The Effect of COVID-19 Restrictions on General and HIV Positive Inpatient Admissions and Treatment Outcomes: An Uncontrolled Before-and-after Study at a Ugandan Tertiary Hospital

Measures to contain the Corona Virus Disease 2019 (COVID-19) pandemic curtailed access to prevention and treatment services for endemic infectious diseases like HIV. We used an uncontrolled before-and-after study design to compare general and HIV positive (HIV+) inpatient outcomes at a tertiary hospital in Uganda, using electronic records of medical inpatients. Data was downloaded, cleaned in Microsoft Excel, and exported to STATA for analysis. We determined the difference in number of admissions and median length of hospital stay using Mann-Whitney U test; and difference in median survival and incidence rates of mortality using Kaplan - Meier statistics, between the pre- and peri-COVID-19 groups. Of 7506 patients admitted to Kiruddu NRH, 50.8% (3812) were female and 18.7% (1,401) were aged 31-40 years, and 18.8% (1,411) were HIV+. Overall, 24.6% (1849) died. Total admissions were lower (2192 vs. 5314 patients), overall mortality rate higher (41.8% vs. 17.6%, p < 0.01), median length of hospital stay longer (6 vs. 4 days, p < 0.01) and median survival shorter (11 vs. 20 days, Chi-square = 252.05, p < 0.01) in the peri- than in pre-COVID-19 period. The adjusted hazard ratio (aHR) of death was 2.08 (95% CI: 1.85-2.23, p < 0.01) in the peri- compared to the pre-COVID-19 period. These differences were more pronounced in HIV + patients. Compared to pre-COVID-19, the peri-COVID-19 period registered lower inpatient admissions but poorer treatment outcomes for general and HIV + inpatients. Emerging epidemic responses should minimize disruption to inpatient care, especially for HIV + individuals.

Prevalence of gastrointestinal bleeding and frequency of selected predictors of mortality on the medical emergency ward at Mulago hospital

BACKGROUND

There was no data on the prevalence of Gastrointestinal bleeding (GI) among patients admitted on the emergency ward at Mulago hospital. This was partly because the medical records were not adequately completed as designed.

OBJECTIVE

To estimate the prevalence of gastrointestinal bleeding and the frequency of selected predictors of mortality on the emergency ward.

METHODS

This was a chart review incorporating quality improvement methods in the process of data collection. The health care team was educated on documentation of gastrointestinal bleeding while being assessed weekly for knowledge and practice of completion of the Casualty Assessment form (CAF) from which a documented diagnosis of GI bleeding and selected predictors of mortality were looked for.

RESULTS

Of the 1881 CAF assessed, 278 had a documented diagnosis of GI bleeding, resulting in a prevalence of 6.8%. Of the patients with GI bleeding, 14.1% had age greater than 60 years, 24.0% had a systolic blood pressure less than 100mmHg and 44.5% had a heart rate greater than 100 beats per minute.

CONCLUSION

The prevalence of GI bleeding on the medical emergency ward of Mulago hospital is high. This calls for strategies for resuscitative management of this life-threatening medical emergency. Among the selected predictors of mortality, tachycardia was most frequent followed by hypotension. These should always be assessed in a patient with GI bleeding and resuscitative measures with blood transfusion and intravenous fluids undertaken to correct them.

HIV, tuberculosis, diabetes mellitus and hypertension admissions and premature mortality among adults in Uganda from 2011 to 2019: is the tide turning?

BACKGROUND

The growing burden of diabetes mellitus (DM) and hypertension (HTN) on the background of endemic Human Immuno-deficiency Virus (HIV) and tuberculosis (TB) is a concern in low- and middle-income countries. We aimed to describe annual trends in admissions, mortality rates and premature mortality (years of potential life lost-YPLLs) due to HIV, tuberculosis (TB), diabetes mellitus (DM) and hypertension (HTN) in Uganda.

METHODS

We conducted a retrospective cohort study, retrieving electronic records of adults admitted to Mulago and Kiruddu national referral hospitals medical wards between 1st January 2011 and 31st December 2019. We used STATA BE 17.0 and GraphPad Prism 8.0.2 to compute total admissions, inpatient crude mortality rates, and YPLLs; and demonstrate trends using Mann-Kendall test.

