Department of Internal Medicine

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Antibiograms from community-acquired uropathogens in Gulu, northern Uganda - a cross-sectional study
(BMC infectious diseases, 2013) Odongo, Charles O; Anywar, Denis A; Luryamamoi, Kenneth; Odongo, Pancras
Background: Urinary tract infections (UTI) are common in clinical practice and empirical treatment is largely employed due to predictability of pathogens. However, variations in antibiotic sensitivity patterns do occur, and documentation is needed to inform local empirical therapy. The current edition of the Uganda Clinical Guidelines recommends amoxicillin or cotrimoxazole as choice drugs for empirical treatment of community-acquired UTI. From our clinical observations, we suspected that this recommendation was not effective in our setting. In order to examine validity, we sought to identify bacteria from community-acquired infections and determine their susceptibility against these antibiotics plus a range of potentially useful alternatives for treatment of UTI. Methods: A cross-sectional study of mid-stream urine collected from 339 symptomatic patients over a three-month period at Gulu regional referral hospital. Qualitative culture and identification of bacteria and antibiotic sensitivity testing using the modified Kirby-Bauer disk diffusion method was done. Participants’ demographic and clinical characteristics were collected using a standard form. Results were analyzed by simple proportions among related variables and confidence intervals computed using binomial exact distribution. Results: Eighty two cultures were positive for UTI. Staphylococcus spp (46.3%) and Escherichia coli (39%) were the most common pathogens. There was high resistance to cotrimoxazole (73.2%), nalidixic acid (52.4%) and amoxicillin (51.2%). The most favorable antibiograms were obtained with gentamicin, amoxicillin-clavulanate and levofloxacin where 85.4%, 72.0%, 67.1% of isolates respectively, were either sensitive or intermediate. Only 51% of isolates were sensitive to ciprofloxacin. Conclusion: There was high resistance to most antibiotics tested in this study. The recommendations contained in the current edition of the Uganda Clinical Guidelines are not in tandem with antibiotic sensitivity pattern of uropathogens seen in our setting. Amoxicillin-clavulanate or gentamicin should be considered for replacement of amoxicillin and cotrimoxazole for empirical treatment of UTI in our setting.
Impaired renal function and associated risk factors in newly diagnosed HIV-infected adults in Gulu Hospital, Northern Uganda
(BMC nephrology, 2015) Odongo, Pancras; Wanyama, Ronald; Obol, James Henry; Apiyo, Paska; Byakika-Kibwika, Pauline
Background: Screening for renal diseases should be performed at the time of diagnosis of human immunodeficiency virus (HIV) infection. Despite the high prevalence of HIV/AIDS in Northern Uganda, little is known about the status of renal function and its correlates in the newly diagnosed HIV-infected individuals in this resource limited region. We aimed to determine the status of renal function and factors associated with impaired renal function in newly diagnosed HIV-infected adults in Northern Uganda. Methods: This was a seven month cross-sectional hospital-based study, involving newly diagnosed HIV-infected patients, 18 years and older. Patients with history of diabetes mellitus, hypertension and renal disease were excluded. Estimated glomerular filtration rate (eGFR) was calculated using Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula (Table one). Factors associated with impaired renal function (eGFR < 60 ml/min/1.73 m2) were thus sought. Results: We enrolled 361 participants (230, 63.7% female) with Mean ± standard deviation age of 31.4 ± 9.5 years. 52, (14.4%) had impaired renal function (eGFR <60 mL/min/1.73 m2) and of this 37 (71.2%) moderate renal impairment (eGFR 30–59.9 mL/min/1.73 m2) while 15 (28.8%) had severe renal impairment (eGFR <30 mL/min/1.73 m2). Proteinuria was recorded in 189 (52.4%) participants. Of these, 154 (81.5%) had mild (1+) while 8 (4.2%) had severe (3+) proteinuria. Using logistic regression, age, CD4 cell count, and proteinuria were significantly associated with impaired renal function; age >34 years (OR 2.8, 95% CI 1.3 – 5.9; P =0.009), CD4 count <350 cells/μL (OR 2.4, 95% CI 1.0-4.7; P =0.039) and proteinuria (OR 9.6, 95% CI 5.2–17.9; P < 0.001). Conclusion: The prevalence of impaired renal function was high in new HIV-infected individuals in this region with limited resources. So, screening for renal disease in HIV is recommended at the time of HIV diagnosis
Are Women In Low Income Setting Gaining Adequate Gestational Weight? A Prospective Cross Sectional Study In Urban Uganda
(School of Biological Sciences, 2016) Wanyama, Ronald; Obai, Gerald; Odongo, Pancras; Kagawa, Mike N.; Baingana, Rhona K.
