Solar-powered O2 delivery for the treatment of children with hypoxaemia in Uganda: a stepped-wedge, cluster randomised controlled trial.

BACKGROUND: Supplemental O2 is not always available at health facilities in low-income and middle-income countries (LMICs). Solar-powered O2 delivery can overcome gaps in O2 access, generating O2 independent of grid electricity. We hypothesized that installation of solar-powered O2 systems on the paediatrics ward of rural Ugandan hospitals would lead to a reduction in mortality among hypoxaemic children. METHODS: In this pragmatic, country-wide, stepped-wedge, cluster randomised controlled trial, solar-powered O2 systems (ie, photovoltaic cells, battery bank, and O2 concentrator) were sequentially installed at 20 rural health facilities in Uganda. Sites were selected for inclusion based on the following criteria: District Hospital or Health Centre IV with paediatric inpatient services; supplemental O2 on the paediatric ward was not available or was unreliable; and adequate space to install solar panels, a battery bank, and electrical wiring. Allocation concealment was achieved for sites up to 2 weeks before installation, but the study was not masked overall. Children younger than 5 years admitted to hospital with hypoxaemia and respiratory signs were included. The primary outcome was mortality within 48 h of detection of hypoxaemia. The statistical analysis used a linear mixed effects logistic regression model accounting for cluster as random effect and calendar time as fixed effect. The trial is registered at ClinicalTrials.gov, NCT03851783. FINDINGS: Between June 28, 2019, and Nov 30, 2021, 2409 children were enrolled across 20 hospitals and, after exclusions, 2405 children were analysed. 964 children were enrolled before site randomisation and 1441 children were enrolled after site randomisation (intention to treat). There were 104 deaths, 91 of which occurred within 48 h of detection of hypoxaemia. The 48 h mortality was 49 (5·1%) of 964 children before randomisation and 42 (2·9%) of 1440 (one individual did not have vital status documented at 48 h) after randomisation (adjusted odds ratio 0·50, 95% CI 0·27-0·91, p=0·023). Results were sensitive to alternative parameterisations of the secular trend. There was a relative risk reduction of 48·7% (95% CI 8·5-71·5), and a number needed to treat with solar-powered O2 of 45 (95% CI 28-230) to save one life. Use of O2 increased from 484 (50·2%) of 964 children before randomisation to 1424 (98·8%) of 1441 children after randomisation (p<0·0001). Adverse events were similar before and after randomisation and were not considered to be related to the intervention. The estimated cost-effectiveness was US$25 (6-505) per disability-adjusted life-year saved. INTERPRETATION: This stepped-wedge, cluster randomised controlled trial shows the mortality benefit of improving O2 access with solar-powered O2. This study could serve as a model for scale-up of solar-powered O2 as one solution to O2 insecurity in LMICs. FUNDING: Grand Challenges Canada and The Women and Children's Health Research Institute.

Infection Prevention and Control Initiatives to Prevent Healthcare-Associated Transmission of SARS-CoV-2, East Africa.

The coronavirus disease pandemic has highlighted the need to establish and maintain strong infection prevention and control (IPC) practices, not only to prevent healthcare-associated transmission of SARS-CoV-2 to healthcare workers and patients but also to prevent disruptions of essential healthcare services. In East Africa, where basic IPC capacity in healthcare facilities is limited, the US Centers for Disease Control and Prevention (CDC) supported rapid IPC capacity building in healthcare facilities in 4 target countries: Tanzania, Ethiopia, Kenya, and Uganda. CDC supported IPC capacity-building initiatives at the healthcare facility and national levels according to each country's specific needs, priorities, available resources, and existing IPC capacity and systems. In addition, CDC established a multicountry learning network to strengthen hospital level IPC, with an emphasis on peer-to-peer learning. We present an overview of the key strategies used to strengthen IPC in these countries and lessons learned from implementation.

The profile and causes of death among medical doctors and dental surgeons in Uganda: 1986 to 2016.