RESULTS

Of 108,357 admissions, 55,620 (51.3%) were female, 15,300 (14.1%) were recorded in 2012, and 22,997 (21.2%) were aged 21-30 years. HIV, TB, DM and HTN accounted for 26,021 (24.0%); 9537 (8.8%); 13,708 (12.7) and 13,252 (12.2%) of all admissions, respectively. Overall inpatient mortality was 16.7% (18,099/108,357), 53.5% (9674/18,099) were male, 21.5% (3898) were aged 31-40 years and 2597 (14.4%) were registered in 2013. HIV, TB, DM and HTN accounted for 35.6% (6444), 14.6% (2646), 9.1% (1648) and 11.8% (2142) of all deaths, respectively. Total admissions (Kendall's tau-B = - 0.833, p < 0.001) and deaths declined (Kendall's tau-B = - 0.611, p = 0.029). A total of 355,514 (mean = 20.8 years, SD 30.0) YPLLs were recorded, of which 54.6% (191,869) were in males; 36.2% (128,755) were among those aged 21-30 years and were recorded in 2012 (54,717; 15.4%). HIV, TB, DM and HTN accounted for 46.5% (165,352); 19.5% (69,347); 4.8% (16,991) and 4.5% (16,167) of YPLLs, respectively. Proportionate contribution of HIV to deaths and YPLLs declined, remained stagnant for TB; and increased for both DM and HTN.

CONCLUSION

TB and HIV account for higher though declining, while DM and HTN account for lower albeit rising morbidity and premature mortality among adult medical patients in Uganda. TB prevention and treatment; and DM/HTN service integration in HIV care should be optimized and scaled up.

Tetanus in Uganda: clinical outcomes of adult patients hospitalized at a tertiary health facility between 2011 and 2020

Background

Tetanus is a vaccine-preventable infectious disease associated with high mortality rates. Increased vaccination coverage globally and locally has resulted in substantial declines in the number of individuals diagnosed with tetanus. We report annual trends in tetanus admissions and deaths over a decade at a national referral hospital in Uganda.

Methods

This was a retrospective cohort study, using data from an electronic database of patients admitted to medical wards at a national referral hospital between 2011 and 2020. Data were abstracted on demographic characteristics, that is, length of hospital stay and mortality outcome. Admission and mortality rate trends were analyzed using the Mann-Kendall’s trend test, whereas Kaplan-Meier survival curves were used to compare gender survival rates.

Results

During the study period, 459 individuals were admitted with tetanus. Of these, 85.8% (394 of 459) were males, and 26.1% (120 of 459) were aged 20 years or less. Overall, 48.8% (224 of 459) participants died, 85.3% (191 of 224) of whom were males (85.3%, n = 191), although females had a higher mortality rate (50.8%, 33 of 65 vs 48.5%, 191 of 394). Those aged 31–40 years accounted for 23.7% (53 of 224) of the deaths; and 88.7% (197 of 224) of the deaths occurred within the first 7 days of admission. The total number of tetanus admissions declined (Tau_A = −.6444, P = .0116). However, mortality rates remained stable (Tau_A = .0222, P > .999). The average length of hospital stay was 8.1 days (standard deviation, 7.5; range, 1–46).

Conclusions

Although tetanus admissions declined, mortality rate remained high. Males were disproportionately affected. We recommend quality-of-care audits for inpatient care improvement and more research on the determinants of infection and mortality to inform vaccination for at-risk men.

Prevalence, short term outcome and factors associated with survival in patients suffering from upper gastrointestinal bleeding in a resource limited-setting, the case of Mulago hospital in Kampala, Uganda

BACKGROUND

Upper gastrointestinal bleeding (UGIB) is a common cause of admission and death in the gastroenterology service. The prevalence, risk factors and the case fatality rate of UGIB may differ by settings.

OBJECTIVES

Our objective was to determine the prevalence of symptoms and the case fatality rate of UGIB among patients at the gastroenterology service of Mulago Hospital in Kampala, Uganda and to describe the clinical and laboratory risk factors associated with the survival of these patients.

