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30 day in-hospital patient mortality after ICU discharge and associated factors : a retrospective cohort study in selected tertiary hospitals in Kampala

(Makerere University, 2021-01-25) Nantongo, Betty

Background: Intensive care medicine is rapidly growing because critical illness is a major component of the global burden of disease especially in LMICs. We retrospectively evaluated the 30 day In-hospital patient mortality after ICU discharge and associated factors. Methods: We conducted a retrospective multicentre Cohort study on all patients that were discharged alive from the ICU at three tertiary hospitals in Kampala- Uganda, patient records discharged between January 2018 to December 2019 were reviewed during their hospital stay to fill the data extraction tool and followed up. In-hospital mortality after ICU discharge as primary outcome. Results: In total 711 patients were included with mean age of 42 years and 56.4% were male. A total of 106/711 patients died after ICU discharge giving a mortality of 14.9% (95% CI: 12.4-17.7). Most (86/711) patients died within the first 20 days with a 0.802 survival probability and were mostly above 40 years. The median number of hospital stay after ICU discharge 7 days (IQR: 5-11). Multivariate analysis identified presence of comorbidities, Respiratory disorder at ICU admission and GIT disorder at ICU admission and inotropic/vasopressor support to be associated with patient mortality after ICU discharge while Tracheostomy placement was found to be protective. Conclusion: The 30-day in hospital patient mortality rate after ICU discharge was high compared to that in high income countries. Most in-hospital patient deaths after ICU discharge occurred during the first 20 days. A prospective study is needed to further explore In-hospital patient mortality after ICU discharge and associated factors.
Acceptance of routine counselling and testing for HIV among medical patients at Mulago Hospital casuality unit.

( 2005-07) Nakanjako, Damalie K

Introduction: HIV counseling and testing is an entry point to comprehensive HIVIAIDS prevention and care. In Uganda, VCT is available in ambulatory settings where clients present by self-selection. Routine Counseling and Testing for HIV (RCT) is not widely offered as part of medical care at Mulago hospital. Data on patient acceptability of RCT in an acute care setting is still limited in Sub-Saharan Africa and Uganda in particular. This study determined the acceptability of RCT and the patient factors influencing uptake of the service in a hospital Methods: This was a cross-sectional study. Participants were selected by systematic sampling of patients attending the medical casualty unit at Mulago Hospital; Interviews were conducted to determine whether patients knew their HIV serostatus. HIV counseling and testing was offered to all eligible patients and results were delivered within 30minutes. WHO clinical staging was performed for the HIV positive patients. Acceptability of RCT was measured by the proportion of patients that agreed to be tested for HIV. Bivariate analysis was done to determine the sociodemographic, socio-economic and medical factors affecting the acceptability of RCT. Results: One hundred ninety three out of 233 patients that came to the Mulago casualty unit between October and December 2004 (83%) were not aware of their HIV serostatus. One hundred seventy one out of the 193 (88%) had sought treatment at a health unit in the previous six months where HIV testing had not been offered. Seventy out of 17 1 (5 1%) who had sought medical care in the previous six months had been to both private and public health units. One hundred ninety eight out of 208 (95%) that were offered HIV testing accepted to test for HIV. The very high acceptability precluded analysis of the factors associated with decline to test for HIV. One hundred and eleven out of 223 (50%) study participants were infected with HIV and 86 of the 111 HIV infections (77%) were diagnosed during the study period. Seventy eight out of 111 HIV infected participants (70%) were in WHO clinical stage 3 and 4. No immediate psychological breakdown was observed following delivery of HIV positive results. Conclusions: Acceptability of routine HIV testing was high at the medical casualty unit at Mulago Hospital. RCT in this setting identified a significant number of HIV infected patients. RCT has a potential public health impact of increasing the number of HIV infections diagnosed and hence the number of persons with access to HIV/AIDS prevention and treatment services. We recommend that RCT should be adopted as standard of care for patients at the medical casualty unit at Mulago hospital and other private and public health units in Uganda in order to meet patients at their earliest contact with the health care system.
Access to anti-hypertensive and anti-diabetic medications amongst people living with HIV in Soroti District, Eastern Uganda

(Makerere University, 2022-12) Mwawule, Wadulo Fredrick

Background: Access to anti-diabetic and anti-hypertensive medicines is one of the factors that needs to be addressed so as to ensure continuous availability of affordable quality of care to HIV clients living with hypertension and diabetes. Inability to bridge the gap of anti-hypertensive and anti-diabetic medicine access will offset the tremendous gains associated with the use of antiretroviral therapy. Objective: To determine access to anti-hypertensive and anti-diabetic medicines amongst HIV clients. Methods: This was a cross-sectional study that collected both qualitative and quantitative data. A semi-structured questionnaire was used to collect quantitative data from 215 HIV positive hypertension and diabetic clients. The collected data was entered into SPSS version 24, and analyzed using descriptive statistics and logistic regression to assess access to anti-hypertensive and anti-diabetic medicines. An interview guide was used to collect qualitative data from 16 key-informants (pharmacist, prescribing clinicians, dispensers, stores attendants and nurse in-charges). Collected data was transcribed, exported into Atlas.ti 22 software, and analyzed thematically. Results: The six anti-hypertensive and anti-diabetic medicines observed were stocked-out for an average of 26.02% (16/60 days) of the days. The anti-hypertensive medicines had more stock-out days (20/60 days) compared to anti-diabetic medicines which had a stock-out duration of (12/60) days. Losartan-hydrochlorothiazide, anti-hypertensive medicine had the highest number of stock-out days (32/60) days. Accessibility was poor, with the majority 193 (89.8%) of the clients travelling more than 5Km for their medicine refills and only 86 (40%) of the clients receiving all their prescribed medicines. Medicine affordability was also poor, with majority 183 (85.1%) of the clients at risk of catastrophic health expenditure. Education level (AOR=0.245; 95% CI: 0.092-0.655; p=0.005˂0.05) was significantly associated with accessibility to non-communicable disease medicines. Supply chain practices affecting access to anti-hypertensive and anti-diabetic medicines included; inadequate technical personnel, and limited funds. Conclusion: Access to non-communicable disease medicines is generally poor as illustrated by poor accessibility, affordability, persistent stock-outs, limited funds, inadequate technical personnel, and delayed delivery of medicines by the central medical store. Recommendation: Government needs to strengthen health facilities in the management of non-communicable diseases by increasing access to medicines. Key words: Access, availability, accessibility, affordability, HIV/AIDS, NCDs, HIV and NCDs.
Access to mental health services by refugees in Imvepi Refugee Settlement, Arua District, Uganda