Introduction: Pre-pregnancy weight and weight gained during pregnancy significantly influence maternal and infant health. Little information is available regarding prevalence of optimal GWG in relation to pre-pregnancy body mass index (BMI) in Uganda. This study aimed at determining the prevalence of inadequate, adequate and excessive GWG in women pregnant for the first and second time. Methods: The study was prospective cross sectional by design and involved HIV negative women pregnant for the first or second time. It was conducted in a health centre IV and recruitment women at ≤18 weeks of gestation. Follow up measurements were done at 26 and 36 weeks gestation age. Maternal height and weight were measured and used to calculate BMI. Depending on BMI category, GWG was categorized as inadequate, adequate and excessive based on the Uganda Ministry of Health guidelines. Results: The participants’ mean±standard deviation (Sd) age was 20.9±2.7 years and mean±Sd BMI was 21.40±2.73kg/m2. None of the participants was obese and 68.8% (n=132) were primigravidae. The mean±Sd GWG at time of delivery was 10.58±2.44kg. Inadequate GWG was recorded in 62.5% (n=120/192) while only 3.1% (n=6/192) of the participants gained excessive gestational weight. Conclusion: About 62% of primigravidae and secundigravidae in low income urban Kampala do not gain adequate gestational weight
Prevalence of anaemia and associated risk factors among pregnant women attending antenatal care in Gulu and Hoima Regional Hospitals in Uganda: A cross sectional study
(BMC pregnancy and childbirth, 2016) Obai, Gerald; Odongo, Pancras; Wanyama, Ronald
Background: Anaemia is a public health problem affecting over 1.62 billion people globally. It affects all age groups of people and is particularly more prevalent in pregnant women. Africa carries a high burden of anaemia; in Uganda 24 % of women of child bearing age have anaemia. Pregnant women living in poverty are at greater risk of developing iron deficiency anaemia. The objective of this study was to determine the prevalence of anaemia and the associated risk factors in pregnant women attending antenatal care at Gulu and Hoima Regional Hospitals in Northern and Western Uganda respectively. Methods: We conducted a cross sectional study in Gulu and Hoima Regional Hospitals from July to October 2012. Our study participants were pregnant women attending antenatal care. Socio-demographic data were collected using structured questionnaires and blood samples were collected for haemoglobin estimation. Haemoglobin concentration was determined using an automated analyzer closed mode of blood sampling. Data were analysed using Stata version 12. Odds ratio was used as a measure of association, with 95 % confidence interval; and independent risk factors for anaemia were investigated using logistic regression analyses. Ethical approval was obtained from Gulu University Research Ethics Committee and written informed consent was obtained from each study participant. Results: The overall prevalence of anaemia was 22.1 %; higher in Gulu (32.9 %) than in Hoima (12.1 %), p < 0.001. In Gulu, the prevalence of mild anaemia was 23 %, moderate anaemia was 9 %, and severe anaemia was 0.8 %, while in Hoima, the prevalence of mild anaemia was 9 %, moderate anaemia was 2.5 %, and severe anaemia was 0.5 %. Independent risk factors for anaemia were: being a housewife [Adjusted Odds Ratio (AOR) = 1.7, 95 % CI: 1.05–2.68]; and being a resident in Gulu (AOR = 3.6, 95 % CI: 2.41–5.58). Conclusion: The prevalence of anaemia in pregnant women in Gulu is higher than in Hoima. Amongst pregnancy women, being a housewife is an independent risk factor for anaemia. Greater efforts are required to encourage early antenatal attendance from women in these at risk groups. This would allow iron and folic acid supplementation during pregnancy, which would potentially reduce the prevalence of anaemia.
