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Mak’s Findings: Index Patients Diagnosed and Treated for COVID-19 in Uganda

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On Tuesday May 26, 2020, Makerere University (Mak) Management converged to share findings from the study whose aim of was “to detail characteristics and treatment outcomes of the Coronavirus (COVID 19) pandemic patients in Uganda”. Coronavirus being a novel and rapidly changing pandemic, it was essential that early lessons are obtained and synthesised.  These lessons directly feed into the clinical care guidelines and eventually contribute to the country’s interventions. With funding from the Government of Uganda through the Makerere University Research and Innovations Fund (Mak-RIF), this study was successfully executed.The multidisciplinary research team was coordinated through the Makerere University Lung Institute (MLI) http://mli.mak.ac.ug/. This study was led by Dr. Bruce Kirenga, Director MLI, and Prof. William Bazeyo, Acting Deputy Vice Chancellor (Finance and Administration)-Mak as Principal Investigators. Other investigators were from Entebbe Regional Referral Hospital, Johns Hopkins University, Baltimore, USA, Uganda Peoples Defence Forces, The AIDS Support Organisation (TASO), Mulago National Referral Hospital, the College of health Sciences and Ministry of Health, Uganda.

This study was conducted on the first group of COVID-19 patients (56) at Mulago National Referral hospital and Entebbe Regional Referral hospitals. Patient enrolment has continued but below we exultantly share preliminary findings.

·         Age: the average age of the patients in Uganda was 33 years which is far lower than has is reported elsewhere. In Wuhan China, for example, the average age is 59 while in the New York USA it is as higher (63 years). Older the patient have higher risk of severe forms of disease and ultimately the poorer treatment outcomes.

·         Patient Presentation: Among symptomatic COVID-19 patients, the most common symptoms were fever (21.4%), cough (19.6%), runny nose (16.1%), headache (12.5%), muscle aches (7.1%) and fatigue (7.1%). However, more than half of the patients did not have any of these symptoms at diagnosis. These patients were largely travellers returning from abroad or contacts of the confirmed/symptomatic patients above. Unlike our patients, 80% of hospitalised patients in the western world were symptomatic.

·         Laboratory and imaging tests: Coronavirus has been reported to affect almost all body tissues. To understand the extent of damage, our research team performed a wide range of tests including complete blood count, kidney function tests, troponin, lactate dehydrogenase which identifies for signs of damage to a wide range of body tissues, and C reactive protein-CRP. We found that 10.6% of the patients had low white blood cells, 26.3% had low platelets, and 12.8% had evidence of liver damage, while the kidneys had no evidence of damage. 12.2% had evidence of systemic inflammation and 43% had evidence of nonspecific tissue damage. The electrical heart activity was also checked with the electrocardiograph (ECG). All patients had normal ECG with the exception of one who had a very slow heart (bradycardia). We checked lung damage with Chest X-rays (CXR) and computed Tomography scans (CT). Three patients had significant lung damage on CT and CXR; while one of them had low oxygen saturation.

·         Comorbidity: About 25% of the initial patients (56) reported having other medical conditions in addition to COVID-19. Most of the conditions reported were the non-communicable diseases such as hypertension and diabetes which accounted for 11%. High blood pressure (higher than 140/90mmHg) was the most common comorbid disease recorded in up to 28% of the patients.

·         Disease severity: At admission, only 2 patients met the classification of severe disease (patients with severe respiratory symptoms requiring oxygen therapy) while the rest had mild disease. Temperature and oxygen saturation were monitored three times a day. All the patients recovered without the need for admission to Intensive care unit (ICU) or ventilation. This is contrary to what has been observed elsewhere, where 5% of COVD-19 patients required ICU care.

·         Treatment: To-date, there is no known cure for COVID-19. The current treatments are meant to alleviate symptoms while waiting for the body to mount an immune response to fight off the infection. The patients were able to recover on supportive care through managing the symptoms, treatment with antibiotics for those who had evidence of bacterial infection, hydroxychloroquine and vitamin C. In instances where the patients had comorbid conditions, proper management of these conditions was part of the treatment.

Conclusion: The initial group of COVID-19 patients diagnosed in the country presented with mild disease and exhibited a clinical course of disease that is quite different from what has been observed elsewhere. Imaging and laboratory tests are critical in management of this disease. Prompt identification of patients and initiation of treatment could help to prevent the development of severe forms of the disease. Frequent monitoring of the oxygen saturation is also critical for rapid patient identification and treatment. In light of the increasing number of cases in the country, these findings help in informing the national preparedness plan for COVID-19 (capacity building of health workers in clinical care for COVID-19, the required logistics, continuous research).

Recommendations

1.      Expand testing for COVID-19 in view of the finding that almost half of those confirmed did not have the classical symptoms for COVID 19. Add rhinorrhoea to symptoms for case screening.  

2.      Efforts should be taken to make clinical, laboratory and imaging tests available at all COVID-19 treatment centres to support proper grading of disease severity. At a minimum, pulse oximetry should be routine in management of COVID patients.

