Households experiencing catastrophic costs due to tuberculosis in Uganda : magnitude and cost drivers

Funding: This survey was funded by CDC (grant number 3U2GGH001180-03S1) toWHO, a USAID Uganda WHO Grant (PIO grant AID-617-10-17-00001) and alsofunding from Doctors with Africa, CUAMM.Background: Tuberculosis (TB) patients in Uganda incur large costs related to the illness, and while seeking and receiving health care. Such costs create access and adherence barriers which affect health outcomes and increase transmission of disease. The study ascertained the proportion of Ugandan TB affected households incurring catastrophic costs and the main cost drivers. Methods: A cross-sectional survey with retrospective data collection and projections was conducted in 2017. A total of 1178 drug resistant (DR) TB (44) and drug sensitive (DS) TB patients (1134), 2 weeks into intensive or continuation phase of treatment were consecutively enrolled across 67 randomly selected TB treatment facilities. Results: Of the 1178 respondents, 62.7% were male, 44.7% were aged 15-34 years and 55.5% were HIV positive. For each TB episode, patients on average incurred costs of USD 396 for a DS-TB episode and USD 3722 for a Multi drug resistant tuberculosis (MDR TB) episode. Up to 48.5% of households borrowed, used savings or sold assets to defray these costs. More than half (53.1%) of TB affected households experienced TB-related costs above 20% of their annual household expenditure, with the main cost drivers being non-medical expenditure such as travel, nutritional supplements and food. Conclusion: Despite free health care in public health facilities, over half of Ugandan TB affected households experience catastrophic costs. Roll out of social protection interventions like TB assistance programs, insurance schemes, and enforcement of legislation related to social protection through multi-sectoral action plans with central NTP involvement would palliate these costs.Publisher PDFPeer reviewe

Tobacco use and presumptive tuberculosis in Uganda: findings from the Uganda National TB Prevalence Survey 2014 - 2016

Background Tuberculosis (TB) patients who smoke tobacco are at an increased risk for adverse TB treatment outcomes. The association between smoking and TB is well known but has not yet received sufficient attention in terms of TB care standards in Uganda. This study describes prevalence of smoking among presumptive TB patients and risk factors associated with presumptive TB among tobacco smokers in Uganda. Methods This was a national cross-sectional population-based study among respondents aged 15 years and above. We defined a presumptive TB patient as any person with cough (≥14 days) and abnormal chest x-ray.We collected information on current and past tobacco use, socio-economic and demographic status using structured interviewer-administered questionnaires. Data analysis entailed descriptive statistics, followed by multivariate logistic regression with backward elimination, adjusted for clustering by facility. Results Detailed interviews were conducted for 45294 individuals; prevalence of presumptive TB was 11.8% (95% CI =11.5-12.1), 12.7% (95% CI=12.4-13.0) had a history of tobacco smoking (both previous and current tobacco smokers). Prevalence of current tobacco smoking was 7.3% (95% CI=7.1-7.6) and prevalence of past tobacco smoking was 7.1% (CI= 6.9-7.4). History of tobacco smoking among presumptive TB patients was 26.7% (95% CI=25.5-27.9), presumptive TB among current tobacco smokers was 13.7% (95% CI=12.8-14.7) while for past tobacco smokers was 15.0% (95% CI=14.0-16.0). Not having any education AOR (Adjusted odds ratio) 2.90 (95% CI=2.34-3.6), primary education OR 1.47 (95% CI=1.22-1.76) and being male AOR 8.6 (95% CI=7.3-10.2) were the key risk factors for history of smoking among TB patients. Conclusions Tobacco smoking was associated with presumptive TB in Ugandans. Smoking cessation interventions should be included in the current TB care standards at various levels of the TB health care system In Uganda

Effects of demand-side incentives in improving the utilisation of delivery services in Oyam District in northern Uganda: a quasi-experimental study

