Browsing by Author "Colebunders, Robert"
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Item Antiretroviral therapy for HIV-1 infected adolescents in Uganda: Assessing the impact on growth and sexual maturation(Journal of Pediatric Infectious Diseases, 2008) Bakeera-Kitakaa, Sabrina; McKellar, Mehri; Snider, Cynthia; Kekitiinwa, Adeodata; Piloya, Theresa; Ronald, Allan; Marjan, Javanbakht; Colebunders, RobertAbstract. There is a paucity of knowledge about perinatally infected human immunodeficiency virus (HIV) positive children surviving into their adolescent years, especially from sub-Saharan Africa. Although studies have described the effects of the disease on the physical and sexual maturation of this population, their response to highly active antiretroviral therapy has not been systematically studied. At the pediatric infectious diseases clinic in Mulago hospital, Kampala, Uganda, we evaluated the effect of antiretroviral therapy (ART) on 118 treatment-naive, perinatally-infected HIV positive adolescents between the ages of 10–19 for 12 months. We monitored physical growth using The Centers for Disease Control and Prevention and recently published World Health Organization (WHO) reference growth standards for height and weight measurements as well as sexual maturation using Tanner staging. Laboratory tests including: complete blood count, absolute CD4 cell count and percentage, and HIV-1 RNA viral load, were performed at baseline and at 3-month intervals. Of 118 children, 64% were female; the median age was 13.6 years old. At baseline, 75% were classified as WHO clinical stages III and IV, with a median CD4 count of 124 cells/ul. Apart from four adolescents, all were on first-line antiretroviral therapy with 2 nucleoside reverse transcriptase inhibitors and 1 non-nucleoside reverse transcriptase inhibitors. After 6 months, the median CD4 count was 304 cells/μL, increasing to 370 cells/μL, by 12 months. Antiretroviral therapy was virologically suppressive (HIV-1 RNA viral load <400 copies/mL) in 79% of the adolescents at 6 months and in 89% at 12 months. Six (5%) patients died during the 12-month study. The median baseline height for age Z score was −2.41 which improved to a median of −1.96 by 12 months (P < 0.0001). The median baseline weight for age Z score was −2.61 and improved to −1.26 by 12 months (P < 0.0001). The median body mass index Z score increased from −1.39 to −0.47 by 12 months (P < 0.0001). At baseline, 63% of the adolescents were noted to have delayed pubertal maturation; this only reduced slightly to 60% after 12 months. Adolescents with predominantly perinatally-acquired HIV infection and significant disease burden showed appropriate virologic and immunological response to ART in addition to having clinically significant improvements in growth and some improvement in sexual maturation.Item Burden of tuberculosis disease among adolescents in a rural cohort in Eastern Uganda(BMC Infectious Diseases,, 2013) Waako, James; Verver, Suzanne; Wajja, Anne; Ssengooba, Willy; Joloba, Moses L; Colebunders, Robert; Musoke, Philippa; Mayanja-Kizza, HarrietBackground: The world health organization (WHO) declared tuberculosis (TB) a global emergency, mainly affecting people in sub-Saharan Africa. However there is little data about the burden of TB among adolescents. We estimated the prevalence and incidence of TB and assessed factors associated with TB among adolescents aged 12–18 years in a rural population in Uganda in order to prepare the site for phase III clinical trials with novel TB vaccines among adolescents. Methods: In a prospective cohort study, we recruited 5000 adolescents and followed them actively, every 6 months, for 1–2 years. Participants suspected of having TB were those who had any of; TB signs and symptoms, history of TB contact or a positive tuberculin skin test (TST) of ≥10 mm. Laboratory investigations included sputum smear microscopy and culture. Results: Of the 5000 participants, eight culture confirmed cases of TB were found at baseline: a prevalence of 160/100,000 (95% confidence interval (CI), 69–315). There were 13 incident TB cases detected in an average of 1.1 person years: an incidence of 235/100,000 person years (95% CI, 125–402). None of the confirmed TB cases were HIV infected. Predictors for prevalent TB disease were: a history of TB contact and a cough ≥ 2 weeks at baseline and being out of school, while the only predictor for incident TB was a positive TST during follow-up. Conclusion: The TB incidence among adolescents in this rural part of Uganda seemed too low for a phase III TB vaccine trial. However, the study site demonstrated capability to handle a large number of participants with minimal loss to follow-up and its suitability for future clinical trials. Improved contact tracing in TB program activities is likely to increase TB case detection among adolescents. Future studies should explore possible pockets of higher TB incidence in urban areas