Cost-effectiveness of village health worker-led integrated community case management (iCCM) versus health facility based management for childhood illnesses in rural southwestern Uganda.

BACKGROUND: In Uganda, village health workers (VHWs) manage childhood illness under the integrated community case management (iCCM) strategy. Care is provided for malaria, pneumonia, and diarrhoea in a community setting. Currently, there is limited evidence on the cost-effectiveness of iCCM in comparison to health facility-based management for childhood illnesses. This study examined the cost-effectiveness of the management of childhood illness using the VHW-led iCCM against health facility-based services in rural south-western Uganda. METHODS: Data on the costs and effectiveness of VHW-led iCCM versus health facility-based services for the management of childhood illness was collected in one sub-county in rural southwestern Uganda. Costing was performed using the ingredients approach. Effectiveness was measured as the number of under-five children appropriately treated. The Incremental Cost-Effectiveness Ratio (ICER) was calculated from the provider perspective. RESULTS: Based on the decision model for this study, the cost for 100 children treated was US$628.27 under the VHW led iCCM and US$87.19 for the health facility based services, while the effectiveness was 77 and 71 children treated for VHW led iCCM and health facility-based services, respectively. An ICER of US$6.67 per under five-year child treated appropriately for malaria, pneumonia and diarrhoea was derived for the provider perspective. CONCLUSION: The health facility based services are less costly when compared to the VHW led iCCM per child treated appropriately. The VHW led iCCM was however more effective with regard to the number of children treated appropriately for malaria, pneumonia and diarrhoea. Considering the public health expenditure per capita for Uganda as the willingness to pay threshold, VHW led iCCM is a cost-effective strategy. VHW led iCCM should, therefore, be enhanced and sustained as an option to complement the health facility-based services for treatment of childhood illness in rural contexts.

Screening HIV associated neurocognitive disorders using international HIV dementia scale: closing the gap through an educational intervention for healthcare workers.

Introduction: the study assessed the effect of an educational intervention on healthcare workers´ knowledge regarding the use of the International HIV Dementia Scale (IHDS) in screening HIV-associated neurocognitive disorder (HAND) at The AIDS Support Organization (TASO) centres in Uganda. Methods: we recruited healthcare workers in southwestern and central Uganda. Data were collected by a questionnaire, cleaned, and analyzed using means and standard deviations. A paired t-test assessed mean knowledge score differences pre-and post-intervention. We used One-Way ANOVA for mean score differences between sites and cadres. Statistical significance was taken at p ≤ 0.05 and 95% confidence interval. Prevalence of HAND for clients screened during educational intervention was computed. Results: mean age was 36.38 years (SD = 7.80) and mean years of experience 8.92 (SD = 6.52). A paired t-test showed that pre-intervention mean score (Mean= 20.38, SD 2.94) was statistically different from post-intervention mean score (Mean=22.24, SD 2.15) at t (36) = - 4.933, p > 0.001). One-way ANOVA showed counselors were statistically different from clinical officers´ pre-intervention (Mean difference 4.432 (95% CI: 0.1- 8.85, p= 0.049) and post-intervention (Mean difference 3.364 (95% CI: 0.07 - 6.65, p= 0.042) respectively. There was no difference in mean knowledge scores between sites pre-intervention (F (4, 32) = 0.827, p = 0.518) and post-intervention (F (4, 32) = 1.299, p = 0.291). Of the 500 clients screened, 72.2% were positive for HAND. Conclusion: the educational intervention improved healthcare workers´ knowledge regarding screening HAND using IHDS at TASO centres in Southwestern and Central Uganda.

Social network correlates of free and purchased insecticide-treated bed nets in rural Uganda.