(Makerere University, 2021-12) Kaggwa, Mary

Background: Uganda continues to have an influx of refugees who are exposed to multiple traumatic events that put them at a higher risk of developing mental disorders as compared to the general population. The availability of human resources, equipment, and drugs to manage mental disorders in a timely fashion hasn’t been well documented within the refugee population in Uganda. Justification: This study aimed to examine access to the types of mental health services available for diagnosing and managing mental disorders, which will guide stakeholders on the development of easily accessible mental health interventions. Objectives: To investigate access to mental health services by refugees within Imvepi refugee settlement. Methods: A cross sectional study using a qualitative methodology was conducted in Imvepi refugee settlement. Participants were purposively selected using an inclusion criterion Qualitative data were collected using eight key informant interviews, six focus group discussions, ten in-depth interviews and two observational checklists. This data was then transcribed, electronically coded, and analysed through a thematic analysis using NVivo software. Results: The study findings showed an evident lack of access to mental health services seen as unawareness of the availability of mental health services within the settlement. The lack of adequately trained mental health workers, persistent psychotropic drug stockouts as well as high transportation costs to get from one’s home to the health centres were the main concerns. Major barriers to accessing care included cultural beliefs and attitudes, stigma and discrimination, language barrier and lack of family or community support. Conclusion: While the refugees were aware of mental disorders and had high mental health needs, poor access to trained mental health personnel and psychotropic medicines alongside poor geographic access were documented. Mental health stigma, lack of psychosocial support as well as language barrier were notable barriers to MH services. The government should provide more resources to develop better mental health policies that can close the mental health treatment gap. This will ensure increased training of mental health workers, improved availability of resources, and raised awareness within the community.
Accuracy of raepid tests as compared with field microscopy, for diagnosis of Malaria in adolescents and adult patients in Mulago Hospital

( 2008) Luzige, Ssekiganda Simon

Background: Blood smear microscopy is the recommended gold standard test for laboratory confirmation of malaria. However, due to some limitations associated with microscopy such as being labor intensive and time consuming, rapid diagnostic tests (RDTs) are becoming attractive alternatives to microscopy because these tests are fast, easy to perform, and do not require electricity or specific equipment. Although their accuracy in a number populations and epidemiological settings has been reviewed, the results are often variable and not easily transferable. This study was therefore performed to evaluate the accuracy of RDTs for the diagnosis of malaria in adolescents and adult patients in Mulago hospital. Methods: From February to May 2007, we evaluated the accuracy of SD malaria pLDH P flPan. SD malaria HRP-ll Pi Paracheck and PI Parabank as compared to field microscopy of blood smears in five hundred fifty five (555) adolescent and adult patients clinically suspected to have malaria at Mulago hospital. With microscopy as the gold standard, we analyzed for the accuracy of each RDT by computing for sensitivity, specificity, positive and negative predictive values as well as positive and negative diagnostic likelihood ratios (DLRs). Results: The adjusted prevalence of smear confirmed malaria was 20% (111 patients). SD malaria pLDH P flPan and Paracheck had similar sensitivities (89%) meanwhile; SD Bioline-Pf HRP2 and Parabank were respectively 87% and 83%. Overall the greater the parasite density the higher was the sensitivity. The pLDH based RDTs SD malaria pLDH Pf/Pan and Parabank had a higher specificity (96%) than the HRP2 based tests SD malaria HRP-11 P f(88%) and Paracheck (91%). The positive predictive values of SD malaria pLDH P jlPan and Parabank were respectively 84 and 87 compared to HRP2 based tests SD malaria HRP-II P.f(64%) and Paracheck (70%). However, the negative predictive values were similar for all tests (96%-97%). Also, the positive diagnostic likelihood ratios for SD malaria pLDH P jlPan, Parabank, SD malaria HRP-II P.f and Paracheck were respectively 21, 23, 7 and 9 whereas the negative diagnostic likelihood ratios was 0.1 for all RDTs. Conclusions: The accuracy of rapid tests (SD malaria pLDH Pf/Pan, Paracheck, 3D Bioline-P .fHRP2 and Parabank) is comparable to blood smear microscopy in the diagnosis of malaria in adolescents and adult patients in Mulago hospital. Rapid diagnostic tests (RDTs) should be considered as alterative methods for supporting or ruling out malaria in adolescents and adult patients suspected to have malaria in Mulago hospital.
Adherence to infection control standards among surgical senior house officers in operating rooms of Mulago Hospital, Uganda