Background: The loss of health workers through death is of great importance and interest to the public, media and the medical profession as it has very profound social and professional consequences on the delivery of health services. Objective: To describe the profile, causes and patterns of death among medical doctors and dental surgeons in Uganda between 1986 and 2016. Methods: We conducted a retrospective descriptive study of mortality among registered medical doctors and dental surgeons. Information on each case was collected using a standard questionnaire and analysed. Cause of death was determined using pathology reports, and if unavailable, verbal autopsies. We summarized our findings across decades using means and standard deviations, proportions and line graphs as appropriate. Cuzick's test for trend was used to assess crude change in characteristics across the three decades. To estimate the change in deaths across decades adjusted for age and sex, we fit a logistic regression model, and used the margins command with a dy/dx option. All analyses were done in Stata version 14.0 (Stata Corp, College Station, TX). Results: There were 489 deaths registered between 1986 and 2016. Of these, 59 (12.1%) were female. The mean age at death was 48.8 years (Standard Deviation (SD) 15.1) among male and 40.1 years (SD 12.8) among females. We ascertained the cause of death for 468/489 (95.7%). The most common causes of death were HIV/AIDS (218/468, 46.6%), cancer (68/468, 14.5%), non-communicable diseases (62/48, 13.3%), alcohol related deaths (36, 7.7%), road traffic accidents (34, 7.3%), gunshots (11, 2.4%), among others. After adjusting for age and sex, HIV/AIDs attributable deaths decreased by 33 percentage points between the decade of 1986 to1995 and that of 2006 to 2016 -0.33 (-0.44, -0.21. During the same period, cancer attributable deaths increased by 13 percentage periods 0.13 (0.05,0.20). Conclusion: The main causes of death were HIV/AIDS, cancer, non-communicable diseases, alcohol-related diseases and road traffic accidents. There was a general downward trend in the HIV/AIDS related deaths and a general upward trend in cancer related deaths. Doctors should be targeted for preventive and support services especially for both communicable and non-communicable diseases.

The profile and causes of death among medical doctors and dental surgeons in Uganda: 1986 to 2016

Background: The loss of health workers through death is of great importance and interest to the public, media and the medical profession as it has very profound social and professional consequences on the delivery of health services. Objective: To describe the profile, causes and patterns of death among medical doctors and dental surgeons in Uganda between 1986 and 2016. Methods: We conducted a retrospective descriptive study of mortality among registered medical doctors and dental surgeons. Information on each case was collected using a standard questionnaire and analyzed. Cause of death was determined using pathology reports, and if unavailable, verbal autopsies. We summarized our findings across decades using means and standard deviations, proportions and line graphs as appropriate. Cuzick's test for trend was used to assess crude change in characteristics across the three decades. To estimate the change in deaths across decades adjusted for age and sex, we fit a logistic regression model, and used the margins command with a dy/dx option. All analyses were done in Stata version 14.0 (Stata Corp, College Station, TX). Results: There were 489 deaths registered between 1986 and 2016. Of these, 59 (12.1%) were female. The mean age at death was 48.8 years (Standard Deviation (SD) 15.1) among male and 40.1 years (SD 12.8) among females. We ascertained the cause of death for 468/489 (95.7%). The most common causes of death were HIV/AIDS (218/468, 46.6%), cancer (68/468, 14.5%), non-communicable diseases (62/48, 13.3%), alcohol related deaths (36, 7.7%), road traffic accidents (34, 7.3%), gunshots (11, 2.4%), among others. After adjusting for age and sex, HIV/AIDs attributable deaths decreased by 33 percentage points between the decade of 1986 to1995 and that of 2006 to 2016 ­0.33 (­0.44, ­0.21. During the same period, cancer attributable deaths increased by 13 percentage periods 0.13 (0.05,0.20). Conclusion: The main causes of death were HIV/AIDS, cancer, non-communicable diseases, alcohol-related diseases and road traffic accidents. There was a general downward trend in the HIV/AIDS related deaths and a general upward trend in cancer related deaths. Doctors should be targeted for preventive and support services especially for both communicable and non-communicable diseases

Solar-powered oxygen delivery for the treatment of children with hypoxemia: protocol for a cluster-randomized stepped-wedge controlled trial in Uganda.