BACKGROUND: Malaria is a major cause of mortality and morbidity in Uganda. Despite Uganda's efforts to distribute bed nets, only half of households have achieved the World Health Organization (WHO) Universal Coverage Criteria (one bed net for every two household members). The role of peer influence on bed net ownership remains underexplored. Data on the complete social network of households were collected in a rural parish in southwestern Uganda to estimate the association between household bed net ownership and peer household bed net ownership. METHODS: Data on household sociodemographics, bed net ownership, and social networks were collected from all households across one parish in southwestern Uganda. Bed nets were categorized as either purchased or free. Purchased and free bed net ownership ratios were calculated based on the WHO Universal Coverage Criteria. Using network name generators and complete census of parish residents, the complete social network of households in the parish was generated. Linear regression models that account for network autocorrelation were fitted to estimate the association between households' bed net ownership ratios and bed net ownership ratios of network peer households, adjusting for sociodemographics and network centrality. RESULTS: One thousand seven hundred forty-seven respondents were interviewed, accounting for 716 households. The median number of peer households to which a household was directly connected was 7. Eighty-six percent of households owned at least one bed net, and 41% of households met the WHO Universal Coverage Criterion. The median bed net ownership ratios were 0.67 for all bed nets, 0.33 for free bed nets, and 0.20 for purchased bed nets. In adjusted multivariable models, purchased bed net ownership ratio was associated with average household wealth among peer households (b = 0.06, 95% CI 0.03, 0.10), but not associated with average purchased bed net ownership ratio of peer households. Free bed net ownership ratio was associated with the number of children under 5 (b = 0.08, 95% CI 0.05, 0.10) and average free bed net ownership ratios of peer households (b = 0.66, 95% CI 0.46, 0.85). CONCLUSIONS: Household bed net ownership was associated with bed net ownership of peer households for free bed nets, but not for purchased bed nets. The findings suggest that public health interventions may consider leveraging social networks as tools for dissemination, particularly for bed nets that are provided free of charge.

An Evaluation of Antibiotic Prescription Rationality at Lower Primary Healthcare Facilities in Three Districts of South-Western Uganda.

Purpose: Antimicrobial resistance is now one of the leading five causes of death globally. This study evaluated the rationality of antibiotic prescriptions at lower primary care levels in three districts of Southwestern Uganda. Methods: This prospective cross-sectional study reviewed 9899 antibiotic prescriptions at 39 health centers following a drug delivery cycle by National Medical Stores in three phases (19 days each on average). Phase 1 started 3 days after delivery, mid-way (Phase 2) and towards the end (Phase 3). The proportion of rationally prescribed antibiotics was determined using a modified criterion by Badar and in reference to Uganda Clinical Guidelines (UCG). Using multivariate logistic regression, the factors associated with rational prescription were determined with 95% confidence intervals. Results: Seven of every 10 antibiotic prescriptions were irrational. Half the prescriptions were made by unauthorized personnel (nurses) and many of the pediatric prescriptions (916, 46.5%) did not bear body weight measurements to guide appropriate dosing. Also, the proportion of rational prescriptions in reference to UCG, 2016 was very low (3387, 34.2%). However, a high proportion of antibiotic prescriptions were legibly written (9462, 95.7%), prescribed by generic names (9083, 91.8%) and had a diagnosis (9677, 97.8%) indicated. Multivariate logistic analysis showed that; availability of medicines (phase 1) (phase 2 AOR=1.14, 95% CI:1.02-1.28, phase 3, AOR=1.23, 95% CI:1.1-1.38), legibly written prescription (AOR=0.61, 95% CI: 0.47-0.78), indication of a date on the prescription (AOR=0.56, 95% CI0.38-0.81) and being a medical officer were factors associated with rational antibiotic prescription. Conclusion: We observed a high rate of irrational prescription in the study sites and the majority of these were by unauthorized personnel. A review of antibiotic use policies and focused interventions is crucial in these settings.

Intimate partner violence disclosure and associated factors among pregnant women attending a city hospital in South-Western Uganda: a cross-sectional study.