(Makerere University, 2021) Bironse, Michael

Background: Hospital acquired infections (HAI) are on the rise and pose a serious concern for patients, attendants, and health workers. Studies show that 5% to 10% of hospitalized patients in developed countries and 25% in developing countries suffer from hospital acquired infections. In Uganda, control of hospital infections is far from ideal. The most effective and appropriate way to prevent HAI is to follow standard precautions. Aim: The aim of the study was to evaluate the adherence to infection control standards and the associated factors among surgical senior house officers operating in Mulago Hospital. Methods and materials: The study adopted a quantitative cross-sectional design. Two observation checklists at 5 operating rooms of Mulago National Referral Hospital were used to collect data on adherence to infection control standards and operating room design and protocols. Self-administered structured questionnaire was used to collect data from 159 senior house officers on knowledge of infection control standards. The data were analysed using STATA version 14. Modified Poisson Regression analysis was used to determine the factors associated with adherence to infection control standards using. The study protocol was approved by the School of Health Sciences Research and Ethics Committee. Study results: The study comprised of 159 senior house officers with mean age of 30.8 (range 25 to 47) years. Majority of the participants were males (57.2%), operating in the casualty theatre (35.8%) and were pursuing general surgery (35.2%). Most participants (62.9%) had experience in surgeries for at least 7 years before this study was conducted. Overall, the prevalence of adherence among the surgical senior house officers was 67.3% (95% CI: 58.9 – 73.6), while the overall prevalence of knowledge in infection control was 88.7% (95% CI: 82.7 – 92.8). The prevalence of infection control standards varied widely among the senior house officers (32.7% - 100%) and the operating rooms (42.1 – 97.7%). Adherence to the infection control standards was significantly associated with senior house officers operating in the casualty theatre (PR=0.58, 95% CI: 0.36 – 0.99) and the main theatre (PR=0.49, 95% CI: 0.24 – 0.95) whereas there was no significant association with the level of knowledge regarding infection control and the rest of the socio-demographics. Conclusion: The prevalence of adherence to infection control standards in the present study was low while the overall prevalence of knowledge in infection control was high. Adherence varied across the domains of the infection control standards among the senior house officers as well as in operating rooms. Adherence was significantly associated with operating in the casualty and the main theatres implying that there is a need to focus our interventions on the operating rooms. However, there were neither significant associations between the level of adherence, nor knowledge and the socio-demographic factors among the senior house officers on infection control standards. This implies there should be a focus on other broader factors or theories such as behavioral change practices.
Administration patterns of magnesium sulphate for women with preeclampsia and immediate newborn outcomes in Kawempe National Referral Hospital

(Makerere University, 2023) Ndiwalana, Mariam

Background: Pre-eclampsia is one of the leading causes of maternal and perinatal mortality and morbidity worldwide. In Uganda, the MOH adopted the WHO recommendation of using MgSO4 to prevent and treat pre-eclampsia with severe features (SPE) and eclampsia among expectant mothers. Previous research has highlighted discrepancies in MgSO4 administration patterns. Aim: To describe MgSO4 administration patterns in women with SPE or eclampsia and the immediate newborn outcomes of neonates exposed to intrapartum MgSO4 at Kawempe National Referral Hospital. Methodology: Analytical cohort study design was employed to collect data from pregnant women at 28 weeks of gestation diagnosed with SPE or eclampsia and being treated with intrapartum magnesium. 207 respondents were targeted at power 80 and 95% confidence. Structured interviews, observations, and document reviews were used to collect data from August to October 2022 from 210 respondents, which was analyzed using SPSS 23. Descriptive statistics were run to report frequencies, means and standard deviations. In addition, bivariate and multivariate logistic regression models were conducted to determine factors associated with the low Apgar score at five minutes. Results: All mothers received MgSO4 loading dose, 181/210 (86.2%), 152/210 (72.4%), 131/210 (62.4%), 112/210 (53.3%), 95/210 (45.2%) and 70/210 (33.3%) received the first, second, third, fourth fifth and sixth maintenance doses respectively. Only 70/210 (33.3%) completed the full dose of MgSO4 that is loading and six maintenance doses. The majority, 178/210 (84.8%), of the mothers delivered live babies, while 32/210 (15.2%) delivered stillbirths (13/32; 40.6% FSBs and 19/32; 59.4% MSBs). 65/210 (31.0%) NICU admissions were done mostly due to; respiratory distress 45/65 (21.4%) and preterm delivery 44/65 (21.0%). Thompson scores were done on 54/65 (83.1%) NICU admissions, 38/54(70.4%) had a score of 1 to 10, 16/54 (29.6%) had a normal score, and 11/65 (5.5%) of the NICU admissions died within seven days of admission. After adjusting for confounders, there was an increased likelihood of newborns having low Apgar scores at five minutes in mothers aged below 25 years (AOR=3.23, CI: 0.29-35.44) and those that were labour induced (AOR=2.08, CI: 0.18-22.89. In addition, 4-hourly timing of the first maintenance dose decreased the likelihood of having low Apgar scores at five minutes among newborns of mothers receiving intrapartum MgSO4. Conclusion: Drug administration patterns in the study were not congruent with the international and local recommendations. NICU admissions and stillbirths were common among neonates exposed to partial intrapartum MgSO4 doses. Respiratory distress and preterm delivery are the leading cause of NICU admissions in newborns exposed to in-utero MgSO4. A complete dose of MgSO4 sulphate decreases the likelihood of low Apgar score at 5 minutes in newborns. Reccomendations: Facilities should adhere to MgSO4 administration guidelines in addition to adopting the use of labour monitoring tools to improve newborn outcomes.
Adult patients with cancer in Uganda : validation of the tool, health-related quality of life, and patient experiences

