Impact of population based indoor residual spraying with and without mass drug administration with dihydroartemisinin-piperaquine on malaria prevalence in a high transmission setting: a quasi-experimental controlled before-and-after trial in northeastern Uganda.

BACKGROUND: Declines in malaria burden in Uganda have slowed. Modelling predicts that indoor residual spraying (IRS) and mass drug administration (MDA), when co-timed, have synergistic impact. This study investigated additional protective impact of population-based MDA on malaria prevalence, if any, when added to IRS, as compared with IRS alone and with standard of care (SOC). METHODS: The 32-month quasi-experimental controlled before-and-after trial enrolled an open cohort of residents (46,765 individuals, 1st enumeration and 52,133, 4th enumeration) of Katakwi District in northeastern Uganda. Consented participants were assigned to three arms based on residential subcounty at study start: MDA+IRS, IRS, SOC. IRS with pirimiphos methyl and MDA with dihydroartemisinin- piperaquine were delivered in 4 co-timed campaign-style rounds 8 months apart. The primary endpoint was population prevalence of malaria, estimated by 6 cross-sectional surveys, starting at baseline and preceding each subsequent round. RESULTS: Comparing malaria prevalence in MDA+IRS and IRS only arms over all 6 surveys (intention-to-treat analysis), roughly every 6 months post-interventions, a geostatistical model found a significant additional 15.5% (95% confidence interval (CI): [13.7%, 17.5%], Z = 9.6, p = 5e-20) decrease in the adjusted odds ratio (aOR) due to MDA for all ages, a 13.3% reduction in under 5's (95% CI: [10.5%, 16.8%], Z = 4.02, p = 5e-5), and a 10.1% reduction in children 5-15 (95% CI: [8.5%, 11.8%], Z = 4.7, p = 2e-5). All ages residents of the MDA + IRS arm enjoyed an overall 80.1% reduction (95% CI: [80.0%, 83.0%], p = 0.0001) in odds of qPCR confirmed malaria compared with SOC residents. Secondary difference-in-difference analyses comparing surveys at different timepoints to baseline showed aOR (MDA + IRS vs IRS) of qPCR positivity between 0.28 and 0.66 (p < 0.001). Of three serious adverse events, one (nonfatal) was considered related to study medications. Limitations include the initial non-random assignment of study arms, the single large cluster per arm, and the lack of an MDA-only arm, considered to violate equipoise. CONCLUSIONS: Despite being assessed at long time points 5-7 months post-round, MDA plus IRS provided significant additional protection from malaria infection over IRS alone. Randomized trials of MDA in large areas undergoing IRS recommended as well as cohort studies of impact on incidence. TRIAL REGISTRATION: This trial was retrospectively registered 11/07/2018 with the Pan African Clinical Trials Registry (PACTR201807166695568).

Current malaria infection, previous malaria exposure, and clinical profiles and outcomes of COVID-19 in a setting of high malaria transmission: an exploratory cohort study in Uganda.

BACKGROUND: The potential effects of SARS-CoV-2 and Plasmodium falciparum co-infection on host susceptibility and pathogenesis remain unknown. We aimed to establish the prevalence of malaria and describe the clinical characteristics of SARS-CoV-2 and P falciparum co-infection in a high-burden malaria setting. METHODS: This was an exploratory prospective, cohort study of patients with COVID-19 who were admitted to hospital in Uganda. Patients of all ages with a PCR-confirmed diagnosis of SARS-CoV-2 infection who had provided informed consent or assent were consecutively enrolled from treatment centres in eight hospitals across the country and followed up until discharge or death. Clinical assessments and blood sampling were done at admission for all patients. Malaria diagnosis in all patients was done by rapid diagnostic tests, microscopy, and molecular methods. Previous P falciparum exposure was determined with serological responses to a panel of P falciparum antigens assessed using a multiplex bead assay. Additional evaluations included complete blood count, markers of inflammation, and serum biochemistries. The main outcome was overall prevalence of malaria infection and malaria prevalence by age (including age categories of 0-20 years, 21-40 years, 41-60 years, and >60 years). The frequency of symptoms was compared between patients with COVID-19 with P falciparum infection versus those without P falciparum infection. The frequency of comorbidities and COVID-19 clinical severity and outcomes was compared between patients with low previous exposure to P falciparum versus those with high previous exposure to P falciparum. The effect of previous exposure to P falciparum on COVID-19 clinical severity and outcomes was also assessed among patients with and those without comorbidities. FINDINGS: Of 600 people with PCR-confirmed SARS-CoV-2 infection enrolled from April 15, to Oct 30, 2020, 597 (>99%) had complete information and were included in our analyses. The majority (502 [84%] of 597) were male individuals with a median age of 36 years (IQR 28-47). Overall prevalence of P falciparum infection was 12% (95% CI 9·4-14·6; 70 of 597 participants), with highest prevalence in the age groups of 0-20 years (22%, 8·7-44·8; five of 23 patients) and older than 60 years (20%, 10·2-34·1; nine of 46 patients). Confusion (four [6%] of 70 patients vs eight [2%] of 527 patients; p=0·040) and vomiting (four [6%] of 70 patients vs five [1%] of 527 patients; p=0·014] were more frequent among patients with P falciparum infection than those without. Patients with low versus those with high previous P falciparum exposure had a increased frequency of severe or critical COVID-19 clinical presentation (16 [30%] of 53 patients vs three [5%] of 56 patients; p=0·0010) and a higher burden of comorbidities, including diabetes (12 [23%] of 53 patients vs two [4%] of 56 patients; p=0·0010) and heart disease (seven [13%] of 53 patients vs zero [0%] of 56 patients; p=0·0030). Among patients with no comorbidities, those with low previous P falciparum exposure still had a higher proportion of cases of severe or critical COVID-19 than did those with high P falciparum exposure (six [18%] of 33 patients vs one [2%] of 49 patients; p=0·015). Multivariate analysis showed higher odds of unfavourable outcomes in patients who were older than 60 years (adjusted OR 8·7, 95% CI 1·0-75·5; p=0·049). INTERPRETATION: Although patients with COVID-19 with P falciparum co-infection had a higher frequency of confusion and vomiting, co-infection did not seem deleterious. The association between low previous malaria exposure and severe or critical COVID-19 and other adverse outcomes will require further study. These preliminary descriptive observations highlight the importance of understanding the potential clinical and therapeutic implications of overlapping co-infections. FUNDING: Malaria Consortium (USA).

