if a participant was male compared with if a participant was female [adjusted odds ratio (AOR): 4.1, 95% confidence interval (CI): 1.8-9.4, p = 0.00]. Participants who agreed (AOR: 0.04, 95% CI: 0.01-0.38, p = 0.003) or strongly agreed (AOR: 0.04, 95% CI: 0.01-0.59, p = 0.005) that they have some immunity against COVID-19 were also significantly less likely to accept the vaccine. Participants who had a history of vaccination hesitancy for their children were also significantly less likely to accept the COVID-19 vaccine (AOR: 0.1, 95% CI: 0.01-0.58, p = 0.016). CONCLUSION: The willingness to receive a COVID-19 vaccine in this group of high-risk individuals was comparable to the global COVID-19 vaccine acceptance rate. Increased sensitization, myth busting and utilization of opinion leaders to encourage vaccine acceptability is recommended.

Prevalence and Factors Associated with Depression among Medical Students at Makerere University, Uganda.

BACKGROUND: Depression affects about a third of medical students worldwide. There is paucity of data on depression among medical students in Uganda. The purpose of this study was to establish the prevalence and factors associated with depression among medical students at Makerere University College of Health Science (MakCHS), Uganda. METHODS: A cross-sectional study was conducted among students pursuing a Bachelor of Medicine and Surgery at MakCHS in May and July 2019. Students were enrolled by consecutive sampling, both online using Google Forms and in person for those unable to access internet. The self-reported Patient Health Questionnaire 9 (PHQ9) was administered to assess depression, defined as a PHQ9 score ≥10. Microsoft Excel 2016 and Stata 16 were used for data analysis. RESULTS: Overall, 331 valid responses (mean age 23.1±3.3 years) were submitted (response rate 93.8%). In a majority of participants, the prevalence of depression was 21.5% (n=71) of which 64.1% had moderate depression (n=50). On bivariate analysis, year of study, worrying about academic performance, and lectures were significantly associated with depression. On multivariate analysis, worrying about academic performance (aOR 2.52, 95% CI 1.50-4.22; P<0.001) and lectures (aOR 1.89, 95% CI 1.11-3.22; P=0.018) were significantly associated with depression. CONCLUSION: Depression affects a significant number of medical students at MakCHS. About one in five medical students have depression. Year of study and academic performance were significantly associated with depression. Efforts aimed at identification and evaluation of students at risk, administering appropriate interventions, and follow-up of affected students are vital. Analytical studies aimed at establishing the causative factors and the effects of depression on medical students are recommended.

Charcot arthropathy of the diabetic foot in a sub-Saharan tertiary hospital: a cross-sectional study.

BACKGROUND: Charcot foot arthropathy is a potentially limb-threatening condition that leads to progressive destruction of the bones and joints in the neuropathic foot. One of its main causes is diabetes mellitus whose prevalence is steadily increasing. The acute phase is often misdiagnosed thus leading to foot deformity, ulceration and increased risk of amputation. There is a paucity of literature on this condition from sub-Saharan Africa. This study aimed at determining the extent of Charcot foot arthropathy, the radiological patterns of Charcot foot arthropathy and patient's factors associated with Charcot foot arthropathy among adult patients with longstanding diabetes in an African setting. METHODS: This was a cross-sectional study that was carried at a national referral and university teaching hospital in Kampala, Uganda. One hundred patients with longstanding diabetes mellitus were consecutively recruited. Patients with a history of having diabetes mellitus for at least seven years since diagnosis were considered to have a longstanding disease. Clinical assessment of both feet was done. Weight-bearing radiographs of the selected foot were taken and evaluated using the Sanders and Frykberg and modified Eichenholtz classifications. A blood sample was taken for glycosylated haemoglobin (HbA1c). Data were summarized using descriptive statistics and student t-test. RESULTS: The proportion of Charcot foot arthropathy among patients with longstanding diabetes was 12% of which one-third (4 out of 12) were acute cases. Fifty percent of the lesions were in the forefoot and 50% in the midfoot. Seventeen percent of lesions were at the inflammatory stage of the modified Eichenholtz classification, 50% at the developmental stage, 25% at the healing stage, and 8% at the remodelling stage. An abnormal foot radiograph was significantly associated with Charcot foot arthropathy among patients with longstanding diabetes. CONCLUSION: Charcot foot arthropathy is fairly common in patients with longstanding diabetes mellitus in these settings with one third of patients presenting in the early acute phase. An abnormal weight-bearing radiograph was an associated factor of Charcot foot arthropathy among this specific group of patients. To reduce on the morbidity and limb threatening sequelae of this condition, clinicians are therefore advised to routinely examine the feet of patients with diabetes and send those with suspicious signs and symptoms for radiographic assessment.

