Dextrose boluses versus burette dextrose infusions in prevention of hypoglycemia among preterms admitted at Mulago Hospital: an open label randomized clinical trial.

BACKGROUND: Hypoglycemia is a major cause of morbidity and mortality among preterm infants and its management remains a challenge in resource limited settings. Use of dextrose infusion by the recommended infusion pumps is not feasible in our environment due to their high costs and yet the current use of mini dextrose boluses with syringes as adapted at Mulago national referral and tertiary teaching hospital has unknown efficacy in prevention of hypoglycemia. OBJECTIVE: We determined the efficacy of dextrose infusions by burettes versus two hourly dextrose boluses in prevention of hypoglycemia among preterms admitted in the first 72 hours at Special Care Unit, Mulago Hospital. METHODS: One hundred and forty preterms aged 0 to 24 hours of life were randomized to receive 10% IV dextrose either as mini boluses or by infusion using burettes in an open label clinical trial. Blood glucose was measured at 0, two hourly for next 6 hours, 6 hourly for next 12 hours and thereafter 12 hourly until end of 72 hours following admission. Primary end point was incidence of hypoglycemia (random blood sugar (RBS) < 2.6 mmol/l) which was expressed as relative risk (RR). Efficacy of the dextrose infusion was computed using 1-RR. RESULTS: From February 2012 to April 2012, 68 preterms in the bolus arm and 72 in the infusion arm were studied. Hypoglycemia was detected in 34% (48/140). The incidence of hypoglycemia in the bolus arm was 59% (40/68) compared to 11% (8/72) in the infusion arm (RR; 0.19, 95% CI; 0.09-0.37). Efficacy (1-RR) of infusion by burettes versus boluses in prevention of hypoglycemia among preterms was 0.81 (95% CI; 0.63-0.90). CONCLUSION: Continuous 10% dextrose infusion by burettes reduced the incidence of hypoglycemia by 81% in the first 72 hours of admission compared to two hourly 10% mini dextrose boluses among preterms admitted at Special Care Unit, Mulago Hospital. (ClinicalTrials.gov Identifier: NCT01688674).

Effectiveness of active case-finding strategies in tuberculosis control in Kampala, Uganda.

BACKGROUND: Passive case finding (PCF) is the strategy implemented by most developing countries to detect new cases of tuberculosis (TB), but detection rates remain low. Active case finding (ACF) is an alternative strategy, although cost is a barrier to implementation. We estimated the cost-effectiveness of a city-wide ACF programme in Kampala, Uganda, compared to the PCF strategy. METHODS: We developed a decision tree and Markov model to compare ACF vs. PCF across several outcome measures. Parameter estimates for costs, probabilities and utility scores were obtained from published reports and peer-reviewed journal articles. The main outcome measures were TB cases detected, deaths averted, life years saved (LYS) and quality-adjusted life years (QALYs). RESULTS: Our model found that ACF implemented city-wide would result in an additional 1594 TB cases detected in 1 year, 675 deaths averted over a 5-year period, 21,928 LYS, and would cost an additional US$109 per additional QALY. The 25-34 year age group received most health benefits (556 cases detected, 229 deaths averted, 8058 LYS), and the programme was most cost-effective in the 45-54 year age group (US$51/QALY). CONCLUSIONS: ACF is an effective strategy for TB control and improving quality of life and is also cost-effective.

A randomized trial of punctuated antiretroviral therapy in Ugandan HIV-seropositive adults with pulmonary tuberculosis and CD4⁺ T-cell counts of ≥ 350 cells/µL.

