Asthma prevalence and mortality in sub Saharan Africa: the case of Uganda

Asthma is a very common disease affecting around 8.8 % of the global population. In Sub Saharan Africa (SSA), data on asthma are very limited and most patients with asthma will not be diagnosed or treated because of lack of resources. In this thesis we conducted studies to understand how many people suffer from asthma, asthma risk factors and the impact asthma had on the people in Uganda as an example of a Sub Saharan African country. We assessed 3416 persons and found 11.0% of them had asthma. Asthma was associated with smoking, family history of asthma and smoke from biomass (mostly wood fires) used for cooking and lighting indoors, history of TB, HIV infection and living in the cities. Air pollution (particles) was 5.3 times the safety levels (132.1 μg/m3). A follow-up study of 449 patients for 2-years documented 17 deaths. Calculated from this we estimate that the mortality is over 20 times higher than in developed high income countries. Only 14% of patients in this study had access to appropriate asthma medications, mainly because the medications were not available or patients could not afford them. The combination of socio economic problems and the low availability of medication makes asthma a disease with a high mortality in Sub Saharan countries surpassing the current mortality from HIV and TB combined. We conclude that asthma is common in Africa, probably because of a high prevalence of HIV, TB and air pollution. The high mortality observed seems due to lack of medication

Health seeking behavior among individuals presenting with chronic cough at referral hospitals in Uganda; missed opportunity for early tuberculosis diagnosis

Funding: This study was conducted with funding from the World Bank under the East African Public Health Laboratory Networking Project (EAPHLNP).Background: Tuberculosis (TB) is the 9th leading cause of death from a single infectious agent. Patients live in a complex health care system with both formal and informal providers, and it is important that a TB diagnosis is not missed at the first interaction with the health care system. In this study, we highlight the health seeking behavior of patients and missed opportunities for early TB diagnosis for which interventions could be instituted to ensure early TB diagnosis and prompt TB treatment initiation. Methods: This study was nested in a cross-sectional study that assessed the accuracy of different Xpert MTB/Rif implementation strategies in programmatic settings at the referral hospitals in Uganda. We documented the symptom profile of presumptive TB patients and assessed the health seeking behavior of those with chronic cough by calculating proportion of patients that visited each type of health facility and further calculated the odds of being TB positive given the type of health facility initially visited for consultation. Results: A total of 1,863 presumptive TB patients were enrolled of which 979 (54.5%) were male, and 1795 (99.9%) had chronic cough. A total of 1352 (75.4%) had previously sought care for chronic cough, with 805 (59.6%) seeking care from a public health facility followed by private health facility (289; 21.4%). Up to 182 (13.5%) patients visited a drug store for chronic cough. Patients whose first contact was a private health facility were more likely to have a positive GeneXpert test (adjOR 1.4, 95% CI: 1.0-1.9; p = 0.047). Conclusions: Chronic cough is a main symptom for many of the presumptive TB patients presenting at referral hospitals, with several patients having to visit the health system more than once before a TB diagnosis is made. This suggests the need for patients to be thoroughly evaluated at first interface with the health care system to ensure prompt diagnosis and treatment initiation. Improved TB diagnosis possibly with the GeneXpert test, at first contact with the health care system has potential to increase TB case finding and break the transmission cycle in the community.Publisher PDFPeer reviewe

Clinical profile and initial treatment of non-small cell lung cancer: a retrospective cohort study at the Uganda Cancer Institute