3.      Capacity to diagnose and treat non communicable comorbid conditions should be built across the country as part of COVID 19 response. Equipment for proper diagnosis of these diseases should be secured, installed and effectively used.

4.      Strengthen monitoring, evaluation and learning as part COVID-19 care. This will allow continued learning of COVID-19 in general and the effectiveness of the different treatments of the disease.

5.      Research should be supported including biomedical sciences research. This will allow growth of locally generated evidence to support the country’s COVID 19 response.

Acknowledgement

·         The Government of the Republic of Uganda, Makerere University Research and Innovations Fund (Mak-RIF), Ministry of Health, Uganda, Uganda Virus Research Institute, Mulago National Referral Hospital, Entebbe Regional Referral Hospital.   

·         The study participants, all health workers engaged and Makerere University leadership.

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Researchers call for interventions to support HIV/AIDS prevention among University Students

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Group photo of Study team and Participants at the Dissemination meeting.

Researchers at Makerere University College of Health Sciences have given recommendations on how the education and health sectors can support HIV/AIDS prevention among students.

The researchers advised that the health sector should develop communication strategies and materials specific to university students and increase support to provide youth-friendly HIV prevention services at universities. The education sector working with University management should include: life skill programs during orientation of new students; HIVST delivery through peers and freshman orientations; Increase sensitization & access to PEP/PrEP by high-risk students; and update and disseminate institutional HIV policies.

The recommendations were made at a dissemination meeting for a study titled ‘HIV risk and factors associated with use of novel prevention interventions among female students at Makerere Universityheld on the 30th September 2022 at the Food Science & Technology Hall, Makerere University Campus.The study funded by Government of Uganda through the Makerere University Research & Innovations Fund (MakRIF) was conducted by Dr. Lorraine Oriokot (Principal Investigator), Dr. Ivan Segawa, Dr. Sabrina Bakeera-Kitaka, Dr. Andrew Mujugira and Ms. Sharon Okello.

The objectives of the study were: to know the percentage of female students at risk of HIV; and to know the characteristics of students that have used the newer HIV prevention methods, which are HIV self-testing; Pre-exposure prophylaxis; and Post-exposure prophylaxis.

A total of 534 female students with an average age of 22years completed the survey. The results and findings of the study were:

  • Behavioural characteristics (12% of the respondents were in multiple sexual relationships; 21% of the respondents had a partner ≥ 10 years from their age; 29% of the respondents used emergency contraceptive (in the past 6 months); 21% of the respondents had never tested for HIV; and 10% of the respondents believed that they were at high risk for HIV)
  • The study considered a person was high risk if they: Had a partner who was HIV positive; Had multiple sexual relationships, anal or transactional sex; Used drugs especially injectable drugs; Had 2 or more sexually transmitted episodes in one year; Were pregnant or breast feeding; Were or had partners who sex workers, fishermen, long-distance truck driver, boda-boda rider, or army officers
  • Overall, 21% students were deemed high risk for HIV; 19% of students had ever used HIV self-test kits; 64% had ever heard of oral HIVST; 93% were willing to use HIVST; HIVST was more likely to be used by older students; HIVST can bridge the HIV testing gaps among students
  • 80% had ever tested for HIV far below the global targets of 95%; Self-test kits are freely available at the University Hospital; Test kits can be purchased over-the-counter in pharmacies
  • For PEP it was found that:3% of students had ever used PEP; 9% among those eligible for PEP; 70% had ever heard of PEP; 65% were willing to use PEP; PEP use was linked to having a partner and high-self risk perception; PEP is currently the only way to reduce the risk of HIV infection in an individual who has been exposed to HIV; PEP is available at Makerere University Hospital at no cost
  • For PreP it was found that:1% of students had ever used PrEP; 2% among high-risk students; 45% had ever heard of PrEP; 52% were willing to use PrEP; PrEP has been linked with decreased new infections of HIV; PreP is currently available as oral tablets. Vaginal rings and injectable forms are being tested for wide roll out; and PrEP is available at KCCA health facilities and facilities offering HIV care.

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Research findings show that Iron levels of blood donors in Uganda are low

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Members of the research team at the dissemination on 15th November 2022.

Makerere University researchers have released research findings showing that some blood donors in Uganda have low iron levels,low iron stores are common in blood donors, and that the donors who are deferred for low blood levels have limited insight into their situation. The findings were presented at a research dissemination workshop held on the 15th November 2022 at Makerere University College of Health Sciences.

In his remarks, Dr. Aggrey Dhabangi, Principal Investigator (PI) of the study explained that lack of iron may result in anaemia, which in turn makes blood donors ineligible to donate. ‘Other complications arising from low iron include, fatigue, low energy, and depression’, he added.

Statistics show that Uganda collects about 300,000 blood donations per year which is below the WHO recommended target of one donation per 100 population per year. As such, more donations are needed to increase blood supply. However, 10% of potential donors are turned away (deferred), 25% of these are due to low blood levels (anaemia); these missed donations may further exacerbate blood shortages in the country. Thresholds for eligibility to donate are 12.5g/dL and 13.5 g/dL for women and men respectively.

