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

Delays in diagnosis and treatment of pulmonary tuberculosis in patients seeking care at a regional referral hospital, Uganda : a cross sectional study

This study was funded using Authors’ personal resources.Objective: A cross-sectional survey involving 134 pulmonary TB patients started on TB treatment at the TB Treatment Unit of the regional referral hospital was conducted to ascertain the prevalence of individual and health facility delays and associated factors. Prolonged health facility delay was taken as delay of more than 1 week and prolonged patient delay as delay of more than 3 weeks. A logistic regression model was done using STATA version 12 to determine the delays. Results: There was a median total delay of 13 weeks and 110 (82.1%) of the respondents had delay of more than 4 weeks. Patient delay was the most frequent and greatest contributor of total delay and exceeded 3 weeks in 95 (71.6%) respondents. At multivariate analysis, factors that influenced delay included poor patient knowledge on TB (adjOR 6.904, 95% CI 1.648-28.921; p = 0.04) and being unemployed (adjOR 3.947, 95% CI 1.382-11.274; p = 0.010) while being female was found protective of delay; adjOR 0.231, 95% CI 0.08-0.67; p = 0.007). Patient delay was the most significant, frequent and greatest contributor to total delay, and factors associated with delay included being unemployed, low knowledge on TB while being female was found protective of delay.Publisher PDFPeer reviewe

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

Cardiovascular risk factors among people with drug-resistant tuberculosis in Uganda

This work was funded by the National Institute for Health Research through the Royal Society of Tropical Medicine and Hygiene.Background Tuberculosis (TB) and its risk factors are independently associated with cardiovascular disease (CVD). We determined the prevalence and associations of CVD risk factors among people with drug-resistant tuberculosis (DRTB) in Uganda. Methods In this cross-sectional study, we enrolled people with microbiologically confirmed DRTB at four treatment sites in Uganda between July to December 2021. The studied CVD risk factors were any history of cigarette smoking, diabetes mellitus (DM) hypertension, high body mass index (BMI), central obesity and dyslipidaemia. We used modified Poisson regression models with robust standard errors to determine factors independently associated with each of dyslipidaemia, hypertension, and central obesity. Results Among 212 participants, 118 (55.7%) had HIV. Overall, 196 (92.5%, 95% confidence interval (CI) 88.0-95.3) had ≥ 1 CVD risk factor. The prevalence; 95% CI of individual CVD risk factors was: dyslipidaemia (62.5%; 55.4–69.1), hypertension (40.6%; 33.8–47.9), central obesity (39.3%; 32.9–46.1), smoking (36.3%; 30.1–43.1), high BMI (8.0%; 5.0–12.8) and DM (6.5%; 3.7–11.1). Dyslipidaemia was associated with an increase in glycated haemoglobin (adjusted prevalence ratio (aPR) 1.14, 95%CI 1.06–1.22). Hypertension was associated with rural residence (aPR 1.89, 95% CI 1.14–3.14) and previous history of smoking (aPR 0.46, 95% CI 0.21–0.98). Central obesity was associated with increasing age (aPR 1.02, 95%CI 1.00–1.03), and elevated diastolic blood pressure (aPR 1.03 95%CI 1.00–1.06). Conclusion There is a high prevalence of CVD risk factors among people with DRTB in Uganda, of which dyslipidaemia is the commonest. We recommend integrated services for identification and management of CVD risk factors in DRTB.Publisher PDFPeer reviewe

Finding the Missing Men with Tuberculosis: A Participatory Approach to Identify Priority Interventions in Uganda

Gender impacts exposure and vulnerability to TB, evidenced by a higher prevalence of both TB disease and missed TB diagnoses among men, who significantly contribute to new TB infections. We present the formative research phase of a study which used participatory methods to identify gender-specific interventions for systematic screening of TB among men in Uganda. Health facility level data was collected at four Ugandan general hospitals (Kawolo, Gombe, Mityana, and Nakaseke) among 70 TB stakeholders, including healthcare workers, TB survivors, policymakers, and researchers. Using health seeking pathways, they delineated and compared men’s ideal and actual step-by-step TB health seeking processes to identify barriers to TB care. The stepping stones method, depicting barriers as a ‘river’ and each ‘steppingstone’ as a solution, was employed to identify interventions which would help link men with TB symptoms to care. These insights were then synthesized in a co-analysis meeting with 17 participants including representatives from each health facility to develop a consensus on proposed interventions. Data across locations revealed the actual TB care pathway diverted from the ideal pathway due to health system, community, health worker and individual level barriers such as delayed health seeking, unfavourable facility operating hours and long waiting times that conflicted with men’s work schedules. Stakeholders proposed to address these barriers through the introduction of male-specific services; integrated TB services that prioritize X-ray screening for men with cough; healthcare worker training modules on integrated male-friendly services; training and supporting TB champions to deliver health education to people seeking care; and engagement of private practitioners to screen for TB. In conclusion, our participatory co-design approach facilitated dialogue, learning, and consensus between different health actors on context-specific, person-centred TB interventions for men in Uganda. The acceptability, effectiveness and cost effectiveness of the package will now be evaluated in a pilot study