and among out of school youthItem Cardiovascular risk factors and clinical outcomes of patients hospitalized with COVID-19 pneumonia in Somalia(Therapeutic Advances in Infectious Disease, 2022) Ahmed, Mohammed A.M.; Mohamud Hussein, Ahmed; Ahmed Moalim Abdullahi, Aweis; Yusuf Ahmed, Abdirizak; Hussain, Hamdi M.A.; Mohamed Ali, Abdiaziz; Abdinur Barre, Abdulqadir; Mohamud Yusuf, Farhia; Olum, Ronald; Goitom Sereke, Senai; Ahmed Elfadul, Maisa; Colebunders, Robert; Bongomin, FelixCoronavirus disease-2019 (COVID-19) is a potentially life-threatening illness with no established treatment. Cardiovascular risk factors (CRFs) exacerbate COVID-19 morbidity and mortality. Objective: To determine the prevalence of CRF and clinical outcomes of patients hospitalized with COVID-19 in a tertiary hospital in Somalia. Methods: We reviewed the medical records of patients aged 18 years or older with a real-time polymerase chain reaction (RT-PCR)–confirmed COVID-19 hospitalized at the De Martino Hospital in Mogadishu, Somalia, between March and July 2020. Results: We enrolled 230 participants; 159 (69.1%) males, median age was 56 (41–66) years. In-hospital mortality was 19.6% (n = 45); 77.8% in the intensive care unit (ICU) compared with 22.2%, in the general wards (p < 0.001). Age ⩾ 40 years [odds ratio (OR): 3.6, 95% confidence interval (CI): 1.2–10.6, p = 0.020], chronic heart disease (OR: 9.3, 95% CI: 2.2–38.9, p = 0.002), and diabetes mellitus (OR: 3.2, 95% CI: 1.6–6.2, p < 0.001) were associated with increased odds of mortality. Forty-three (18.7%) participants required ICU admission. Age ⩾ 40 years (OR: 7.5, 95% CI: 1.7–32.1, p = 0.007), diabetes mellitus (OR: 3.2, 95% CI: 1.6–6.3, p < 0.001), and hypertension (OR: 2.5, 95% CI: 1.2–5.2, p = 0.014) were associated with ICU admission. For every additional CRF, the odds of admission into the ICU increased threefold (OR: 2.7, 95% CI: 1.2–5.2, p < 0.001), while the odds of dying increased twofold (OR: 2.1, 95% CI: 1.3–3.2, p < 0.001). Conclusions: We report a very high prevalence of CRF among patients hospitalized with COVID-19 in Somalia. Mortality rates were unacceptably high, particularly among those with advanced age, underlying chronic heart disease, and diabetes.Item Client-provider interactions in provider-initiated and voluntary HIV counseling and testing services in Uganda(BMC Health Services Research, 2013) Wanyenze, Rhoda K.; Kyaddondo, David; Kinsman, John; Makumbi, Fredrick; Colebunders, Robert; Hardon, AnitaProvider-initiated HIV testing and counselling (PITC) is based on information-giving while voluntary counselling and testing (VCT) includes individualised client-centered counseling. It is not known if the providerclient experiences, perceptions and client satisfaction with the information provided differs in the two approaches. Methods: In 2008, we conducted structured interviews with 627 individuals in Uganda; 301 tested through PITC and 326 through voluntary counselling and testing (VCT). We compared client experiences and perceptions based on the essential elements of consent, confidentiality, counseling, and referral for follow-up care. We conducted multivariate analysis for predictors of reporting information or counselling as sufficient. Results: In VCT, 96.6% (282) said they were asked for consent compared to 91.3% (198) in PITC (P = 0.01). About the information provided, 92.0% (286) in VCT found it sufficient compared to 78.7% (221) in PITC (P = <0.01). In VCT 79.9% (246) thought their results were kept confidential compared to 71.7% (200) in PITC (P = 0.02). Eighty percent (64) of HIV infected VCT clients said they were referred for follow-up care versus 87.3% (48) in PITC (p = 0.2). Predictors of perceived adequacy of information in PITC included an opportunity to ask questions (adj.RR 1.76, CI 1.41, 2.18) and expecting the test results received (adj.RR 1.18, CI 1.06, 1.33). For VCT significant factors included being given an opportunity to ask questions (adj.RR 1.62, CI 1.00, 2.60) and 3+ prior times tested, (adj.RR 1.05, CI 1.00, 1.09).Item Development and Evaluation of a Clinical Algorithm to Monitor Patients on Antiretrovirals in Resource-Limited Settings using Adherence, Clinical and CD4 Cell Count Criteria(Journal of the International AIDS Society, 2009) Meya, David; Spacek, Lisa A.; Tibenderana, Hilda; John, Laurence; Namugga, Irene; Magero, Stephen; Dewar, Robin; Quinn, Thomas C.; Colebunders, Robert; Kambugu, Andrew; Reynol, Steven J.Routine viral load monitoring of patients on antiretroviral therapy (ART) is not affordable in most resource-limited settings.A cross-sectional study of 496 Ugandans established on ART was performed at the Infectious Diseases Institute, Kampala, Uganda. Adherence, clinical and laboratory parameters were assessed for their relationship with viral failure by multivariate logistic regression. A clinical algorithm using targeted viral load testing was constructed to identify patients for second-line ART. This