Access to and utilisation of antimicrobials among forcibly displaced persons in Uganda, Yemen and Colombia: a pilot cross-sectional survey.

OBJECTIVES: Identifying key barriers to accessing quality-assured and affordable antimicrobials among forcibly displaced persons in Uganda, Yemen and Colombia and investigating their (1) utilisation patterns of antibiotics, (2) knowledge about antimicrobial resistance (AMR) and (3) perception of the quality of antimicrobials received. DESIGN: Pilot cross-sectional survey. SETTING: Data were collected from five health facilities in the Kiryandongo refugee settlement (Bweyale, Uganda), three camps for internally displaced persons (IDPs) in the Dar Sad district (Aden, Yemen) and a district with a high population of Venezuelan migrants (Kennedy district, Bogotá, Colombia). Data collection took place between February and May 2021. The three countries were selected due to their high number of displaced people in their respective continents. PARTICIPANTS: South Sudanese refugees in Uganda, IDPs in Yemen and Venezuelan migrants in Colombia. OUTCOME MEASURE: The most common barriers to access to quality-assured and affordable antimicrobials. RESULTS: A total of 136 participants were enrolled in this study. Obtaining antimicrobials through informal pathways, either without a doctor's prescription or through family and friends, was common in Yemen (27/50, 54.0%) and Colombia (34/50, 68.0%). In Yemen and Uganda, respondents used antibiotics to treat (58/86, 67.4%) and prevent (39/86, 45.3%) a cold. Knowledge of AMR was generally low (24/136, 17.6%). Barriers to access included financial constraints in Colombia and Uganda, prescription requirements in Yemen and Colombia, and non-availability of drugs in Uganda and Yemen. CONCLUSION: Our multicentred research identified common barriers to accessing quality antimicrobials among refugees/IDPs/migrants and common use of informal pathways. The results suggest that knowledge gaps about AMR may lead to potential misuse of antimicrobials. Due to the study's small sample size and use of non-probability sampling, the results should be interpreted with caution, and larger-scale assessments on this topic are needed. Future interventions designed for similar humanitarian settings should consider the interlinked barriers identified.

New Vibrio cholerae sequences from Eastern and Southern Africa alter our understanding of regional cholera transmission.

Despite ongoing containment and vaccination efforts, cholera remains prevalent in many countries in sub-Saharan Africa. Part of the difficulty in containing cholera comes from our lack of understanding of how it circulates throughout the region. To better characterize regional transmission, we generated and analyzed 118 Vibrio cholerae genomes collected between 2007-2019 from five different countries in Southern and Eastern Africa. We showed that V. cholerae sequencing can be successful from a variety of sample types and filled in spatial and temporal gaps in our understanding of circulating lineages, including providing some of the first sequences from the 2018-2019 outbreaks in Uganda, Kenya, Tanzania, Zambia, and Malawi. Our results present a complex picture of cholera transmission in the region, with multiple lineages found to be co-circulating within several countries. We also find evidence that previously identified sporadic cases may be from larger, undersampled outbreaks, highlighting the need for careful examination of sampling biases and underscoring the need for continued and expanded cholera surveillance across the African continent.

Factors associated with family planning use among refugee and host populations in Adjumani district, West Nile, Uganda: a comparative study.

INTRODUCTION: Uganda currently hosts an estimated 1.5 million refugees. The refugees have challenges in accessing family planning (FP) services in the host country. The study aimed to investigate factors associated with FP use among host and refugee populations in Adjumani district, Uganda. METHODS: A comparative cross-sectional study was conducted in May 2021 in three refugee settlements and their host communities in Adjumani district. A total of 1,310 respondents, (664 refugees and 646 host) were randomly selected using multistage cluster sampling and interviewed. Quantitative data were collected using structured questionnaires and analyzed using STATA V.15. Descriptive and Multivariate analysis performed. RESULTS: We found that modern Contraceptive Prevalence Rate (mCPR) was 30.2% (32.2% for host and 28.2% for refugees). Multivariate analysis showed that women who live singly (AOR = 2.25, 95%, CI: 1.56 -3.84), completed primary education [AOR = 1.65, 95% CI: 1.27-2.16], acquired skills [AOR = 2.28, 95% CI: 2.11-2.47], have the desire for another child [AOR = 3.73, 95% CI: 1.45- 9.60], have stayed in the study area between 3-5 years [AOR = 2.24, 95% CI: 1.46-3.42] were statistically significantly associated with FP use among both refugee and host populations. The key barrier to FP use by host was harassment of women and separation/divorce for not consulting the family members. Whereas amongst the refugees, they do not want to use FP methods. CONCLUSION: Our findings revealed low FP use amongst both populations in Adjumani district. The main factors associated with FP use amongst refugee populations included marital status, level of education, type of occupation, and duration of stay in the study area whereas amongst the host is the marital status. Main reasons for not using FP methods included fear of side effects by hosts and not wanting to use FP by refugees. There is need to sensitize both communities about the benefits of FP at community level.