(Makerere University, 2025) Naamala, Allen

Background: This study aimed to assess the validity and reliability of the Luganda version of the tool used to measure health-related quality of life (HRQoL), specifically the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (EORTC QLQ-C30). The study sought to investigate the prevalence of poor HRQoL concerning clinical and sociodemographic characteristics and to describe the experiences of adult cancer patients undergoing treatment at a specialized cancer facility in Uganda. Methods: A sequential explanatory multi-method study was conducted at the Uganda Cancer Institute among adult patients with various types and stages of cancer. Clinical and sociodemographic information was collected using study-specific items and patients' medical records. Sub-study 1: Tool validation evaluated the reliability and validity (including construct, known group, and criterion validity) of the Luganda and English versions of the EORTC QLQ-C30 instrument. Sub-study 2: This sub-study investigated the prevalence of and factors associated with poor health-related quality of life (HRQoL). It used predetermined validated clinical thresholds to identify patients with poor HRQoL and conducted a multivariable logistic regression analysis to determine the associated factors. Sub-study 3: This sub-study described the experiences of adult men and women receiving treatment at a specialized cancer facility, utilizing reflexive thematic analysis. Main results: Sub-study 1. Construct validity, CFA yielded good fit indices (RMSEA = 0.08, SRMR = 0.05, and CFI = 0.93). Known-groups validity was supported by statistically significant better HRQoL among patients with early-stage compared to those in late-stage. Criterion validity: positive correlations between the Karnofsky Performance Scale and the Physical Function (0.75 - 0.76) and Global quality of life (0.59 - 0.72) for Luganda and English versions, respectively. Cognitive function did not reach acceptable Cronbach’s alpha values (Luganda α = 0.66, English α = 0.50). Sub-study 2: (68%−87%) reported functional impairment and symptoms of pain (80%) and fatigue (63%). Increasing age, no formal education, unemployment, being an inpatient, diagnosed with cervical cancer or leukemia were factors associated with poor HRQoL. Sub-study 3: Organization of care, personal challenges, mental suffering, and satisfaction with care were the themes generated. Conclusion: The validated Luganda and English versions of the EORTC QLQ- C30 appear to be a valid and reliable instrument recommended for assessing HRQOL in adult Ugandans with cancer. Most patients reported poor functioning and a significant burden of symptoms, including pain and fatigue, that warrant concern. The prevalence of poor health-related quality of life (HRQoL) is especially noticeable among older adults, those without formal education, and those who are unemployed. Furthermore, being an inpatient and having a cancer diagnosis are both linked to a lower quality of life related to health. Patients also described their penurious experiences of care, including inadequate infrastructure and resources (food, staff, and drugs), delays in accessing care, the poor health system, and high treatment costs as well as stigma, abandonment, isolation, and emotional distress. This situation calls for policymakers'’ interventions including a need to adapt and adopt the cancer pain management clinical guidelines in the Ugandan context, development of a psychosocial oncology center, and training of health professionals Policymakers are urged to update the budget for cancer care to improve the infrastructural challenges and ensure adequate resources, decentralize cancer care for easier access, and to create awareness about cancer and its treatment to reduce stigma.
Adult patients with cancer in Uganda: validation of the tool, health-related quality of life, and patient experiences

(Makerere University, 2025) Naamala, Allen

Background: This study aimed to assess the validity and reliability of the Luganda version of the tool used to measure health-related quality of life (HRQoL), specifically the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (EORTC QLQ-C30). The study sought to investigate the prevalence of poor HRQoL concerning clinical and sociodemographic characteristics and to describe the experiences of adult cancer patients undergoing treatment at a specialized cancer facility in Uganda. Methods: A sequential explanatory multi-method study was conducted at the Uganda Cancer Institute among adult patients with various types and stages of cancer. Clinical and sociodemographic information was collected using study-specific items and patients' medical records. Sub-study 1: Tool validation evaluated the reliability and validity (including construct, known group, and criterion validity) of the Luganda and English versions of the EORTC QLQ-C30 instrument. Sub-study 2: This sub-study investigated the prevalence of and factors associated with poor health-related quality of life (HRQoL). It used predetermined validated clinical thresholds to identify patients with poor HRQoL and conducted multivariable logistic regression analysis to determine the associated factors. Sub-study 3: This sub-study described the experiences of adult men and women receiving treatment at a specialized cancer facility, utilizing reflexive thematic analysis. Main results: Sub-study 1. Construct validity, CFA yielded good fit indices (RMSEA = 0.08, SRMR = 0.05, and CFI = 0.93). Known-groups validity was supported by statistically significant better HRQoL among patients with early-stage compared to those in late-stage. Criterion validity: positive correlations between the Karnofsky Performance Scale and the Physical Function (0.75 - 0.76) and Global quality of life (0.59 - 0.72) for Luganda and English versions, respectively. Cognitive function did not reach acceptable Cronbach’s alpha values (Luganda α =0.66, English α = 0.50). Sub-study 2: (68%−87%) reported functional impairment and symptoms of pain (80%) and fatigue (63%). Increasing age, no formal education, unemployment, being an inpatient, diagnosed with cervical cancer or leukemia were factors associated with poor HRQoL. Sub-study 3: Organisation of care, personal challenges, mental suffering, and satisfaction with care were the themes generated. Conclusion: The validated Luganda and English versions of the EORTC QLQ-C30 appear to be a valid and reliable instrument recommended for assessing HRQOL in adult Ugandans with cancer. Most patients reported poor functioning and a significant burden of symptoms, including pain and fatigue, that warrant concern. The prevalence of poor health-related quality of life (HRQoL) is especially noticeable among older adults, those without formal education, and those who are unemployed. Furthermore, being an inpatient and having a cancer diagnosis are both linked to a lower quality of life related to health. Patients also described their penurious experiences of care, including inadequate infrastructure and resources (food, staff, and drugs), delays in accessing care, the poor health system, and high treatment costs as well as stigma, abandonment, isolation, and emotional distress. This situation calls for policymakers'’ interventions including a need to adapt and adopt the cancer pain management clinical guidelines in the Ugandan context, development of a psychosocial oncology center, and training of health professionals Policymakers are urged to update the budget for cancer care to improve the infrastructural challenges and ensure adequate resources, decentralize cancer care for easier access, and create awareness about cancer and its treatment to reduce stigma.
Allele-Specific Expression of Active TB in pediatric HIV individuals in Eswatini, Botswana and Uganda