An assessment of the knowledge, practices and resources during the delivery of malaria health care services among private health care practitioners: a cross section study in the Mid-Western Region of Uganda.

BACKGROUND: Approximately 50 % of the population in Uganda seeks health care from private facilities but there is limited data on the quality of care for malaria in these facilities. This study aimed to document the knowledge, practices and resources during the delivery of malaria care services, among private health practitioners in the Mid-Western region of Uganda, an area of moderate malaria transmission. METHODS: This was a cross sectional study in which purposive sampling was used to select fifteen private-for-profit facilities from each district. An interviewer-administered questionnaire that contained both quantitative and open-ended questions was used. Information was collected on availability of treatment aides, knowledge on malaria, malaria case management, laboratory practices, malaria drugs stock and data management. We determined the proportion of health workers that adequately provided malaria case management according to national standards. RESULTS: Of the 135 health facilities staff interviewed, 61.48 % (52.91-69.40) had access to malaria treatment protocols while 48.89 % (40.19-57.63) received malaria training. The majority of facilities, 98.52 % (94.75-99.82) had malaria diagnostic services and the most commonly available anti-malarial drug was artemether-lumefantrine, 85.19 % (78-91), followed by Quinine, 74.81 % (67-82) and intravenous artesunate, 72.59 % (64-80). Only 14.07 % (8.69-21.10) responded adequately to the acceptable cascade of malaria case management practice. Specifically, 33.33 % (25.46-41.96) responded correctly to management of a patient with a fever, 40.00 % (31.67-48.79) responded correctly to the first line treatment for uncomplicated malaria, whereas 85.19 % (78.05-90.71) responded correctly to severe malaria treatment. Only 28.83 % submitted monthly reports, where malaria data was recorded, to the national database. CONCLUSIONS: This study revealed sub-optimal malaria case management knowledge and practices at private health facilities with approximately 14 % of health care workers demonstrating correct malaria case management cascade practices. To strengthen the quality of malaria case management, it is recommended that the NMCD distributes current guidelines and tools, coupled with training; continuous mentorship and supportive supervision; provision of adequate stock of essential anti-malarials and RDTs; reinforcing communication and behavior change; and increasing support for data management at private health facilities.

Relationships between test positivity rate, total laboratory confirmed cases of malaria, and malaria incidence in high burden settings of Uganda: an ecological analysis.

BACKGROUND: Malaria surveillance is critical for monitoring changes in malaria morbidity over time. National Malaria Control Programmes often rely on surrogate measures of malaria incidence, including the test positivity rate (TPR) and total laboratory confirmed cases of malaria (TCM), to monitor trends in malaria morbidity. However, there are limited data on the accuracy of TPR and TCM for predicting temporal changes in malaria incidence, especially in high burden settings. METHODS: This study leveraged data from 5 malaria reference centres (MRCs) located in high burden settings over a 15-month period from November 2018 through January 2020 as part of an enhanced health facility-based surveillance system established in Uganda. Individual level data were collected from all outpatients including demographics, laboratory test results, and village of residence. Estimates of malaria incidence were derived from catchment areas around the MRCs. Temporal relationships between monthly aggregate measures of TPR and TCM relative to estimates of malaria incidence were examined using linear and exponential regression models. RESULTS: A total of 149,739 outpatient visits to the 5 MRCs were recorded. Overall, malaria was suspected in 73.4% of visits, 99.1% of patients with suspected malaria received a diagnostic test, and 69.7% of those tested for malaria were positive. Temporal correlations between monthly measures of TPR and malaria incidence using linear and exponential regression models were relatively poor, with small changes in TPR frequently associated with large changes in malaria incidence. Linear regression models of temporal changes in TCM provided the most parsimonious and accurate predictor of changes in malaria incidence, with adjusted R2 values ranging from 0.81 to 0.98 across the 5 MRCs. However, the slope of the regression lines indicating the change in malaria incidence per unit change in TCM varied from 0.57 to 2.13 across the 5 MRCs, and when combining data across all 5 sites, the R2 value reduced to 0.38. CONCLUSIONS: In high malaria burden areas of Uganda, site-specific temporal changes in TCM had a strong linear relationship with malaria incidence and were a more useful metric than TPR. However, caution should be taken when comparing changes in TCM across sites.