Exploring women's interpretations of survey questions on pregnancy and pregnancy outcomes: cognitive interviews in Iganga Mayuge, Uganda.

BACKGROUND: In 2021, Uganda's neonatal mortality rate was approximately 19 deaths per 1000 live births, with an estimated stillbirth rate of 15.1 per 1000 total births. Data are critical for indicating areas where deaths occur and why, hence driving improvements. Many countries rely on surveys like Demographic and Health Surveys (DHS), which face challenges with respondents' misinterpretation of questions. However, little is documented about this in Uganda. Cognitive interviews aim to improve questionnaires and assess participants' comprehension of items. Through cognitive interviews we explored women's interpretations of questions on pregnancy and pregnancy outcomes. METHODS: In November 2021, we conducted cognitive interviews with 20 women in Iganga Mayuge health and demographic surveillance system site in eastern Uganda. We adapted the reproductive section of the DHS VIII women's questionnaire, purposively selected questions and used concurrent verbal probing. Participants had secondary school education and were English speaking. Cognition was measured through comparing instructions in the DHS interviewers' manual to participants' responses and researcher's knowledge. A qualitative descriptive approach to analysis was undertaken. RESULTS: We report findings under the cognitive aspect of comprehension. Some questions were correctly understood, especially those with less technical terms or without multiple sections. Most participants struggled with questions asking whether the woman has her living biological children residing with her or not. Indeed, some thought it referred to how many living children they had. There were comprehension difficulties with long questions like 210 that asks about miscarriages, newborn deaths, and stillbirths together. Participants had varying meanings for miscarriages, while many misinterpreted stillbirth, not linking it to gestational age. Furthermore, even amongst educated women some survey questions were misunderstood. CONCLUSIONS: Population surveys may misclassify, over or under report events around pregnancy and pregnancy outcomes. Interviewers should begin with a standard definition of key terms and ensure respondents understand these. Questions can be simplified through breaking up long sentences, while interviewer training should be modified to ensure they thoroughly understand key terms. We recommend cognitive interviews while developing survey tools, beyond basic pre-testing. Improving respondents' comprehension and thus response accuracy will increase reporting and data quality.

Diagnostic and pre-treatment intervals among patients with cervical cancer attending care at the Uganda Cancer Institute: a cross-sectional study.

BACKGROUND: Majority of patients with cervical cancer in the low- and middle-income countries experience long diagnostic and pre-treatment intervals. This study sought to determine the factors associated with the diagnostic and pre-treatment intervals among patients with cervical cancer. METHODS: This was a cross-sectional study conducted at the Uganda Cancer Institute (UCI) during October 2019 to January 2020. Patients aged ≥ 18 years with histological diagnosis of cervical cancer were consecutively sampled. Data were collected using a pre-tested semi-structured questionnaire and a data abstraction form. Diagnostic intervals, defined as the time between first visit of a patient to a primary healthcare provider to time of getting confirmed diagnosis, of ≤ 3 months was defined as early & >3 months as late. Pre-treatment intervals, which is the time from histological diagnosis to starting cancer chemo-radiotherapy of ≤ 1 month was defined as early and > 1 month as late. Data were analysed using STATA version 14.0. We used modified Poisson regression models with robust variance to determine socio-demographic and clinical factors associated with the intervals. RESULTS: The mean age of the participants was 50.0 ± 11.7 years. The median diagnostic and pre-treatment intervals were 3.1 (IQR: 1.4-8.2) months and 2.4 (IQR: 1.2-4.1) months respectively. Half of the participants, 49.6% (200/403) were diagnosed early; one in 5 patients, 20.1% (81/403) promptly (within one month) initiated cancer chemo-radiotherapy. Participants more likely to be diagnosed early included those referred from district hospitals (level 5) (aPR = 2.29; 95%CI: 1.60-3.26) and with squamous cell carcinomas (aPR = 1.55; 95%CI: 1.07-2.23). Participants more likely to be diagnosed late included those who first discussed their symptoms with relatives, (aPR = 0.77; 95%CI: (0.60-0.98), had > 2 pre-referral visits (aPR = 0.75; 95%CI (0.61-0.92), and had advanced stage (stages 3 or 4) (aPR = 0.68; 95%CI: 0.55-0.85). Participants more likely to initiate cancer chemo-radiotherapy early included older patients (≥ 60 years) (aPR = 2.44; 95%CI: 1.18-5.03). Patients likely to start treatment late were those who had ≥2 pre-referral visits  (aPR = 0.63; 95%CI: 0.41-0.98) and those that took 3 - 6 months with symptoms before seeking healthcare (aPR = 0.52;95%CI: 0.29 - 0.95). CONCLUSION: Interventions to promote prompt health-seeking and early diagnosis of cervical cancer need to target primary healthcare facilities and aim to enhance capacity of primary healthcare professionals to promptly initiate diagnostic investigations. Patients aged < 60 years require targeted interventions to promote prompt initiation of chemo-radiation therapy.

