Integration of Mental Health into Primary Health Care in a rural district in Uganda

Objective: Mental health has been identified as a major priority in the Ugandan Health Sector Strategic Plan. Efforts are currently underway to integrate mental health services into the Primary Health Care system. In this study, we report aspects of the integration of mental health into primary health care in one rural district in Uganda. Method: Qualitative methods were used for data collection. Semi-structured interviews and focus group discussions were conducted with various stakeholders within the ministry of health as well as line ministries. Data analysis was done using Nvivo 7, specifically adopting framework analysis approach. Results: Attempts to offer organized mental health services were found to be present in only a few health facilities. The district had only a single mental health nurse, and very few General Health Workers adequately equipped with the knowledge and skills to provide mental health services. The vertical referral system was not being followed as planned and there was no evidence of any organized community interventions for those with mental disorders. The mental health nurse and a few PHC nurses however expressed interest and commitment to providing services for persons with mental illness, despite the challenges. Conclusion: Although mental healthis expected to be integrated into primary health care, mental health services in this district have not yet achieved the expected level of integration. This implies that this important policy requirement has not yet been effectively realized in this rural district, which could be the case in many other districts of a similar status. There is thus a need to direct more efforts towards realization of this important policy requirement.Key words: Mental health; Primary Health Care; Integration; Ugand

Media and Mental Health in Uganda

Objective: The media is largely regarded as an important stakeholder in health service delivery, with a great influence on publicattitudes. However, little is known about its interest in mental health and the guiding factors that influence media coverage of mentalhealth issues. This article describes the importance accorded to mental health by the media and the factors that influence mediacoverage of mental health issues in Uganda. Method: Semi-structured interviews were held with representatives from sixprominent media houses as part of the situational analysis of the mental health system in Uganda. Data was analyzed using Nvivo7 qualitative data analysis software. Results: The media was found to be interested and actively involved in health initiatives, butwith little attention devoted to mental health. Coverage and interest in mental health was noted to be mainly dependent on theindividual journalists’ interests, and mostly for personal reasons. Low interest was largely attributed to mental health beingperceived as a non-priority area, and the fact that mental illness is not a major contributor to mortality. Media coverage andreporting is guided by prioritization of the Health Department. Conclusion: The media in Uganda is an important stakeholderin the health care system with a key role of advocacy, publicity and mass education. Media houses however are less interested inmental health as evidenced by low coverage of mental health issues. This calls for advocacy and sensitization as a way ofpersuading media for more involvement in mental health initiatives.Key words: Media; Mental health; Uganda; Publi

FCRL5 Delineates Functionally Impaired Memory B Cells Associated with Plasmodium falciparum Exposure.

Exposure to Plasmodium falciparum is associated with circulating "atypical" memory B cells (atMBCs), which appear similar to dysfunctional B cells found in HIV-infected individuals. Functional analysis of atMBCs has been limited, with one report suggesting these cells are not dysfunctional but produce protective antibodies. To better understand the function of malaria-associated atMBCs, we performed global transcriptome analysis of these cells, obtained from individuals living in an area of high malaria endemicity in Uganda. Comparison of gene expression data suggested down-modulation of B cell receptor signaling and apoptosis in atMBCs compared to classical MBCs. Additionally, in contrast to previous reports, we found upregulation of Fc receptor-like 5 (FCRL5), but not FCRL4, on atMBCs. Atypical MBCs were poor spontaneous producers of antibody ex vivo, and higher surface expression of FCRL5 defined a distinct subset of atMBCs compromised in its ability to produce antibody upon stimulation. Moreover, higher levels of P. falciparum exposure were associated with increased frequencies of FCRL5+ atMBCs. Together, our findings suggest that FCLR5+ identifies a functionally distinct, and perhaps dysfunctional, subset of MBCs in individuals exposed to P. falciparum

Validity and diagnostic accuracy of the Luganda version of the 9-item and 2-item Patient Health Questionnaire for detecting major depressive disorder in rural Uganda.

BACKGROUND: The prevalence of depression in rural Ugandan communities is high and yet detection and treatment of depression in the primary care setting is suboptimal. Short valid depression screening measures may improve detection of depression. We describe the validation of the Luganda translated nine- and two-item Patient Health Questionnaires (PHQ-9 and PHQ-2) as screening tools for depression in two rural primary care facilities in Eastern Uganda. METHODS: A total of 1407 adult respondents were screened consecutively using the nine-item Luganda PHQ. Of these 212 were randomly selected to respond to the Mini International Neuropsychiatric Interview diagnostic questionnaire. Descriptive statistics for respondents' demographic characteristics and PHQ scores were generated. The sensitivity, specificity and positive predictive values (PPVs), and area under the ROC curve were determined for both the PHQ-9 and PHQ-2. RESULTS: The optimum trade-off between sensitivity and PPV was at a cut-off of ≧5. The weighted area under the receiver Operating Characteristic curve was 0.74 (95% CI 0.60-0.89) and 0.68 (95% CI 0.54-0.82) for PHQ-9 and PHQ-2, respectively. CONCLUSION: The Luganda translation of the PHQ-9 was found to be modestly useful in detecting depression. The PHQ-9 performed only slightly better than the PHQ-2 in this rural Ugandan Primary care setting. Future research could improve on diagnostic accuracy by considering the idioms of distress among Luganda speakers, and revising the PHQ-9 accordingly. The usefulness of the PHQ-2 in this rural population should be viewed with caution