BACKGROUND: Intimate partner violence (IPV) during pregnancy is a public health problem in Uganda that negatively impacts maternal and newborn health outcomes. However, IPVdisclosure and associated factors among pregnant women have remained poorly documented in southwestern Uganda. Therefore, this study determined IPV disclosure and associated factors among pregnant women attending a large City hospital. METHODS: In a cross-sectional design, 283 women attending Mbarara City Hospital Antenatal care (ANC) clinic were consecutively recruited into the study. Data was collected using a semi-structured questionnaire. This was administered by the research team and the exercise took over a month. That is; from 7th January 2019 to 7th February 2019. The collected data was entered in STATA, and it was analyzed using chi-square, and univariate logistic regression statistics. RESULTS: Out of the 283 pregnant women who participated in the study, 199 of them, representing seventy-point three percent (70.3%), had reportedly experienced at least one type of IPV during their current pregnancy. However, nearly fifty percent of those that experienced IPV (49.7%, n = 99) disclosed it to a third party, while the majority disclosed it to their biological family member (66.7%), followed by their friends (55.5%), members of their husband's family (35.3%), neighbors (12.1%), healthcare providers (9.1%), religious leaders (8.1%), and the police (3.1%). Gravidity, OR = 1.9(95% CI: 1.07-3.31, p = 0.027), parity OR = 1.9(95% CI: 1.08-3.34, p = 0.026) and witnessed IPV OR: 5.4(95% CI: 1.93-14.96; p = 0.001) were significantly associated with IPV disclosure. CONCLUSION: A large proportion of the pregnant women who experienced IPV did not disclose it to any third party. In addition to the above, pregnant women's characteristics seem to have a strong influence on IPV disclosure. Therefore, it is important for healthcare providers to routinely screen for IPV during antenatal care if a high IPV disclosure rate is to be achieved.

Predictors of sleeping under cost-free mosquito bed nets among children under-five years in Mbarara, Uganda: a household survey.

BACKGROUND: In 2010, Uganda Malaria Control Programme distributed cost-free mosquito bed nets to households with children under-five years and pregnant women in selected sub-counties. We assessed the factors associated with sleeping under costfree mosquito nets among children under-five years in Nyakayojo sub-county, Mbarara District, Uganda. METHODS: 381 households with at least a child under-five years and benefited from cost-free bed nets in Nyakayojo were randomly selected. Caregivers of children were interviewed using a questionnaire. RESULTS: 74% children slept under bed nets a night before the study. Children from households with ≥2 nets [aOR=1.75; 95% CI: 1.09-2.81, p=0.02], female caregiver [aOR=2.11; 95% CI: 1.16-3.79, p=0.01] and children from households that did not face problems (skin irritation, torn nets, suffocation, night sweating, nasal congestion and candle fire) when sleeping under bed nets [aOR=1.81; 95% CI: 1.10-2.98, p=0.02] were more likely to use nets. Main reason for not sleeping under a net was damage to the net (47.1%). CONCLUSION: The proportion of children sleeping under nets was comparable to MDG target. Improvements in use of mosquito nets by children can be achieved through increasing number of nets in a household.

Social norms, misperceptions, and mosquito net use: a population-based, cross-sectional study in rural Uganda.

BACKGROUND: Mosquito net use is an essential part of malaria prevention. Although previous research has shown that many people sleep under a mosquito net in endemic areas, it is unknown whether people underestimate how common it is to sleep under a net every night. Furthermore, perceived social norms about whether most others sleep under a mosquito net every night may contribute to personally sleeping under a net, given decades of research showing that people often mimic others' behaviours. METHODS: Population-based data were collected from 1669 adults across eight villages in one rural parish in southwestern Uganda. Individuals' perception about whether most adults in their community sleep under a mosquito net every night was compared with whether daily mosquito net use was the actual norm in their community to identify the extent of norm misperception. The association between whether an individual perceived daily mosquito net use to be the norm and personal mosquito net use was assessed while adjusting for the ratio of nets:people in the household and other factors. RESULTS: Although the majority (65%) of participants reported sleeping under a mosquito net every night (and 75% did so among the 86% of people with at least one net), one-quarter of participants thought that most adults in their community did not sleep under a mosquito net every night. Another 8% were unsure how many nights per week most adults in their community sleep under a mosquito net. Participants who perceived that daily mosquito net use was the norm were 2.94 times more likely to report personally sleeping under a mosquito net every night (95% CI 2.09-4.14, p < 0.001) compared to participants who thought doing so was not normative, adjusting for other factors. CONCLUSIONS: Results suggest an opportunity for anti-malarial interventions to reduce misperceptions about mosquito net use norms and emphasize the commonness of daily mosquito net use in malaria-endemic regions. If people correctly perceive most others to sleep under a net every night, then they may personally do so when possible and support others to do so too.