Quality of healthcare for children with severe acute malnutrition in a refugee setting: cross-sectional study in West Nile Region, Uganda.

OBJECTIVES: 5.0 million annual deaths in low-income and middle-income countries are due to poor quality of care (QOC). We evaluated the QOC provided to malnourished children in West Nile Region in Uganda. DESIGN: Cross-sectional study. SETTING: West Nile Region, an area hosting over one million refugees. PARTICIPANTS: Among 148 facilities providing nutritional services, 30 randomly selected facilities (20%) and the records of 1467 children with severe acute malnutrition (100% of those attending the 30 facilities during last year) were assessed. OUTCOMES: The national Nutrition Service Delivery Assessment (NSDA) tool was used to assess capacity areas related to QOC. Case management, data quality and health outcomes were assessed from official health records. Multivariate analysis was performed to explore factors significantly associated with better cure rates. RESULTS: Of 305 NSDA scores allocated to 30 participating centres, 201 (65.9%) were 'good' or 'excellent'. However, 20 (66.7%) facilities had 'poor' 'quality improvement mechanisms' and 13 (43.3%) had 'poor' 'human resources'. Overall data quality in official records was poor, while recorded quality of case management was overall fair. Average cure rate was significantly lower than international Sphere standards (50.4% vs 75% p<0.001) with a higher default rate (23.2% vs 15% p<0.001). Large heterogeneity among facilities was detected for all indicators. Refugee-hosting and non-refugee-hosting facilities had a similar cure rate (47.1% vs 52.1%) though transfer rates were higher for those hosting refugees (21.5% vs 1.9%, p<0.001) despite better 'equipment and supplies'. 'Good/excellent' 'equipment' and 'store management' were significantly associated with better cure rates in outpatient therapeutic centres (+55.9, p<0.001; +65.4, p=0.041, respectively) in multivariate analysis. CONCLUSIONS: Though most NSDA capacity areas were rated good or excellent, health outcomes of malnourished children in West Nile Region, both in refugee-hosting and non-refugee-hosting facilities, are significantly below international standards. Effective and sustainable approaches to improve malnourished child health outcomes are needed.

The Impact of Control Interventions on Malaria Burden in Young Children in a Historically High-Transmission District of Uganda: A Pooled Analysis of Cohort Studies from 2007 to 2018.

There is limited evidence on whether malaria elimination is feasible in high-transmission areas of Africa. Between 2007 and 2018, we measured the impact of malaria control interventions in young children enrolled in three clinical trials and two observational studies in Tororo, Uganda, a historically high-transmission area. Data were pooled from children aged 0.5-2 years. Interventions included individually assigned chemoprevention and repeated rounds of indoor residual spraying (IRS) of insecticide. All children received long-lasting insecticidal nets (LLINs) and treatment for symptomatic malaria with artemisinin-based combination therapy. Malaria incidence was measured using passive surveillance and parasite prevalence by microscopy and molecular methods at regular intervals. Poisson's generalized linear mixed-effects models were used to estimate the impact of various control interventions. In total, 939 children were followed over 1,221.7 person years. In the absence of chemoprevention and IRS (reference group), malaria incidence was 4.94 episodes per person year and parasite prevalence 47.3%. Compared with the reference group, implementation of IRS was associated with a 97.6% decrease (95% CI: 93.3-99.1%, P = 0.001) in the incidence of malaria and a 96.0% decrease (95% CI: 91.3-98.2%, P < 0.001) in parasite prevalence (both measured after the fifth and sixth rounds of IRS). The addition of chemoprevention with monthly dihydroartemisinin-piperaquine to IRS was associated with a 99.5% decrease (95% CI: 98.6-99.9%, P < 0.001) in the incidence of malaria. In a historically high-malaria burden area of Uganda, a combination of LLINs, effective case management, IRS, and chemoprevention was associated with almost complete elimination of malaria in young children.

Improving the quality of neonatal data capture and clinical care at a tertiary-care hospital in Uganda through enhanced surveillance, training and mentorship.