Introduction: Lung cancer is a major global public health burden constituting 11.6% of all new cancer diagnoses and 18.4% of all cancer-related mortality. Purpose: To describe the clinical profile and initial treatment of non-small cell lung cancer in Uganda. Methods: We reviewed charts of a cohort of patients with a histologically confirmed diagnosis of non-small cell lung cancer, treated between January 2013 and November 2015 at the Uganda Cancer Institute. Results: A total of 74 patients met the inclusion criteria. The median age was 56 years (IQR 47-70), with 16.2% below the age 45 years, and 51% were female. Only 10 percent were active smokers and the most frequent histological subtype was adenocarcinoma (71%). The majority (91.9%) had stage IV disease at diagnosis and frequent metastases to contralateral lung, liver, and bones. Twenty-seven (27) patients received platinum-based chemotherapy, while 27 patients received erlotinib, and only 4 patients received palliative thoracic radiotherapy. The median survival time was 12.4 months, and the overall response rate was 32.7%. There was no survival difference by type of systemic treatment, and on multivariate analysis, poor performance status was predictive of adverse outcomes (p < 0.001). Conclusions: Patients with non-small cell lung cancer in Uganda frequently presented with late-stage disease at diagnosis. The majority of patients were female, never-smokers, and had predominantly adenocarcinoma subtype. Keywords: Non-small cell lung cancer; Uganda; erlotinib; lung cancer; Uganda Cancer Institute

Prevalence of chronic respiratory disease in urban and rural Uganda.

OBJECTIVE: To determine the prevalence of chronic respiratory diseases in urban and rural Uganda and to identify risk factors for these diseases. METHODS: The population-based, cross-sectional study included adults aged 35 years or older. All participants were evaluated by spirometry according to standard guidelines and completed questionnaires on respiratory symptoms, functional status and demographic characteristics. The presence of four chronic respiratory conditions was monitored: chronic obstructive pulmonary disease (COPD), asthma, chronic bronchitis and a restrictive spirometry pattern. FINDINGS: In total, 1502 participants (average age: 46.9 years) had acceptable, reproducible spirometry results: 837 (56%) in rural Nakaseke and 665 (44%) in urban Kampala. Overall, 46.5% (698/1502) were male. The age-adjusted prevalence of any chronic respiratory condition was 20.2%. The age-adjusted prevalence of COPD was significantly greater in rural than urban participants (6.1 versus 1.5%, respectively; P?<?0.001), whereas asthma was significantly more prevalent in urban participants: 9.7% versus 4.4% in rural participants (P?<?0.001). The age-adjusted prevalence of chronic bronchitis was similar in rural and urban participants (3.5 versus 2.2%, respectively; P?=?0.62), as was that of a restrictive spirometry pattern (10.9 versus 9.4%; P?=?0.82). For COPD, the population attributable risk was 51.5% for rural residence, 19.5% for tobacco smoking, 16.0% for a body mass index <?18.5 kg/m2 and 13.0% for a history of treatment for pulmonary tuberculosis. CONCLUSION: The prevalence of chronic respiratory disease was high in both rural and urban Uganda. Place of residence was the most important risk factor for COPD and asthma

Access to affordable medicines and diagnostic tests for asthma and COPD in sub Saharan Africa: the Ugandan perspective.

BACKGROUND: Equitable access to affordable medicines and diagnostic tests is an integral component of optimal clinical care of patients with asthma and chronic obstructive pulmonary disease (COPD). In Uganda, we lack contemporary data about the availability, cost and affordability of medicines and diagnostic tests essential in asthma and COPD management. METHODS: Data on the availability, cost and affordability of 17 medicines and 2 diagnostic tests essential in asthma and COPD management were collected from 22 public hospitals, 23 private and 85 private pharmacies. The percentage of the available medicines and diagnostic tests, the median retail price of the lowest priced generic brand and affordability in terms of the number of days' wages it would cost the least paid public servant were analysed. RESULTS: The availability of inhaled short acting beta agonists (SABA), oral leukotriene receptor antagonists (LTRA), inhaled LABA-ICS combinations and inhaled corticosteroids (ICS) in all the study sites was 75%, 60.8%, 46.9% and 45.4% respectively. None of the study sites had inhaled long acting anti muscarinic agents (LAMA) and inhaled long acting beta agonist (LABA)-LAMA combinations. Spirometry and peak flow-metry as diagnostic tests were available in 24.4% and 6.7% of the study sites respectively. Affordability ranged from 2.2 days' wages for inhaled salbutamol to 17.1 days' wages for formoterol/budesonide inhalers and 27.8 days' wages for spirometry. CONCLUSION: Medicines and diagnostic tests essential in asthma and COPD care are not widely available in Uganda and remain largely unaffordable. Strategies to improve access to affordable asthma and COPD medicines and diagnostic tests should be implemented in Uganda