Effect of maternal Helicobacter Pylori infection on gestational weight gain in an urban community of Uganda
(The Pan African Medical Journal, 2017) Wanyama, Ronald; Obai, Gerald; Odongo, Pancras; Kagawa, Michael; Baingana, Rhona
Introduction: Maternal Helicobacter pylori (H. pylori) infection has been associated with undesirable effects during pregnancy such as; hyperemesis gravidarum, anemia, intrauterine fetal growth restriction and miscarriage. Our aim was to document the effect of H. pylori infection on gestational weight gain (GWG) in a low-income urban setting in Uganda. Methods: This was a prospective cohort study conducted in Kampala between May 2012 and May 2013. The participants were HIV negative, H. pylori positive and H. pylori negative primigravidae and secundigravidae. Recruitment was at gestation age of eighteen or less weeks and follow up assessments were carried out at 26 and 36 weeks gestation age. H. pylori infection was determined using H. pylori stool antigen test. Maternal weight and height were measured, and body mass index (BMI) and rates of GWG were calculated. Results: The participants’ mean±standard deviation (sd) age was 20.9±2.7 years. Primigravidae were 68.8% (n = 132) and 57.3% (n = 110) of the participants were positive for H. pylori infection. Low pre-women pregnancy BMI (< 18.5 kg/m2) was recorded in 14.6% (n = 28). The mean±sd rate of GWG during second and third trimesters was 300.5±79.7 grams/week. The mean±sd weight gained by 36 weeks of gestation was 9.6±2.2 kg while gestation age at delivery was 39.4±1.0 weeks. Factors independently associated with the rates of GWG during the second and third trimesters were parity (P=0.023), H. pylori infection (P = 0.006), pre-pregnancy BMI (P = 0.037), height (P = 0.022) and household income (P = 0.003). Conclusion: H. pylori infection is associated with low rates of GWG among primigravidae and secundigravidae.
Improving the accuracy of heart failure diagnosis in low-resource settings through task sharing and decentralization
(Global Health Action, 2019) DeWyer, Alyssa; Scheel, Amy; Otim, Isaac Omara; Longenecker, Christopher T.; Okello, Emmy; Ssinabulya, Isaac; Morris, Stephen; Okwir, Mark; Oyang, William; Joyce, Erine; Nabongo, Betty; Sable, Craig; Alencherry, Ben; Tompsett, Alison; Aliku, Twalib; Beaton, Andrea
Background: Task sharing of TTE may improve capacity for heart failure diagnosis and management in patients in remote, low-resource settings but the impact on diagnostic accuracy and patient outcomes has not been studied. Objectives: Determine feasibility and impact of non-expert training in transthoracic echocardio graphy (TTE) to improve the diagnosis and outcomes of patients with suspected heart failure in Uganda. Methods: This two-part study examined an innovative training program to develop TTE competency among non-experts and used a pre-post design to determine the impact of decentralized TTE. Four of 8 non-experts (50%) passed a three-part training course. The training comprised of distance learning through a web-based curriculum, a 2-day hands-on workshop with cardiologists, and independent practice with remote mentorship. Continuous measures were compared (pre- vs. post-TTE) using t-tests or Wilcoxon rank-sum tests as distributionally appropriate and categorical variables assessed through chi-square testing. Sensitivity and specificity were calculated according to standard methodology comparing diagnosis pre- and post-TTE during phase 2. Results: Performance in the post-training phase showed good agreement with expert cate gorization (κ = 0.80) with diagnostic concordance in 421 of 454 studies (92.7%). TTE changed the preliminary diagnosis in 81% of patients, showing low specificity of clinical decision making alone (14.2%; 95% CI 10.1–19.2%). Dilated cardiomyopathy, hypertensive heart dis ease with preserved systolic function, and right heart failure were the most underdiagnosed conditions prior to TTE while hypertensive heart disease with decreased systolic function was the most over-diagnosed condition. Conclusions: In conclusion, non-expert providers can achieve a high level of proficiency for the categorization of heart failure using handheld TTE in low-resource settings and use of telemedicine and remote mentorship may improve performance and feasibility. The addition of TTE resulted in substantial improvement in etiological specificity. Further study is needed to understand implications of this strategy on healthcare utilization, long-term patient outcomes, and cost. KEYWORDS: Echocardiography; Uganda; task-shifting; telemedicine; training
Health seeking behaviour of small income market vendors: Diabetes primary care in Gulu Municipality, northern Uganda
(South Sudan Medical Journal, 2020) Loum, Constantine S.L.; Wanyama, Ronald; Anywar, Denis; Odongkara, Beatrice M.; Odongo, Pancras
Introduction: Uganda faces a serious threat of non-communicable diseases including type 2 diabetes; sedentary lifestyles predispose people to these diseases. Objective: To understand the diabetes health seeking behaviour of market vendors at the main market, Gulu Municipality. Method: This cross-sectional study used quantitative and qualitative methods to understand experiences of market vendors on health seeking behaviour. After general sensitization and mobilisation in the market, 400 participants were enrolled for the study, however quantitative analysis was done only on data from 375 participants (316 women and 59 men); 25 participants had missing data; 30 of these 375 were interviewed and the qualitative analyses of their responses offered further insight on health seeking – and is reported here. The qualitative data will be reported later. Results: Mixed responses were obtained from these 30 market vendors about their health seeking behaviour for diabetes. The factors were responsible for their overall health seeking behaviour included crowded hospitals and low frequency of clinic days; lack of accurate knowledge, and uninformed beliefs on diabetes, and poor work-life balance. Major impediments to health seeking were the fear of losing work time and money, and feeling healthy and hence seeing no need for health check-ups or medical care. Conclusion: Awareness of diabetes and the need to seek health care exists, but market vendors are not well informed on tests and care. We recommend that more comprehensive simple-message sensitisation is undertaken to change health seeking behaviour and prevent escalation of non-communicable diseases in northern Uganda and beyond.