Factors associated with diagnostic and pre-treatment intervals among breast cancer patients attending care at the Uganda Cancer Institute: A cross-sectional study.

BACKGROUND: Most breast cancer (BC) patients in Uganda are diagnosed with advanced-stage disease and experience poor outcomes. This study examined the diagnostic and pre-treatment intervals and factors associated with these intervals among BC patients attending care at the Uganda Cancer Institute (UCI). METHODS: This was a cross-sectional, facility-based study. Data were collected using structured questionnaire administered by trained research assistants and analyzed using STATA version 14.0. Modified Poisson regressions models were used to determine the strength of associations between independent variables and diagnostic and pre-treatment intervals. RESULTS: The mean age (±SD) of the 401 participants was 47.1 ± 11.7 years. Four in 10 participants had stage III (41.9%; n = 168) and over a third (34.7%; n = 140) stage IV cancers. The median interval from first consultation to diagnosis, i.e. diagnostic interval (DI) was 5.6 months (IQR: 1.5-17.0), while the median interval from histological diagnosis to start of chemotherapy, i.e. pre-treatment interval (PTI) was 1.7 months (IQR: 0.7-4.5). Majority (85%, n = 341) of participants were diagnosed at ≥3 months from first consultation with clinicians. Participants with tertiary education and those who lived within 100-199 km from the UCI were about four times and twice more likely to be diagnosed early (DI <3 months from first consultation) ([aPR = 3.88; 95% CI: 1.15-13.0] and [aPR = 2.19; 95% CI: 1.06-4.55]), respectively. About half (48.3%; n = 176) of participants started chemotherapy within 1 month of cancer diagnosis. Patients who lived more than 300 km from the UCI were less likely to start chemotherapy within 1 month of histology diagnosis of cancer. [Correction added on October 17, 2023 after first online publication. The term ', i.e.' has been included in the results section in this version.] CONCLUSION: Majority of breast cancer patients are diagnosed late and in advanced stages. There is need to promote all efforts toward timely diagnosis when cancers are still in early stages by identifying factors responsible for prolonged diagnostic intervals among breast cancer patients.

Cholera and COVID-19 pandemic prevention in multiple hotspot districts of Uganda: vaccine coverage, adverse events following immunization and WASH conditions survey.

BACKGROUND: Between March, 2020 and December, 2021 due to cholera and coronavirus disease 2019 (COVID-19) pandemics, there were 1,534 cholera cases with 14 deaths and 136,065 COVID-19 cases with 3,285 deaths reported respectively in Uganda. This study investigated mass vaccination campaigns for the prevention of the two pandemics namely: oral cholera vaccine (OCV) and COVID-19 vaccine coverage; adverse events following immunization (AEFI); barriers and enablers for the vaccine uptake and assessed water, sanitation and hygiene (WASH) conditions in the six cholera and COVID-19 hotspot districts of Uganda. METHODS: A household survey was conducted between January and February, 2022 in the six cholera hotspot districts of Uganda which had recently conducted OCV mass vaccination campaigns and had ongoing COVID-19 mass vaccination campaigns. The survey randomly enrolled 900 households with 4,315 persons of whom 2,085 were above 18 years. Data were collected using a data entry application designed in KoBoToolbox and analysed using STATA version 14. Frequencies, percentages, odds ratios, means, confidence intervals and maps were generated and interpreted. RESULTS: The OCV coverage for dose one and two were 85% (95% CI: 84.2-86.4) and 67% (95% CI: 65.6-68.4) respectively. Among the 4,315 OCV recipients, 2% reported mild AEFI, 0.16% reported moderate AEFI and none reported severe AEFI. The COVID-19 vaccination coverage for dose one and two were 69.8% (95% CI: 67.8-71.8) and 18.8% (95% CI: 17.1-20.5) respectively. Approximately, 23% (478/2,085) of COVID-19 vaccine recipient reported AEFI; most 94% were mild, 0.6% were moderate and 2 cases were severe. The commonest reason for missing COVID-19 vaccine was fear of the side effects. For most districts (5/6), sanitation (latrine/toilet) coverage were low at 7.4%-37.4%. CONCLUSION: There is high OCV coverage but low COVID-19 vaccine and sanitation coverage with high number of moderate cases of AEFI recorded due to COVID-19 vaccines. The low COVID-19 vaccine coverage could indicate vaccine hesitancy for COVID-19 vaccines. Furthermore, incorporation of WASH conditions assessment in the OCV coverage surveys is recommended for similar settings to generate data for better planning. However, more studies are required on COVID-19 vaccine hesitancy.