METHODS

In a cross-sectional study performed between September 2013 and April 2014, patients were screened for UGIB symptoms. Data was collected on socio-demographic characteristics, clinical presentation and patient's outcome within one week of admission. Bivariate, multivariate, and survival analysis were performed to identify variables that were significantly associated with mortality.

RESULTS

Out of 1085 patients screened, we identified the prevalence of UGIB symptoms in 220 patients (20.3%). Among these, 150 met the inclusion criteria for our study. The majority were males (70.7%) and 40 years of age or less (60%). The most prevalent clinical diagnosis were gastritis (39.3%), esophageal varices (17.3%) and peptic ulcer disease (PUD) (16%). Among patients who underwent endoscopy, esophageal varices (42.2%), PUD (26.3%) and gastritis (15.8%) were the leading causes of bleeding. The overall case fatality rate was 16.7% (25/150). Uremia remained associated with mortality after controlling for confounders.Survival was significantly reduced for males as well as for patients with uremia and malignancy.

CONCLUSION

the prevalence of symptoms and the case fatality rate of UGIB among patients admitted to the gastroenterology ward in Mulago hospital were higher than in developed countries and similar to other resource-limited setting. The majority of patients were young men and presented with both hematemesis and melena. The most common causes of UGIB were esophageal varices, gastritis and PUD. Survival analysis indicate that male gender, uremia, and malignancy are associated with reduced survival.

Trends of admissions and case fatality rates among medical in-patients at a tertiary hospital in Uganda; A four-year retrospective study

BACKGROUND

Sub-Saharan Africa suffers from a dual burden of infectious and non-communicable diseases. There is limited data on causes and trends of admission and death among patients on the medical wards. Understanding the major drivers of morbidity and mortality would help inform health systems improvements. We determined the causes and trends of admission and mortality among patients admitted to Mulago Hospital, Kampala, Uganda.

METHODS AND RESULTS

The medical record data base of patients admitted to Mulago Hospital adult medical wards from January 2011 to December 2014 were queried. A detailed history, physical examination and investigations were completed to confirm the diagnosis and identify comorbidities. Any histopathologic diagnoses were made by hematoxylin and eosin tissue staining. We identified the 10 commonest causes of hospitalization, and used Poisson regression to generate annual percentage change to describe the trends in causes of hospitalization. Survival was calculated from the date of admission to the date of death or date of discharge. Cox survival analysis was used to identify factors associate with in-hospital mortality. We used a statistical significance level of p<0.05. A total of 50,624 patients were hospitalized with a median age of 38 (range 13-122) years and 51.7% females. Majority of patients (72%) had an NCD condition as the primary reason for admission. Specific leading causes of morbidity were HIV/AIDS in 30% patients, hypertension in 14%, tuberculosis (TB) in 12%), non-TB pneumonia in11%) and heart failure in 9.3%. There was decline in the proportion of hospitalization due to malaria, TB and pneumonia with an annual percentage change (apc) of -20% to -6% (all p<0.03) with an increase in proportions of admissions due to chronic kidney disease, hypertension, stroke and cancer, with apc 13.4% to 24%(p<0.001). Overall, 8,637(17.1%) died during hospitalization with the highest case fatality rates from non-TB pneumonia (28.8%), TB (27.1%), stroke (26.8%), cancer (26.1%) and HIV/AIDS (25%). HIV-status, age above 50yrs and being male were associated with increased risk of death among patients with infections.

CONCLUSION

Admissions and case fatality rates for both infectious and non-infectious diseases were high, with declining trends in infectious diseases and a rising trend in NCDs. Health care systems in sub-Saharan region need to prepare to deal with dual burden of disease.

The utility of the Helicobacter pylori stool antigen test in managing dyspepsia: an experience from a low resource setting

BACKGROUND

Dyspepsia is defined as a chronic or recurrent pain or discomfort centered in the upper abdomen. Endoscopy is the best strategy for confirming the cause of dyspepsia. Non- invasive strategies would be more appropriate in low resource countries where endoscopy is not readily available. However, there is concern that these strategies may miss serious disease like gastric cancer. One test that needs to be assessed in this regard is the Helicobacter pylori stool antigen test (HPSAT).

OBJECTIVE

To determine the validity of the stool antigen test in predicting H. pylori associated disease among patients with dyspepsia.