(Makerere University, 2022-08-03) Mthande, Sibonakaliso Mzwakhile

Tuberculosis (TB) and Human Immunodeficiency Virus (HIV) has been declared a deadly combination by the World Health Organization (WHO) and about 1.4 million deaths are reported yearly. Sub – Saharan Africa has about 70% of the 36.9 million people living with HIV. HIV and TB coinfection has led to the expression of some genes. There are some known genetic loci associated with risk for active TB, however, these are population specific, and some have not been replicated. Equally gene expression signatures have been characterized for different populations and TB clinical phenotypes, however, there remains a knowledge gap in the genetic mechanism of active TB including the mechanism of regulation of gene expression. One possible mechanism of regulation of gene expression is through allelic imbalance /allele specific expression at specific heterozygous loci. Allele Specific Expression (ASE) or allelic imbalance (AI) is when one allele is expressed more than the other at a heterozygous loci. This study aimed at determining differential expression of alleles at heterozygous loci in children coinfected with active TB and HIV in three sub-Saharan African countries under the Collaborative African Genomics Network (CAfGEN) project, which are Botswana, Uganda and Eswatini. It also aimed at identifying genomic variants that plays a role in active TB pathogenesis in HIV positive pediatric individuals. The study utilized RNA sequence data from assented and consented HIV positive pediatric individuals with the cases being children diagnosed with active TB while the controls were age and sex matched children without TB. HaplotypeCaller was used for joint variant calling of variants and annovar with snpEff and SnpSift were used for annotation of variants. GATK ASEReadCounter was used for the allelic imbalance analysis. 144521, 44795 and 27401 variants were called, with 3.12 %, 2.64% and 5 % of them being exon variants from Uganda, Botswana and Eswatini respective. The majority of the called variants were SNPs. rs1050504 was found to be related to the pathogenesis of TB in Moroccan population. rs7256672 was found to be related to hypercholesterolemia. Another variant was rs9881 which is related to susceptibility of pulmonary TB in the Chinese population. 60% of all the analyzed variants showed an allelic imbalance and 40% did not show an allelic imbalance. This shows that active TB plays a role in the allelic imbalance at heterozygous site. More allelic imbalance studies need to be conducted with haplotypes in order to validate the obtained results so that the findings can be generalized.
Analysis of the effect of adjustments on the forecast accuracy of antiretroviral medicines in Uganda

(Makerere University, 2021) Kirungi, Gloria

Background: Outputs from the quantifications are used to advocate and allocate funding, as well as develop supply plans with the aim of ensuring availability of medicines. However, the actual consumption is not always equal to the forecast (Akhlaghi et al, 2011) and thus forecasting teams often adjust further to improve the forecast accuracy. However, this could introduce bias (Davydenko & Fildes, 2013) affecting downstream processes. Objectives: The study aimed at determining forecast accuracy of the final forecast, the effect of adjustments, and the factors that affect the forecast accuracy of ARVs in Uganda. Methods: A descriptive study using both quantitative and qualitative data collection methods were conducted. The statistical forecasts, final forecasts, and actual consumption data from January 2016 to December 2019 was collected retrospectively from the Ministry of Health Pharmacy Department, and the Web based ordering and reporting system. Data cleaning and analysis was done using Microsoft excel. The mean average percentage error (MAPE) was used to measure forecast accuracy and student-t test was used for determining the significance of adjustments. Key informant interviews were held to determine the factors that affect the forecast accuracy. Results: The national final forecast MAPE ranged from 2.33% to 5.15% (Jan 2016 -Jan 2019) while the statistical MAPE ranged from 2.65% to 4.31% (Aug 2017 - Jan 2019). The MAPE for adult ARVs were generally lower than those of pediatric ARVs and a variation in forecast accuracy with one of the central warehouses (n=3) was noted. Adjustments generally lowered the MAPE for adult ARVs but increased the MAPE for most pediatric ARVs. Adjustments were significant for 53.8% (n=13, p=0.05) of the ARVs. Factors including dispensing practices, complexity of the quantification, adherence to treatment guidelines, data quality, product availability and quantification team attributes were identified to affect the forecast accuracy. Conclusion: The final and statistical forecast have a good accuracy and adjustments made improved the accuracy of adult ARV forecasts however decreased the accuracy for pediatric ARVs. Accuracy of the forecast is affected by the quantification complexity, product usage and availability and team attributes. Recommendations: More precautions are required when adjusting for pediatric ARVs. There is need to develop ARV use guides especially to aid manage coping habits in case of drug shortages. Forecast accuracy of new drugs and the degree of significance of the factors affecting forecasting should be further studied.
Anthropometric Profile of Secondary School Pupils in Uganda: A case Study of Kampala and Kamuli Districts.

( 2004) Baalwa, Joshua

The incidence of youthful obesity in Uganda is rising, parallel to the growth of Urbanisation. Obesity in Childhood and early Adulthood strongly predicts Adulthood obesity and the risk for Cardiovascular diseases. Primary prevention thus ought to be initiated in Childhood and early Adulthood, however, the prevalence of obesity in this population is known.
Antibacterial activity of selected medicinal plants used for the management of chicken diseases by poultry farmers in Najjembe Sub-County, Buikwe District, Uganda

(Makerere University, 2023-04-06) Epiaka, Stephen Mark

Background: The use of conventional antibiotics in the management of chicken diseases has accelerated the development of antibiotic resistance. Plants are a source of new novel antibiotics that are effective and cheap. The study documented locally used medicinal plants for the management of chicken diseases and investigated their antibacterial potential against chicken related bacteria responsible for chicken diseases. Methods: Data on the use of medicinal plants was collected through a semi-structured questionnaire and during a field survey to collect the medicinal plants. Plant extracts were obtained through maceration of the plant materials using solvents of different polarities. Phytochemical analysis was carried out using the protocols of Guyasa et al (2018). The antibacterial activity of the plant extracts was determined using the disc diffusion method. Results: The commonly used plant species were Aloe vera L., Ocimum gratissum L., Nicotiana tabacum L., Bidens pilosa L., and Vernonia amygdalina Del. Plant extracts were applied orally accounting for (98%). All the bacteria were sensitive to the plant extracts tested. Ethanolic extracts, at 0.5 mg/ml against E. coli had zones of inhibition ranging from 10-16 mm and 17-22 mm for S. aureus. Water extracts at 0.5 mg/ml against S. aureus had zones of inhibition ranging between 10-15 mm. The MIC of ethanolic extracts of the plant studied ranged from 0.03125-0.25 g/ml against E. coli and 0.03125-0.125 g/ml against S. aureus. The MIC of water extracts of the plant studied ranged from 0.125 to 0.25 g/ml against E. coli and 0.125 to 0.25 g/ml against S. aureus. Ethanolic extract of Vernonia amygdalina Del. and Nicotiana tabacum L. showed MBC against E. coli at 0.125 g/ml and 0.03125 g/ml against S. aureus for Vernonia amygdalina Del. Water extract showed MBC at 0.125 g/ml for Aloe vera L. against E. coli and 0.125 g/ml against S. aureus for Ocimum gratissimum L. Conclusion: Aloe vera, Ocimum gratissum, Nicotiana tabacum, Bidens pilosa, and Vernonia amygdalina were the most used plants for the management of bacterial infections in chicken. Keywords: Medicinal plants, Antibacterial activity, Ethanolic extracts, Water extracts, Chicken, S. aureus, E. coli
Antibacterial Activity of Selected Medicinal Plants used to Prevent and treat Infections in Humans and Animals in Uganda.