Challenges associated with the roll-out of HCC surveillance in sub-Saharan Africa - the case of Uganda
(Journal of Hepatology, 2020) Stijn, Van Hees; Muyindike, Winnie; Erem, Geoffrey; Ocama, Ponsianoo; Seremba, Emmanuel; Apiyo, Paska; Michielsen, Peter; Okwir, Mark; Vanwolleghem, Thomas
In sub-Saharan Africa, where HBV infections are the main cause of HCC, surveillance programs are mostly not available.2 Nonetheless, with an incidence rate of 8.9 cases per 100,000 inhabitants per year, which is likely to be an underestimate, HCC surveillance is a pressing medical need in this part of the world.2,3 The recent introduction of country-wide vaccination programs in these countries will likely result in a drop in HCC incidence a few decades from now, but this does not apply to patients that are currently infected.4 In a recent African cohort of 1,315 hepatocellular tumors, 84% of the tumors were diagnosed at a late, multifocal disease stage with a mean size of 8 ± 4 cm and a median survival of 2.5 months.2 Given the strong association between early detection and improved survival, these findings highlight the need to set up surveillance programs in sub-Saharan Africa, provided curative treatment options are available.1 We have recently launched such a program in Uganda, where HCC is one of the most common malignancies. Age-standardized incidence rates of 6.5/100,000 in men and 6.0/100,000 in women have been reported. Unfortunately, its mortality rate almost mirrors its incidence.2,5–7 Following a kick-off meeting in Kampala in August 2019 where representatives from the radiology and internal medicine departments of 5 Ugandan, tertiary care hospitals were present, a questionnaire was launched among the participants to identify gaps that needed bridging in order to set up an HCC surveillance program. Participants were asked about the number of patients with HBV and HCC in their centers, the availability of alpha fetoprotein and ultrasound testing, as well as the available manpower to perform ultrasound. A summary of the findings is displayed in Table 1. None of the centers had an HCC surveillance program in place. However, outpatient HBV clinics are available in 3/5 centers and planned in the fourth. The estimated number of patients fre quenting these HBV clinics varies between <100 and 500–1,000. Given a nationwide HBsAg seroprevalence of 10% in Uganda, these varying numbers might point to the regional differences in HBV-infected patients, but they may also point to variations in linkage to care.8 Ultrasound machines are widely available in all centers and except for 2, all were manufactured within the last decade (Table 1). The number of staff trained to perform ultrasound largely varies between centers, ranging between 1 and 39, but corresponds to a coverage of 87% for the total number of medical staff at the radiology departments (radiologists/radiographers). Regular post-graduate training for ultrasound staff is provided in 3/5 centers. AFP testing is avail able in 2 centers; in a third center testing is offered based on reagent availability. A registry of the number of HCC cases is available in 1 center, though survival data are not systematically recorded. Diagnosis of HCC is based on clinical signs, such as a palpable liver mass or liver lesions on ultrasound in patients with clinical deterioration and not identified during screening of patients at risk. Liver surgery for non-advanced HCC is available in 1 center. Our survey highlights the feasibility of rolling out an HCC surveillance program in Uganda, as manpower, US equipment and treatment options are available. Further investment should aim at establishing HBV clinics with optimal linkage to care and broadening HCC treatment capacities. Our findings may guide other groups aiming to roll out surveillance programs in different countries. keywords: Challenges, HCC surveillance, and sub-Saharan Africa
Blood Culture Testing Outcomes among Non-Malarial Febrile Children at Antimicrobial Resistance Surveillance Sites in Uganda, 2017–2018
(Tropical Medicine and Infectious Disease, 2021) Kisame, Rogers; Najjemba, Robinah; van Griensven, Johan; Kitutu, Freddy Eric; Takarinda, Kudakwashe; Thekkur, Pruthu; Delamou, Alexandre; Walwema, Richard; Kakooza, Francis; Mugerwa, Ibrahim; Sekamatte, Musa; Kimera, Robert; Katairo, Thomas; Opollo, Marc Sam; Otita, Morgan; Lamorde, Mohammed
: Blood culture (BC) processes are critical to the utility of diagnostic testing, bloodstream infection (BSI) management, and antimicrobial resistance (AMR) surveillance. While Uganda has established BC guidelines, often laboratory practice does not meet the desired standards. This compromises pathogen recovery, reliability of antimicrobial susceptibility testing, and diagnostic test utility. This study assessed laboratory BC process outcomes among non-malarial febrile children be low five years of age at five AMR surveillance sites in Uganda between 2017 and 2018. Secondary BC testing data was reviewed against established standards. Overall, 959 BC specimens were processed. Of these, 91% were from female patients, neonates, infants, and young children (1–48 months). A total of 37 AMR priority pathogens were identified; Staphylococcus aureus was predominant (54%), followed by Escherichia coli (19%). The diagnostic yield was low (4.9%). Only 6.3% of isolates were identified. AST was performed on 70% (18/26) of identified AMR priority isolates, and only 40% of these tests adhered to recommended standards. Interventions are needed to improve laboratory BC practices for effective patient management through targeted antimicrobial therapy and AMR surveillance in Uganda. Further research on process documentation, diagnostic yield, and a review of patient outcomes for all hospitalized febrile patients is needed. Keywords: blood culture; bloodstream infections; febrile illness; antimicrobial resistance; antimicro bial susceptibility testing; operational research; SORT IT