Tuberculosis Treatment in HIV Infected Ugandans with CD4 Counts >350 Cells/mm3 Reduces Immune Activation with No Effect on HIV Load or CD4 Count

Both HIV and TB cause a state of heightened immune activation. Immune activation in HIV is associated with progression to AIDS. Prior studies, focusing on persons with advanced HIV, have shown no decline in markers of cellular activation in response to TB therapy alone.) and pulmonary TB. HIV load, CD4 count, and markers of immune activation (CD38 and HLA-DR on CD4 and CD8 T cells) were measured prior to starting, during, and for 6 months after completion of standard 6 month anti-tuberculosis (TB) therapy in 38 HIV infected Ugandans with smear and culture confirmed pulmonary TB.Expression of CD38, and co-expression of CD38 and HLA-DR, on CD8 cells declined significantly within 3 months of starting standard TB therapy in the absence of anti-retroviral therapy, and remained suppressed for 6 months after completion of therapy. In contrast, HIV load and CD4 count remained unchanged throughout the study period.

LAND USE/COVER CHANGE PATTERNS IN HIGHLAND ECOSYSTEMS OF LAKE BUNYONYI CATCHMENT IN WESTERN UGANDA

Land use and cover changes influence the livelihood and degradation of fragile ecosystems. The extents of these changes in pattern were investigated in Lake Bunyonyi Catchment which lies in the South Western Highlands of Uganda. The dynamics and magnitude of land use and cover changes were assessed using Landsat (TM/ETM+) satellite images and collection of socio-economic data through interviews. The images were processed and analysed using the mean-shift image segmentation algorithm to cluster and quantify the land use and cover features. The study noted that in the assessment period 1987-2014, the small-scale farmlands, open water and grasslands remained quasi constant; while the woodlots followed a quadratic trend, with the lowest acreage experienced in 2000. The tropical high forests and wetlands cover types experienced significant decline over the years (P<0.05). Patches of small-scale farmlands, woodlots, and wetland interchangeably lost or gained more land dependant on climate variability. Even though the tropical high forest lost more than it gained, it only gained and lost to small scale farmland and woodlots; while grassland mainly lost to small scale farmland and woodlots.L\u2019occupation du sol et les changements de couverture influencent la subsistance et la d\ue9gradation des \ue9cosyst\ue8mes fragiles. La tendance des niveaux de ces changements \ue9taient \ue9valu\ue9e dans le basin versant du lac Bunyonyi qui relie les r\ue9gions montagneuses du Sud-Ouest d\u2019Ouganda. Les dynamiques et l\u2019 envergure d\u2019utilisaton de la terre et les changements de couverture \ue9taient \ue9valu\ue9es en utilisant les images du satellite Landsat (TM/ETM+) et la collecte des donn\ue9es socio-\ue9conomiques \ue0 travers des interviews. Les images \ue9taient trait\ue9es et analy\ue9es en utilisant l\u2019algorithme de segmentation de passage-moyen-d\u2019image pour grouper et quantifier les occupations du sol et les caract\ue9ristiques de la couverture. L\u2019\ue9tude a montr\ue9 que dans la p\ue9riode d\u2019\ue9valuation de 1987-2014, la petite \ue9tendue de terres cultivables, l\u2019eau libre et les prairies sont demeur\ue9es quasi constantes; tandis que les terres bois\ue9es ont suivi une tendance quadratique, avec la plus petite superficie observ\ue9e en l\u2019an 2000. Les grandes for\ueats tropicales et les zones humides ont exp\ue9riment\ue9 un d\ue9clin significatif au cours des ann\ue9es (P<0.05). Les petites parcelles de terres agricoles, les terres bois\ue9es, et les zones humides indistinctement ont perdu et gagn\ue9 plus de terres d\ue9pendamment de la variabilit\ue9 climatique. Bien que la grande for\ueat tropicale aie perdu plus qu\u2019elle en a gagn\ue9e; elle a seulement perdu de tr\ue8s petites \ue9tendues de terres agricoles et bois\ue9es; alors que les prairies ont principalement perdu de tr\ue8s petites \ue9tendues de terres agricoles et bois\ue9es

Analysis of host responses to Mycobacterium tuberculosis antigens in a multi-site study of subjects with different TB and HIV infection states in sub-Saharan Africa.

