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).
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.
· 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.
Etheldreda Nakimuli-Mpungu: Innovator in Mental Health
Etheldreda Nakimuli-Mpungu is a rising researcher and clinician doing innovative work in mental health and HIV in sub-Saharan Africa. She is a Senior Lecturer and psychiatric epidemiologist in the Department of Psychiatry at Makerere University College of Health Sciences (MakCHS) and head of the consultation–liaison psychiatric service at Mulago National Referral Hospital, Kampala, Uganda. Almost a decade ago, she recalls that “around that time, there were researchers who had resolved that Africans cannot comprehend psychotherapy; therefore, they gave persons living with HIV antidepressants as first-line treatment for mild-to-moderate depression in their research studies. In fact, there was an NIH funded grant in my department at the time that was evaluating the use of antidepressants for depression among people living with HIV. I said to myself, but this is not right because antidepressants are not the first-line treatment.” She “strongly believed that what we should be doing was to develop culturally appropriate psychotherapy for depression” in this population.
Nakimuli-Mpungu’s PhD had shown depression was fairly common among patients attending rural HIV clinics in Uganda and it affected their adherence to antiretroviral treatment. She successfully submitted a research proposal to Grand Challenges Canada and, together with her colleagues, teamed up with Edward Mills in Canada to develop and test in a pilot trial a culturally sensitive group support psychotherapy (GSP) for people with mild-to-moderate major depression and HIV. Nakimuli-Mpungu and colleagues went on to complete a cluster randomised trial to evaluate the model on a large scale, with trained lay health workers delivering the GSP. They showed that the effect of GSP on depression was sustained at 2 years, and treating depression resulted in improved adherence to antiretroviral medication. Nakimuli-Mpungu and colleagues are now seeking to replicate their work on GSP outside of Uganda. “That is the next step…If we have that evidence as well, then we’re at the stage of scaling up.” They are also adapting their model for young people aged 10–18 years and are creating an online platform to deliver psychotherapy because, she notes, the COVID-19 pandemic has created a need for digital health.
Mills, Professor at the Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada, comments: “Ethel is among the most important clinical researchers in Africa as she has the unique ability to ask important questions, get the clinical trials funded and conducted reliably, and personally analyses the data. Very few researchers anywhere can do all of this themselves.”
Her parents encouraged Nakimuli-Mpungu to pursue medicine. “Our parents really wanted us to get educated and become worthwhile citizens”, she says. “My earliest memory was that my mum used to say that girls become doctors”. Fortunately, Nakimuli-Mpungu found sciences interesting and excelled in them. She studied medicine at MakCHS, graduating in 1999. Her path to psychiatry and research came during a job as a medical officer at Butabika National Referral Mental Hospital in Kampala. She initially thought she would be working in the hospital’s general ward. But when she arrived, she was assigned to the female psychiatric ward and told to start seeing patients. “Almost immediately, I noticed there were really physically sick people on the psychiatric ward, and I had never seen this in my training. Very sick people: wasted, coughing, chronic diarrhoea. It didn’t take long to realise that these were patients with HIV.” But she could find little information on HIV and mental health in her psychiatric textbooks and searched online for research on HIV and mental disorders. “When I read those papers, immediately I said, I think this is the research I should also be doing, here in these patients who I’m seeing on a daily basis.” Butabika Hospital gave her a scholarship and she enrolled in the masters in psychiatry programme at MakCHS in 2003, graduating in 2006. Her research was a comparative study of primary mania versus secondary mania of HIV/AIDS. “It was, to my knowledge, the first time on the African continent that that kind of research was done”, she says. In 2007, she was awarded an International Fulbright Science and Technology Award for PhD studies and went on to complete her PhD in psychiatric epidemiology at Johns Hopkins University, Baltimore, MD, USA, in 2012.