Development of a Scorecard to Monitor Progress toward National Cholera Elimination: Its Application in Uganda.

In 2017, the Global Task Force for Cholera Control (GTFCC) set a goal to eliminate cholera from ≥ 20 countries and to reduce cholera deaths by 90% by 2030. Many countries have included oral cholera vaccine (OCV) in their cholera control plans. We felt that a simple, user-friendly monitoring tool would be useful to guide national progress toward cholera elimination. We reviewed cholera surveillance data of Uganda from 2015 to 2021 by date and district. We defined a district as having eliminated cholera if cholera was not reported in that district for at least 4 years. We prepared maps to show districts with cholera, districts that had eliminated it, and districts that had eliminated it but then "relapsed." These maps were compared with districts where OCV was used and the hotspot map recommended by the GTFCC. Between 2018 and 2021, OCV was administered in 16 districts previously identified as hotspots. In 2018, cholera was reported during at least one of the four previous years from 36 of the 146 districts of Uganda. This number decreased to 18 districts by 2021. Cholera was deemed "eliminated" from four of these 18 districts but then "relapsed." The cholera elimination scorecard effectively demonstrated national progress toward cholera elimination and identified districts where additional resources are needed to achieve elimination by 2030. Identification of the districts that have eliminated cholera and those that have relapsed will assist the national programs to focus on addressing the factors that result in elimination or relapse of cholera.

Traditional health practices: A qualitative inquiry among traditional health practitioners in northern Uganda on becoming a healer, perceived causes of illnesses, and diagnostic approaches.

BACKGROUND: The practice of traditional and complementary medicine is increasing in most low-and middle-income countries especially for chronic communicable and non-communicable diseases. In this study, we aimed to understand how people gain healing power and become traditional health practitioners (THPs), perceived causes of illnesses, and how THPs diagnose illnesses. METHODS: This was a cross-sectional qualitative interview-based study. We used semi-structured in-depth guides to collect data from THPs identified through the Acoli cultural institutions and snowball sampling technique. The study team visited the THPs and interviewed them in their homes. Some THPs allowed the study team to visit them more than once and as well observe their healing practices and medicines. Thematic analysis approach was used to analyze the data. Atlas.ti version 9.2 was used to support data analysis. RESULTS: Twenty two THPs aged 39-80 years were included in the study. Most of the respondents were male, and married. We identified three main themes: (i) how people gain healing power and become traditional health practitioners; (ii) perceived causes of illnesses; and (iii) how illnesses are diagnosed. The majority of respondents reported that most people become THPs through: inheriting healing power from their parents or grandparents; transfer of healing powers from senior healers; instructions during visions and dreams; and, acquiring healing power during spirits possessions. Perceived causes of illnesses included: fate and natural causes, spirits attacks, curses by elders, witchcraft, contagion and infections, poor hygiene, heredity, and malevolent actions. THPs diagnose illnesses through various approaches including consultations with spirits, observing patterns of occurrences and events, evaluation of symptoms and signs of illnesses, use of bones from animals/birds and other objects to diagnose illnesses, performing diagnostic rituals, and using biomedical laboratory testing in health facilities. CONCLUSION: Healing knowledge and powers are acquired in particular ways that can be traced to appraise authenticity of healers during registration and licensing to ensure safety of patients. Understanding perspectives of the THPS on causes of illnesses and how diagnoses are made potentially informs strategies for integration and or collaboration between the national biomedical health system and traditional health practices.

Sustainability of health services in refugee hosting districts: a qualitative study of health services in three west Nile refugee hosting districts, Uganda.