( 2004) Bbosa, Godfrey S.

The study screened for the Antibacterial activity of Capsicum Frutescens, Carica Papaya, Erythrina abyssinica, Eucalyptus globulus and Mangifera indica selected mediinal plants used to treat and prevent infections in Humans and Animals. The medicinal plants were collected from Botanical gardens and others from Wakiso District. The dry powders of the medicinal plants were extracted succesively with ether, ethanol and water (Aqueous). The resultant dry extracts were subjected to qualitative chemical tests, antibacterial activity tests and serial dilutions to obtain the minimum Inhibitory concentration(MIC) for those tested active. Mangifera Indica, Eucalyptus globulus and carica papaya were active against all the test Bacterial organisms (Styphylococcus aureus, Esherichia coli and Pseudomonas aeruginosa) while Erythrina abyssinica and capsicum frutescens didnot shw any activity.
Antibacterial activity of the root extracts of draceana laxissima and draceana fragrans on selected urinary tract pathogens

(Makerere University, 2012-01) Wotoyitide, Tonny Lukwago

Introduction: Over 150 million people are diagnosed with urinary tract infections (UTI) each year. The prevalence rate for UTIs in the Ugandan population was estimated to be at 1 in 33 or 3.03%. The main causal organisms of UTIs in Uganda are Escherichia coli, Pseudomonas aeruginosa, Staphylococcus aureus, Proteus mirabilis. The emerging resistance of the above organisms to commonly used medicines like quinolones and penicillin’s has forced scientists to look for newer antibacterial agents. Extracts from Dracaena species have been used worldwide for many generations in the management of such infections. So these plant could be a possible alternative in the management of urinary tract infections. Objective: To investigate the antibacterial activity of the root extracts of Draceana Laxissima and Draceana Fragrans on selected urinary tract pathogens. Methods: In this study, Plant materials were collected and cleaned according to the standard plant collection procedures. Extraction was by cold maceration and concentration was either by rotary evaporator or freeze drying. The phytochemical screening was carried out using standard methods. Nathans Agar well diffusion method was used for sensitivity test. The toxicity of the Dracaena species was also determined using standard methods Results: The Phytochemical screening of the roots of the selected plants shows that the plants contain alkaloids, tannins and saponins. Both the methanol and water extracts of Dracaena laxissima and Dracaena fragrans showed no antibacterial activity against all the three test organisms’ i.e. S. aureus, E. coli and P. aeruginosa. No zones of inhibition were identified. The acute toxicity (LD50) of both plants was estimated to be above 16,000mg/kg suggesting that the extract was very safe since its LD50 value was more than 1000mg/kg . Conclusions: The results of this study demonstrated that the methanolic and water extracts of the roots of Dracaena laxissima and Dracaena fragrans have no antibacterial effect against E. coli, S. aureus and P. aeruginosa.
Antibacterial activity, safety and chemical composition of crude extracts of selected wild edible Marasmius species of Mushroom from central Uganda (a nested study)

(Makerere University, 2022-11) Kabajurizi, Teddy

Background: Mushrooms are evenly distributed worldwide and are mainly used for food, medicine and for commercial purposes. But few of the species have been investigated for medicinal potential, safety and chemical compounds present. Similarly, mushroom in the genus Marasmius have reportedly been used in treatment of ailments such as boils, wounds, cough, sore throat and GIT disorders like diarrhoea by the Ugandan local population but limited studies have been done to identify their antibacterial activity, safety and the chemical compounds profile. Aim: The study was aimed at determining the antibacterial activity, safety and chemical compounds present in the Marasmius spp mushroom extracts. Methods: Experimental laboratory-based study was carried out. Determination of the antibacterial activity; sensitivity test (zones of inhibition) was determined by agar well diffusion technique, followed by determination of MIC and MBC of the two selected species of Marasmius mushroom extracts on different species of bacteria including E. coli, P.aeruginosa and S.aureus. Safety studies including acute toxicity was determined using a procedure proposed by Ghosh (2019), on Swiss albino mice whereas Sub-acute toxicity was done using a procedure by OECD 407 guidelines on Wistar albino rats together with haematological and biochemical blood and the histopathological studies on the liver and kidney. To determine the compounds present, a qualitative chemical analysis of the extracts was also done. The experimental data was summarised in tables and analysed employing ANOVA and the t-test statistical techniques in STATA statistical package version 13. Results: The total crude extract (i.e., combined methanol, diethyl-ether, and aqueous) of Marasmius sp1 (i.e., Omutundugo omweru) (Luganda) was sensitive against all three organisms namely E. coli, P.aeruginosa and S.aureus. While the aqueous extract of Marasmius sp1, aqueous and total crude extracts of Marasmius sp2 (i.e., Omutundugo omumyufu) (Luganda) were only sensitive against S. aureus. However, all extracts were less sensitive than the control. Total crude extract of Marasmius spp1 had a Minimum Inhibitory Concentration (MIC) of 125mg/mL on S.aureus, 125mg/mL on P. aeruginosa and 250mg/mL on E.coli. The aqueous extract of Marasmius sp1, and the aqueous extract and total crude extract of Marasmius sp2 had MIC of 250mg/mL, 250mg/mL and 250mg/mL respectively on S.aureus. The Minimum Bactericidal Concentration (MBC) of both aqueous extracts of Marasmius sp2 and Marasmius sp1, and total crude extracts of Marasmius sp2 Marasmius sp1 on S.aureus was 500mg/mL, 500mg/mL, 500mg/mL and 250mg/ml respectively. MBC of total crude extract of Marasmius sp1 on P. aeruginosa was 250mg/ml whereas that of Marasmius sp1 on E. coli was 500mg/ml. In acute toxicity study; no death of animals occurred in 24 hours following dosing of the extracts. In sub acute toxicity study; haematology parameters generally reduced on day 7 and 14 but increased through day 21 and 28 but all remained in the normal range for both of the groups that received extracts and the control. Blood chemistry parameters generally increased throughout the study for both the treatment groups and the control but all remained in the normal ranges. For histopathology studies; both the liver and the kidney from animals had no significant lesions detected. Chemical compounds including alkaloids, flavonoids, reducing sugars, non-reducing sugars and saponins were found in the extracts. Conclusion: The two species of Marasmius mushrooms (i.e., Marasmius sp1, and Marasmius sp2) showed antibacterial activity and were non-toxic in Swiss albino mice. No adverse effects on haematological and blood chemistry were registered and no significant lesions were found in the liver and kidney of animals that received treatment. Chemical compounds including alkaloids, flavonoids, reducing sugars, non-reducing sugars and saponins were present in the mushrooms extracts which might be responsible for their antibacterial and other ethno-botanical uses by the local communities near Mpanga forest.
Antimalarial drug levels in biological samples: methods and applications.