BACKGROUND: Child mortality due to pneumonia is a major global health problem and is associated with hypoxemia. Access to safe and continuous oxygen therapy can reduce mortality; however, low-income countries may lack the necessary resources for oxygen delivery. We have previously demonstrated proof-of-concept that solar-powered oxygen (SPO2) delivery can reliably provide medical oxygen remote settings with minimal access to electricity. This study aims to demonstrate the efficacy of SPO2 in children hospitalized with acute hypoxemic respiratory illness across Uganda. METHODS: Objectives: Demonstrate efficacy of SPO2 in children hospitalized with acute hypoxemic respiratory illness. STUDY DESIGN: Multi-center, stepped-wedge cluster-randomized trial. SETTING: Twenty health facilities across Uganda, a low-income, high-burden country for pediatric pneumonia. Site selection: Facilities with pediatric inpatient services lacking consistent O2 supply on pediatric wards. PARTICIPANTS: Children aged < 5 years hospitalized with hypoxemia (saturation < 92%) warranting hospital admission based on clinical judgement. Randomization methods: Random installation order generated a priori with allocation concealment. Study procedure: Patients receive standard of care within pediatric wards with or without SPO2 system installed. OUTCOME MEASURES: Primary: 48-h mortality. Secondary: safety, efficacy, SPO2 system functionality, operating costs, nursing knowledge, skills, and retention for oxygen administration. Statistical analysis of primary outcome: Linear mixed effects logistic regression model with 48-h mortality (dependent variable) as a function of SPO2 treatment (before versus after installation), while adjusting for confounding effects of calendar time (fixed effect) and site (random effect). SAMPLE SIZE: 2400 patients across 20 health facilities, predicted to provide 80% power to detect a 35% reduction in mortality after introduction of SPO2, based on a computer simulation of > 5000 trials. DISCUSSION: Overall, our study aims to demonstrate mortality benefit of SPO2 relative to standard (unreliable) oxygen delivery. The innovative trial design (stepped-wedge, cluster-randomized) is supported by a computer simulation. Capacity building for nursing care and oxygen therapy is a non-scientific objective of the study. If successful, SPO2 could be scaled across a variety of resource-constrained remote or rural settings in sub-Saharan Africa and beyond. TRIAL REGISTRATION: Clinicaltrials.gov, NCT03851783. Registered on 22 February 2019.

Relationship Between Viremia and Specific Organ Damage in Ebola Patients: A Cohort Study.

Background: Pathogenesis of Ebola virus disease remains poorly understood. We used concomitant determination of routine laboratory biomarkers and Ebola viremia to explore the potential role of viral replication in specific organ damage. Methods: We recruited patients with detectable Ebola viremia admitted to the EMERGENCY Organizzazione Non Governativa Organizzazione Non Lucrativa di Utilità Sociale (ONG ONLUS) Ebola Treatment Center in Sierra Leone. Repeated measure of Ebola viremia, alanine aminotransferase (ALT), aspartate aminotransferase (AST), bilirubin, creatine phosphokinase (CPK), lactate dehydrogenase (LDH), activated prothrombin time (aPTT), international normalized ratio (INR), creatinine, and blood urea nitrogen (BUN) were recorded. Patients were followed up from admission until death or discharge. Results: One hundred patients (49 survivors and 51 nonsurvivors) were included in the analysis. Unadjusted analysis to compare survivors and nonsurvivors provided evidence that all biomarkers were significantly above the normal range and that the extent of these abnormalities was generally higher in nonsurvivors than in survivors. Multivariable mixed-effects models provided strong evidence for a biological gradient (suggestive of a direct role in organ damage) between the viremia levels and either ALT, AST, CPK LDH, aPTT, and INR. In contrast, no direct linear association was found between viremia and either creatinine, BUN, or bilirubin. Conclusions: This study provides evidence to support that Ebola virus may have a direct role in muscular damage and imbalance of the coagulation system. We did not find strong evidence suggestive of a direct role of Ebola virus in kidney damage. The role of the virus in liver damage remains unclear, but our evidence suggests that acute severe liver injury is not a typical feature of Ebola virus disease.

Blood kinetics of Ebola virus in survivors and nonsurvivors.

BACKGROUND: Infection with Ebola virus (EBOV) results in a life-threatening disease, with reported mortality rates between 50%-70%. The factors that determine patient survival are poorly understood; however, clinical observations indicate that EBOV viremia may be associated with fatal outcome. We conducted a study of the kinetics of Zaire EBOV viremia in patients with EBOV disease (EVD) who were managed at an Ebola Treatment Centre in Sierra Leone during the recent West African outbreak. METHODS: Data from 84 EVD patients (38 survivors, 46 nonsurvivors) were analyzed, and EBOV viremia was quantified between 2 and 13 days after symptom onset. Time since symptom onset and clinical outcome were used as independent variables to compare EBOV viral kinetics in survivors and nonsurvivors. RESULTS: In all patients, EBOV viremia kinetics was a quadratic function of time; however, EBOV viremia was 0.94 logarithm (log) copies per ml (cp/ml) (P = 0.011) higher in nonsurvivors than in survivors from day 2 after the onset of symptoms. Survivors reached peak viremia levels at an earlier time after symptom onset than nonsurvivors (day 5 versus day 7) and had lower mean peak viremia levels compared with nonsurvivors (7.46 log cp/ml; 95% CI, 7.17-7.76 vs. 8.60 log cp/ml; 95% CI, 8.27-8.93). Before reaching peak values, EBOV viremia similarly increased both in survivors and nonsurvivors; however, the decay of viremia after the peak was much stronger in survivors than in nonsurvivors. CONCLUSION: Our results demonstrate that plasma concentrations of EBOV are markedly different between survivors and nonsurvivors at very early time points after symptom onset and may be predicative of outcome. Further studies focused on the early phase of the disease will be required to identify the causal and prognostic factors that determine patient outcome. FUNDING: Italian Ministry of Health; Italian Ministry of Foreign Affairs; EMERGENCY's private donations; and Royal Engineers for DFID-UK.