BACKGROUND: Humanitarian health assistance programmes have expanded from temporary approaches addressing short-term needs to providing long-term interventions in emergency settings. Measuring sustainability of humanitarian health services is important towards improving the quality of health services in refugee settings. OBJECTIVE: To explore the sustainability of health services following the repatriation of refugees from the west Nile districts of Arua, Adjumani and Moyo. METHODS: This was a qualitative comparative case study conducted in three west Nile refugee-hosting districts of Arua, Adjumani, and Moyo. In-depth interviews were conducted with 28 purposefully selected respondents in each of the three districts. Respondents included health workers and managers, district civic leaders, planners, chief administrative officers, district health officers, project staff of aid agencies, refugee health focal persons and community development officers. RESULTS: The study shows that in terms of organization capacity, the District Health Teams provided health services to both refugee and host communities with minimal support from aid agencies. Health services were available in most former refugee hosting areas in Adjumani, Arua and Moyo districts. However, there were several disruptions notably reduction and inadequate services due to shortage of drugs and essential supplies, lack of health workers, and closure or relocation of health facilities in around former settlements. To minimize disruptions the district health office reorganized health services. In restructuring health services, the district local governments closed or upgraded health facilities to address reduced capacity and catchment population. Health workers employed by aid agencies were recruited into government services while others who were deemed excess or unqualified were laid off. Equipment and machinery including machines and vehicles were transferred to the district health office in specific health facilities. Funding for health services was mainly provided by the Government of Uganda through the Primary Health Care Grant. Aid agencies, however, continued to provide minimal support health services for refugees who remained in Adjumani district. CONCLUSION: Our study showed that while humanitarian health services are not designed for sustainability, several interventions continued at the end of the refugee emergency in the three districts. The embeddedness of the refugee health services in the district health systems ensured health services continued through public service delivery structures. It is important to strengthen the capacity of the local service delivery structures and ensure health assistance programmes are integrated into local health systems to promote sustainability.

Prediction of pre-eclampsia at St. Mary's hospital lacor, a low-resource setting in northern Uganda, a prospective cohort study.

BACKGROUND: Pre-eclampsia is the second leading cause of maternal death in Uganda. However, mothers report to the hospitals late due to health care challenges. Therefore, we developed and validated the prediction models for prenatal screening for pre-eclampsia. METHODS: This was a prospective cohort study at St. Mary's hospital lacor in Gulu city. We included 1,004 pregnant mothers screened at 16-24 weeks (using maternal history, physical examination, uterine artery Doppler indices, and blood tests), followed up, and delivered. We built models in RStudio. Because the incidence of pre-eclampsia was low (4.3%), we generated synthetic balanced data using the ROSE (Random Over and under Sampling Examples) package in RStudio by over-sampling pre-eclampsia and under-sampling non-preeclampsia. As a result, we got 383 (48.8%) and 399 (51.2%) for pre-eclampsia and non-preeclampsia, respectively. Finally, we evaluated the actual model performance against the ROSE-derived synthetic dataset using K-fold cross-validation in RStudio. RESULTS: Maternal history of pre-eclampsia (adjusted odds ratio (aOR) = 32.75, 95% confidence intervals (CI) 6.59-182.05, p = 0.000), serum alkaline phosphatase(ALP) < 98 IU/L (aOR = 7.14, 95% CI 1.76-24.45, p = 0.003), diastolic hypertension ≥ 90 mmHg (aOR = 4.90, 95% CI 1.15-18.01, p = 0.022), bilateral end diastolic notch (aOR = 4.54, 95% CI 1.65-12.20, p = 0.003) and body mass index of ≥ 26.56 kg/m2 (aOR = 3.86, 95% CI 1.25-14.15, p = 0.027) were independent risk factors for pre-eclampsia. Maternal age ≥ 35 years (aOR = 3.88, 95% CI 0.94-15.44, p = 0.056), nulliparity (aOR = 4.25, 95% CI 1.08-20.18, p = 0.051) and white blood cell count ≥ 11,000 (aOR = 8.43, 95% CI 0.92-70.62, p = 0.050) may be risk factors for pre-eclampsia, and lymphocyte count of 800 - 4000 cells/microliter (aOR = 0.29, 95% CI 0.08-1.22, p = 0.074) may be protective against pre-eclampsia. A combination of all the above variables predicted pre-eclampsia with 77.0% accuracy, 80.4% sensitivity, 73.6% specificity, and 84.9% area under the curve (AUC). CONCLUSION: The predictors of pre-eclampsia were maternal age ≥ 35 years, nulliparity, maternal history of pre-eclampsia, body mass index, diastolic pressure, white blood cell count, lymphocyte count, serum ALP and end-diastolic notch of the uterine arteries. This prediction model can predict pre-eclampsia in prenatal clinics with 77% accuracy.