Introduction: Accurate documentation of neonatal morbidity and mortality is limited in many countries in sub-Saharan Africa. This project aimed to establish a surveillance system for neonatal conditions as an approach to improving the quality of neonatal care.Methods: A systematic data capture and surveillance system was established at Jinja Regional Referral Hospital, Uganda using a standardised neonatal medical record form which collected detailed individual patient level data. Additionally, training and mentorship were conducted and basic equipment was provided.Results: A total of 4178 neonates were hospitalised from July 2014 to December 2016. Median (IQR) age on admission was one day (1-3) and 48.0% (1851/3859) were male. Median (IQR) duration of hospitalisation was 17 days (IQR 10-40) and the longest duration of hospitalisation was 47 days (IQR 41-58). The majority were referrals from government health facilities (54.4%, 2012/3699), though 30.6% (1123/3669) presented as self-referrals. Septicaemia (44.9%, 1962/4371), prematurity (21.0%, 917/4371) and birth asphyxia (19.1%, 833/4371) were the most common diagnoses. The overall mortality was 13.8% (577/4178) and the commonest causes of death included septicaemia (26.9%, 155/577), prematurity (24.3%, 140/577), birth asphyxia (21.0%, 121/577), hypothermia (9.9%, 57/577) and respiratory distress (8.0%, 46/577). The majority of deaths (51.5%, 297/577) occurred within the first 24 h of hospitalisation although a significant proportion of deaths also occurred after 7 days of hospitalisation (24.1%, 139/577). A modest decrease in mortality and improvement in clinical outcome were observed.Conclusion: Improvement in neonatal data capture and quality of care was observed following establishment of an enhanced surveillance system, training and mentorship.Abbreviations: aOR: adjusted odds ratio; CHRP: Centre for Health research and Programmes; HC: health centre; HMIS: Health Management Information System; JRRH: Jinja Regional Referral Hospital; NMRF: neonatal medical record form; PMTCT: prevention of mother-to-child transmission of HIV; UPA: Uganda Paediatric Association.

Supportive supervision to improve the quality and outcome of outpatient care among malnourished children: a cluster randomised trial in Arua district, Uganda.

INTRODUCTION: Suboptimal quality of paediatric care has been reported in resource-limited settings, but little evidence exists on interventions to improve it in such settings. This study aimed at testing supportive supervision (SS) for improving health status of malnourished children, quality of case management, overall quality of care, and the absolute number of children enrolled in the nutritional services. METHODS: This was a cluster randomised trial conducted in Arua district. Six health centres (HCs) with the highest volume of work were randomised to either SS or no intervention. SS was delivered by to HCs staff (phase 1), and later extended to community health workers (CHWs) (phase 2). The primary outcome was the cure rate, measured at children level. Quality of case management was assessed by six pre-defined indicators. Quality of care was assessed using the national Nutrition Service Delivery Assessment (NSDA) tool. Access to care was estimated with the number of children accessing HC nutritional services. RESULTS: Overall, 737 children were enrolled. In the intervention arm, the cure rate (83.8% vs 44.9%, risk ratio (RR)=1.91, 95% CI: 1.56-2.34, p=0.001), quality of care as scored by NSDA (RR=1.57, 95% CI: 1.01-2.44, p=0.035) and correctness in complementary treatment (RR=1.52, 95% CI: 1.40-1.67, p=0.001) were significantly higher compared with control. With the extension of SS to CHWs (phase 2), there was a significant 38.6% more children accessing care in the intervention HCs (RR=1.26, 95% CI: 1.11-1.44, p=0.001) compared with control. CONCLUSION: SS significantly improved the cure rate of malnourished children, and the overall quality of care, SS to CHWs significantly increased the crude number of children enrolled in the nutritional services. More studies should confirm these results, and evaluate the cost-effectiveness of SS.

Implementing population-based mass drug administration for malaria: experience from a high transmission setting in North Eastern Uganda.

BACKGROUND: Mass drug administration (MDA) is a suggested mean to accelerate efforts towards elimination and attainment of malaria-free status. There is limited evidence of suitable methods of implementing MDA programme to achieve a high coverage and compliance in low-income countries. The objective of this paper is to assess the impact of this MDA delivery strategy while using coverage measured as effective population in the community and population available. METHODS: Population-based MDA was implemented as a part of a larger program in a high transmission setting in Uganda. Four rounds of interventions were implemented over a period of 2 years at an interval of 6 to 8 months. A housing and population census was conducted to establish the eligible population. A team of 19 personnel conducted MDA at established village meeting points as distribution sites at every village. The first dose of dihydroartemisinin-piperaquine (DHA-PQ) was administered via a fixed site distribution strategy by directly observed treatment on site, the remaining doses were taken at home and a door-to-door follow up strategy was implemented by community health workers to monitor adherence to the second and third doses. RESULTS: Based on number of individuals who turned up at the distribution site, for each round of MDA, effective coverage was 80.1%, 81.2%, 80.0% and 80% for the 1st, 2nd, 3rd and 4th rounds respectively. However, coverage based on available population at the time of implementing MDA was 80.1%, 83.2%, 82.4% and 82.9% for rounds 1, 2, 3 and 4, respectively. Intense community mobilization using community structures and mass media facilitated community participation and adherence to MDA. CONCLUSION: A hybrid of fixed site distribution and door-to-door follow up strategy of MDA delivery achieved a high coverage and compliance and seemed feasible. This model can be considered in resource-limited settings.

Implementation of an individual patient prospective database of hospital births in Sri Lanka and its use for improving quality of care.