Retention of HIV exposed infants in care at Arua regional referral hospital, Uganda: a retrospective cohort study.

BACKGROUND: Retention of HIV Exposed Infants (HEIs) in care ensures adequate care. Data on retention of HEIs at large referral hospitals in Uganda is limited. We investigated the retention level of HEIs and associated factors. METHODS: We conducted a retrospective cohort study on 352 HEIs in care (January 2014 and April 2015) at Arua Regional Referral Hospital, North-western Uganda. Electronic medical data were retrieved and analyzed with Stata. Chi-square, Fisher's exact, and Students t-tests were used for bivariate analysis. Logistic regression was performed to determine factors independently associated with retention. RESULTS: 236 (67.0%) HEIs were delivered in a health facility and 306 (86.9%) received Nevirapine prophylaxis from birth until 6-weeks. Of mothers, 270 (76.7%) were 25-46 years, 202 (57.4%) attended antenatal care (ANC) at recent pregnancy, and 328 (93.2%) were on life-long anti-retroviral therapy. At 18-months, 277 (78.7%) HEIs were retained in care. Maternal age (25-46 years) (Adjusted Odds Ratio (AOR), 2.32; 95% CI, 1.32-4.06), ANC attendance during recent pregnancy (AOR, 2.01; 95% CI, 1.19-4.3.41) and Nevirapine prophylaxis initiation from birth until 6-weeks (AOR, 3.07; 95% CI, 1.50-6.26) were associated with retention. CONCLUSION: Retention was suboptimal. Older maternal age, ANC visits at last pregnancy, and timely NVP initiation increased retention.

Assessment of attitudes and targeted educational needs for refugee care providers in a Ugandan hospital.

OBJECTIVES: To evaluate medical trainees' attitudes toward refugee patients in a refugee host country, and to identify educational needs. METHODS: A 54-question cross-sectional questionnaire was administered to a convenience sample of 81 post-graduate medical trainees at Mbarara Regional Referral Hospital, Uganda, in 2016. Descriptive statistics on medical trainees' attitudes and educational needs regarding care for refugees were calculated. One-way ANOVA was used to assess relationships between an attitude scale and respondent characteristics. Reliability and validity of the survey items and attitude scale were assessed using Cronbach's alpha, item-to-scale correlation, and factor analysis. RESULTS: The mean score on the attitude scale of 2.8 (SD=1.7) indicated positive attitudes toward refugees. All respondents had contact with refugees, and 89% (n=72) reported a need for further training. Many specifically indicated the need for training in use of translators, support personnel, and behavioral health.  Cronbach's alpha values of greater than 0.7 indicated good internal consistency. Item-to-scale correlation and factor analysis validate the use of an attitude scale. ANOVA showed no significant difference between mean attitude scores in gender (F(1,77)=0.11, p=0.7367), country of origin (F(1.78) =0.53, p=0.8723), or year of study (F(4,74) =0.31, p=0.8273). CONCLUSIONS: Medical trainees in Uganda report positive attitudes toward refugees and a need for additional education in refugee care in multiple specific areas. This study piloted the use of an attitude scale for refugee healthcare providers with promising validity and reliability. Use of these questions could inform curriculum development in refugee host countries.

Determinants of treatment completion among rural smear positive pulmonary tuberculosis patients: a cross-sectional survey conducted in south-western Uganda.