( 2008-09) Ntale, Muhammad

This thesis deals with the development and validation of analytical methods that are field-adapted and their application in the determination of antimalarial drug levels in biological samples. These methods are suitable in countries where resources are limited. Usually studies about malaria are done in remote areas where access to basic facilities such as power is limited. Under such circumstances, methods which required refrigeration of samples cannot be applied. High performance liquid chromatographic methods have been applied for the quantitative determination of the drugs and their metabolites which has enabled most of the methods used/ developed to be sensitive and specific with low limits of detection. The determination of antimalarial drugs in biological samples from Ugandan healthy volunteers and patients is discussed. Attention has been drawn to some antimalatial drugs (Chloroquine, sulfadoxine and pyrimethamine amodiaquine and lumefantrine) that are used for the treatment of malaria in Uganda. Earlier published analytical methods have been optimised and used to determine the drug levels in plasma obtained from healthy volunteers. The results have been used to assess the bioavailability of chloroquine, sulfadoxine and pyrimethamine in a locally manufactured fixed-dose formulation (HOMAPAK). The efficacy and safety as well as aspects of their pharmacokinetics have been discussed. Field adapted analytical methods for determining therapeutic levels of amodiaquine, lumefantrine and their metabolites from whole blood, dried on filter papers have been developed and validated. Both amodiaquinine and lumefantrine had previously been reported to be very unstable on filter paper and rapidly degraded at room temperature. The field-adapted methods came into mind after the national antimalarial drug policy was changed from SP/CQ to coartem, a co-formulation of artemether and lumefantric. Amodiaquine plus artesunate is the alternative first line treatment for uncomplicated malaria in Uganda. Lastly, The method developed for quantification of amodiaquine and its metabolite, DAQ has been applied in the field to explore the practical applicability of the sampling procedure and its sensitivity. Blood collected from pediatric malaria patients on treatment form amodiaquine plus artesunate (AQ=AS) has been analysed for drug levels. A discussion of parasite clearance in relation to the attained drug levels has been given. In conclusion, new fielded adapted methods suitable for use in malaria endemic and resource poor countries have been developed. The methods will serve as a useful tool for future population based studies involving the use of amodiaquine and lumefantrine.
Antimicrobial self medication in post conflict northern Uganda: Implications on chloroquine and artemisinin genotypic resistance in the community

(Makerere University, 2016-04) Ochan, Moses

Background: Antimicrobial self-medication is a common medical action practiced globally. Its use though associated with risks, provides hope of improved access to healthcare for communities especially in resource limited settings who face challenges of inadequate healthcare systems. This therefore, poses a dilemma to the regulators of healthcare systems especially in developing countries who have to ensure that the risks due to antimicrobial self-medication are minimized. Aim: To explore the prevalence of antimicrobial self-medication in post conflict northern Uganda and its implication on chloroquine and artemisinin genotypic resistance in the communities. Method: This was a cross sectional study and was sub-divided into four sub-studies. In sub-study one we performed a systematic review of antimicrobial self-medication in low and middle income countries. In the review we observed the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) guidelines and the protocol was registered in International Prospective Register of Systematic Reviews (PROSPERO). In sub-study two we performed a household antimicrobial self-medication survey in northern Uganda. The households were randomly selected using multi-cluster sampling method. One individual in each household who had experienced illness in the three months prior to data collection was interviewed using an interviewer administered questionnaire. In sub-study three, patients reporting to outpatient departments (OPD) of Lira and Gulu regional referral hospitals were randomly recruited using systematic sampling. Data was collected using interviewer administered questionnaires and urine antibacterial activity bioassay performed. In sub-study four, patients reporting to outpatient departments (OPD) of Lira and Gulu regional referral hospitals with symptoms of malaria (fever) were recruited into the study. Malaria screening was done using rapid diagnostic test (HRP-2) and microscopy. For patients with Plasmodium falciparum, capillary blood from finger prick was collected on filter paper, parasite DNA was extracted using chelix-resin method. The parasite DNA was analyzed using restriction fragment length polymorphism (RFLP) and sequencing to establish presence of Pfcrt K76T, Pfmdr-1 and K13-gene polymorphisms respectively. All the results were analyzed using STATA 12.0 at 95% level of significance. xv Results: From the review, the prevalence of antimicrobial self-medication in low and middle income countries was 38.8% (Article I). However, in the communities of northern Uganda, the prevalence of antimicrobial self-medication was 75.7% (Article II). A third of the households (34.6%) in northern Uganda store antimicrobial agents (Article III). Among the patients who presented to hospitals in northern Uganda, 30.4% had used antibacterial agents for the same symptoms before coming to the hospital (Article IV). The most common antimicrobial agents used without a prescription in northern Uganda include coartem, amoxicillin, cotrimoxazole, metronidazole, and ciprofloxacin. Individuals who practice antimicrobial self-medication obtain drug related information on the medicines used from past experiences, old prescriptions, friends/relatives, health professionals, and drug leaflets. The common source of antimicrobial agents used in self-medication include drug shops/pharmacies, hospitals, and leftover agents. The predictors of antimicrobial self-medication in northern Uganda include gender (female), drug knowledge, reading drug leaflets, advice from friends, previous experience, long waiting time in the hospitals, and distance to the health facility. Over half (54.4%: 116/213) of the Plasmodium falciparum DNA samples analyzed had mutant (chloroquine resistant) genotype Pfcrt K76T. Majority, 97% (164/169) of the Plasmodium falciparum DNA samples carry wild type 86N genotype of Pfmdr-1 gene. Two non-synonymous mutations at codon 522 and 533 of the K13-propeller gene (artemisinin resistant) were detected in the samples analyzed. The study also found one synonymous mutation at codon 509 of the K13-propeller domain. Conclusion and recommendation The prevalence of antimicrobial self-medication in northern Uganda is about twice that found in other developing countries. Over a third of out-patients presenting to hospitals in northern Uganda have used antibacterial agents for the same illness prior to hospital visit. Chloroquine sensitive strains of Plasmodium falciparum parasites are re-emerging in northern Uganda at a slow rate than that seen in other sub-Saharan countries. Non-synonymous mutation in K13-gene (codon 533) for artemisinin resistance previously reported in Cambodia is present in northern Uganda. Validation and surveillance for artemisinin resistance gene markers should be considered. Enforcement of regulations on OTC access of antimicrobial agents should be considered in addition to education intervention involving both community members and healthcare professionals.
Antimicrobial susceptibility of 3rd generation Cephalosporins-resistant escherichia coli, Klebsiella pneumoniae and Enterobacter spp isolates carried in the gut of patients on admission to Mulago Hospital