Knowledge and compliance with Covid-19 infection prevention and control measures among health workers in regional referral hospitals in northern Uganda: a cross sectional online survey [version 2; peer review: 1 approved, 1 approved with reservations]
(F1000Research, 2021) Amanya, Sharon Bright; Nyeko, Richard; Obura, Bonniface; Acen, Joy; Nabasirye, Caroline; Nakaziba, Rebecca; Oyella, Florence; Afayo, Victor; Okwir, Mark
Background: Infection prevention and control (IPC) has increasingly been underscored as a key tool for limiting the transmission of coronavirus disease 2019 (Covid-19) and safeguarding health workers from infections during their work. Knowledge and compliance with IPC measures is therefore essential in protecting health workers. However, this has not been established among health workers in northern Uganda in light of the Covid-19 pandemic. The objective of this study was to determine the knowledge and compliance with Covid-19 infection prevention and control measures among health workers in regional referral hospitals in northern Uganda. Methods: An online cross-sectional descriptive study was conducted among health workers in regional referral hospitals within northern Uganda. A structured questionnaire was distributed to health workers via WhatsApp messenger. Sufficient knowledge was considered at a correct response score of ≥80%, while adequate compliance was rated ≥75% of the maximum score. Data were analyzed using SPSS v21. Results: Of the 213 health workers approached, 75 (35%) participated in the study. The majority were males, 39(52%) and the mean age was 36.92 years. Of the 75 participants, 52(69%) had sufficient knowledge of Covid-19 IPC while 51(68%) had adequate compliance with Covid-19 IPC. Adequate compliance was significantly associated with training in Covid-19 IPC (OR, 2.86; 95% CI, (1.04-7.88); p=0.039), access to Covid-19 IPC materials at workstations (OR, 2.90; 95% CI, (1.06 - 8.09); p=0.036), and having strong institutional support (OR, 3.08; 95% CI, (1.08 – 8.74); p=0.031). However, there was no significant relationship between knowledge and compliance with IPC (p=0.07). The socio demographic characteristics of health workershad no statistically significant relationship with Covid-19 IPC knowledge or compliance. Conclusion: Our results show fairly good knowledge and compliance with Covid-19 IPC among health workers in northern Uganda. There is need for more training and provision of guidelines to promote compliance with Covid-19 IPC. Keywords Infection prevention and control, knowledge, training, compliance
Delays in Cryptococcal Meningitis Diagnosis and Care: A Mixed Methods Study in Rural Uganda
(Annals of global health,, 2022) LINK, ABIGAIL; OKWIR, MARK; NABONGO, BETTY; MEYA, DAVID; IRIBARREN, SARAH; BOHJANEN, PAUL; KASPRZYK, DANUTA
Background: Cryptococcal meningitis (CM) remains a major cause of mortality for HIV infected persons in sub-Saharan Africa, despite widespread access to antiretroviral therapy. Delays in CM diagnosis and treatment contribute to high mortality, with patients often arriving “too late” for treatment to be effective. Little is known about patient-related delays and their experiences with CM. Objectives: This study seeks to identify the factors related to delays in diagnosis and care among patients with cryptococcal meningitis. Methods: A convergent mixed-methods approach was used to understand delays related to diagnosis and treatment of CM among patients admitted to Lira Regional Referral Hospital in rural northern Uganda. We collected data from February to March 2020 using surveys followed by semi-structured interviews from 20 CM patients who survived hospitalization and 20 family members of deceased patients during February 2017–November 2019. Interviews were audio-recorded, transcribed, and thematically coded for analysis. Findings: Delays to CM care were related to 1) self-medication, 2) lack of CM education, 3) seeking treatment multiple times at health centers with 4) missed/misdiagnosis, and 5) cultural factors. Among patients who died, 70% sought care ≥3 times, while those who survived, 35% of sought care ≥3 times before CM diagnosis. Only 10% of patients and 40% of family members knew what caused CM, indicating a lack of knowledge. Conclusions: Patients sought medical care for CM symptoms, but several factors contributed to CM diagnosis and care delays. Many of these factors relate to a lack of CM education and knowledge among patients and providers. A CM awareness campaign for the general public, targeted education for HIV patients, and continuing medical education for healthcare providers can decrease delays and improve outcomes.