Seggane Musisi, Professor of Psychiatry at MakCHS’s Department of Psychiatry, describes Nakimuli-Mpungu as “a bright and gifted scholar…She has impacted Ugandan and world psychiatry by working to improve access to care of stigmatised, marginalised, and hard to reach people with severe
mental illness in LMICs.” Nakimuli-Mpungu believes the mental health focus in Uganda needs to shift. “The problem in Uganda, maybe not only in Uganda, is that our focus is on the extreme end of the mental health spectrum, severe mental disorders…I feel that we should prioritise mental health. This requires creating awareness, education, and identifying the mild cases and then you step in at that stage…All health workers need to have at least the basic knowledge; they need to learn simple mental health screening to recognise depression. And when you identify a problem, immediately do something, give them an intervention. This does not call for specialised health workers because they’re not there. But we all have mental health, and our mental health needs to be taken care of. Otherwise, it makes our physical health worse, we can’t work, so we can’t develop our communities.”
IDI Supports Namboole CTU
Today, the U.S. Ambassador to Uganda, H.E. Natalie E. Brown visited the Namboole COVID-19 Treatment Unit (CTU) which was reactivated on 28th May 2021 to manage mild, moderate, and severe COVID-19 patients in order to de-congest Mulago and Entebbe CTUs.
With support from Centers for Disease Control and Prevention (CDC), the Infectious Diseases Institute (IDI) Makerere University has continued to provide technical, human resource, and logistical support to strengthen Infection Prevention and Control, Clinical Care, Emergency Medical Services and Psychosocial support.
The US Ambassador was joined by Dr. Mwebesa Henry, the Director-General Health Services, Ministry of Health, Dr. Ivan Kisuule, In-charge Namboole CTU, Dr. Jennifer Galbraith, Ag. CDC Country Director, Dr. Amy Boore, Program Director Division of Global Health Protection CDC, Dr. Andrew Kambugu, IDI Executive Director, Francis Kakooza, Deputy Head of Department IDI Global Health Security Program, and Judith Nanyondo Program manager CDC/IDI Strengthening Partnerships for Preparedness and Response in Uganda Project.
Africa Must Step Up! Reflections from WHS Regional Meeting 2021
The World Health Summit regional meeting in Kampala, Uganda (June 27-30), which was first slated to take place end of April 2020 has just been concluded. The reason for the postponement of the meeting in 2020 was, you guessed it, the COVID-19 pandemic. Unfortunately, one year later, the pandemic is still far from over, with the host country, Uganda currently hit by its second wave of COVID-19. The latest wave seems largely fueled by the (more infectious and deadly) Delta variant. The current peak of cases in Uganda is over 400% the one registered during the first wave in December 2020, and the country has been under a 42-day total lockdown since June 18. The summit thus required special permission to have a few delegates on site.
Against this backdrop, it was thus not surprising that the prominent message from the summit was the need for vaccine equity as many countries in the global south have so far been left behind in accessing the life-saving intervention. Just 1.1% of the African population have received COVID-19 vaccination, mostly through the COVAX facility. A stark comparison was made between the developed countries of which many are currently opening up, having ramped up vaccinations for their populations, while at the same time many countries especially in Africa are locking up (again) amidst a third COVID-19 wave that is sweeping the continent. “A pandemic fueled by inequity”, vaccine ‘nationalism’ and ‘apartheid’ were some of the terms being used. The WHO Director-General, Dr. Tedros Adhanom Ghebreyesus re-echoed the need for sharing vaccines now and investing in local production, stressing also that Africa needs to build its own capacity to manufacture COVID-19 and other vaccines.
Amidst the acknowledgement of the unfairness of the rich world in hoarding vaccines and neglecting Africa, a consensus emerged on the need for Africa to step up its capacity to deal with, and solve its problems. “Selfishness in the world is bad but also good to wake up Africans.” the Ugandan president, H.E Yoweri Kaguta Museveni, remarked at the opening of the summit. He continued “Africa should not depend on others for vaccines and essential commodities. We need to invest in Africa. Africa has fought Ebola; it can address its problems.”