METHODS

In this prospective study patients with dyspepsia attending Mulago Hospital were recruited consecutively. Helicobacter pylori was determined using the Rapid Strip HpSA ®, endoscopy and gastric mucosal biopsy were done.

RESULTS

167 patients with dyspepsia were recruited into the study. There were ninety six (57.5%) females and seventy one (42.5%) males with an average age of 48.1(±18.1) years. Patients presenting with dyspepsia in Mulago hospital were more likely to come from the Central 60 (36%) and western tribes 55 (33%). The commonest endoscopic finding was oesophagitis 25 (15%). Peptic ulcer disease was found in 32 (19.2%) and 54 (32.3%) had normal endoscopy findings. H pylori was found in 33.5% and 32.5% using the HPSAT and histology respectively. The validity of the HPSAT in predicting H.pylori associated diseases was generally low with an overall sensitivity of 55.8%, and specificity of 74.2%. However, the validity was higher in predicting the diagnosis of peptic ulcer disease with a sensitivity 59.4% and specificity 72.6%.

CONCLUSION AND RECOMMENDATIONS

The HPSAT may be used in the test and treat strategy for young patients with dyspepsia without alarm signs and symptoms in low resource settings. However, because of its low validity in predicting H.pylori associated disease, it is important to follow up patients so that if symptoms persist or recur endoscopy is performed.

Religiosity for promotion of behaviors likely to reduce new HIV infections in Uganda: a study among Muslim youth in Wakiso District

The study was done to determine the association between religiosity and behaviors likely to reduce new HIV infections among 1,224 Muslim youth. Respondents with Sujda, the hyperpigmented spot on the forehead due to prostration during prayers, were more likely to abstain from sex, be faithful in marriage, and avoid alcohol and narcotics. Males wearing a Muslim cap were more likely to abstain from sex and avoid alcohol and narcotics. Females wearing the long dress (Hijab) were also more likely to avoid alcohol. This data should be used by stakeholders in promoting behaviors likely to reduce new HIV infections among Muslims.

Diagnosis of alcohol misuse and alcoholic liver disease among patients in the medical emergency admission service of a large urban hospital in Sub-Saharan Africa; a cross sectional study

Introduction

Uganda is among the top ten consumers of alcohol worldwide though there is little data on alcohol related liver disease. We describe alcohol use, alcohol misuse, and alcoholic liver disease among adults at the emergency admission service of a large urban hospital in Uganda.

Methods

All adults who consented were prospectively evaluated for alcohol use by inquiry and alcohol misuse by the “Cutting down, Annoyance, Guilt and Eye-opener- CAGE” questionnaire. Alcohol related hepatocellular liver injury was assessed using aspartate aminotransferase, and alanine aminotransferase levels. A combination of CAGE score ≥2 and De Ritis ratio ≥2 defined alcoholic liver disease (ALD). Human Immunodeficiency Virus (HIV), and viral hepatitis B and C serologies were evaluated in all the patients. Descriptive and inferential statistics were generated to answer our research questions.

Results

Three hundred and eighty individuals consented and participated in the study. Among these, 46.8% acknowledged use of alcohol while 21% and 10% met the study definition of alcoholic misuse and alcoholic liver disease respectively. Both alcohol misuse and alcoholic liver disease was significantly associated (p-value ≤ 0.05) with male gender, region of origin, number of life time sexual partners and serum albumin below 3.5 mg/dl after univariate and multivariate analysis.

Conclusion

Alcohol misuse and alcoholic liver disease is frequent in this medical emergency unit. Our study suggests a link between alcohol misuse or alcoholic liver disease and male gender, region of origin, number of sexual partners, and serum albumin below 3.5mg/dl.

Religiosity for HIV prevention in Uganda: a case study among Muslim youth in Wakiso district

BACKGROUND

Evidence for the association between religiosity and HIV infections is limited. Sujda, the hyper-pigmented spot on the forehead due to repeated prostration during prayers and fasting to worship, involving abstaining from food, drink and sex during daytime in Ramadhan and other specified days, are measures of religiosity among Muslims

OBJECTIVES

To assess the association between religiosity and HIV infections.

METHODS

This was an unmatched case-control study with 29 HIV positive cases and 116 HIV negative controls, from 1224 Muslims, 15-24 years.