(Makerere University, 2019-11-11) Kiiza, Hillary

Background: Resistance to 3rd and 4th generation cephalosporin is on an increase worldwide. These cephalosporins are used in management of severe infections caused by Enterobacteriaceae. The main objective of the study was to determine the susceptibility of third generation cephalosporins-resistant Escherichia coli, Klebsiella pneumoniae and Enterobacter spp isolated from patients at Mulago Hospital. Methods: This was a cross-sectional study that looked at 80 Enterobacteriaceae Isolates, 42 Escherichia coli, 30 Klebsiella pneumoniae and 8 Enterobacter species that were isolated from rectal samples of patients on admission to Mulago Hospital. Antimicrobial susceptibility testing was done using amoxicillin/clavulanate, ampicillin/sulbactam, piperacillin/tazobactam, cefotaxime, ceftriaxone, ceftazidime, aztreonam, ertapenem, imipenem, meropenem, tigecycline, fosfomycin, trimethoprim-sulfamethoxazole, gentamicin, amikacin, nalidixic acid, nitrofurantoin, chloramphenicol, cefoxitin, ciprofloxacin, cefepime,ampicilin and tetracycline discs. The plates were incubated and interpreted according to CLSI guidelines after measuring the zone diameters. For Tigecycline the FDA guidelines were used. Agar dilution method for testing susceptibility of cefoperazone-sulbactam was used on three concentrations (16µg/ml, 32 µg/ml and 64 µg/ml) of cefoperazone/sulbactam dissolved in MHA. Phenotypic ESBL production was detected using the Double Disc Synergy Test. The modified inhibition carbapenamase test was used for detection of carbapenamase production. OXA gene variants were detected using PCR. The PCR products were then sequenced. Results: Results show that 77(96.2 %) were ESBL producers while 3 (3.8 %) were of non-ESBL phenotype. E.coli was the most isolated organism 42(52.5 %), followed by K.pneumoniae 30 (37.5 %) and Enterobacter spp 8(10%).E.coli had the highest percentage of ESBL producers 41(97.6%). Susceptibility was the highest 75(93.8%) to Meropenem and Ertapenem. There was no isolate recorded that produced AmpC and carbapenamase enzymes. 20% of the isolates were positive for OXA-1, 7.5% for OXA-10 and 6.25% for OXA-48. Conclusions: This study reveals a high resistance to drug-inhibitor combinations and cefepime among E. coli, K. pneumoniae and Enterobacter spp that are resistant to 3rd generation cephalosporins isolated from rectal samples of patients on admission to Mulago Hospital.
Antiphospholipid antibodies and recurrent pregnancy loss among women seen at Mulago hospital: A matched case control study

(Makerere University, 2015-10) Mutonyi, Sarah

Introduction: Recurrent pregnancy loss (RPL) is spontaneous loss of three or more consecutive pregnancies. One of the important causes of RPL is Antiphospholipid antibodies (APA). Recurrent abortions constituted 28.6% of patients seen with abortions at Mulago Hospital in the period November to December 2013. It is not known how much of the recurrent abortions are due to APA. The aim of this study was to establish the frequency of APA among women with RPL so as to guide on protocols for management/investigation of these patients. Objective: To determine whether women with RPL have higher frequency of positive APA levels compared to women who have normal pregnancies at Mulago Hospital. Methods: We conducted a matched case control study at Mulago Hospital. A total of 82 participants were enrolled. Cases (n= 41) were women with recurrent pregnancy loss while controls (n=41) were pregnant women with no history of pregnancy loss in the ratio of 1:1. Assays for the presence of Antiphospholipid antibodies were done using quantitative ELISA method on serum that was extracted from the collected blood samples. Antibody levels were measured for women who tested positive for Antiphospholipid antibodies. Frequencies and percentages were used to show proportion of women with positive APA among cases and controls. Categorical data was summarized using percentages while continuous data was summarized using means. Odds ratios were used to analyse the strength of the association between APA and RPL. Pearson Chi-square tests were used for categorical variables while Wilcoxon and Fishers exact tests were used for continuous variables that had outcomes measuring < 5 at bivariate analysis. P-values of < 0.05 were considered statistically significant, with the confidence interval set at 95%. Results: In this study, 9.8 % (4/41) of the cases and 2.4 % (1/41) of the controls were positive for APA. However, this difference was not statistically significant (p-value of 0.375). Positive APA levels were moderate to high titers in the RPL group while in the control group they were low. Conclusion: There was no significant difference in the frequency of APA between cases and controls. However, positive APA levels were seen to be higher among cases than controls.

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