BACKGROUND: Treatment completion among tuberculosis patients remains low across various regions of Uganda, despite implementation of directly observed treatment short course. This study evaluated the determinants of treatment completion in a rural health sub-district of south western Uganda. METHODS: In April 2012, health facility records were reviewed to identify tuberculosis patients who had been initiated on treatment between June 2008 and May 2011, in Rwampara Health Sub-District, south-western Uganda. Out of the 162 patients identified, 128 (79%) were traced and subsequently interviewed during a survey conducted in June 2012. Eleven (6.8%) of the 162 patients died, while 23 (14.2%) could not be traced. A review of records showed that 17 of those that could not be traced completed treatment while the other six did not have definitive records. RESULTS: Treatment completion among the 128 patients interviewed was 89.8%. Pre-treatment counselling (aOR = 24.3, 95% CI: 1.4-26.6, P = 0.03), counselling at the time of submission of sputum during follow up (aOR = 6.8, 95% CI: 1.4-33.7, P = 0.02), and refill of drugs on the exact appointment date (aOR = 13.4, 95% CI: 1.9-93.0, P = 0.01), were independently associated with treatment completion. CONCLUSIONS: The level of treatment completion was higher than the national average, with service- related determinants identified as being critical for ensuring treatment completion. These data provide further evidence for the need to provide ongoing counselling support to tuberculosis patients. Enhancing the opportunities for counselling of tuberculosis patients should therefore be rigorously promoted as an approach to increase treatment completion in rural settings.

Seroprevalence of Ebola virus infection in Bombali District, Sierra Leone.

A serosurvey of anti-Ebola Zaire virus nucleoprotein IgG prevalence was carried out among Ebola virus disease survivors and their Community Contacts in Bombali District, Sierra Leone. Our data suggest that the specie of Ebola virus (Zaire) responsible of the 2013-2016 epidemic in West Africa may cause mild or asymptomatic infection in a proportion of cases, possibly due to an efficient immune response.

Seroprevalence of Ebola virus infection in Bombali District, Sierra Leone

A serosurvey of anti-Ebola Zaire virus nucleoprotein IgG prevalence was carried out among Ebola virus disease survivors and their Community Contacts in Bombali District, Sierra Leone. Our data suggest that the specie of Ebola virus (Zaire) responsible of the 2013-2016 epidemic in West Africa may cause mild or asymptomatic infection in a proportion of cases, possibly due to an efficient immune response

Effect of Village Health Team Home Visits and Mobile Phone Consultations on Maternal and Newborn Care Practices in Masindi and Kiryandongo, Uganda: A Community-Intervention Trial.

INTRODUCTION: The World Health Organisation recommends home visits conducted by Community Health Workers (in Uganda known as Village Health Teams--VHTs) in order to improve maternal and newborn health. This study measured the effect of home visits combined with mobile phone consultations on maternal and newborn care practices. METHOD: In a community intervention trial design 16 health centres in Masindi and Kiryandongo districts, Uganda were randomly and equally allocated to one of two arms: control and intervention arms. Eight control health centres received the usual maternal and newborn educational messages offered by professional health workers and eight intervention health centres that received an intervention package for maternal care and essential newborn care practices. In the intervention arm VHTs made two prenatal and one postnatal home visit to households. VHTs were provided with mobile phones to enable them make regular telephone consultations with health workers at the health centre serving the catchment area. The primary outcome was health facility delivery. Other outcomes included antenatal attendances, birth preparedness, cord and thermal care and breastfeeding practices. Analysis was by intention-to-treat. RESULTS: A total of 1385 pregnant women were analysed: 758 and 627 in the control and intervention arms respectively. Significant post-intervention differences were: delivery place [adjusted Odds Ratio aOR: 17.94(95%CI: 6.26-51.37); p<0.001], cord care [aOR: 3.05(95%CI: 1.81-5.12); p<0.001] thermal care [aOR: 7.58(95%CI: 2.52-22.82); p<0.001], and timely care-seeking for newborn illness [aOR: 4.93(95%CI: 1.59-15.31); p = 0.006]. CONCLUSION: VHTs can have an effect in promoting proper cord and thermal care for the newborn and improve timely care-seeking for health facility delivery and newborn illness, because they could answer questions and refer patients correctly. However, VHTs should be supported by professional health workers through the use of mobile phones. TRIAL REGISTRATION: ClinicalTrials.gov NCT02084680.

Harnessing the power of light to treat staphylococcal infections focusing on MRSA.