Prevalence of Intestinal Helminth Coinfection in Drug-Resistant Tuberculosis in Uganda
(Oxford University Press., 2022) Baluku, Joseph Baruch; Nakazibwe, Bridget; Wasswa, Amir; Naloka, Joshua; Ntambi, Samuel; Waiswa, Damalie; Okwir, Mark; Nabwana, Martin; Bongomin, Felix; Katuramu, Richard; Nuwagira, Edwin; Ntabadde, Kauthrah; Katongole, Paul; Senyimba, Catherine; Andia-Biraro, Irene
Background. Although a third of people with tuberculosis (TB) are estimated to be coinfected with helminths, the prevalence is largely unknown among people with drug-resistant TB (DR-TB). We determined the prevalence of helminth coinfection among people with DR-TB in Uganda. Methods. In a multicenter, cross-sectional study, eligible Ugandan adults with confirmed DR-TB were consecutively enrolled between July to December 2021 at 4 treatment centers. Sociodemographic data were collected using a questionnaire. Participants underwent anthropometric and blood pressure measurements, and blood samples were evaluated for random blood glucose, glycated hemoglobin, nonfasting lipid profile, human immunodeficiency virus (HIV) infection, and a complete blood count. Fresh stool samples were evaluated for adult worms, eggs, and larvae using direct microscopy after Kato-Katz concentration techniques. Results. Of 212 participants, 156 (73.6%) were male, 118 (55.7%) had HIV, and 3 (2.8%) had malaria coinfection. The prevalence of intestinal helminth coinfection was 4.7% (10/212) (95% confidence interval, 2.6%–8.6%). The frequency of helminth infections was Ancylostoma duodenale (n=4), Schistosoma mansoni (n=2), Enterobius vermicularis (n=2), Ascaris lumbricoides (n=1), and Trichuris trichiura (n=1). Conclusions. The prevalence of helminth coinfection was low among people with DR-TB. More studies are needed to determine the clinical relevance of helminth/DR-TB coinfection. Keywords. DR-TB; drug-resistant tuberculosis; helminth; MDR; TB; worms
Impact of a Cryptococcal meningitis diagnosis and treatment program at Lira Regional Referral Hospital in rural, Northern Uganda
(PLOS global public health, 2022) Link, Abigail; Okwir, Mark; Meya, David; Nabongo, Betty; Okello, James; Kasprzyk, Danuta; Bohjanen, Paul R.