OBJECTIVES: This study was aimed at piloting a prospective individual patient database on hospital deliveries in Colombo, Sri Lanka, and at exploring its use for developing recommendations for improving quality of care (QoC). DESIGN: Observational study. SETTING: De Soysa Maternity Hospital, the largest referral hospital for maternity care in Sri Lanka. DATA COLLECTION AND ANALYSIS: From July 2015 to June 2017, 150 variables were collected for each delivery using a standardised form and entered into a database. Data were analysed every 8 months, and the results made available to local staff. Outcomes of the study included: technical problems; data completeness; data accuracy; key database findings; and use of data. RESULTS: 7504 deliveries were recorded. No technical problem was reported. Data completeness exceeded that of other existing hospital recording systems. Less than 1% data were missing for maternal variables and less than 3% for newborn variables. Mistakes in data collection and entry occurred in 0.01% and 0.09% of maternal and newborn data, respectively. Key QoC indicators identified in comparison with international standards were: relatively low maternal mortality (0.053%); relatively high maternal near-miss cases (3.4%); high rate of induction of labour (24.6%), caesarean section (30.0%) and episiotomy (56.1%); relatively high rate of preterm births (9.4%); low birthweight rate (16.5%); stillbirth (0.97%); and of total deaths in newborn (1.98%). Based on key indicators identified, a list of recommendations was developed, including the use checklists to standardise case management, training, clinical audits and more information for patients. A list of lessons learnt with the implementation of the data collection system was also drawn. CONCLUSIONS: The study shows that the implemented system of data collection can produce a large quantity of reliable information. Most importantly, this experience provides an example on how database findings can be used for discussing hospital practices, identifying gaps and to agree on recommendations for improving QoC.

Implementation of the WHO manual for Robson classification: an example from Sri Lanka using a local database for developing quality improvement recommendations.

OBJECTIVES: This study aimed at describing the use of a prospective database on hospital deliveries for analysing caesarean section (CS) practices according to the WHO manual for Robson classification, and for developing recommendations for improving the quality of care (QoC). DESIGN: Observational study. SETTING: University Obstetric Unit at De Soysa Hospital for Women, the largest maternity unit in Sri Lanka. DATA COLLECTION AND ANALYSIS: For each childbirth, 150 variables were routinely collected in a standardised form and entered into a database. Data were routinely monitored for ensuring quality. Information on deliveries occurring from July 2015 to June 2017 were analysed according the WHO Robson classification manual. Findings were discussed internally to develop quality improvement recommendations. RESULTS: 7504 women delivered in the hospital during the study period and at least one maternal or fetal pathological condition was reported in 2845 (37.9%). The CS rate was 30.0%, with 11.9% CS being performed prelabour. According to the Robson classification, Group 3 and Group 1 were the most represented groups (27.0% and 23.1% of population, respectively). The major contributors to the CS rate were group 5 (29.6%), group 1 (14.0%), group 2a (13.3%) and group 10 (11.5%). The most commonly reported indications for CS included abnormal cardiotocography/suspected fetal distress, past CS and failed progress of labour or failed induction. These suggested the need for further discussion on CS practices. Overall, 18 recommendations were agreed on. Besides updating protocols and hands-on training, activities agreed on included monitoring and supervision, criterion-based audits, risk management meetings and appropriate information for patients, and recommendations to further improve the quality of data. CONCLUSIONS: This study provides an example on how the WHO manual for Robson classification can be used in an action-oriented manner for developing recommendations for improving the QoC, and the quality of data collected.

Utilization of safe male circumcision among adult men in a fishing community in rural Uganda.

BACKGROUND: In Uganda, most-at-riskpopulations(MARPs) such as fishing communities remain vulnerable to preventable HIV acquisition. Safe Male Circumcision (SMC) has been incorporated into Uganda's HIV prevention strategies. This study aimed at determining SMC utilization and associated factors among adult men in a rural fishing community in Uganda. METHODS: A cross-sectional study was conducted in a rural fishing village in central Uganda. Stratified random sampling of 369 fishermen aged 18-54 yearswas used according to their occupational category; fish monger, boat crew and general merchandise. The dependent variable wasutilization of SMC.A forward fitting multivariable logistic regression model was fitted with variables significant at p≤0.05 controlling for confounding and effect modification. RESULTS: Respondents'mean(SD) age was 30.0(9.3) years. Only8.4%hadSMC and among non-circumcised men, 84.9% had adequate knowledge of SMC benefits while 79.3% did not know were SMC services were offered. Peer support(AOR0.17;95%-CI0.05-0.60) and perceived procedural safety (AOR6.8;95%CI2.16-21.17) were independently associated with SMC utilization. CONCLUSION: In this rural fishing community, SMC utilization was low. These findings underscore the need to inform HIV preventionstrategies inthecontextof peer support and perceptionsheld by rural dwelling men.

Community facilitators and barriers to a successful implementation of mass drug administration and indoor residual spraying for malaria prevention in Uganda: a qualitative study.