algorithm was compared with the World Health Organization (WHO) guidelines, which use clinical and immunological criteria to identify failure in the absence of viral load testing.Forty-nine (10%) had a viral load of >400 copies/mL and 39 (8%) had a viral load of >1000 copies/mL. An algorithm combining adherence failure (interruption >2 days) and CD4 failure (30% fall from peak) had a sensitivity of 67% for a viral load of >1000 copies/mL, a specificity of 82%, and identified 22% of patients for viral load testing. Sensitivity of the WHO-based algorithm was 31%, specificity was 87%, and would result in 14% of those with viral suppression (<400 copies/mL) being switched inappropriately to second-line ART.Algorithms using adherence, clinical and CD4 criteria may better allocate viral load testing, reduce the number of patients continued on failing ART, and limit the development of resistance.Item Disease diagnosis in primary care in Uganda(BMC Family Practice, 2014) Kayitale Mbonye, Martin; Burnett, Sarah M.; Colebunders, Robert; Naikoba, Sarah; Van Geertruyden, Jean-Pierre; Weaver, Marcia R.; Ronald, AllanThe overall burden of disease (BOD) especially for infectious diseases is higher in Sub-Saharan Africa than other regions of the world. Existing data collected through the Health Management Information System (HMIS) may not be optimal to measure BOD. The Infectious Diseases Capacity Building Evaluation (IDCAP) cooperated with the Ugandan Ministry of Health to improve the quality of HMIS data. We describe diagnoses with associated clinical assessments and laboratory investigations of outpatients attending primary care in Uganda. Methods: IDCAP supported HMIS data collection at 36 health center IVs in Uganda for five months (November 2009 to March 2010) prior to implementation of the IDCAP interventions. Descriptive analyses were performed on a cross-sectional dataset of 209,734 outpatient visits during this period. Results: Over 500 illnesses were diagnosed. Infectious diseases accounted for 76.3% of these and over 30% of visits resulted in multiple diagnoses. Malaria (48.3%), cough/cold (19.4%), and intestinal worms (6.6%) were the most frequently diagnosed illnesses. Body weight was recorded for 36.8% of patients and less than 10% had other clinical assessments recorded. Malaria smears (64.2%) and HIV tests (12.2%) accounted for the majority of 84,638 laboratory tests ordered. Fewer than 30% of patients for whom a laboratory investigation was available to confirm the clinical impression had the specific test performed. Conclusions: We observed a broad range of diagnoses, a high percentage of multiple diagnoses including true co-morbidities, and underutilization of laboratory support. This emphasizes the complexity of illnesses to be addressed by primary healthcare workers. An improved HMIS collecting timely, quality data is needed. This would adequately describe the burden of disease and processes of care at primary care level, enable appropriate national guidelines, programs and policies and improve accountability for the quality of care.Item Effect of Integrated Capacity-Building Interventions on Malaria Case Management by Health Professionals in Uganda: A Mixed Design Study with Pre/Post and Cluster Randomized Trial Components(PloS one, 2014) Kayitale Mbonye, Martin; Burnett, Sarah M.; Burua, Aldomoro; Colebunders, Robert; Crozier, Ian; Kinoti, Stephen N.; Ronald, Allan; Naikoba, Sarah; Rubashembusya, Timothy; Van geertruyden, Jean-Pierre; Willis, Kelly S.; Weaver, Marcia R.The Integrated Infectious Diseases Capacity Building Evaluation (IDCAP) designed two interventions: Integrated Management of Infectious Disease (IMID) training program and On-Site Support (OSS). We evaluated their effects on 23 facility performance indicators, including malaria case management. Methodology: IMID, a three-week training with two follow-up booster courses, was for two mid- level practitioners, primarily clinical officers and registered nurses, from 36 primary care facilities. OSS was two days of training and continuous quality improvement activities for nine months at 18 facilities, to which all health workers were invited to participate. Facilities were randomized as clusters 1:1 to parallel OSS ‘‘arm A’’ or control ‘‘arm B’’. Outpatient data on four malaria case management indicators were collected for 14 months. Analysis compared changes before and during the interventions within arms (relative risk = RR). The effect of OSS was measured with the difference in changes across arms (ratio of RR = RRR). Findings: The proportion of patients with suspected malaria for whom a diagnostic test result for malaria was recorded decreased in arm B (adjusted RR (aRR) = 0.97; 99%CI: 0.82,1.14) during IMID, but increased 25% in arm A (aRR = 1.25; 99%CI:0.94, 1.65) during IMID and OSS relative to baseline; (aRRR = 1.28; 99%CI:0.93, 1.78). The estimated proportion of patients that received an appropriate antimalarial among those prescribed