Acute kidney injury among adult patients with sepsis in a low-income country: clinical patterns and short-term outcomes.

BACKGROUND: Acute kidney injury (AKI) is a common complication of sepsis. We determined the prevalence of AKI among adult patients with sepsis on the medical wards in a low-income country and described their clinical pattern and outcomes at discharge. METHODS: We conducted a cross-sectional study of sepsis-related AKI on the adult medical wards of Mulago National Referral Hospital between January and April 2013. All patients meeting the American College of Chest Physicians (ACP) sepsis criteria were recruited. Demographic, clinical, laboratory and ultrasonography data were recorded and all patients with AKI were followed up to a maximum of 2 weeks. Proportional analysis was carried out and odds ratios with 95% confidence intervals were calculated in the bivariate analysis. RESULTS: Of 387 patients recruited, 217 (55.6%) were male and the average age was 37 years (range18-90 years). The prevalence of sepsis-related AKI was 16.3%. Age >59 years (p = 0.023), a postural drop in systolic blood pressure of >9 mmHg (p = 0.015) and a white blood cell count >12,000 cells/mL (p = 0.003) were significantly associated with AKI. In-hospital mortality among patients with AKI was 21% (13/63). 59% (20/49) of patients who were discharged alive or were still on the wards after 2 weeks had persistent kidney injury. Acute Kidney Injury Network (AKIN) Stage 3 was significantly associated with persistence of kidney injury (p = 0.001). None of the patients requiring dialysis or ICU care received either because of limited access. CONCLUSIONS: The prevalence, morbidity and mortality due to AKI among sepsis patients in Uganda is very high and limited access to dialysis and ICU care is a major factor in poor outcomes for these patients.

Comparison of fasting plasma glucose and haemoglobin A1c point-of-care tests in screening for diabetes and abnormal glucose regulation in a rural low income setting.

AIMS: Glycated haemoglobin (HbA1C) has been suggested to replace glucose tests in identifying diabetes and pre-diabetes. We assessed agreement between fasting plasma glucose (FPG) and HbA1C rapid tests in classifying abnormal glucose regulation (AGR), and their utility for preventive screening in rural Africa. METHODS: A population-based survey of 795 people aged 35-60 years was conducted in a mainly rural district in Uganda. FPG was measured using On-Call® Plus glucometers, and classified using World Health Organization (WHO) and American Diabetes Association (ADA) criteria. HbA1C was measured using A1cNow® kits and classified using ADA criteria. Body mass index and blood pressure were measured. Percentage agreement between the two tests was computed. RESULTS: Using HbA1C, 11.3% of participants had diabetes compared with 4.8% for FPG. Prevalence of HbA1C-defined pre-diabetes (26.4%) was 1.2 times and 2.5 times higher than FPG-defined pre-diabetes using ADA (21.8%) and WHO (10.1%) criteria, respectively. With FPG as the reference, agreement between FPG and HbA1C in classifying diabetes status was moderate (Kappa=22.9; Area Under the Curve (AUC)=75%), while that for AGR was low (Kappa=11.0; AUC=59%). However, agreement was high (over 90%) among negative tests and among participants with risk factors for type 2 diabetes (obesity, overweight or hypertension). HbA1C had more procedural challenges than FPG. CONCLUSIONS: Although low in the general sample, agreement between HbA1C and FPG is excellent among persons who test negative with either test. A single test can therefore identify the majority at lower risk for type 2 diabetes. Nurses if trained can conduct these tests.

Diabetes and pre-diabetes among persons aged 35 to 60 years in eastern Uganda: prevalence and associated factors.