BACKGROUND: There is growing interest to add mass drug administration (MDA) to the already existing malaria prevention strategies, such as indoor residual spraying (IRS). However, successful MDA and IRS requires high population-wide coverage, emphasizing the importance of community acceptance. This study's objectives were to identify community-level facilitators and barriers during the implementation of both MDA and IRS in communities with high malaria transmission intensity. METHODS: This was a qualitative study conducted in two sub-counties in Katakwi district. Kapujan sub-county residents received two rounds of IRS and MDA while Toroma sub-county residents received two rounds of IRS only. Key informant interviews and focus group discussions were conducted with key influential district and sub-county personnel and community members. Data were analysed using thematic analysis. Transcripts and interview notes from the in-depth interviews were analysed using a coding scheme developed from pre-defined topics together with themes emerging from the data. The Nvivo software program was used to aggregate the data by codes and to present study findings. RESULTS: Overall, 14 key informants were interviewed: 4 from Katakwi district and 5 each from Kapujan and Toroma sub-counties. Five focus group discussions were conducted: 4 with community members (men and women), 2 in each sub-county and one with medical staff of Toroma health centre IV. Important themes for consideration raised by the respondents include community sensitization, conducting implementation during the low activity dry season, involvement of government and local leadership, use of the competent locally composed team, community knowledge of malaria effects and consequences, combining interventions and evidence of malaria reduction from interventions. Potential barriers such as spreading of misinformation regarding interventions, the strong unpleasant smell from Actellic and inadequate duration of engagement with the community should be taken into consideration. CONCLUSION: This study documents important community engagement strategies that need to be considered when implementing malaria MDA in combination with IRS, for malaria prevention in such settings. This information is useful for malaria programmes, especially during the design and implementation of such community level interventions.

Quality of care for children with acute malnutrition at health center level in Uganda: a cross sectional study in West Nile region during the refugee crisis.

BACKGROUND: Arua district, in Uganda, hosts some of the largest refugee camps in the country. The estimated prevalence of moderate and severe acute malnutrition in children is higher than the national estimates (10.4 and 5.6% respectively, compared to 3.6 and 1.3%). This study aimed at assessing the quality of care provided to children with acute malnutrition at out-patient level in such a setting. METHODS: Six facilities with the highest number of children with malnutrition were selected. The main tool used was the National Nutrition Service Delivery Assessment Tool, assessing 10 key areas of service delivery and assigned a score as either poor, fair, good or excellent. Health outcomes, quality of case management and data quality were assessed from the health management information system and from the official nutrition registers. RESULTS: All facilities except two scored either poor or fair under all the 10 assessment areas. Overall, 33/60 (55%) areas scored as poor, 25/60 (41%) as fair, 2/60 (3.3%) as good, and none as excellent. Main gaps identified included: lack of trained staff; disorganised patient flow; poor case management; stock out of essential supplies including ready-to-use therapeutic foods; weak community linkage. A sample coverage of 45.4% (1020/2248) of total children admitted in the district during the 2016 financial year were included. The overall mean cure rate was 52.9% while the default rate was 38.3%. There was great heterogeneity across health facilities in health outcomes, quality of case management, and data quality. CONCLUSION: This study suggests that quality of care provided to children with malnutrition at health center level is substandard with unacceptable low cure rates. It is essential to identify effective approaches to enhance adherence to national guidelines, provision of essential nutritional commodities, regular monitoring of services and better linkage with the community through village health teams.

Long lasting insecticidal bed nets ownership, access and use in a high malaria transmission setting before and after a mass distribution campaign in Uganda.

INTRODUCTION: Uganda is conducting a second mass LLIN distribution campaign and Katakwi district recently received LLINs as part of this activity. This study was conducted to measure the success of the campaign in this setting, an area of high transmission, with the objectives to estimate LLIN ownership, access and use pre and post campaign implementation. METHODS: Two identical cross sectional surveys, based on the Malaria Indicator Survey methodology, were conducted in three sub-counties in this district (Kapujan, Magoro and Toroma), six months apart, one before and another after the mass distribution campaign. Data on three main LLIN indicators including; household LLIN ownership, population with access to an LLIN and use were collected using a household and a women's questionnaire identical to the Malaria Indicator Survey. RESULTS: A total of 601 and 607 households were randomly selected in survey one and two respectively. At baseline, 60.57% (56.53-64.50) of households owned at least one net for every two persons who stayed in the household the night before the survey which significantly increased to 70.35% (66.54-73.96) after the campaign (p = 0.001). Similarly, the percentage of the household population with access to an LLIN significantly increased from 84.76% (82.99-86.52) to 91.57% (90.33-92.81), p = 0.001 and the percentage of household population that slept under an LLIN the night before the survey also significantly increased from 56.85% (55.06-58.82) to 81.72% (76.75-83.21), p = 0.001. CONCLUSION: The LLIN mass campaign successfully achieved the national target of over eighty-five percent of the population with access to an LLIN in this setting, however, universal household coverage and use were fourteen and three percent points less than the national target respectively. This is useful for malaria programs to consider during the planning of future campaigns by tailoring efforts around deficient areas like mechanisms to increase universal coverage and behavior change communication.

Willingness by people living with HIV/AIDS to utilize HIV services provided by Village Health team workers in Kalungu district, central Uganda.