RESULTS

Respondents without Sujda had more HIV infections (odds ratio 2.90, 95% CI 1.07-7.86, p=0.029). Those with Sujda were more likely to abstain from sex (odds ratio 1.69, 95% CI 1.31-2.20, p<0.001) and be faithful in marriage (odds ratio 1.69, 95% CI 1.11-2.57, p=0.012). Respondents without Sujda were more likely to have ever taken alcohol before sex (odds ratio 5.00, 95% CI 1.39-17.95, p=0.006) and to have ever used narcotics (odds ratio 2.12, 95% CI, 1.11-4.05, p=0.019). Respondents who fasted less, had more HIV infections (odds ratio 2.46, 95% CI 1.07-5.67, p=0.028).

CONCLUSION

Sujda and fasting were associated with lower HIV infections. Imams should use this information to intensify the Islamic approach to HIV prevention.

Evidence-based monitoring and evaluation of the faith-based approach to HIV prevention among Christian and Muslim youth in Wakiso district in Uganda

BACKGROUND

The Islamic Medical Association of Uganda, has been implementing the faith-based approach to HIV prevention without baseline data on expected positive outcomes.

OBJECTIVES

To establish evidence-based baseline data on expected positive outcomes of the faith-based approach to HIV prevention.

METHODS

A cross-sectional study of 15-24 year-old youths was analyzed for significant associations between HIV infections, risky behaviors, and religiosity

RESULTS

HIV prevalence was 3.6% among Christians and 2.4% among Muslims. Abstaining from sex among teenagers was at 54% for Christians and 58% for Muslims. Being faithful in marriage among males was at 41% for Christians and 34% for Muslims and among females it was 65% for Christians and 69% for Muslims. Praying privately was associated with lower HIV infections and was observed among 60% of Christians. Sujda, the hyperpigmented marker of regular prayers on the forehead of Muslims was associated with lower HIV infections and observed in 42% of them. Ever drank alcohol was associated with higher HIV prevalence and observed in 52% of Christians and 17% of Muslims. Male circumcision rates were 15% for Christians and 98% for Muslims.

CONCLUSION

A sero-behavioral-religiosity survey can provide evidence-based data for monitoring and evaluation of the faith-based approach to HIV prevention.

Religiosity for HIV prevention in Uganda: a case study among Christian youth in Wakiso district

BACKGROUND

Utilization of religious institutions is one of the strategies for HIV prevention in Uganda. There is limited data on the association between religiosity and HIV infection rates.

OBJECTIVE

To determine the association between religiosity and HIV prevalence rates among Christians.

METHODS

An unmatched case-control study was done. Data from 106 HIV positive cases and 424 HIV negative controls between 15- 24 years were analyzed.

RESULTS

Lower religiosity was associated with higher HIV infection rates when the following dimensions were analyzed: feeling guided by God in daily activities (odds ratio 1.90, 95%CI 1.03-3.50, p=0.035), feeling thankful for God's blessings (odds ratio 1.76, 95%CI 1.01-3.11, p=0.042), praying privately (odds ratio 2.02, 95%CI 1.30-3.11, p=0.001), trying hard to be patient in life (odds ratio1.74, 95%CI 1.07-2.84, p=0.024) and trying hard to love God (odds ratio 1.57, 95%CI 1.01-2.42, p=0.039). Higher HIV infection rates were associated with having multiple life-time sexual partners (odds ratio 5.37, 95%CI 1.86-15.47, p<0.001), ever drinking alcohol (odds ratio 2.28, 95%CI 1.43-3.65, p<0.001) and ever using narcotics for recreation (odds ratio 2.49, 95%CI 1.14-5.44, p=0.018).

CONCLUSION

Lower levels of several dimensions religiosity are significantly associated with higher HIV infection rates. This data supports strengthening religiosity in HIV prevention strategies.

Atypical presentation of colon adenocarcinoma: a case report

Introduction

Adenocarcinoma of the colon is the most common histopathological type of colorectal cancer. In Western Europe and the United States, it is the third most common type and accounts for 98% of cancers of the large intestine. In Uganda, as elsewhere in Africa, the majority of patients are elderly (at least 60 years old). However, more recently, it has been observed that younger patients (less than 40 years of age) are presenting with the disease. There is also an increase in its incidence and most patients present late, possibly because of the lack of a comprehensive national screening and preventive health-care program. We describe the clinicopathological features of colorectal carcinoma in the case of a young man in Kampala, Uganda.