any antimalarial increased in arm B (aRR = 1.09; 99%CI: 0.87, 1.36) and arm A (aRR = 1.50; 99%CI: 1.04, 2.17); (aRRR = 1.38; 99%CI: 0.89, 2.13). The proportion of patients with a negative diagnostic test result for malaria prescribed an antimalarial decreased in arm B (aRR = 0.96; 99%CI: 0.84, 1.10) and arm A (aRR = 0.67; 99%CI: 0.46, 0.97); (aRRR = 0.70; 99%CI: 0.48, 1.00). The proportion of patients with a positive diagnostic test result for malaria prescribed an antibiotic did not change significantly in either arm.Item Effectiveness of educational outreach in infectious diseases management: a cluster randomized trial in Uganda(BMC Public Health, 2016) Kayitale Mbonye, Martin; Burnett, Sarah M.; Naikoba, Sarah; Ronald, Allan; Colebunders, Robert; Van Geertruyden, Jean-Pierre; Weaver, Marcia R.Integrated Infectious Diseases Capacity Building Evaluation (IDCAP) teams designed and implemented two health worker in-service training approaches: 1) an off-site classroom-based integrated management of infectious diseases (IMID) course with distance learning aspects, and 2) on-site support (OSS), an educational outreach intervention. We tested the effects of OSS on workload and 12 facility performance indicators for emergency triage assessment and treatment, HIV testing, and malaria and pneumonia case management among outpatients by two subgroups: 1) mid-level practitioners (MLP) who attended IMID training (IMID-MLP) and 2) health workers who did not (No-IMID). Methods: Thirty-six health facilities participated in the IDCAP trial, with 18 randomly assigned to Arm A and 18 to Arm B. Two MLP in both arms received IMID. All providers at Arm A facilities received nine monthly OSS visits from April to December 2010 while Arm B did not. From November 2009 to December 2010, 777,667 outpatient visits occurred. We analyzed 669,580 (86.1 %) outpatient visits, where provider cadre was reported. Treatment was provided by 64 IMID-MLP and 1,515 No-IMID providers. The effect of OSS was measured by the difference in pre/post changes across arms after controlling for covariates (adjusted ratio of relative risks = aRRR). Results: The effect of OSS on patients-per-provider-per-day (workload) among IMID-MLP (aRRR = 1.21; p = 0.48) and No-IMID (aRRR = 0.90; p = 0.44) was not statistically significant. Among IMID-MLP, OSS was effective for three indicators: malaria cases receiving an appropriate antimalarial (aRRR = 1.26, 99 % CI = 1.02-1.56), patients with negative malaria test result prescribed an antimalarial (aRRR = 0.49, 99 % CI = 0.26-0.92), and patients with acid-fast bacilli smear negative result receiving empiric treatment for acute respiratory infection (aRRR = 2.04, 99 % CI = 1.06-3.94). Among No-IMID, OSS was effective for two indicators: emergency and priority patients admitted, detained or referred (aRRR = 2.12, 99 % CI = 1.05-4.28) and emergency patients receiving at least one appropriate treatment (aRRR = 1.98, 99 % CI = 1.21-3.24). Conclusion: Effects of OSS on workload were not statistically significant. Significant OSS effects on facility performance across subgroups were heterogeneous. OSS supported MLP who diagnosed and treated patients to apply IMID knowledge. For other providers, OSS supported team work to manage emergency patients. This evidence on OSS effectiveness could inform interventions to improve health workers’ capacity to deliver better quality infectious diseases care.Item Electronic Medical Records and Same Day Patient Tracing Improves Clinic Efficiency and Adherence to Appointments in a Community Based HIV/AIDS Care Program, in Uganda(AIDS and Behavior, 2012) Alamo, Stella T.; Wagner, Glenn J.; Sunday, Pamela ,; Wanyenze, Rhoda K.; Ouma, Joseph; Kamya, Moses; Colebunders, Robert; Wabwire-Mangen, FredPatients who miss clinic appointments make unscheduled visits which compromise the ability to plan for and deliver quality care. We implemented Electronic Medical Records (EMR) and same day patient tracing to minimize missed appointments in a community-based HIV clinic in Kampala. Missed, early, on-schedule appointments and waiting times were evaluated before (pre- EMR) and 6 months after implementation of EMR and patient tracing (post-EMR). Reasons for missed appointments were documented pre and post-EMR. The mean daily number of missed appointments significantly reduced from 21 pre-EMR to 8 post-EMR. The main reason for missed appointments was forgetting (37%) but reduced significantly by 30% post-EMR. Loss to followup (LTFU) also significantly decreased from 10.9 to 4.8% The total median waiting time to see providers significantly decreased from 291 to 94 min. Our findings suggest that EMR and same day patient tracing can significantly reduce missed appointments, and LTFU and improve clinic efficiency.Item Factors associated with carcinoma of the oesophagus at Mulago Hospital, Uganda(African health sciences, 2008) Ocama, Ponsiano; Kagimu, Magid M.; Odida, Michael; Wabinga, Henry; Opio, Christopher