Access to affordable medicines and diagnostic tests for asthma and COPD in sub Saharan Africa : the Ugandan perspective

Funding: This study was supported by a small grant from Uganda Diabetes Association, a diabetes professional association for diabetic patients and healthcare practitioners.Background: Equitable access to affordable medicines and diagnostic tests is an integral component of optimal clinical care of patients with asthma and chronic obstructive pulmonary disease (COPD). In Uganda, we lack contemporary data about the availability, cost and affordability of medicines and diagnostic tests essential in asthma and COPD management. Methods: Data on the availability, cost and affordability of 17 medicines and 2 diagnostic tests essential in asthma and COPD management were collected from 22 public hospitals, 23 private and 85 private pharmacies. The percentage of the available medicines and diagnostic tests, the median retail price of the lowest priced generic brand and affordability in terms of the number of days' wages it would cost the least paid public servant were analysed. Results: The availability of inhaled short acting beta agonists (SABA), oral leukotriene receptor antagonists (LTRA), inhaled LABA-ICS combinations and inhaled corticosteroids (ICS) in all the study sites was 75%, 60.8%, 46.9% and 45.4% respectively. None of the study sites had inhaled long acting anti muscarinic agents (LAMA) and inhaled long acting beta agonist (LABA)-LAMA combinations. Spirometry and peak flow-metry as diagnostic tests were available in 24.4% and 6.7% of the study sites respectively. Affordability ranged from 2.2 days' wages for inhaled salbutamol to 17.1 days' wages for formoterol/budesonide inhalers and 27.8 days' wages for spirometry. Conclusion: Medicines and diagnostic tests essential in asthma and COPD care are not widely available in Uganda and remain largely unaffordable. Strategies to improve access to affordable asthma and COPD medicines and diagnostic tests should be implemented in Uganda.Publisher PDFPeer reviewe

Implication of the Global Initiative for Chronic Obstructive Lung Disease 2023 report for resource-limited settings: tracing the G in the GOLD

The new Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2023 report provides a very useful synthesis of available scientific evidence to guide COPD management, research and prevention, as always [1, 2]. Important changes include the revision of the definition of the condition and the replacement of groups C and D with E, which highlights the importance of exacerbations in COPD [2]

Availability and affordability of medicines and diagnostic tests recommended for management of asthma and chronic obstructive pulmonary disease in sub-Saharan Africa: a systematic review.

BACKGROUND: Early accurate diagnosis and sustainable availability of affordable medicines and diagnostic tests is fundamental in optimal management of asthma and chronic obstructive pulmonary disease (COPD). We systematically reviewed original research articles about availability and affordability of medicines and diagnostic tests recommended for management of asthma and COPD in sub-Saharan Africa (SSA). METHODS: We searched PubMed, Scopus and African Journal Online for original research articles conducted in SSA between 2000 and March 2018 containing information about availability and affordability of any recommended medicine and diagnostic test for asthma and COPD. RESULTS: The search yielded 9 eligible research articles. Availability of short-acting beta agonists (SABA), inhaled corticosteroids (ICS) and short acting anti-muscarinic agents (SAMA) ranged between 19.9-100%, 0-45.5% and 0-14.3% respectively. Combination of ICS-long acting beta agonists (LABA) were available in 0-14.3% of facilities surveyed. There was absence of inhaled long acting anti-muscarinic agents (LAMA) and LAMA/LABA combinations. Spirometry and peak expiratory flow devices were available in 24.4-29.4% and 6.7-53.6% respectively. Affordability of SABA and ICS varied greatly, ranging from < 2 to 107 days' wages while ICS-LABA combinations, SAMA and oral theophylline plus leukotriene receptor antagonists cost 6.4-17.1, 13.7 and 6.9 days' wages respectively. CONCLUSION: Availability and affordability of medicines and diagnostics recommended for the management of asthma and COPD is a big challenge in SSA. Research about this subject in this region is still limited. More robustly performed studies are required to further understand the magnitude of inequity in access to these medicines and diagnostic tests in SSA and also to formulate simple pragmatic solutions to address this challenge