BACKGROUND: Less than one quarter of people in need have access to HIV services in Uganda. This study assessed willingness of people living with HIV/AIDS (PLWHAs) to utilize HIV services provided by Village Health Teams (VHTs) in Kalungu district, central Uganda. METHODS: A cross-sectional study conducted in two health facilities providing anti-retroviral therapy enrolled 312 PLWHAs. Pre-tested semi-structured questionnaires were administered to participants at household level. A forward fitting logistic regression model computed the predictors of willingness of PLWHAs to utilize services provided by VHTs. RESULTS: Overall, 49% were willing to utilize HIV services provided by VHTs increasing to 75.6% if the VHT member was HIV positive. PLWHAs who resided in urban areas were more likely to utilize HIV services provided by VHTs (AOR 0.24, 95%CI 0.06-0.87). Barriers to utilizing HIV services provided by VHTs were: income level > 40 USD (AOR 6.43 95%CI 1.19-34.68), being a business person (AOR 8.71 95%CI 1.23-61.72), peasant (AOR 7.95 95%CI 1.37-46.19), lack of encouragement from: peers (AOR 6.33 95%CI 1.43-28.09), spouses (AOR 4.93 95%CI 1.23-19.82) and community leader (AOR 9.67 95%CI 3.35-27.92). CONCLUSION: Social support could improve willingness by PLWHAs to utilize HIV services provided by VHTs for increased access to HIV services by PLWHA.

Malaria incidence among children less than 5 years during and after cessation of indoor residual spraying in Northern Uganda.

BACKGROUND: In June 2015, a malaria epidemic was confirmed in ten districts of Northern Uganda; after cessation of indoor residual spraying (IRS). Epidemic was defined as an increase in incidence per month beyond one standard deviation above mean incidence of previous 5 years. Trends in malaria incidence among children-under-5-years were analysed so as to describe the extent of change in incidence prior to and after cessation of IRS. METHODS: Secondary data on out-patient malaria case numbers for children-under-5-years July 2012 to June 2015 was electronically extracted from the district health management information software2 (DHIS2) for ten districts that had IRS and ten control districts that didn't have IRS. Data was adjusted by reporting rates, cleaned by smoothing and interpolation and incidence of malaria per 1000 population derived. Population data obtained from 2002 and 2014 census reports. Data on interventions obtained from malaria programme reports, rainfall data obtained from Uganda National Meteorological Authority. Three groups of districts were created; two based on when IRS ended, the third not having IRS. Line graphs were plotted showing malaria incidence vis-à-vis implementation of IRS, mass net distribution and rainfall. Changes in incidence after withdrawal of IRS were obtained using incidence rate ratios (IRR). IRR was calculated as incidence for each month after the last IRS divided by incidence of the IRS month. Poisson regression was used to test statistical significance. RESULTS: Incidence of malaria declined between spray activities in districts that had IRS. Decline in IRR for 4 months after last IRS month was greater in the sprayed than control districts. On the seventh month following cessation of IRS, incidence in sprayed districts rose above that of the last spray month [1.74: 95% CI (1.40-2.15); and 1.26: 95% CI (1.05-1.51)]. Rise in IRR continued from 1.26 to 2.62 (95% CI 2.21-3.12) in June 2015 for districts that ended IRS in April 2014. Peak in rainfall occurred in May 2015. CONCLUSION: There was sustained control of malaria incidence during IRS implementation. Following withdrawal and peak in rainfall, incidence rose to epidemic proportions. This suggests a plausible link between the malaria epidemic, peak in rainfall and cessation of IRS.

Factors associated with malaria parasitaemia among children under 5 years in Uganda: a secondary data analysis of the 2014 Malaria Indicator Survey dataset.

BACKGROUND: In the midst of success with malaria reduction in Uganda, there are areas that still have high prevalence of malaria parasitaemia. This project aimed at investigating factors associated with this prevalence and its relationship with anaemia. METHODS: This is a secondary data analysis of the 2014 Malaria Indicator Survey dataset of children under 5 years. All had a blood sample taken by finger or heel prick for determination of malaria parasitaemia and estimation of haemoglobin level for anaemia status. The main outcome was the presence of malaria parasitaemia by microscopy and independent variables included: age, gender, residence (urban vs rural), use of a long-lasting, insecticidal-treated net, indoor residual spraying (IRS) of household in the past 6 months, mother's highest education level, mother heard malaria prevention message in the past 6 months, and household wealth status. RESULTS: The analysis included 4930 children and of these, 938 (19.04%: 95% CI 16.63-21.71) tested positive for malaria parasites. Malaria parasite prevalence significantly increased from 11.08 (95% CI 9.12-13.40) among children with no anaemia to 50.99% (95% CI 39.13-62.74) with severe anaemia (Chi-square p-value = 0.001). Additionally, prevalence significantly rose from the youngest age group (under 6 months) by 1.62 times (95% CI 1.04-2.52, p = 0.033) among the age group of 7-12 months and to four times (95% CI 2.57-6.45, p = 0.001) among those who were between 49 and 59 months. The following were associated with reduced parasitaemia: IRS use (AOR 0.23 [0.08-0.61], p = 0.004), educated mothers (primary AOR 0.75 [0.59-0.96], p = 0.023 to tertiary AOR 0.11 [0.02-0.53], 0.006), mother heard malaria message (AOR 0.78 [0.62-0.99], p = 0.037), and wealthier households (richest AOR 0.17 [0.08-0.36], p = 0.001). CONCLUSIONS: Increasing malaria parasite prevalence among children under 5 years is still related to increasing age and severity of anaemia even in the context of decreasing malaria prevalence. Designing interventions that include the use of IRS and behaviour change communication tailored to include older children, especially in areas with high malaria prevalence, could be of added value. All this should be done in an environment that improves the socio-economic status and equity of such populations.