K.; Colebunders, Britt; Ierssel, Sabrina van; Colebunders, RobertIn Uganda, as in many other parts of the world cancer of the oesophagus (CAE) is on the rise. Squamous cell carcinoma and adenocarcinoma are the common subtypes. Risk factors for this cancer have been identified but not studied systematically in Uganda. Identification of these factors would enable establishment of preventive measures. Objective To determine the prevalence, histological features and associated factors for CAE among patients referred to the endoscopic unit of Mulago hospital, Kampala, Uganda. Methods: We performed a 1-year cross-sectional study in 2004 and 2005 of all patients presenting for oesophageal-gastro-duodenoscopy (EGD) at Mulago Hospital. Demographic characteristics, behavioural practices, endoscopy findings and histology results where biopsies were performed were collected using a study tool. Data analysis was done using STATA 8® statistical package Results: Two hundred nineteen patients were enrolled in the study, three were excluded because they could not tolerate the endoscopy procedure. Fifty five (19%) of the 287 had histologically proven CAE. Squamous cell carcinoma was found in 100% of tumours of the upper third, 91% middle third, and 73% lower third of the oesophagus. Four patients had a histological diagnosis of adenocarcinoma of the oesophagus. Factors that were associated with CAE included age (OR 1.63, CI 1.34-1.98, p value <0.001), smoking (OR 3.63, CI 1.82-7.23, p value <0.001) and gender (OR 2.17, CI 1.07-4.41, p value 0.032). Conclusion: Many patients referred for EGD in Uganda had esophageal cancer most of which were.squamous cell type. Smoking, male gender and older age were risk factors. Preventive measures should target stopping smoking.Item Hepatitis B virus genotypes A and D in Uganda(Journal of virus eradication,, 2016) Zirabamuzale, Jackie T.; Opio, Christopher K.; Bwanga, Freddie; Seremba, Emmanuel; Apica, Betty S.; Colebunders, Robert; Ocama, PonsianoThe prevalence of hepatitis B virus (HBV) infection in Uganda is 10%. Hepatitis B virus genotypes impact on treatment response, rate of spontaneous recovery and progression of chronic HBV infection and hepatocellular carcinoma. There is little information on the HBV genotypic distribution in Uganda. Objectives: To determine HBV genotypes in Uganda. Methods: The MBN clinical laboratory performs HBV viral load and genotype testing in Uganda. It receives hepatitis B surface antigen (HBsAg)-positive samples from all over the country for additional HBV testing. Samples are stored for 6 months before being discarded. Our study used delinked stored samples. PCR-positive samples had DNA extracted and used as template for HBV genome amplification by nested PCR. Reverse hybridisation was performed and genotypes were determined by the line probe assay method (INNO-LiPA). Results: One hundred stored HBsAg-positive plasma samples with detectable viral loads were analysed. Of these, 93 samples showed PCR amplification products and gave genotype-specific probe lines on the INNO-LiPA assay. Of the patients, where gender was recorded, 60.9% were female, and the overall median age (IQR) was 25 (2–60) years. There was a predominance of HBV genotype D (47 patients; 50.5%), followed by genotype A, (16 patients; 17.2%). One patient (1.1%) had genotype E. In 28% of the samples mixed infections were detected with genotypes A/E (9.7%) and A/D (6.5%) being most common. Genotypes B, C, E and H only occurred as part of mixed infections. Conclusion Hepatitis B genotypes D and A were predominant in our study population.Item Histological examination of post-mortem brains of children with nodding syndrome(Annals of Translational Medicine, 2018) Hotterbeekx, An; Onzivua, Sylvester; Menon, Sonia; Colebunders, RobertWe read with interest the editorial by Boivin about the aetiology of nodding syndrome (1). In this paper the author mentions that histological examination of post-mortem brains of children with nodding syndrome revealed polarizable material which proved difficult to characterize or identify in the majority of specimens (1). We recently performed a post-mortem study on a person with nodding syndrome in Uganda but we did not observe polarized material in the brain. Moreover, these polarized crystal-like structures were not described on MRI scans of persons with nodding syndrome (2), suggesting that they appeared post mortem. Indeed, polarized material has been seen in brain tissue that was not processed in an appropriate way and these crystalized structures have been called Buscaino bodies, representing myelin altered by fixation and handling (3). This was most likely what happened with previous post-mortem studies performed in patients with nodding syndrome. During these studies the composition of the formaldehyde used in preserving these brains was not documented. Currently, in onchocerciasis endemic districts of northern Uganda, a state of the art post-mortem study