Case presentation

A 27-year-old man from Kampala, Uganda, presented with gross abdominal distension, progressive loss of weight, and fever. He was initially screened for tuberculosis, hepatitis, and lymphoma, and human immunodeficiency virus/acquired immunodeficiency syndrome infection. After a battery of tests, a diagnosis of colorectal carcinoma was finally established with hematoxylin and eosin staining of a cell block made from the sediment of a liter of cytospun ascitic fluid, which showed atypical glands floating in abundant extracellular mucin, suggestive of adenocarcinoma. Ancillary tests with alcian blue/periodic acid Schiff and mucicarmine staining revealed that it was a mucinous adenocarcinoma. Immunohistochemistry showed strong positivity with CDX2, confirming that the origin of the tumor was the colon.

Conclusions

Colorectal carcinoma has been noted to occur with increasing frequency in young adults in Africa. Most patients have mucinous adenocarcinoma, present late, and have rapid disease progression and poor outcome. Therefore, colorectal malignancy should no longer be excluded from consideration only on the basis of a patient's age. A high index of suspicion is important in the diagnosis of colorectal malignancy in young African patients.

Hepatitis B virus and HIV infection among patients with primary hepatocellular carcinoma in Kampala, Uganda

BACKGROUND

Hepatitis B virus (HBV) is the commonest cause of primary hepatocellular (PHC) carcinoma worldwide. Co-infection with the HIV leads to more rapid progression of liver disease.

OBJECTIVES

We described prevalence of HBV and HIV among patients with PHC admitted to Mulago Hospital, Kampala, Uganda.

METHODS

We assessed all patients admitted to the gastrointestinal service of Mulago hospital with a diagnosis of PHC for HBV and HIV infection.

RESULTS

From March to June 2008, we recruited 15 patients. Nine (60%) were male; the overall median age was 32 years (IQR 15 -67), with median ages for male and female 33 and 36 years respectively. Alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase and AFP were all elevated with median values of 57.5 IU/L, 222 IU/L, 392 IU/L and 362 ng/ml respectively (IQR 14-145, 49-393, 165-1294 and 7-480). Eight (53%) patients were from North and Northeastern Uganda. The HBsAg was reactive in 13(87%) patients and HIV in 3(20%), all of whom were also co-infected with HBV.

CONCLUSION

There is high prevalence of HBV and HBV/HIV co-infection among patients with PHC in Uganda with high mortality. Reduction in incidence and mortality due to PHC in Uganda will require urgent large scale HBV vaccination.

Hepatotoxicity from first line antiretroviral therapy: an experience from a resource limited setting

BACKGROUND

Highly active antiretroviral therapy (HAART) has been associated with liver toxicity. The role of monitoring for liver toxicity has not been well studied in resource-limited settings (RLS).

OBJECTIVES

To determine the background prevalence and incidence of liver injury and describe the associated signs and symptoms of acute hepatitis after initiating HAART; and to determine the role of liver enzyme tests in monitoring hepatotoxicity.

METHODS

In this prospective study, in Mulago Hospital AIDS Clinics, we consecutively enrolled adult patients initiated on one of three first line HAART regimens [Stavudine (d4T)-Lamivudine (3TC) and nevirapine (NVP); Zidovudine (AZT)-3TC and Efavirenz (EFV) or d4T-3TC-EFV]. We monitored ALT (alanine aminotransferase) and clinical evidence of acute hepatitis at baseline, 2(nd), 6(th), 10(th) and 14(th) week of therapy.

RESULTS

Two hundred and forty HIV-positive HAART- naïve patients were enrolled in the study. The baseline prevalence of transaminitis was 1.7% with an incidence of 4.2% at 14 weeks. Grade 3-4 hepatotoxicity was documented in 1.3%. Jaundice was seen in grade 2-4 ALT elevations. Being on concurrent HAART and antituberculous drugs was associated with grade 2-4 toxicity compared to those who were only on HAART [OR; 16.0 (95% CI; 2.4-104.2)].