Abstract Background We evaluated the effects and financial costs of two interventions with respect to utilisation of institutional deliveries and other maternal health services in Oyam District in Uganda. Methods We conducted a quasi-experimental study involving intervention and comparable/control sub-counties in Oyam District for 12 months (January–December 2014). Participants were women receiving antenatal care, delivery and postnatal care services. We evaluated two interventions: the provision of (1) transport vouchers to women receiving antenatal care and delivering at two health centres (level II) in Acaba sub-county, and (2) baby kits to women who delivered at Ngai Health Centre (level III) in Ngai sub-county. The study outcomes included service coverage of institutional deliveries, four antenatal care visits, postnatal care, and the percentage of women ‘bypassing’ maternal health services inside their resident sub-counties. We calculated the effect of each intervention on study outcomes using the difference in differences analysis. We calculated the cost per institutional delivery and the cost per unit increment in institutional deliveries for each intervention. Results Overall, transport vouchers had greater effects on all four outcomes, whereas baby kits mainly influenced institutional deliveries. The absolute increase in institutional deliveries attributable to vouchers was 42.9%; the equivalent for baby kits was 30.0%. Additionally, transport vouchers increased the coverage of four antenatal care visits and postnatal care service coverage by 60.0% and 49.2%, respectively. ‘Bypassing’ was mainly related to transport vouchers and ranged from 7.2% for postnatal care to 11.9% for deliveries. The financial cost of institutional delivery was US$9.4 per transport voucher provided, and US$10.5 per baby kit. The incremental cost per unit increment in institutional deliveries in the transport-voucher system was US$15.9; the equivalent for the baby kit was US$30.6. Conclusion The transport voucher scheme effectively increased utilisation of maternal health services whereas the baby-kit scheme was only effective in increasing institutional deliveries. The transport vouchers were less costly than the baby kits in the promotion of institutional deliveries. Such incentives can be sustainable if the Ministry of Health integrates them in the health system

Measles outbreak propagated by children congregating at water collection points in Mayuge District, eastern Uganda, July–October, 2016

The research article is about investigation of measles outbreak to determine its scope, identify risk factors for transmission, evaluate vaccination coverage and vaccine effectiveness, and recommend evidence-based control measures.Background On 12 October, 2016 a measles outbreak was reported in Mayuge District, eastern Uganda. We investigated the outbreak to determine its scope, identify risk factors for transmission, evaluate vaccination coverage and vaccine effectiveness, and recommend evidence-based control measures. Methods We defined a probable case as onset of fever (≥3 days) and generalized rash, plus ≥1 of the following: conjunctivitis, cough, and/or runny nose in a Mayuge District resident. A confirmed case was a probable case with measles-specific IgM (+) not explained by vaccination. We reviewed medical records and conducted active community case-finding. In a case-control investigation involving probable case-persons and controls matched by age and village, we evaluated risk factors for transmission for both cases and controls during the case-person’s likely exposure period (i.e., 7–21 days prior to rash onset). We estimated vaccine effectiveness (VE) using the formula: VE ≈ (1-ORprotective) × 100. We calculated vaccination coverage using the percentage of controls vaccinated. Results We identified 62 probable case-persons (attack rate [AR] = 4.0/10,000), including 3 confirmed. Of all age groups, children < 5 years were the most affected (AR = 14/10,000). The epidemic curve showed a propagated outbreak. Thirty-two percent (13/41) of case-persons and 13% (21/161) of control-persons visited water-collection sites (by themselves or with parents) during the case-persons’ likely exposure period (ORM-H = 5.0; 95% CI = 1.5–17). Among children aged 9–59 months, the effectiveness of the single-dose measles vaccine was 75% (95% CI = 25–92); vaccination coverage was 68% (95% CI = 61–76). Conclusions Low vaccine effectiveness, inadequate vaccination coverage and congregation at water collection points facilitated measles transmission in this outbreak. We recommended increasing measles vaccination coverage and restriction of children with signs and symptoms of measles from accessing public gatherings

Molecular characterisation of second-line drug resistance among drug resistant tuberculosis patients tested in Uganda: a two and a half-year's review.