is ongoing, investigating the histopathological abnormalities in the brains of persons with epilepsy, including nodding syndrome. Hopefully this study will help us to obtain a better understanding of how the Onchocerca volvulus parasite is able to cause epilepsy.Item Impact of COVID-19 on the well-being of children with epilepsy including nodding syndrome in Uganda: A qualitative study(Epilepsy & Behavior, 2023) Nono, Denis; Gumisiriza, Nolbert; Tumwine, Christopher; Amaral, Luis-Jorge; Ainamani, Herbert Elvis; Seggane, Musisi; Colebunders, RobertTo investigate the impact of the COVID-19 pandemic and related restrictions on the access and use of health services by children with epilepsy including nodding syndrome in Uganda. Methods: Four focus group discussions (FGD) with parents/caregivers of children with epilepsy and five in-depth interviews with key informants were conducted between April and May 2021 at Butabika National Mental Referral Hospital and Kitgum General Hospital. Results: COVID-19-related restrictions, including the halting of non-essential services and activities, and suspension of public transport, created several challenges not only for children with epilepsy and their parents/caregivers but also for their healthcare providers. Study participants described extreme transport restrictions that reduced their access to healthcare care services, increased food insecurity and shortage or inability to afford essential medicines as consequences of COVID-19-related restrictions. However, parents/ caregivers and healthcare workers adopted several coping strategies for these challenges. Parents/caregivers mentioned taking on casual work to earn an income to buy food, medicines, and other necessities. Healthcare workers intensified outreach services to affected communities. A positive impact of lockdown measures described by some FGD participants was that most family members stayed at home and were able to care for children with epilepsy in turn. Conclusions: Our study highlights the significant negative impact of the COVID-19 pandemic and related restrictions on access to health services and the general well-being of children with epilepsy. Decentralized epilepsy treatment services and nutritional support could reduce the suffering of children with epilepsy and their families during the ongoing COVID-19 pandemic and similar future emergencies.Item Implementation of tuberculosis infection control in health facilities in Mukono and Wakiso districts, Uganda(BMC Infectious Diseases, 2013) Buregyeya, Esther; Nuwaha, Fred; Verver, Suzanne; Criel, Bart; Colebunders, Robert; Wanyenze, Rhoda; Kalyango, Joan N; Katamba, Achilles; Mitchell, Ellen MHTuberculosis infection control (TBIC) is rarely implemented in the health facilities in resource limited settings. Understanding the reasons for low level of implementation is critical. The study aim was to assess TBIC practices and barriers to implementation in two districts in Uganda. Methods: We conducted a cross-sectional study in 51 health facilities in districts of Mukono and Wakiso. The study included: a facility survey, observations of practices and eight focus group discussions with health workers. Results: Quantitative: Only 16 facilities (31%) had a TBIC plan. Five facilities (10%) were screening patients for cough. Two facilities (4%) reported providing masks to patients with cough. Ventilation in the waiting areas was inadequate for TBIC in 43% (22/51) of the facilities. No facility possessed N95 particulate respirators. Qualitative: Barriers that hamper implementation of TBIC elicited included: under-staffing, lack of space for patient separation, lack of funds to purchase masks, and health workers not appreciating the importance of TBIC. Conclusion: TBIC measures were not implemented in health facilities in the two Ugandan districts where the survey was done. Health system factors like lack of staff, space and funds are barriers to implement TBIC. Effective implementation of TBIC measures occurs when the fundamental health system building blocks -governance and stewardship, financing, infrastructure, procurement and supply chain management are in place and functioning appropriately.Item Incidence and Predictors of Mortality and the Effect of Tuberculosis Immune Reconstitution Inflammatory Syndrome in a Cohort of TB/HIV Patients Commencing Antiretroviral Therapy(JAIDS Journal of Acquired Immune Deficiency Syndromes, 2011) Worodria, William; Massinga-Loembe, Marguerite; Mazakpwe, Doreen; Luzinda, Kenneth; Mayanja-Kizza, Harriet; Mugerwa, Roy D.; Reiss, Peter; Colebunders, Robert; For the TB-IRIS Study GroupTuberculosis-HIV (TB-HIV) coinfection remains an important cause of mortality in antiretroviral therapy (ART) programs. In a cohort of TB-HIV-coinfected patients starting ART, we examined the incidence and predictors of early mortality.Consecutive TB-HIV-coinfected patients eligible for ART were enrolled in a cohort study at the Mulago National Tuberculosis and Leprosy Program clinic in Kampala, Uganda. Predictors of mortality were assessed using Cox proportional hazards analysis. Three hundred and two patients [median CD4 count 53 cells/μL (interquartile range, 20-134)] were enrolled. Fifty-three patients died, 36 (68%) of these died within the first 6 months of TB diagnosis. Male sex [hazard (HR): 2.19; 95% confidence interval (CI): 1.19 to 4.03; P = 0.011], anergy to tuberculin skin test [HR: 2.59 (1.10 to 6.12); P = 0.030], a positive serum cryptococcal antigen result at enrollment (HR: 4.27; 95% CI: 1.50 to 12.13; P = 0.006) and no ART use (HR: 4.63; 95% CI: 2. 