Methicillin-resistant Staphylococcus aureus (MRSA) has become the most important drug-resistant microbial pathogen in countries throughout the world. Morbidity and mortality due to MRSA infections continue to increase despite efforts to improve infection control measures and to develop new antibiotics. Therefore alternative antimicrobial strategies that do not give rise to development of resistance are urgently required. A group of therapeutic interventions has been developed in the field of photomedicine with the common theme that they rely on electromagnetic radiation with wavelengths between 200 and 1000 nm broadly called "light". These techniques all use simple absorption of photons by specific chromophores to deliver the killing blow to microbial cells while leaving the surrounding host mammalian cells relatively unharmed. Photodynamic inactivation uses dyes called photosensitizers (PS) that bind specifically to MRSA cells and not host cells, and generate reactive oxygen species including singlet oxygen and singlet oxygen upon illumination. Sophisticated molecular strategies to target the PS to MRSA cells have been designed. Ultraviolet C radiation can damage microbial DNA without unduly harming host DNA. Blue light can excite endogenous porphyrins and flavins in MRSA cells that are not present in host cells. Near-infrared lasers can interfere with microbial membrane potentials without raising the temperature of the tissue. Taken together these innovative approaches towards harnessing the power of light suggest that the ongoing threat of MRSA may eventually be defeated.

Timing of malaria messages for target audience on radio airwaves.

BACKGROUND: Due to the limitations of face-to-face communication to teach families how to manage, control and prevent malaria, national and local malaria programmes try to reach people through the radio. However, information regarding the timing of radio messages for the target audiences is lacking. METHODS: Within a large-scale trial (Clinicaltrials.gov: NCT00565071), data regarding the time at which people listen to the radio was collected from 1,628 consenting outpatients (and caregivers for minors) attending six rural government primary level health care centres in Bushenyi and Iganga districts of Uganda from February to July 2011. RESULTS: The majority of households, 1,099 (67.5%) owned a radio. The majority, 1,221 (86.3%), participants had heard about malaria from the radio. Some participants started listening to the radio at about 06.00 East African local time (EAT). The peak hours at which people listen to the radio are 12.00-14.00 and 18.00-23.00 local time. The median time of listening to the radio by men is 20.00 (inter-quartile range (IQR): 18.30-21.00) and women 19.30 (IQR: 13.00-20.30). CONCLUSION: Planners of malaria radio interventions need to broadcast their messages within the two peak EAT of 12.00-14.00 and 18.00-23.00.

Cost-effectiveness of malaria microscopy and rapid diagnostic tests versus presumptive diagnosis: implications for malaria control in Uganda.

BACKGROUND: Current Uganda National Malaria treatment guidelines recommend parasitological confirmation either by microscopy or rapid diagnostic test (RDT) before treatment with artemether-lumefantrine (AL). However, the cost-effectiveness of these strategies has not been assessed at rural operational primary care centres. METHODS: Three health centres (HCs) were randomized to three diagnostic arms (microscopy, RDT and presumptive diagnosis) in a district of low and another of high malaria transmission intensities in Uganda. Some 22,052 patients presenting with fever at outpatients departments were enrolled from March 2010 to February 2011. Of these, a random sample of 1,627 was selected to measure additional socio-economic characteristics. Costing was performed following the standard step-down cost allocation and the ingredients approach. Effectiveness was measured as the number and proportion of patients correctly diagnosed and treated. Incremental Cost-Effectiveness Ratios (ICERs) were estimated from the societal perspective (http://Clinicaltrials.gov, NCT00565071). RESULTS: Overall RDT was most cost-effective with lowest ICER US$5.0 compared to microscopy US$9.61 per case correctly diagnosed and treated. In the high transmission setting, ICER was US$4.38 for RDT and US$12.98 for microscopy. The corresponding ICERs in the low transmission setting were US$5.85 and US$7.63 respectively. The difference in ICERs between RDT and microscopy was greater in the high transmission area (US$8.9) than in low transmission setting (US$1.78). At a willingness to pay of US$2.8, RDT remained cost effective up to a threshold value of the cost of treatment of US$4.7. CONCLUSION: RDT was cost effective in both low and high transmission settings. With a global campaign to reduce the costs of AL and RDT, the Malaria Control Programme and stakeholders need a strategy for malaria diagnosis because as the cost of AL decreases, presumptive treatment is likely to become more attractive.