A total of 500 donors were involved in the cross-sectional study conducted within the central region blood collection sites of the Uganda Blood Transfusion Services (UBTS). The key findings of the study included:

  • The results showed that, of all potential donors screened to donate, 20.6 % had low iron stores. Among donors with blood levels acceptable to donate, 11.5% had low iron stores, while among those already turned away from donating for low blood levels, 61.5% also had had low iron.
  • The prevalence of low iron stores was higher among females (33.0%) compared to males (2.5%), but even higher among younger females i.e., 24 years and below (35.4%).
  • Further analysis revealed that, NOT eating an“iron-rich” diet was a major factor linked to low storesamong blood donors.
  • Interviews with donors turned away from donating for low blood levels revealed that many did not receive sufficient explanations as to why they were turned away, and what they were told was sometimes confusing to them.
  • Although the majority were surprised to be found with low blood levels and seemed frustrated for being turned away; deferral for low blood levels was generally poorly understood. Some interpreted it to mean, they had just ‘enough blood for themselves, but not enough to donate’. Others took the issue very lightly, yet their iron measurements have shown that 61.5% of these individuals besides being low on blood, they also had low iron.

The researchers gave the following recommendations:

  • Dietary (Iron-rich diet):Action – The population should be encouraged to adopt healthy eating lifestyle/diet which is iron-rich.Foods like leafy greens (bbugga, dodo, nakati), liver, beef, beans among others should be included in diets.
  • Behavioural change communicationon nutrition should be instituted to get the populations to change their diets and eating habits.
  • Consider Iron supplements for the population to repleteiron stores. The UBTS/Ministry of Health can offer iron pills to the affected donors. In the past this was done.
  • Identify donors at risk of Iron Deficiency through screening to identify affected persons early enough for interventions.
  • Improved communication is necessary for better handling of blood donors; the capacity of UBTS staff should be built; produce IEC materials for deferred donors: anaemia treatment, and prevention
  • Referral – to physicians for work-up and further management of anaemia

This study was made possible through collaboration between Makerere University College of Health Sciences and Uganda Blood Transfusion Services. Funding support was provided by the Government of the Republic of Uganda, through the Makerere University Research and Innovations Fund (Mak-RIF) – Round 3, financial year 2021/22.

Research Team: Dr. Aggrey Dhabangi (Principal Investigator (PI) and Co-PIs Dr. Godfrey Siu, Dr. Ronald Ssenyonga, Dr. Susan Acan, Mrs. Dorothy Kyeyune, and Dr. Imelda Bates.

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METS Newsletter October 2022

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Mabel from METS takes Biostatisticians through eCBSS during the DHIS2 training. Photo: MakSPH METS.

The Monitoring and Evaluation Technical Support (METS) Program is a 5-year CDC-supported collaboration of Makerere University School of Public Health (MakSPH), the University of California San Francisco (UCSF) and Health Information Systems Program (HISP Uganda).

Highlights of the METS August 2022 Newsletter

  • Advancing health information security, privacy and confidentially
    • With support from the Makerere University School of Public Health (MakSPH) – METS Program and other partners, the MoH has developed the national Health Information Exchange (HIE) and Interoperability guidelines that will guide the implementation of HIE initiatives within the health sector.
  • Inaugural HIV Recency Testing Data Quality Assessment
    • The inaugural HIV Recency Testing Data Quality Assessment (DQA) was conducted from 28th August – 10th September 2022, with an aim of designing interventions for improving data quality for public health action.
    • The DQA was carried out in a representative sample of 170 facilities geographically distributed across the country by 15 teams of members from MoH, METS, UCSF, implementing partners (IPs) and districts health teams.
  • Case Based Surveillance Learning Exchange in Kenya
    • The main objective of the learning visit was to benchmark the Kenyan CBS program with the aim of harnessing the implementation modalities, lessons learned, and best practices that will guide program improvements in Uganda.
    • The key lessons learnt for implementation of the CBS program in Uganda will require key steps including; strong leadership, coordination and involvement by MoH and partners, alignment of funding priorities with national needs; clear documentation of policies and guidelines; adoption of a unique identifier to manage de-duplication of patients across the health sector; strengthening communities of practice within the workforce capable of maintaining and extending the CBS implementation and development of a national data warehouse for surveillance.
  • Milestones in equipping health facilities to track commodities
    • UgandaEMR is an electronic medical records system that is currently in use in over 1,400 health facilities in Uganda. UgandaEMR currently supports the following service areas such as HIV, TB, MCH, Laboratory, SMC, and Cervical Cancer, among others. Since 2015, the MakSPH-METS program has been supporting the Ministry of Health in the design and development of UgandaEMR.
    • One of the latest modules added to UgandaEMR by MaKSPH-METS is the stock management and dispensing (SMD) module that supports the documentation of essential medical supplies distributed and/or received at health facilities from the national medical warehouses.

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