Negative experiences and coping strategies to stressful situations by undergraduate University students during Covid- 19 lockdown period in Uganda.

Aim: To describe the negative experiences, coping strategies for stressful situations, and factors associated with COVID-19 worry among undergraduate students at Makerere University during the second COVID-19 lockdown in Uganda. Methods: Descriptive cross-sectional study at Makerere University. Negative experiences and coping strategies were measured using a semi-structured questionnaire formulated based on literature and findings from previous studies on mental health and COVID-19. Descriptive statistics and measures of association were done using Stata 13. Results: A total of 301 participants were enrolled. Their median age were 23 years. The majority were male (192, 64.0 %), single (269, 89.7 %,) and on normal academic progress (241, 80.3 %). 48.0 % of the participants were worried about COVID-19. Disruption of students' academics (277, 92.0 %) and financial problems (184, 61.1 %) were the most reported negative experiences. Coping strategies included listening to music (203, 67.4 %), talking to family and friends (191, 63.5 %,) and watching movies (174, 57.8 %). Female students than males (aOR: 2.0, 95% CI: 1.0-45.0, p= 0.118) and students without paid employment than those with paid work (aOR: 2.2, 95% CI: 1.0-5.0, p=0.109) were more worried about COVID-19. Conclusion: Nearly half of the students were worried about COVID-19, which disrupted their social and academic lives. The students utilized a myriad of coping strategies.

Repatriation of South Sudanese refugees from the West Nile districts, Uganda. What do we learn from the process?

Introduction: Repatriation is a fundamental and often preferred solution to the refugee crisis around the world. This study explored the process of repatriation of the South Sudanese refugees from the West Nile districts in Uganda. Methods: This was a retrospective analysis of the process of repatriation of refugees in three west Nile refugee districts of Adjumani, Arua, and Moyo, Uganda. Both qualitative and qualitative data were collected. Results: The findings showed that several stakeholders were involved in the repatriation exercise including the government at central and district levels, United Nations agencies and non-governmental organizations, and refugee communities. The key steps undertaken during repatriation include information and education campaigns to promote returns focussing on security and socio-economic conditions in South Sudan and the facilitation of confidence-building visits in the areas of origin. During the repatriation exercise, key interventions provided included health care screening and treatment, and the provision of reintegration support services including the provision of food security items and cash allowances. Conclusions: The findings highlight the fundamental steps followed during a well-planned, structured, and effective repatriation of South Sudanese refugees from Uganda. Understanding repatriation requires an appreciation of how it is implemented to support offering an effective, durable, and lasting solution to refugees to promote their health and welfare.

Prediction of stillbirth low resource setting in Northern Uganda.

BACKGROUND: Women of Afro-Caribbean and Asian origin are more at risk of stillbirths. However, there are limited tools built for risk-prediction models for stillbirth within sub-Saharan Africa. Therefore, we examined the predictors for stillbirth in low resource setting in Northern Uganda. METHODS: Prospective cohort study at St. Mary's hospital Lacor in Northern Uganda. Using Yamane's 1967 formula for calculating sample size for cohort studies using finite population size, the required sample size was 379 mothers. We doubled the number (to > 758) to cater for loss to follow up, miscarriages, and clients opting out of the study during the follow-up period. Recruited 1,285 pregnant mothers at 16-24 weeks, excluded those with lethal congenital anomalies diagnosed on ultrasound. Their history, physical findings, blood tests and uterine artery Doppler indices were taken, and the mothers were encouraged to continue with routine prenatal care until the time for delivery. While in the delivery ward, they were followed up in labour until delivery by the research team. The primary outcome was stillbirth 24 + weeks with no signs of life. Built models in RStudio. Since the data was imbalanced with low stillbirth rate, used ROSE package to over-sample stillbirths and under-sample live-births to balance the data. We cross-validated the models with the ROSE-derived data using K (10)-fold cross-validation and obtained the area under curve (AUC) with accuracy, sensitivity and specificity. RESULTS: The incidence of stillbirth was 2.5%. Predictors of stillbirth were history of abortion (aOR = 3.07, 95% CI 1.11-8.05, p = 0.0243), bilateral end-diastolic notch (aOR = 3.51, 95% CI 1.13-9.92, p = 0.0209), personal history of preeclampsia (aOR = 5.18, 95% CI 0.60-30.66, p = 0.0916), and haemoglobin 9.5 - 12.1 g/dL (aOR = 0.33, 95% CI 0.11-0.93, p = 0.0375). The models' AUC was 75.0% with 68.1% accuracy, 69.1% sensitivity and 67.1% specificity. CONCLUSION: Risk factors for stillbirth include history of abortion and bilateral end-diastolic notch, while haemoglobin of 9.5-12.1 g/dL is protective.