BACKGROUND: Second-line drug resistance (SLD) among tuberculosis (TB) patients is a serious emerging challenge towards global control of the disease. We characterized SLD-resistance conferring-mutations among TB patients with rifampicin and/or isoniazid (RIF and/or INH) drug-resistance tested at the Uganda National TB Reference Laboratory (NTRL) between June 2017 and December 2019. METHODS: This was a descriptive cross-sectional secondary data analysis of 20,508 M. tuberculosis isolates of new and previously treated patients' resistant to RIF and/or INH. DNA strips with valid results to characterise the SLD resistance using the commercial Line Probe Assay Genotype MTBDRsl Version 2.0 Assay (Hain Life Science, Nehren, Germany) were reviewed. Data were analysed with STATAv15 using cross-tabulation for frequency and proportions of known resistance-conferring mutations to injectable agents (IA) and fluoroquinolones (FQ). RESULTS: Among the eligible participants, 12,993/20,508 (63.4%) were male and median (IQR) age 32 (24-43). A total of 576/20,508 (2.8%) of the M. tuberculosis isolates from participants had resistance to RIF and/or INH. These included; 102/576 (17.7%) single drug-resistant and 474/576 (82.3%) multidrug-resistant (MDR) strains. Only 102 patients had test results for FQ of whom 70/102 (68.6%) and 01/102 (0.98%) had resistance-conferring mutations in the gyrA locus and gyrB locus respectively. Among patients with FQ resistance, gyrAD94G 42.6% (30.0-55.9) and gyrA A90V 41.1% (28.6-54.3) mutations were most observed. Only one mutation, E540D was detected in the gyrB locus. A total of 26 patients had resistance-conferring mutations to IA in whom, 20/26 77.0% (56.4-91.0) had A1401G mutation in the rrs gene locus. CONCLUSIONS: Our study reveals a high proportion of mutations known to confer high-level fluoroquinolone drug-resistance among patients with rifampicin and/or isoniazid drug resistance. Utilizing routinely generated laboratory data from existing molecular diagnostic methods may aid real-time surveillance of emerging tuberculosis drug-resistance in resource-limited settings

Effectiveness of thermal screening in detection of COVID-19 among truck drivers at Mutukula Land Point of Entry, Uganda.

IntroductionDespite the limited evidence for its effectiveness, thermal screening at points of entry has increasingly become a standard protocol in numerous parts of the globe in response to the COVID-19 pandemic. We sought to determine the effectiveness of thermal screening as a key step in diagnosing COVID-19 in a resource-limited setting.Materials and methodsThis was a retrospective cross-sectional study based on a review of body temperature and Xpert Xpress SARS CoV-2 test results records for truck drivers entering Uganda through Mutukula between 15th May and 30th July 2020. All records missing information for body temperature, age, gender, and Xpert Xpress SARS CoV-2 status were excluded from the data set. A data set of 7,181 entries was used to compare thermal screening and Xpert Xpress SARS CoV-2 assay test results using the diagnostic statistical test in STATAv15 software. The prevalence of COVID-19 amongst the truck drivers based on Xpert Xpress SARS CoV-2 assay results was determined. The sensitivity, specificity, positive predictive value, negative predictive value, positive and negative Likelihood ratios were obtained using Xpert Xpress SARS CoV-2 assay as the gold standard.ResultsBased on our gold standard test, the proportion of persons that tested positive for COVID-19 was 6.7% (95% CI: 6.1-7.3). Of the 7,181 persons that were thermally screened, 6,844 (95.3%) were male. The sample median age was 38 years (interquartile range, IQR: 31-45 years). The median body temperature was 36.5°C (IQR: 36.3-36.7) and only n (1.2%) had a body temperature above 37.5°C. The sensitivity and specificity of thermal screening were 9.9% (95% CI: 7.4-13.0) and 99.5% (95% CI: 99.3-99.6) respectively. The positive and negative predictive values were 57.8 (95% CI: 46.5-68.6) and 93.9 (95% CI: 93.3-94.4) respectively. The positive and negative Likelihood Ratios (LRs) were 19 (95% CI: 12.4-29.1) and 0.9 (95% CI: 0.88-0.93) respectively.ConclusionIn this study population, the use of Thermal screening alone is ineffective in the detection of potential COVID-19 cases at point of entry. We recommend a combination of screening tests or additional testing using highly sensitive molecular diagnostics such as Polymerase Chain Reaction

Location of Nyakabande Transit Centre (NTC), Kisoro District, Southwestern Uganda (Map drawn using QGIS 3.22, link to base layer shape file.

Location of Nyakabande Transit Centre (NTC), Kisoro District, Southwestern Uganda (Map drawn using QGIS 3.22, link to base layer shape file.</p

Fig 2 -

Distribution of COVID-19 positive tests by date of testing among refugees in Nyakabande Transit Centre, Kisoro District, Uganda, April-June 2022(a)-tests done at time of relocation (b)-tests done at time of entry.</p

Socio-demographic characteristics of cases and controls in Nyakabande Transit Centre, Kisoro District, Uganda, June–July 2022.

Socio-demographic characteristics of cases and controls in Nyakabande Transit Centre, Kisoro District, Uganda, June–July 2022.</p