BACKGROUND: Our aim was to estimate the prevalence of abnormal glucose regulation (AGR) (i.e. diabetes and pre-diabetes) and its associated factors among people aged 35-60 years so as to clarify the relevance of targeted screening in rural Africa. METHODS: A population-based survey of 1,497 people (786 women and 711 men) aged 35-60 years was conducted in a predominantly rural Demographic Surveillance Site in eastern Uganda. Participants responded to a lifestyle questionnaire, following which their Body Mass Index (BMI) and Blood Pressure (BP) were measured. Fasting plasma glucose (FPG) was measured from capillary blood using On-Call® Plus (Acon) rapid glucose meters, following overnight fasting. AGR was defined as FPG ≥6.1 mmol L⁻¹ (World Health Organization (WHO) criteria or ≥5.6 mmol L⁻¹ (American Diabetes Association (ADA) criteria. Diabetes was defined as FPG >6.9 mmol L⁻¹, or being on diabetes treatment. RESULTS: The mean age of participants was 45 years for men and 44 for women. Prevalence of diabetes was 7.4% (95%CI 6.1-8.8), while prevalence of pre-diabetes was 8.6% (95%CI 7.3-10.2) using WHO criteria and 20.2% (95%CI 17.5-22.9) with ADA criteria. Using WHO cut-offs, the prevalence of AGR was 2 times higher among obese persons compared with normal BMI persons (Adjusted Prevalence Rate Ratio (APRR) 1.9, 95%CI 1.3-2.8). Occupation as a mechanic, achieving the WHO recommended physical activity threshold, and higher dietary diversity were associated with lower likelihood of AGR (APRR 0.6, 95%CI 0.4-0.9; APRR 0.6, 95%CI 0.4-0.8; APRR 0.5, 95%CI 0.3-0.9 respectively). The direct medical cost of detecting one person with AGR was two US dollars with ADA and three point seven dollars with WHO cut-offs. CONCLUSIONS: There is a high prevalence of AGR among people aged 35-60 years in this setting. Screening for high risk persons and targeted health education to address obesity, insufficient physical activity and non-diverse diets are necessary.

Research site monitoring for compliance with ethics regulatory standards: review of experience from Uganda.

BACKGROUND: On site monitoring of research is one of the most effective ways to ensure compliance during research conduct. However, it is least carried out primarily for two reasons: presumed high costs both in terms of human resources and finances; and the lack of a clear framework for undertaking site monitoring. In this paper we discuss a model for research site monitoring that may be cost effective and feasible in low resource settings. METHODS: This was a retrospective review of research site monitoring reports covering a period of four years. RESULTS: The monitoring was conducted by the Uganda National Council for Science and Technology, the National Drug Authority and the National HIV/AIDS Research and Ethics Committee over the period 2007 to 2010.The monitoring team was usually three members comprising of two experts in research ethics and an assistant. A total of 28 site monitoring visits covering 40 research projects were reviewed. 25% of the site monitoring reports revealed violation of the regulatory requirement for valid ethical approval. 36% of the site reports showed some instances of informed consent violation, 28% showed violation of the rights and welfare of research participants, 38% revealed that sites did not report SAEs to regulatory authorities and many sites lacked adequate GCP and GCLP. However, most of the sites monitored had adequate facilities to conduct the respective studies and good working practices. CONCLUSION: This model employed by the monitoring teams to evaluate research compliance is effective in auditing ethical practice. Compliance monitoring is feasible and affordable in a resource limited setting. Research protocol non compliance is still a major problem in Uganda, and there is need for a pro-active approach to this vice by all stake holders if ethical conduct of research is to be achieved.

Bioethics training in Uganda: report on research and clinical ethics workshops.

This essay describes and critically evaluates a co-operative educational program to train Ugandan health care workers in bioethics. It describes one "bottom-up" effort, a week-long intensive workshop in bioethics provided by the authors to health care professionals in a developing country-Uganda. We will describe the background and circumstances that led to the organization of the workshop, and review its planning, design, curriculum, and outcome. We will focus especially on measures taken to make the workshop relevant for the audience of Ugandan professionals, and describe lessons learned after two presentations of the workshop. Finally, we will discuss the strengths and weaknesses of such a format, and its potential value in raising bioethical expertise in developing countries.

Safety and immunogenicity of recombinant low-dosage HIV-1 A vaccine candidates vectored by plasmid pTHr DNA or modified vaccinia virus Ankara (MVA) in humans in East Africa.

The safety and immunogenicity of plasmid pTHr DNA, modified vaccinia virus Ankara (MVA) human immunodeficiency virus type 1 (HIV-1) vaccine candidates were evaluated in four Phase I clinical trials in Kenya and Uganda. Both vaccines, expressing HIV-1 subtype A gag p24/p17 and a string of CD8 T-cell epitopes (HIVA), were generally safe and well-tolerated. At the dosage levels and intervals tested, the percentage of vaccine recipients with HIV-1-specific cell-mediated immune responses, assessed by a validated ex vivo interferon gamma (IFN-gamma) ELISPOT assay and Cytokine Flow Cytometry (CFC), did not significantly differ from placebo recipients. These trials demonstrated the feasibility of conducting high-quality Phase 1 trials in Africa.