BACKGROUND: Optimal treatment of human immunodeficiency virus (HIV)-associated tuberculosis in patients with high CD4⁺ T-cell counts is unknown. Suppression of viral replication during therapy for tuberculosis may block effects of immune activation on T cells and slow HIV disease progression. METHODS: We conducted a randomized trial in 214 HIV-infected patients with active tuberculosis and CD4⁺ T-cell counts of ≥ 350 cells/µL to determine whether 6 months of antiretroviral therapy given during tuberculosis treatment would improve clinical outcomes. Subjects were randomized to receive 6 months of abacavir-lamivudine-zidovudine concurrent with tuberculosis therapy or delayed antiretroviral therapy. Endpoints were CD4⁺ T-cell counts of < 250 cells/µL, AIDS, or death. RESULTS: Intervention and comparison arms had similar median CD4⁺ counts (517 and 534 cells/µL, respectively) and HIV RNA levels (4.6 and 4.7 log10 copies/µL, respectively). Viral suppression was achieved in 86% of patients allocated to intervention. Seventeen subjects (15.6%) in the intervention arm developed study outcome compared to 25 subjects (22.8%) in the comparison arm (P = .17). Grade 3 or 4 adverse events were less frequent in the intervention arm. By 2 months, 90% of subjects in both arms were culture-negative for tuberculosis. CONCLUSIONS: Short-term antiretroviral therapy during tuberculosis treatment in patients with CD4⁺T-cell counts of >350 cells/µL was safe and associated with clinical benefits.

Impact of emergency mass immunisations on measles control in displaced populations in Gulu district, northern Uganda.

OBJECTIVE: To assess the impact of supplemental mass measles immunisations. DESIGN: Retrospective study of hospital and health centre records. SETTING: Gulu district, Northern Uganda, having approximately 81% of the population living in internally displaced persons' (IDPs) camps. RESULTS: The mean age in months for 4,812 measles cases seen was 28.2 +/- 46.0 (p < 0.0001). Supplemental mass immunisations in 1997 and 2000 caused a 91% reduction of measles cases, 93% reduction of mortality, 91% reduction of bed-days and 79% reduction of outpatient cases. There was a 67% reduction in mean measles case admissions, 63% reduction in mean measles mortality, and 73% reduction in mean measles bed-days following district mass measles immunisations in 1997. However, following IDPs camps supplemental immunisations in 2000; there was 82% reduction of mean measles case admissions, 80% reduction of mean measles mortality and 88% reduction of mean measles bed-days. CONCLUSIONS: In similar situations, supplemental mass measles immunisations should be focused on IDPs camps with a wide age group in addition to improved routine immunization activities in the entire district.

Ebola haemorrhagic fever among hospitalised children and adolescents in northern Uganda: epidemiologic and clinical observations.

BACKGROUND: A unique feature of previous Ebola outbreaks has been the relative sparing of children. For the first time, an out break of an unusual illness-Ebola haemorrhagic fever occurred in Northern Uganda Gulu district. OBJECTIVES: To describe the epidemiologic and clinical aspects of hospitalised children and adolescents on the isolation wards. METHODS: A retrospective descriptive survey of hospital records for hospitalised children and adolescents under 18 years on the isolation wards in Gulu, Northern Uganda was conducted. All patient test notes were consecutively reviewed and non was excluded because being deficient. RESULTS: Analysis revealed that 90 out of the 218 national laboratory confirmed Ebola cases were children and adolescents with a case fatality of 40%. The mean age was 8.2 years +/- SD 5.6 with a range of 16.99 years. The youngest child on the isolation wards was 3 days old. The under fives contributed the highest admission (35%) among children and adolescents; and case fatality because of prolonged close contact with the seropositive relatives among the laboratory confirmed cases. All (100%) Ebola positive children and adolescents were febrile while only 16% had hemorrhagic manifestations. CONCLUSION: Similar to previous Ebola outbreaks, a relative sparing of children in this outbreak was observed. The under fives were at an increased risk of contact with the sick and dying. RECOMMENDATIONS: Strategies to shield children from exposure to dying and sick Ebola relatives are recommended in the event of future Ebola outbreaks. Health education to children and adolescents to avoid contact with sick and their body fluids should be emphasized.