Epidemiology of Ebola virus disease transmission among health care workers in Sierra Leone, May to December 2014: a retrospective descriptive study.

BACKGROUND: Anecdotal evidence suggests that much of the continuing infection of health care workers (HCWs) with Ebola virus during the current outbreak in Sierra Leone has occurred in settings other than Ebola isolation units, and it is likely that some proportion of acquisition by HCWs occurs outside the workplace. There is a critical need to define more precisely the pathways of Ebola infection among HCWs, to optimise measures for reducing risk during current and future outbreaks. METHODS: We conducted a retrospective descriptive study of Ebola acquisition among health workers in Sierra Leone during May-December 2014. The data used were obtained mainly from the national Ebola database, a cross-sectional survey conducted through administration of a structured questionnaire to infected HCWs, and key informant interviews of select health stakeholders. RESULTS: A total of 293 HCWs comprising 277 (95 %) confirmed, 6 (2 %) probable, and 10 (3 %) suspected cases of infection with Ebola virus were enrolled in the study from nine districts of the country. Over half of infected HCWs (153) were nurses; others included laboratory staff (19, 6.5 %), doctors (9, 3.1 %), cleaners and porters (9, 3.1 %), Community Health Officers (8, 2.7 %), and pharmacists (2, 0.7 %). HCW infections were mainly reported from the Western Area (24.9 %), Kailahun (18.4 %), Kenema (17.7 %), and Bombali (13.3 %) districts. Almost half of the infected HCWs (120, 47.4 %) believed that their exposure occurred in a hospital setting. Others believed that they were exposed in the home (48, 19 %), at health centres (45, 17.8 %), or at other types of health facilities (13, 5.1 %). Only 27 (10.7 %) of all HCW infections were associated with Ebola virus disease (EVD) isolation units. Over half (60 %, 150) of infected HCWs said they had been trained in infection prevention and control prior to their infection, whereas 34 % (85) reported that they had not been so trained. CONCLUSIONS: This study demonstrated the perception that most HCW infections are associated with general health care and home settings and not with dedicated EVD settings, which should provide substantial reassurance to HCWs that measures in place at dedicated EVD facilities generally provide substantial protection when fully adhered to.

Managing Ebola from rural to urban slum settings: experiences from Uganda.

BACKGROUND: Five outbreaks of ebola occurred in Uganda between 2000-2012. The outbreaks were quickly contained in rural areas. However, the Gulu outbreak in 2000 was the largest and complex due to insurgency. It invaded Gulu municipality and the slum- like camps of the internally displaced persons (IDPs). The Bundigugyo district outbreak followed but was detected late as a new virus. The subsequent outbreaks in the districts of Luwero district (2011, 2012) and Kibaale (2012) were limited to rural areas. METHODS: Detailed records of the outbreak presentation, cases, and outcomes were reviewed and analyzed. Each outbreak was described and the outcomes examined for the different scenarios. RESULTS: Early detection and action provided the best outcomes and results. The ideal scenario occurred in the Luwero outbreak during which only a single case was observed. Rural outbreaks were easier to contain. The community imposed quarantine prevented the spread of ebola following introduction into Masindi district. The outbreak was confined to the extended family of the index case and only one case developed in the general population. However, the outbreak invasion of the town slum areas escalated the spread of infection in Gulu municipality. Community mobilization and leadership was vital in supporting early case detection and isolations well as contact tracing and public education. CONCLUSION: Palliative care improved survival. Focusing on treatment and not just quarantine should be emphasized as it also enhanced public trust and health seeking behavior. Early detection and action provided the best scenario for outbreak containment. Community mobilization and leadership was vital in supporting outbreak control. International collaboration was essential in supporting and augmenting the national efforts.

War experiences, general functioning and barriers to care among former child soldiers in Northern Uganda: the WAYS study.