Adverse pregnancy outcome disclosure and women's social networks: a qualitative multi-country study with implications for improved reporting in surveys.

BACKGROUND: Globally, approximately 6,700 newborn deaths and 5,400 stillbirths occur daily. The true figure is likely higher, with under reporting of adverse pregnancy outcomes (APOs) noted. Decision-making in health is influenced by various factors, including one's social networks. We sought to understand APOs disclosure within social networks in Uganda, Ghana, Guinea-Bissau and Bangladesh and how this could improve formal reporting of APOs in surveys.  METHODS: A qualitative, exploratory multi-country study was conducted within four health and demographic surveillance system sites. 16 focus group discussions were held with 147 women aged 15-49 years, who had participated in a recent household survey. Thematic analysis, with both deductive and inductive elements, using three pre-defined themes of Sender, Message and Receiver was done using NVivo software. RESULTS: Disclosure of APOs was a community concern, with news often shared with people around the bereaved for different reasons, including making sense of what happened and decision-making roles of receivers. Social networks responded with comfort, providing emotional, in-kind and financial support. Key decision makers included men, spiritual and traditional leaders. Non-disclosure was usually to avoid rumors in cases of induced abortions, or after a previous bad experience with health workers, who were frequently excluded from disclosure, except for instances where a woman sought advice on APOs. CONCLUSIONS: Communities must understand why they should report APOs and to whom. Efforts to improve APOs reporting could be guided by diffusion of innovation theory, for instance for community entry and sensitization before the survey, since it highlights how information can be disseminated through community role models. In this case, these gatekeepers we identified could promote reporting of APOs. The stage at which a person is in decision-making, what kind of adopter they are and their take on the benefits and other attributes of reporting are important. In moving beyond survey reporting to getting better routine data, the theory would be applicable too. Health workers should demonstrate a more comforting and supportive response to APOs as the social networks do, which could encourage more bereaved women to inform them and seek care.

Cholera risk in cities in Uganda: understanding cases and contacts centered strategy (3CS) for rapid cholera outbreak control.

INTRODUCTION: in the recent past, cities in sub-Saharan Africa have reported serious cholera outbreaks that last for several months. Uganda is one of the African countries where cities are prone to cholera outbreaks. Studies on cholera in Bangladesh show increased risk of cholera for the immediate household members (contacts) yet the control interventions mainly target cases with little or no focus on contacts. This study aimed to describe the rapid control of cholera outbreaks in Kampala and Mbale cities, Uganda, using, "Cases and Contacts Centered Strategy (3CS)" that consisted of identification and treatment of cases, promotion of safe water, sanitation, hygiene (WaSH) and selective chemoprophylaxis for the contacts. METHODS: a cross-sectional study was conducted in 2015-2016 in the Kampala and Mbale cities during cholera outbreaks. Cholera cases were treated and 816 contacts from 188 households were listed and given cholera preventive packages. Data were collected, cleaned, analysed and stored in spreadsheet. Comparison of categories was done using Chi-Square test. RESULTS: a total of 58 and 41 confirmed cholera cases out of 318 and 153 suspected cases were recorded in Kampala and Mbale cities respectively. The outbreaks lasted for 41 days in both cities. Case fatality rates were high; 12.1% (5/41) for Mbale city and 1.7% (1/58) for Kampala city. Fifty-five percent (210/379) of stool samples were tested by culture to confirm V. choleraeO1. No contacts listed and given cholera preventive package developed cholera. Both sexes and all age groups were affected. In Kampala city, the males were more affected than the females in the age groups less than 14 years, p-value of 0.0097. CONCLUSION: this study showed that by implementing 3CS, it was possible to rapidly control cholera outbreaks in Kampala and Mbale cities and no cholera cases were reported amongst the listed household contacts. The findings on 3CS and specifically, selective antibiotic chemoprophylaxis for cholera prevention, could be used in similar manner to oral cholera vaccines to complement the core cholera control interventions (disease surveillance, treatment of cases and WaSH). However, studies are needed to guide such rollout and to understand the age-sex differences in Kampala city.

Refugee Settlements and Cholera Risks in Uganda, 2016-2019.