Abstract In rural areas of sub-Saharan Africa, infrastructure and resources for treatment of crypto coccal meningitis (CM) are often lacking. We introduced a CM diagnosis and treatment pro gram (CM-DTP) at Lira Regional Referral Hospital (LRRH) in rural Uganda to determine if implementing high-quality standard of care protocols would improve outcomes. Information extracted from hospital charts and clinical record forms at LRRH were used to compare diagnoses, treatments, and outcomes for all patients diagnosed with meningitis (n = 281) over a two-year period after initiation of the CM-DTP in February of 2017 to all patients diag nosed with meningitis (n = 215) in the two preceding years. After implementation of the CM DTP, we observed increased confirmed diagnoses of CM from 22.2% (48 of 215) to 35.2% (99 of 281), (p = 0.002) among all patients diagnosed with meningitis. Among all patients treated for CM, the proportion who received standard of care treatment with amphotericin B plus fluconazole increased from 63 of 127 (49.6%) to 109 of 146 (74.7%), (p <0.001) and mortality improved from 66 of 127 (52.0%) to 57 of 146 (39.0%), (p = 0.04) after implementa tion of the CM-DTP. Implementation of the CM-DTP was associated with increased number of lumbar punctures and decreased use of antibiotics in patients with CM, as well as decreased mortality among patients with meningitis from all causes. Improved diagnosis, treatment, and mortality were observed following implementation of the CM-DTP. Our results demonstrate that quality treatment of CM in rural Uganda is feasible
High Burden of Cryptococcal Meningitis Among Antiretroviral Therapy–Experienced Human Immunodeficiency Virus–Infected Patients in Northern Uganda in the Era of “Test and Treat”: Implications for Cryptococcal Screening Programs
(Open forum infectious diseases, 2022) Okwir, Mark; Link, Abigail; Rhein, Joshua; Obbo, John Stephen; Okello, James; Nabongo, Betty; Alal, Jimmy; Meya, David; Bohjanen, Paul R.
Background. The impact of the “test and treat” program for human immunodeficiency virus (HIV) treatment in rural areas of Uganda on cryptococcal antigen (CrAg) screening or cryptococcal meningitis (CM) is poorly understood. Methods. We retrospectively evaluated clinical factors in 212 HIV-infected patients diagnosed with CM from February of 2017 to November of 2019 at Lira Regional Referral Hospital in northern Uganda. Results. Among 212 patients diagnosed with CM, 58.5% were male. Median age was 35 years; CD4 count and HIV viral load (VL) were 86 cells/μL and 9463 copies/mL, respectively. Only 10% of patients had a previous history of CM. We found that 190 of 209 (90.9%) patients were ART experienced and 19 (9.1%) were ART naive. Overall, 90 of 212 (42.5%) patients died while hospital ized (median time to death, 14 days). Increased risk of death was associated with altered mental status (hazard ratio [HR], 6.6 [95% confidence interval {CI}, 2.411–18.219]; P ≤ .0001) and seizures (HR, 5.23 [95% CI, 1.245–21.991]; P = .024). Conclusions. Current guidelines recommend CrAg screening based on low CD4 counts for ART-naive patients and VL or clin ical failure for ART-experienced patients. Using current guidelines for CrAg screening, some ART-experienced patients miss CrAg screening in resource-limited settings, when CD4 or VL tests are unavailable. We found that the majority of HIV-infected patients with CM were ART experienced (90.9%) at presentation. The high burden of CM in ART-experienced patients supports a need for improved CrAg screening of ART-exposed patients. Keywords. antiretroviral therapy; cryptococcal meningitis outcomes; screening.
Lack of education, knowledge, and supplies are barriers to cryptococcal meningitis care among nurses and other healthcare providers in rural Uganda: A mixed methods study
(Nurse Education Today, 2023) Link, Abigail; Okwir, Mark; Irebarren, Sarah; Meya, David; Bolijanen, Paul. R.; Danuta, Kasprzyk
Abstract Background Cryptococcal meningitis (CM) is one of the deadliest opportunistic infections related to HIV/AIDS. A research gap exists surrounding the barriers to CM diagnosis, treatment delivery, and care from the healthcare provider's perspective. Objectives The purpose of this study was to elucidate provider's behaviors, to identify barriers and facilitators to diagnose and treat CM, and to assess their knowledge of CM, cryptococcal screening, and treatment. Design, setting, and participants A convergent mixed-methods study among twenty healthcare providers who provided CM patient referrals to Lira Regional Referral Hospital in Lira, Uganda. Methods Surveys and interviews were conducted to obtain information from healthcare providers who referred CM patients to Lira Regional Referral Hospital from 2017 to 2019. Questions related to provider education, knowledge, barriers to CM care, and patient education were inquired to understand the providers' perspectives. Results Nurses had the least amount of CM knowledge with half knowing the cause of CM. Approximately half the participants knew about CM transmission, but only 15 % knew the duration of CM maintenance therapy. Most participants (74 %) last had education regarding CM during didactic training. In