Comparative feasibility of implementing rapid diagnostic test and microscopy for parasitological diagnosis of malaria in Uganda.

BACKGROUND: In Uganda, parasite-based diagnosis is recommended for every patient suspected to have malaria before prescribing anti-malarials. However, the majority of patients are still treated presumptively especially in low-level health units. The feasibility of implementing parasite-based diagnosis for uncomplicated malaria in rural health centres (HCs) was investigated with a view to recommending measures for scaling up the policy. METHODS: Thirty HCs were randomized to implement parasite-based diagnosis based on rapid diagnostic tests [RDTs] (n = 10), blood microscopy (n = 10) and presumptive diagnosis (control arm) (n = 10). Feasibility was assessed by comparing the proportion of patients who received parasite-based diagnosis; with a positive malaria parasite-based diagnosis who received artemether-lumefantrine (AL); with a negative malaria parasite-based diagnosis who received AL; and patient waiting time. Clinicaltrials.gov: NCT00565071. RESULTS: 102, 087 outpatients were enrolled. Patients were more likely to be tested in the RDT 44, 565 (96.6%) than in microscopy arm 19, 545 (60.9%) [RR: 1.59]. RDTs reduced patient waiting time compared to microscopy and were more convenient to health workers and patients. Majority 23, 804 (99.7%) in presumptive arm were prescribed AL. All (100%) of patients who tested positive for malaria in RDT and microscopy arms were prescribed anti-malarials. Parasitological-based diagnosis significantly reduced AL prescription in RDT arm [RR: 0.62] and microscopy arm [RR: 0.72] compared to presumptive treatment. Among patients not tested in the two intervention arms, 12, 044 (96.1%) in microscopy and 965 (61.6%) in RDT arm were treated with AL [RR: 1.56]. Overall 10, 558 (29.4%) with negative results [5, 110 (23.4%) in RDT and 5, 448 (39.0%) in microscopy arms] were prescribed AL. CONCLUSION: It was more feasible to implement parasite-based diagnosis for malaria using RDT than with microscopy. A high proportion of patients with negative malaria results are still prescribed anti-malarials. There is need to increase access to parasite-based diagnosis where microscopy is used. In order to fully harness the benefits of parasitological confirmation of malaria, it is necessary to reduce the prescription of anti-malarials in negative patients.

Antibiotic use among patients with febrile illness in a low malaria endemicity setting in Uganda.

BACKGROUND: Uganda embraced the World Health Organization guidelines that recommend a universal 'test and treat' strategy for malaria, mainly by use of rapid diagnostic test (RDT) and microscopy. However, little is known how increased parasitological diagnosis for malaria influences antibiotic treatment among patients with febrile illness. METHODS: Data collection was carried out within a feasibility trial of presumptive diagnosis of malaria (control) and two diagnostic interventions (microscopy or RDT) in a district of low transmission intensity. Five primary level health centres (HCs) were randomized to each diagnostic arm (diagnostic method in a defined group of patients). All 52,116 outpatients (presumptive 16,971; microscopy 17,508; and RDT 17,638) aged 5 months to ninety five years presenting with fever (by statement or measured) were included. Information from outpatients and laboratory registers was extracted weekly from March 2010 to July 2011. The proportion of patients who were prescribed antibiotics was calculated among those not tested for malaria, those who tested positive and in those who tested negative. RESULTS: Seven thousand and forty (41.5%) patients in the presumptive arm were prescribed antibiotics. Of the patients not tested for malaria, 1,537 (23.9%) in microscopy arm and 810 (56.2%) in RDT arm were prescribed antibiotics. Among patients who tested positive for malaria, 845 (25.8%) were prescribed antibiotics in the RDT and 273(17.6%) in the microscopy arm. Among patients who tested negative for malaria, 7809 (61.4%) were prescribed antibiotics in the RDT and 3749 (39.3%) in the microscopy arm. Overall the prescription of antibiotics was more common for children less than five years of age 5,388 (63%) compared to those five years and above 16798 (38.6%). CONCLUSION: Prescription of antibiotics in patients with febrile illness is high. Testing positive for malaria reduces antibiotic treatment but testing negative for malaria increases use of antibiotics. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00565071.