Analgesic Effects of Preincision Ketamine on Postspinal Caesarean Delivery in Uganda's Tertiary Hospital: A Randomized Clinical Trial.

Background. Good postoperative analgesic management improves maternal satisfaction and care of the neonate. Postoperative pain management is a challenge in Mulago Hospital, yet ketamine is accessible and has proven benefit. We determined ketamine's postoperative analgesic effects. Materials and Methods. We did an RCT among consenting parturients that were randomized to receive either intravenous ketamine (0.25 mg/kg) or placebo after spinal anesthetic. Pain was assessed every 30 mins up to 24 hours postoperatively using the numerical rating scale. The first complaint of pain requiring treatment was noted as "time to first breakthrough pain." Results. We screened 100 patients and recruited 88 that were randomized into two arms of 44 patients that received either ketamine or placebo. Ketamine group had 30-minute longer time to first breakthrough pain and lower 24-hour pain scores. Postoperative diclofenac consumption was lesser in the ketamine group compared to placebo and Kaplan-Meier graphs showed a higher probability of experiencing breakthrough pain earlier in the placebo group. Conclusion. Preincision intravenous ketamine (0.25 mg/kg) offered 30-minute prolongation to postoperative analgesia requirement with reduced 24-hour pain scores. We recommend larger studies to explore this benefit. This trial is registered with Pan African Clinical Trial Registry number PACTR201404000807178.

Oral zinc for treating diarrhoea in children.

BACKGROUND: In developing countries, diarrhoea causes around 500,000 child deaths annually. Zinc supplementation during acute diarrhoea is currently recommended by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF). OBJECTIVES: To evaluate oral zinc supplementation for treating children with acute or persistent diarrhoea. SEARCH METHODS: We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (the Cochrane Library 2016, Issue 5), MEDLINE, Embase, LILACS, CINAHL, mRCT, and reference lists up to 30 September 2016. We also contacted researchers. SELECTION CRITERIA: Randomized controlled trials (RCTs) that compared oral zinc supplementation with placebo in children aged one month to five years with acute or persistent diarrhoea, including dysentery. DATA COLLECTION AND ANALYSIS: Both review authors assessed trial eligibility and risk of bias, extracted and analysed data, and drafted the review. The primary outcomes were diarrhoea duration and severity. We summarized dichotomous outcomes using risk ratios (RR) and continuous outcomes using mean differences (MD) with 95% confidence intervals (CI). Where appropriate, we combined data in meta-analyses (using either a fixed-effect or random-effects model) and assessed heterogeneity.We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS: Thirty-three trials that included 10,841 children met our inclusion criteria. Most included trials were conducted in Asian countries that were at high risk of zinc deficiency. Acute diarrhoeaThere is currently not enough evidence from well-conducted RCTs to be able to say whether zinc supplementation during acute diarrhoea reduces death or number of children hospitalized (very low certainty evidence).In children older than six months of age, zinc supplementation may shorten the average duration of diarrhoea by around half a day (MD -11.46 hours, 95% CI -19.72 to -3.19; 2581 children, 9 trials, low certainty evidence), and probably reduces the number of children whose diarrhoea persists until day seven (RR 0.73, 95% CI 0.61 to 0.88; 3865 children, 6 trials, moderate certainty evidence). In children with signs of malnutrition the effect appears greater, reducing the duration of diarrhoea by around a day (MD -26.39 hours, 95% CI -36.54 to -16.23; 419 children, 5 trials, high certainty evidence).Conversely, in children younger than six months of age, the available evidence suggests zinc supplementation may have no effect on the mean duration of diarrhoea (MD 5.23 hours, 95% CI -4.00 to 14.45; 1334 children, 2 trials, moderate certainty evidence), or the number of children who still have diarrhoea on day seven (RR 1.24, 95% CI 0.99 to 1.54; 1074 children, 1 trial, moderate certainty evidence).None of the included trials reported serious adverse events. However, zinc supplementation increased the risk of vomiting in both age groups (children greater than six months of age: RR 1.57, 95% CI 1.32 to 1.86; 2605 children, 6 trials, moderate certainty evidence; children less than six months of age: RR 1.54, 95% CI 1.05 to 2.24; 1334 children, 2 trials, moderate certainty evidence). Persistent diarrhoeaIn children with persistent diarrhoea, zinc supplementation probably shortens the average duration of diarrhoea by around 16 hours (MD -15.84 hours, 95% CI -25.43 to -6.24; 529 children, 5 trials, moderate certainty evidence). AUTHORS' CONCLUSIONS: In areas where the prevalence of zinc deficiency or the prevalence of malnutrition is high, zinc may be of benefit in children aged six months or more. The current evidence does not support the use of zinc supplementation in children less six months of age, in well-nourished children, and in settings where children are at low risk of zinc deficiency.