BACKGROUND: Tuberculosis (TB) remains a global health threat with 9 million new cases and 1.4 million deaths per year. In order to develop a protective vaccine, we need to define the antigens expressed by Mycobacterium tuberculosis (Mtb), which are relevant to protective immunity in high-endemic areas. METHODS: We analysed responses to 23 Mtb antigens in a total of 1247 subjects with different HIV and TB status across 5 geographically diverse sites in Africa (South Africa, The Gambia, Ethiopia, Malawi and Uganda). We used a 7-day whole blood assay followed by IFN-γ ELISA on the supernatants. Antigens included PPD, ESAT-6 and Ag85B (dominant antigens) together with novel resuscitation-promoting factors (rpf), reactivation proteins, latency (Mtb DosR regulon-encoded) antigens, starvation-induced antigens and secreted antigens. RESULTS: There was variation between sites in responses to the antigens, presumably due to underlying genetic and environmental differences. When results from all sites were combined, HIV- subjects with active TB showed significantly lower responses compared to both TST(-) and TST(+) contacts to latency antigens (Rv0569, Rv1733, Rv1735, Rv1737) and the rpf Rv0867; whilst responses to ESAT-6/CFP-10 fusion protein (EC), PPD, Rv2029, TB10.3, and TB10.4 were significantly higher in TST(+) contacts (LTBI) compared to TB and TST(-) contacts fewer differences were seen in subjects with HIV co-infection, with responses to the mitogen PHA significantly lower in subjects with active TB compared to those with LTBI and no difference with any antigen. CONCLUSIONS: Our multi-site study design for testing novel Mtb antigens revealed promising antigens for future vaccine development. The IFN-γ ELISA is a cheap and useful tool for screening potential antigenicity in subjects with different ethnic backgrounds and across a spectrum of TB and HIV infection states. Analysis of cytokines other than IFN-γ is currently on-going to determine correlates of protection, which may be useful for vaccine efficacy trials

A survey of biosecurity practices of pig farmers in selected districts affected by African swine fever in Uganda

IntroductionIn Uganda, pig production is an important source of livelihood for many people and contributes to food security. African swine fever (ASF) is a major constraint to pig production in Uganda, threatening the food supply and sustainable livelihoods. Prevention of ASF primarily relies on good biosecurity practices along the pig value chain. Previous studies showed that biosecurity along the pig value chain and on farms in Uganda is poor. However, the biosecurity practices of pig farmers in ASF affected areas of Uganda and their opinions on on-farm ASF morbidity and mortality were previously not comprehensively characterized. The objectives of this study were to document pig farmers’ experiences with ASF in their farms and to describe the pig biosecurity practices in districts of Uganda that were highly affected by ASF.MethodsA total of 99 farmers were interviewed in five districts. Data were collected by way of triangulation through farmer interviews, field observations during the farmer interviews, and a survey of key informants. However, farmer interviews were considered the primary source of data for this study. Farmers’ biosecurity practices were scored using a biosecurity scoring algorithm.ResultsForty-one out of 96 (42.7%) farmers reported having pigs with ASF in the past 12 months. The level of pig farming experience (p = 0.0083) and herd size (p < 0.0001) were significantly associated with the reported occurrence of ASF. Overall, the biosecurity scores for the respondents were considered poor with 99% (98/99) scoring <70% and just one farmer obtaining a fair score of 72.2%. District (p = 0.0481), type of husbandry system (p = 0.014), and type of pig breed raised (p = 0.004) were significantly associated with farmer’s biosecurity score.ConclusionContinued farmer education on ASF and the importance of good biosecurity practices is necessary. More in-depth scientific inquiry into the factors influencing the biosecurity practices among pig farmers in Uganda is necessary

Low CD4 count plus coma predicts cryptococcal meningitis in Tanzania

<p>Abstract</p> <p>Background</p> <p>Largely due to the lack of diagnostic reagents, the prevalence and clinical presentation of cryptococcal meningitis in Tanzania is poorly understood. This in turn is limiting the impact of increased fluconazole availability.</p> <p>Methods</p> <p>We evaluated a cohort of 149 consecutive HIV-infected adult inpatients presenting with headache or altered mental status for clinical features, CD4 count, cryptococcal infection, and outcome. Cryptococcal meningitis was diagnosed via India ink and latex agglutination assay of CSF (<it>n </it>= 24 and 40 positive, respectively). Associations between cryptococcal meningitis and clinical features were evaluated by t-test. The sensitivity, specificity, and positive likelihood ratio of such features were determined.</p> <p>Results</p> <p>Cryptococcal meningitis was associated with confusion, social withdrawal, seizures, fever, tachycardia, meningismus, oral candidiasis, and low Glasgow coma scales and CD4 count. CD4 count < 100/μl provided the highest sensitivity for the diagnosis (93%), coma (Glasgow coma scale ≤ 8) provided the highest specificity (84%), and the combination provided the highest positive likelihood ratio (3.8). All cryptococcal meningitis patients were initiated on 800 milligrams of fluconazole daily and 50% survived to discharge, however no clinical or laboratory findings correlated with prognosis.</p> <p>Conclusion</p> <p>Cryptococcal meningitis is common among Tanzanian HIV inpatients presenting with headache or altered mental status. Purely clinical features are insensitive for establishing the diagnosis or prognosis. We advocate expanding laboratory capacity for cryptococcal antigen testing to maximize survival.</p