addition, 25 % disclosed they never educate patients due to time constraints (30 %) and lack of knowledge (30 %). Nurses (75 %) were least likely to provide patient education. Most participants acknowledged their lack of CM knowledge and attributed it to a lack of education and perceived inexperience with CM. Conclusions Providers' gaps in knowledge due to the lack of education and experience contributes to decreased patient education, and the lack of access to appropriate supplies affects their provision for CM diagnosis, treatment, and care. These results can guide evidence-based interventions to improve health providers' knowledge. Recommendations for standardized CM education should be developed for both providers and patients in collaboration with professional boards and the Uganda Ministry of Health
Utilization of antiretroviral therapy services and associated factors among adolescents living with HIV in northern Uganda: A cross-sectional study
(PLoS ONE, 2023) Odongo, Innocent; Arim, Barbara; Ayer, Patrick; Murungi, Tom; Akullo, Susan; Aceng, Docus; Oboke, Henry; Kumakech, Edward; Obua, Celestino; Auma, Anna Grace; Richard, Nyeko
Background Suboptimal utilization of antiretroviral therapy (ART) services remains a problem among adolescents in low- and middle-income countries, which has a negative impact on their response to treatment and increases the risk of developing resistance. Optimal use is essential to enhancing treatment efficacy. We investigated the optimal use of ART service and predictors among adolescents living with HIV (ALHIV) in northern Uganda. Methods We used a cross-sectional study design to collect quantitative data from 293 ALHIV at three health facilities in Lira municipality, northern Uganda. We used an interviewer-administered questionnaire and data abstraction form. Data were analysed using SPSS version 23 soft ware. Descriptive analysis and logistic regressions were performed to determine the relation ship between the predictor and outcome variables. Statistical significance was determined at P-value<0.05 and the adjusted odds ratio with a 95% confidence interval was used. Results The level of utilization of ART services was suboptimal among 27.6% (81/293) of the partici pants, and only 63.1% (185/293) were virally suppressed. Of the participants who were opti mally utilizing ART services, the majority 86.8% (184/212) were virally suppressed. Age 10– 14 years (aOR = 3.34), the presence of both parents (aOR = 1.85), parental and peer reminders (aOR = 2.91) and (aOR = 0.49) respectively, and being on ART for five years or less were the characteristics related with optimal utilization of ART services. Conclusions and recommendations Not all ALHIV used ART services to their full potential. However, factors such as partici pants’ age, the presence of both parents, reminders from parents and peers, and being on ART for some time were all related to the optimal use of ART services. There is a need for developing strategies to increase family and peer support with a focus on older adolescents if the 95-95-95 goal is to be achieved in this age group.
Poor long-term outcomes despite improved hospital survival for patients with cryptococcal meningitis in rural, Northern Uganda
(PLoS ONE, 2024) Okwir, Mark; Link, Abigail; Opio, Bosco; Okello, Fred; Nakato, Ritah; Nabongo, Betty; Alal, Jimmy; Rhein, Joshua; Meya, David; Liu, Yu; Bohjanen, Paul R.
Background Cryptococcal meningitis (CM) remains a major cause of death among people living with HIV in rural sub-Saharan Africa. We previously reported that a CM diagnosis and treatment program (CM-DTP) improved hospital survival for CM patients in rural, northern Uganda. This study aimed to evaluate the impact on long-term survival. Methods We conducted a retrospective study at Lira Regional Referral Hospital in Uganda evaluating long-term survival (�1 year) of CM patients diagnosed after CM-DTP initiation (February 2017-September 2021). We compared with a baseline historical group of CM patients before CM-DTP implementation (January 2015-February 2017). Using Cox proportional hazards models, we assessed time-to-death in these groups, adjusting for confounders. Results We identified 318 CM patients, 105 in the Historical Group, and 213 in the CM-DTP Group. The Historical Group had a higher 30-day mortality of 78.5% compared to 42.2% in the CMDTP Group. The overall survival rate for the CM-DTP group at three years was 25.6%. Attendance at follow-up visits (HR:0.13, 95% CI: [0.03–0.53], p <0.001), ART adherence (HR:0.27, 95% CI: [0.10–0.71], p = 0.008), and fluconazole adherence: (HR:0.03, 95% CI: [0.01–0.13], p <0.001), weight >50kg (HR:0.54, 95% CI: [0.35–0.84], p = 0.006), and performance of therapeutic lumbar punctures (HR:0.42, 95% CI: [0.24–0.71], p = 0.001), were associated with lower risk of death. Altered mentation was associated with increased death risk (HR: 1.63, 95% CI: 1.10–2.42, p = 0.016). Conclusion Long-term survival of CM patients improved after the initiation of the CM-DTP. Despite this improved survival, long-term outcomes remained sub-optimal, suggesting that further work is needed to enhance long-term survival.

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