37 to 9.03; P < 0.001) were independent predictors of mortality by multivariate analysis. Six (10%) patients with TB immune reconstitution inflammatory syndrome died, and in most, an alternative contributing cause of death was identified.Mortality among these TB-HIV-coinfected patients was high particularly when presenting with advanced HIV disease and not starting ART, reinforcing the need for timely and joint treatment for both infections. Screening for a concomitant cryptococcal infection and antifungal treatment for patients with cryptococcal antigenemia may further improve clinical outcome.Item Is nodding syndrome in northern Uganda linked to consumption of mycotoxin contaminated food grains?(BMC Research Notes, 2018) Echodu, Richard; Edema, Hilary; Malinga, Geoffrey Maxwell; Hendy, Adam; Colebunders, Robert; Kaducu, Joyce Moriku; Ovuga, Emilio; Haesaert, GeertNodding syndrome (NS) is a type of epilepsy characterized by repeated head-nodding seizures that appear in previously healthy children between 3 and 18 years of age. In 2012, during a WHO International Meeting on NS in Kampala, Uganda, it was recommended that fungal contamination of foods should be investigated as a possible cause of the disease. We therefore aimed to assess whether consumption of fungal mycotoxins contributes to NS development. Results: We detected similar high levels of total aflatoxin and ochratoxin in mostly millet, sorghum, maize and groundnuts in both households with and without children with NS. Furthermore, there was no significant association between concentrations of total aflatoxin, ochratoxin and doxynivalenol and the presence of children with NS in households. In conclusion, our results show no supporting evidence for the association of NS with consumption of mycotoxins in contaminated foods.Item Level and Determinants of Adherence to COVID-19 Preventive Measures in the First Stage of the Outbreak in Uganda(International journal of environmental research and public health, 2020) Amodan, Bob O.; Bulage, Lilian; Katana, Elizabeth; Ario, Alex R.; Siewe Fodjo, Joseph N.; Colebunders, Robert; Wanyenze, Rhoda K.We conducted an online survey in the first two months of the Coronavirus Disease 2019 (COVID-19) epidemic in Uganda to assess the level and determinants of adherence to and satisfaction with the COVID-19 preventive measures recommended by the government. We generated Likert scales for adherence and satisfaction outcome variables and measured them with four preventive measures, including handwashing, wearing face masks, physical distancing, and coughing/sneezing hygiene. Of 1726 respondents (mean age: 36 years; range: 12–72), 59% were males, 495 (29%) were adherent to, and 545 (32%) were extremely satisfied with all four preventive measures. Adherence to all four measures was associated with living in Kampala City Centre (AOR: 1.7, 95% CI: 1.1–2.6) and receiving COVID-19 information from health workers (AOR: 1.2, 95% CI: 1.01–1.5) or village leaders (AOR: 1.4, 95% CI: 1.02–1.9). Persons who lived with younger siblings had reduced odds of adherence to all four measures (AOR: 0.75, 95% CI: 0.61–0.93). Extreme satisfaction with all four measures was associated with being female (AOR: 1.3, 95% CI: 1.1–1.6) and health worker (AOR: 1.2, 95% CI: 1.0–1.5). Experiencing violence at home (AOR: 0.25, 95% CI: 0.09–0.67) was associated with lower satisfaction. Following reported poor adherence and satisfaction with preventive measures, behavior change programs using health workers should be expanded throughout, with emphasis on men.Item Malaria Care in Infants Aged under Six Months in Uganda: An Area of Unmet Needs!