During 2016 to 2019, cholera outbreaks were reported commonly to the Ministry of Health from refugee settlements. To further understand the risks cholera posed to refugees, a review of surveillance data on cholera in Uganda for the period 2016-2019 was carried out. During this 4-year period, there were seven such outbreaks with 1,495 cases and 30 deaths in five refugee settlements and one refugee reception center. Most deaths occurred early in the outbreak, often in the settlements or before arrival at a treatment center rather than after arrival at a treatment center. During the different years, these outbreaks occurred during different times of the year but simultaneously in settlements that were geographically separated and affected all ages and genders. Some outbreaks spread to the local populations within Uganda. Cholera control prevention measures are currently being implemented; however, additional measures are needed to reduce the risk of cholera among refugees including oral cholera vaccination and a water, sanitation and hygiene package during the refugee registration process. A standardized protocol is needed to quickly conduct case-control studies to generate information to guide future cholera outbreak prevention in refugees and the host population.

Use of surveys to evaluate an integrated oral cholera vaccine campaign in response to a cholera outbreak in Hoima district, Uganda.

OBJECTIVES: To evaluate the quality and coverage of the campaign to distribute oral cholera vaccine (OCV) during a cholera outbreak in Hoima, Uganda to guide future campaigns of cholera vaccine. DESIGN: Survey of communities targeted for vaccination to determine vaccine coverage rates and perceptions of the vaccination campaign, and a separate survey of vaccine staff who carried out the campaign. SETTING: Hoima district, Uganda. PARTICIPANTS: Representative clusters of households residing in the communities targeted for vaccination and staff members who conducted the vaccine campaign. RESULTS: Among 209 households (1274 individuals) included in the coverage survey, 1193 (94%; 95% CI 92% to 95%) reported receiving at least one OCV dose and 998 (78%; 95% CI 76% to 81%) reported receiving two doses. Among vaccinated individuals, minor complaints were reported by 71 persons (5.6%). Individuals with 'some' education (primary school or above) were more knowledgeable regarding the required OCV doses compared with non-educated (p=0.03). Factors negatively associated with campaign implementation included community sensitisation time, staff payment and problems with field transport. Although the campaign was carried out quickly, the outbreak was over before the campaign started. Most staff involved in the campaign (93%) were knowledgeable about cholera control; however, 29% did not clearly understand how to detect and manage adverse events following immunisation. CONCLUSION: The campaign achieved high OCV coverage, but the surveys provided insights for improvement. To achieve high vaccine coverage, more effort is needed for community sensitisation, and additional resources for staff transportation and timely payment for campaign staff is required. Pretest and post-test assessment of staff training can identify and address knowledge and skill gaps.

The quality of drinking and domestic water from the surface water sources (lakes, rivers, irrigation canals and ponds) and springs in cholera prone communities of Uganda: an analysis of vital physicochemical parameters.

BACKGROUND: Water is the most abundant resource on earth, however water scarcity affects more than 40% of people worldwide. Access to safe drinking water is a basic human right and is a United Nations Sustainable Development Goal (SDG) 6. Globally, waterborne diseases such as cholera are responsible for over two million deaths annually. Cholera is a major cause of ill-health in Africa and Uganda. This study aimed to determine the physicochemical characteristics of the surface and spring water in cholera endemic communities of Uganda in order to promote access to safe drinking water. METHODS: A longitudinal study was carried out between February 2015 and January 2016 in cholera prone communities of Uganda. Surface and spring water used for domestic purposes including drinking from 27 sites (lakes, rivers, irrigation canal, springs and ponds) were tested monthly to determine the vital physicochemical parameters, namely pH, temperature, dissolved oxygen, conductivity and turbidity. RESULTS: Overall, 318 water samples were tested. Twenty-six percent (36/135) of the tested samples had mean test results that were outside the World Health Organization (WHO) recommended drinking water range. All sites (100%, 27/27) had mean water turbidity values greater than the WHO drinking water recommended standards and the temperature of above 17 °C. In addition, 27% (3/11) of the lake sites and 2/5 of the ponds had pH and dissolved oxygen respectively outside the WHO recommended range of 6.5-8.5 for pH and less than 5 mg/L for dissolved oxygen. These physicochemical conditions were ideal for survival of Vibrio. cholerae. CONCLUSIONS: This study showed that surface water and springs in the study area were unsafe for drinking and had favourable physicochemical parameters for propagation of waterborne diseases including cholera. Therefore, for Uganda to attain the SDG 6 targets and to eliminate cholera by 2030, more efforts are needed to promote access to safe drinking water. Also, since this study only established the vital water physicochemical parameters, further studies are recommended to determine the other water physicochemical parameters such as the nitrates and copper. Studies are also needed to establish the causal-effect relationship between V. cholerae and the physicochemical parameters.