Are rapid diagnostic tests more accurate in diagnosis of plasmodium falciparum malaria compared to microscopy at rural health centres?

BACKGROUND: Prompt, accurate diagnosis and treatment with artemisinin combination therapy remains vital to current malaria control. Blood film microscopy the current standard test for diagnosis of malaria has several limitations that necessitate field evaluation of alternative diagnostic methods especially in low income countries of sub-Saharan Africa where malaria is endemic. METHODS: The accuracy of axillary temperature, health centre (HC) microscopy, expert microscopy and a HRP2-based rapid diagnostic test (Paracheck) was compared in predicting malaria infection using polymerase chain reaction (PCR) as the gold standard. Three hundred patients with a clinical suspicion of malaria based on fever and or history of fever from a low and high transmission setting in Uganda were consecutively enrolled and provided blood samples for all tests. Accuracy of each test was calculated overall with 95% confidence interval and then adjusted for age-groups and level of transmission intensity using a stratified analysis. The endpoints were: sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). This study is registered with Clinicaltrials.gov, NCT00565071. RESULTS: Of the 300 patients, 88(29.3%) had fever, 56(18.7%) were positive by HC microscopy, 47(15.7%) by expert microscopy, 110(36.7%) by Paracheck and 89(29.7%) by PCR. The overall sensitivity >90% was only shown by Paracheck 91.0% [95%CI: 83.1-96.0]. The sensitivity of expert microscopy was 46%, similar to HC microscopy. The superior sensitivity of Paracheck compared to microscopy was maintained when data was stratified for transmission intensity and age. The overall specificity rates were: Paracheck 86.3% [95%CI: 80.9-90.6], HC microscopy 93.4% [95%CI: 89.1-96.3] and expert microscopy 97.2% [95%CI: 93.9-98.9]. The NPV >90% was shown by Paracheck 95.8% [95%CI: 91.9-98.2]. The overall PPV was <88% for all methods. CONCLUSION: The HRP2-based RDT has shown superior sensitivity compared to microscopy in diagnosis of malaria and may be more suitable for screening of malaria infection.

Challenges to implementation of artemisinin combination therapy policy in Uganda.

UNLABELLED: Uganda launched an artemisinin combination therapy (ACT) policy in 2006, using artemether-lumefantrine (AL) as first-line treatment for uncomplicated malaria, but insufficient information is available regarding its implementation. Semi-structured interviews were conducted with key personnel: 32 clinical and four laboratory staff from 32 health centres (HCs) in Bushenyi and Iganga districts and the Ministry of Health. Structured interviews with 613 patients receiving malaria treatment at six randomly chosen HCs were held. Data were collected on availability of antimalarials, treatment guidelines, staffing and malaria treatment decisions. Posts for clinical staff were inadequately filled. Only 15 (46.9%) HCs stocked AL for all weight categories. Nationwide, AL was out-of-stock March-July 2007. Twenty-one (65.6%) HCs stocked chloroquine. Out of 193 patients, 177 (91.7%) used antimalarials other than AL before coming to HCs. The unrecommended antimalarials were mainly sourced from the private for profit (PFP) sector yet there were no guidelines regarding provision of AL in the PFP sector. Only 53/613 (8.6%) patients were examined for parasites and only 8 (15.1%) had a positive blood slide. The majority of the patients attending HCs (560; 91.4%) received antimalarials but only 323 (57.7%) received AL. In order to improve the implementation of the current policy, AL should be availed in adequate amounts at all points of care including the PFP sector; non-recommended drugs should be withdrawn from the market and it should be ensured that malaria is confirmed by laboratory diagnosis. STUDY REGISTRATION: Clinicaltrials.gov NCT00565071.