(PLoS One, 2015) Kayitale Mbonye, Martin; Burnett, Sarah M.; Naikoba, Sarah; Colebunders, Robert; Wouters, Kristien; Weaver, Marcia R.; Van Geertruyden, Jean PierreLittle information exists on malaria burden, artemisinin-based combination therapy (ACT) use, and malaria care provided to infants under six months of age. The perception that malaria may be rare in this age group has led to lack of clinical trials and evidence-based treatment guidelines. The objective of this study was to identify malaria parasitemia positivity rate (MPPR) among patients under six months, and practices and predictors of malaria diagnosis and treatment in this population. Methods Cross-sectional data collected from October 2010 to September 2011 on 25,997 individual outpatients aged <6 months from 36 health facilities across Uganda were analysed. Findings Malaria was suspected in 18,415 (70.8%) patients, of whom 7,785 (42.3%) were tested for malaria. Of those tested, the MPPR was 36.1%, with 63.9%testing negative, of which 1,545 (31.1%) were prescribed an antimalarial. Among children <5kgs, off-label prescription of ACT was high (104/285, 36.5%). Younger age (1-6 days, aOR=0.47, p=0.01; 7-31 days, aOR=0.43, p<0.001; and 1-2 months, aOR=0.61, p<0.001), pneumonia (aOR=0.78, p=0.01) or cough/cold (aOR=0.65, p<0.001) diagnosis, and fever (aOR=0.56, p=0.01) reduced the odds of receiving a malaria test. Fever (aOR=2.22, p<0.001), anemia diagnosis (aOR=3.51, p=0.01), consulting midwives (aOR=3.58, p=0.04) and other less skilled providers (aOR=4.75, p<0.001) relative to medical officers, consulting at hospitals (aOR=3.31, p=0.03), visiting health facilities in a medium-high malaria transmission area (aOR=2.20, p<0.001), and visiting during antimalarial (aOR=1.82, p=0.04) or antibiotic (aOR=2.23, p=0.04) shortages increased the odds of prescribing an antimalarial despite a negative malaria test result. Conclusions We found high malaria suspicion but low testing rates in outpatient children aged <6 months. Among those tested, MPPR was high. Despite a negative malaria test result, many infants were prescribed antimalarials. Off-label ACT prescription was common in children weighing <5kgs. Evidence-based malaria guidelines for infants weighing <5 kilograms and aged <6 months are urgently needed.Item Neuroinflammation and Not Tauopathy Is a Predominant Pathological Signature of Nodding Syndrome(Journal of Neuropathology & Experimental Neurology, 2019) Hotterbeekx, An; Lammens, Martin; Idro, Richard; Akun, Pamela R.; Lukande, Robert; Akena, Geoffrey; Nath, Avindra; Olwa, Francis; Colebunders, RobertNodding syndrome (NS) is an epileptic disorder occurring in children in African onchocerciasis endemic regions. Here, we describe the pathological changes in 9 individuals from northern Uganda who died with NS (n = 5) or other forms of onchocerciasis-associated epilepsy (OAE) (n = 4). Postmortem examinations were performed and clinical information was obtained. Formalin-fixed brain samples were stained by hematoxylin and eosin and immunohistochemistry was used to stain astrocytes (GFAP), macrophages (CD68), ubiquitin, α-synuclein, p62, TDP-43, amyloid β, and tau (AT8). The cerebellum showed atrophy and loss of Purkinje cells with hyperplasia of the Bergmann glia. Gliosis and features of past ventriculitis and/or meningitis were observed in all but 1 participant. CD68-positive macrophage clusters were observed in all cases in various degrees. Immunohistochemistry for amyloid β, α-synuclein, or TDP-43 was negative. Mild to sparse AT8-positive neurofibrillary tangle-like structures and threads were observed in 4/5 NS and 2/4 OAE cases, preferentially in the frontal and parietal cortex, thalamic- and hypothalamic regions, mesencephalon and corpus callosum. Persons who died with NS and other forms of OAE presented similar pathological changes but no generalized tauopathy, suggesting that NS and other forms of OAE are different clinical presentations of a same disease with a common etiology.Item Neuropathological Changes in Nakalanga Syndrome—A Case Report(Pathogens, 2021) Hotterbeekx, An; Lammens, Martin; Onzivua, Sylvester; Lukande, Robert; Olwa, Francis; Kumar-Singh, Samir; Hees, Stijn Van; Idro, Richard; Colebunders, RobertNakalanga syndrome is a clinical manifestation of onchocerciasis-associated epilepsy characterized by stunting, delayed or absent secondary sexual development and skeletal deformities, and is often accompanied by epileptic seizures. The pathophysiology of Nakalanga syndrome is unknown. Here, we describe the post-mortem findings of a 17-year-old female who died with Nakalanga syndrome in northern Uganda. Macroscopic and histopathological examination of all major organs (liver, lungs, kidney and heart), including the brain and the pituitary gland, was performed. The suspected cause of death was malaria, and all major organs and pituitary gland appeared normal, except the lungs, which were edematous consistent with the malaria. Neuropathological changes include signs of neuro-inflammation (gliosis and activated microglia), which co-localized with tau-reactive neurofibrillary tangles and threads. The pathology was most abundant in the frontal cortex, thalamic and hypothalamic regions, and mesencephalon. The choroid plexus showed psammoma bodies. These findings indicate accelerated aging, probably due to repeated seizures. The neuropathological findings were similar to other persons who died with onchocerciasis-associated epilepsy. Examination of the pituitary gland did not reveal new information concerning the underlying pathophysiological mechanism of Nakalanga syndrome. Therefore, more post-mortem studies should be performed.