CONCLUSIONS

Incidence of severe hepatotoxicity within three months of first-line antiretroviral therapy was low, suggesting that routine measurement of transaminases may not be necessary in all patients initiating HAART in RLS. Routine measurement may be important in following patients on HAART and concurrent TB treatment as well as those with jaundice to avoid missing hepatotoxicity.

Validity of the rapid strip assay test for detecting HBsAg in patients admitted to hospital in Uganda

Commercially available rapid strip assays (RSAs) for hepatitis B surface antigen (HBsAg) are used for most routine clinical testing in sub-Saharan Africa. This study evaluated the validity of RSA and a more sophisticated enzyme immunoassay (EIA) with confirmation by nucleic acid testing (NAT) in hospitalized patients in Uganda. Sera from 380 consecutive patients collected and tested for HBsAg and anti-HIV in Kampala, Uganda by RSA were sent frozen to Dallas for EIA including HBsAg, total anti-hepatitis B core, hepatitis B e antigen, and anti-HIV. NAT was performed on all HBsAg-positives and on a random sample of 102 patients that were HBsAg-negative by both assays. Overall, 31 (8%) were HBsAg positive by RSA while 50 (13%) were HBsAg-positive by EIA; 26 were concordant between the two assays. Of 55 HBsAg-positive patients, nearly all showed detectable serum hepatitis B virus (HBV) DNA by bDNA (46) or PCR (4) assay. The 26 patients who were HBsAg positive by both EIA and RSA had significantly higher median serum HBV DNA levels than the 24 patients who were HBsAg positive by EIA alone. An additional 12/102 (12%) HBsAg negative patients had very low serum HBV DNA levels by NAT. Several differences in expected results of serologic testing were observed in this large series of African patients. RSA HBsAg testing is less sensitive than EIA; even EIA failed to detect all HBV DNA positive sera. A more complex testing protocol than RSA alone will be needed in Africa to improve patient care.

Poor performance of hepatitis C antibody tests in hospital patients in Uganda

Most hepatitis C testing in Uganda is performed using commercial rapid strip assays (RSA) to detect antibodies to hepatitis C virus (anti-HCV), rather than enzyme immunoassays (EIA). The prevalence of hepatitis C antibodies in a Ugandan hospital population was determined using both methods to test their accuracy using nucleic acid testing (NAT) as a reference. Sera from 380 consecutive hospitalized Ugandan patients were tested for anti-HCV using an RSA in Uganda, with subsequent automated third-generation EIA testing in the United States, followed by NAT. Recombinant immunoblot assays (RIBA) were used as a supplementary test to detect anti-HCV epitopes. Overall, anti-HCV was detected in 48/380 (13%) by one or both antibody tests. Anti-HCV was detected in 19 (5.0%) patients by RSA and in 33 (8.7%) patients by EIA; only four patients were anti-HCV positive by both methods. Fourteen of the 48 anti-HCV positive patients had detectable serum HCV RNA, 7 each by bDNA assay or by PCR. RSA detected only 7 of 14 HCV RNA positive sera. Of 29 RNA negative but anti-HCV positive patients tested by RIBA, only two were anti-HCV positive; 27 were anti-HCV negative or indeterminate. Anti-HCV testing by RSA and/or EIA was neither sensitive nor specific for detection of ongoing HCV infection in hospitalized Ugandan patients. Our findings underscore the importance of confirmatory nucleic acid testing, which, despite its increased cost, appears essential to manage African patients with HCV.

Screening for hepatitis C among HIV positive patients at Mulago hospital in Uganda

BACKGROUND

In industrialized countries with more resources, it is recommended that HIV infected patients should be screened for hepatitis C virus (HCV) on entry into the health care system. Implementation of these guidelines in a country like Uganda with limited resources requires some modification after taking into account the prevailing circumstances. These include the prevalence of HCV in HIV positive patients and the cost of HCV testing.

OBJECTIVE

The objective of the study was to estimate the prevalence of HCV in HIV positive patients.