The global inequity of COVID-19 diagnostics : challenges and opportunities

Diagnostics for COVID-19 have advanced at an unprecedented pace over the last two years. Testing is a critical pillar of pandemic control, and is required for epidemiological tracking, treatment, and surveillance. Despite high quality SARS-CoV-2 viral diagnostic capability, there are vast global inequities in access. The Virology, Immunology, and Diagnostics Working Group(WG) of the COVID-19 Clinical Research Coalition (CRC) brings together experts in immunology, infectious diseases, and microbiology to advocate for equity-based COVID-19 research, prioritising solutions driven by communities in low-income and lower middle-income countries (LMICs).1 This commentary shares the unique perspective of the WG on the asymmetry in COVID-19 diagnostic access between low-income and high-income settings, the barriers to these disparities, and highlights opportunities to remedy these inequities.PostprintPeer reviewe

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

Association of fluvoxamine with mortality and symptom resolution among inpatients with COVID-19 in Uganda : a prospective interventional open-label cohort study

Funding: We acknowledge the funding support from the Government of the Republic of Uganda through the Makerere University Research and Innovations Fund (Mak-RIF).Prior research suggests that fluvoxamine, a selective serotonin reuptake inhibitor (SSRI) used for the treatment of obsessive-compulsive disorder and major depressive disorder, could be repurposed against COVID-19. We undertook a prospective interventional open-label cohort study to evaluate the efficacy and tolerability of fluvoxamine among inpatients with laboratory-confirmed COVID-19 in Uganda. The main outcome was all-cause mortality. Secondary outcomes were hospital discharge and complete symptom resolution. We included 316 patients, of whom 94 received fluvoxamine in addition to standard care [median age, 60 years (IQR = 37.0); women, 52.2%]. Fluvoxamine use was significantly associated with reduced mortality [AHR = 0.32; 95% CI = 0.19–0.53; p < 0.001, NNT = 4.46] and with increased complete symptom resolution [AOR = 2.56; 95% CI = 1.53–5.51; p < 0.001, NNT = 4.44]. Sensitivity analyses yielded similar results. These effects did not significantly differ by clinical characteristic, including vaccination status. Among the 161 survivors, fluvoxamine was not significantly associated with time to hospital discharge [AHR 0.81, 95% CI (0.54–1.23), p = 0.32]. There was a trend toward greater side effects with fluvoxamine (7.45% versus 3.15%; SMD = 0.21; χ2 = 3.46, p = 0.06), most of which were light or mild in severity and none of which were serious. One hundred mg of fluvoxamine prescribed twice daily for 10 days was well tolerated and significantly associated with reduced mortality and with increased complete symptom resolution, without a significant increase in time to hospital discharge, among inpatients with COVID-19. Large-scale randomized trials are urgently needed to confirm these findings, especially for low- and middle-income countries, where access to vaccines and approved treatments against COVID-19 is limited.Publisher PDFPeer reviewe

The burden of severe asthma in sub-Saharan Africa : findings from the African Severe Asthma Project

Funding: Funded by a project grant from the GSK Africa Non-communicable Disease Open Lab (project 8019).Background Severe asthma is associated with high morbidity, mortality and health care utilization but its burden in Africa is unknown. Objective To determine the burden (prevalence, mortality and activity and work impairment) of severe asthma in three Easter Africa countries (Uganda, Kenya and Ethiopia). Methods Using the American Thoracic Society/European Respiratory Society (ATS/ERS) case definition of severe asthma we analyzed for the prevalence of severe asthma (requiring GINA steps 4–5 asthma medications for the previous year to achieve control) and severe refractory asthma (remains uncontrolled despite treatment with GINA steps 4–5 asthma medications) in a cohort of 1086 asthma patients who had been in care for 12 months and had received all GINA recommended medications. Asthma control was assessed using the asthma control questionnaire (ACQ). Results Overall, the prevalence of severe asthma and severe refractory asthma was 25.6% (95% CI 23.1–28.3) and 4.6% (95% CI 3.5–6.0) respectively. Patients with severe asthma were (non- severe vs. severe vs. severe refractory) older (39, 42, 45 years, p=0.011), had high skin prick test reactivity (67.1%, 76.0%, 76.0%, p=0.004), had lower FEV1% (81%, 61%, 55.5%, p=<0.001), lower quality of life score (129, 127 vs 121, p=<0.001) and higher activity impairment (10%, 30%, 50%, p=<0.001). Conclusion The prevalence of severe asthma in Africa is high and is associated with high morbidity and poor quality of life.Publisher PDFPeer reviewe