BACKGROUND: Exposure to war is associated with considerable risks for long-term mental health problems (MHP) and poor functioning. Yet little is known about functioning and mental health service (MHS) use among former child soldiers (FCS). We assessed whether different categories of war experiences predict functioning and perceived need for, sources of and barriers to MHS among FCS. METHODS: Data were drawn from an on-going War-affected Youths (WAYS) cohort study of FCS in Uganda. Participants completed questionnaires about war experiences, functioning and perceived need for, sources of and barriers to MHS. Regression analyses and parametric tests were used to assess between-group differences. RESULTS: Deaths, material losses, threat to loved ones and sexual abuse significantly predicted poor functioning. FCS who received MHS function better than those who did not. Females reported more emotional and behavioural problems and needed MHS more than males. FCS who function poorly indicated more barriers to MHS than those who function well. Stigma, fear of family break-up and lack of health workers were identified as barriers to MHS. CONCLUSIONS: Various war experiences affect functioning differently. A significant need for MHS exists amidst barriers to MHS. Nevertheless, FCS are interested in receiving MHS and believe it would benefit them.

Country leadership and policy are critical factors for implementing laboratory accreditation in developing countries: a study on Uganda.

Accreditation of laboratories is one means to promote quality laboratory services, underscoring the need to document factors that facilitate laboratory accreditation. A desk review and key informant's interviews were conducted to determine the roles of country leadership and policies in laboratory accreditation. Overall, the review revealed that Uganda has enabling factors for laboratory accreditation, putting the country in a state of accreditation-readiness and including strong leadership that provides stewardship and availability of a national health laboratory policy with an explicit statement on laboratory accreditation. A National Laboratory Technical and Policy Committee coordinated the development of the policy. Laboratory training schools provide leadership in training laboratory professionals, while the Association of Medical Laboratory Technologists provides professional leadership. Although there is no national accreditation system, some laboratories are participating in international laboratory accreditation. Key informants expressed strong support for and observed that laboratory accreditation is beneficial and can be implemented in Uganda. Lessons from this study can benefit countries planning to implement laboratory accreditation. Countries that have not developed national laboratory policies and strategic plans should do so to guide the strengthening of laboratory systems and services as a part of health systems strengthening, which would be a springboard for laboratory accreditation.

Ebola hemorrhagic fever associated with novel virus strain, Uganda, 2007-2008.

During August 2007-February 2008, the novel Bundibugyo ebolavirus species was identified during an outbreak of Ebola viral hemorrhagic fever in Bundibugyo district, western Uganda. To characterize the outbreak as a requisite for determining response, we instituted a case-series investigation. We identified 192 suspected cases, of which 42 (22%) were laboratory positive for the novel species; 74 (38%) were probable, and 77 (40%) were negative. Laboratory confirmation lagged behind outbreak verification by 3 months. Bundibugyo ebolavirus was less fatal (case-fatality rate 34%) than Ebola viruses that had caused previous outbreaks in the region, and most transmission was associated with handling of dead persons without appropriate protection (adjusted odds ratio 3.83, 95% confidence interval 1.78-8.23). Our study highlights the need for maintaining a high index of suspicion for viral hemorrhagic fevers among healthcare workers, building local capacity for laboratory confirmation of viral hemorrhagic fevers, and institutionalizing standard precautions.

Towards effective Ponseti clubfoot care: the Uganda Sustainable Clubfoot Care Project.

UNLABELLED: Neglected clubfoot is common, disabling, and contributes to poverty in developing nations. The Ponseti clubfoot treatment has high efficacy in correcting the clubfoot deformity in ideal conditions but is demanding on parents and on developing nations' healthcare systems. Its effectiveness and the best method of care delivery remain unknown in this context. The 6-year Uganda Sustainable Clubfoot Care Project (USCCP) aims to build the Ugandan healthcare system's capacity to treat children with the Ponseti method and assess its effectiveness. We describe the Project and its achievements to date (March 2008). The Ugandan Ministry of Health has approved the Ponseti method as the preferred treatment for congenital clubfoot in all its hospitals. USCCP has trained 798 healthcare professionals to identify and treat foot deformities at birth. Ponseti clubfoot care is now available in 21 hospitals; in 2006-2007, 872 children with clubfeet were seen. USCCP-designed teaching modules on clubfoot and the Ponseti method are in use at two medical and three paramedical schools. 1152 students in various health disciplines have benefited. USCCP surveys have (1) determined the incidence of clubfoot in Uganda as 1.2 per 1000 live births, (2) gained knowledge surrounding attitudes, beliefs, and practices about clubfoot across different regions, and (3) identified barriers to adherence to Ponseti treatment protocols. USCCP is now following a cohort of treated children to evaluate its effectiveness in the Ugandan context. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.