METHODS

This was a cross sectional study among HIV positive outpatients in Mulago hospital. HCV screening was done using anti-HCV Enzyme Immuno Assay (Roche Diagnostics)

RESULTS

Between October 2003 and February 2004, one hundred and twenty two HIV positive patients were enrolled into the study with a mean age of 33.9 years. There were more females 81 (66.4%) than males. Only 4 patients had anti-HCV, giving an estimated HCV prevalence of 3.3%.

CONCLUSION

In view of the low HCV prevalence found in our study and similar studies and considering the high cost of HCV screening, routine HCV testing cannot be recommended among all HIV positive patients in our health care settings with limited resources. We recommend that HCV screening be limited to investigating HIV positive patients with features suggestive of liver disease in order to identify HCV as a possible cause.

Prevalence of hepatitis B virus (HBV) infection among Makerere University medical students

BACKGROUND

Medical students in the course of their clinical work are at risk of acquiring hepatitis B virus (HBV) infection or transmitting it to their patients. HBV immunization for medical students in Uganda is recommended but not strictly enforced. It is important to assess the prevalence of HBV infection in medical students in order to improve on the interventions to control this infection among them.

OBJECTIVES

The objective of the study was to assess the seroprevalence rates of HBsAg and anti-HBc among clinical and preclinical medical students.

METHODS

This was a cross-sectional study done over three months from November 2000 to January 2001 among Makerere University Medical students. A random sample of medical students was recruited from both the pre-clinical and clinical years. Blood samples from each participant were tested for HBsAg and anti-HBc.

RESULTS

The overall prevalence was 11.0% for HBsAg and 65.9% for anti HBc. Nine pre-clinical students (12.2%) were positive for HBsAg compared to 11 (10.2%) clinical students. This difference was not statistically significant. However, clinical students were more likely to have been exposed to HBV with 86 (79.6%) testing positive for anti-HBc compared to 34 (45.9%) among preclinical students (p-value <001). Risk factors associated HBV infection included having a sexual relationship, accidental needlestick injuries, and unprotected exposure to patients' body fluids.

CONCLUSION

Medical students need to be offered more sensitization and support regarding prevention of HBV infection including vaccination and the use of universal precautions for infection control.

Evaluation of the effectiveness of AIDS health education interventions in the Muslim community in Uganda

In 1992 the Islamic Medical Association of Uganda designed an AIDS prevention project and conducted a baseline survey prior to community level activities. Results of that baseline were previously reported in this journal. During 2 years of prevention activities in local Muslim communities, 23 trainers educated over 3,000 religious leaders and their assistants, who in turn educated their communities on AIDS during home visits and at religious gatherings. After 2 years, there was a significant increase in correct knowledge of HIV transmission, methods of preventing HIV infection and the risk associated with ablution of the dead and unsterile circumcision (p < 0.001). There was a significant reduction in self-reported sexual partners among the young respondents less than 45 years. In addition there was a significant increase in self-reported condom use among males in urban areas (p < 0.001). Collaboration between health professionals and religious leaders can be achieved and can contribute to the success of AIDS prevention efforts.

Who should be screened to reduce the endoscopy workload in Mulago Hospital?

A retrospective study of 330 patients who had been endoscoped in Mulago hospital was done. It was found that of these 119 (36.1%) were normal endoscopically. Normal endoscopy was significantly associated with patients presenting with dyspepsia. Dyspepsia was commoner in the age group 13-45 years compared to the age group 46-85 years. The older age group, 46-85 years, had a significantly higher prevalence of serious disease. It is concluded that it is the younger patients with dyspepsia who should be screened to reduce the endoscopy workload. Published guidelines should be used to assist in the screening process.

Planning and evaluating strategies for AIDS health education interventions in the Muslim community in Uganda

In 1992 the Islamic Medical Association of Uganda designed an AIDS prevention project. A baseline survey was conducted to assess prevailing knowledge, attitudes, and practices among the Muslim communities in two districts. A low rate of incorrect beliefs about HIV transmission was found, although gaps in knowledge remain, particularly regarding vertical transmission and asymptomatic HIV infection. Less than 10% knew that condoms can protect against HIV transmission. Lack of knowledge was documented regarding the risk of HIV transmission associated with practices common in the Islamic community, such as polygamous marriages, circumcision, and ablution of the dead. The AIDS prevention project has incorporated specific messages and interventions as a result of these findings.