R4D Uganda

Mortality after Fluid Bolus in African Children with Severe Infection.

Wed, 30 May 2012 05:23 GMT

Document Type: Journal Article

Production Year: 2011

Citation: Maitland, K.; Kiguli, S.; Opoka, R.O.; Engoru, C.; Olupot-Olupot, P.; Akech, S.O.; Nyeko, R.; Mtove, G.; Reyburn, H.; Lang, T.; Brent, B.; Evans, J.A.; Tibenderana, J.K.; Crawley, J.; Russell, E.C.; Levin, M.; Babiker, A.G.; Gibb, D.M.; Feast Trial Group. Mortality after Fluid Bolus in African Children with Severe Infection. New England Journal of Medicine (2011) 364 (26) 2483-2495. [DOI: 10.1056/NEJMoa1101549]

Summary:

BACKGROUND: The role of fluid resuscitation in the treatment of children with shock and life-threatening infections who live in resource-limited settings is not established.

METHODS: We randomly assigned children with severe febrile illness and impaired perfusion to receive boluses of 20 to 40 ml of 5% albumin solution (albumin-bolus group) or 0.9% saline solution (saline-bolus group) per kilogram of body weight or no bolus (control group) at the time of admission to a hospital in Uganda, Kenya, or Tanzania (stratum A); children with severe hypotension were randomly assigned to one of the bolus groups only (stratum B). All children received appropriate antimicrobial treatment, intravenous maintenance fluids, and supportive care, according to guidelines. Children with malnutrition or gastroenteritis were excluded. The primary end point was 48-hour mortality; secondary end points included pulmonary edema, increased intracranial pressure, and mortality or neurologic sequelae at 4 weeks.

RESULTS: The data and safety monitoring committee recommended halting recruitment after 3141 of the projected 3600 children in stratum A were enrolled. Malaria status (57% overall) and clinical severity were similar across groups. The 48-hour mortality was 10.6% (111 of 1050 children), 10.5% (110 of 1047 children), and 7.3% (76 of 1044 children) in the albumin-bolus, saline-bolus, and control groups, respectively (relative risk for saline bolus vs. control, 1.44; 95% confidence interval [CI], 1.09 to 1.90; P=0.01; relative risk for albumin bolus vs. saline bolus, 1.01; 95% CI, 0.78 to 1.29; P=0.96; and relative risk for any bolus vs. control, 1.45; 95% CI, 1.13 to 1.86; P=0.003). The 4-week mortality was 12.2%, 12.0%, and 8.7% in the three groups, respectively (P=0.004 for the comparison of bolus with control). Neurologic sequelae occurred in 2.2%, 1.9%, and 2.0% of the children in the respective groups (P=0.92), and pulmonary edema or increased intracranial pressure occurred in 2.6%, 2.2%, and 1.7% (P=0.17), respectively. In stratum B, 69% of the children (9 of 13) in the albumin-bolus group and 56% (9 of 16) in the saline-bolus group died (P=0.45). The results were consistent across centers and across subgroups according to the severity of shock and status with respect to malaria, coma, sepsis, acidosis, and severe anemia.

CONCLUSIONS: Fluid boluses significantly increased 48-hour mortality in critically ill children with impaired perfusion in these resource-limited settings in Africa.

This paper won the prestigious BMJ Research Paper of the Year award, May 2012.

Xanthomonas hortorum pathogenic on Artemisia annua newly reported in Uganda

Fri, 25 May 2012 02:10 GMT

Document Type: Journal Article

Production Year: 2009

Citation: Ssekiwoko, F.; Mulumba, J.W.; Carter, B.A.; Stanford, H.; Parkinson, N.; Kelly, P.; Smith, J.J. Xanthomonas hortorum pathogenic on Artemisia annua newly reported in Uganda. Plant Pathology (2009) 58 (4) 795-795. [DOI: 10.1111/j.1365-3059.2009.02072.x]

Summary: A disease of A. annua was observed in August 2007 in Kamuganguzi, near Kabale (south-west Uganda). Affected plants initially showed longitudinal water-soaked stem lesions characteristic of a bacterial infection, which turned into necrotic streaks that split open to expose the pith or in stem breaking. Leaves borne on affected parts wilted and died. Bacterial isolation from leaf material was undertaken on yeast extract peptone glucose agar. A shiny yellow convex, mucoid, bacterial colony dominated isolation plates after 48 h of incubation at 27°C. Fatty acid profiling (MIDI system) and sequencing of the Gyrase B gene revealed that the pathogen was most similar to X. hortorum (Midi ID score = 0.735; sequence similarity to X. hortorum type strain NCPPB939 = 96%). Pathogenicity on A. annua was confirmed. This is the first report of a X. hortorum strain pathogenic on Artemisia. A reference culture is held by the UK National Collection of Plant Pathogenic Bacteria, accession no. NCPPB 4435. The GenBank Accession No. for the gyrB sequence is EU815325.

First confirmed report of citrus black spot caused by Guignardia citricarpa on sweet oranges (Citrus sinensis) in Uganda

Thu, 24 May 2012 08:14 GMT

Document Type: Journal Article

Production Year: 2009

Citation: Reeder, R.; Kelly, P.L.; Harling, R. First confirmed report of citrus black spot caused by Guignardia citricarpa on sweet oranges (Citrus sinensis) in Uganda. Plant Pathology (2008) 58 (2) 399-399. [DOI: 10.1111/j.1365-3059.2008.01966.x]

Summary: In November 2006, orange fruits showing black spot symptoms were brought to the rural plant clinic at Katine market near Soroti, run by the local organization SOCADIDO. Small 4-5 mm lesions with light centres, surrounded by a darker red to purple rim were observed on the surface of the fruit. Within the lesions, numerous dark black fruiting bodies were seen, typical of Guignardia citricarpa infection. This fungus is a damaging pathogen on Citrus species and causes black spots on leaves and fruits. Fruit quality is affected by the disease and blemishes reduce the aesthetic value and saleability of the fruit. Observations on morphological and cultural characteristics confirmed the identity of the pathogen. This is the first confirmed record of G. citricarpa from Uganda.

Occurrence of ‘Candidatus Phytoplasma aurantifolia’ (16SrII group) in cassava and four other species in Uganda

Thu, 24 May 2012 07:51 GMT

Document Type: Journal Article

Production Year: 2009

Citation: Arocha, Y.; Echodu, R.; Talengera, D.; Muhangi, J.; Rockefeller, E.; Asher, O.; Nakacwa, R.; Serugga, R.; Gumisiriza, G.; Tripathi, J.; Kabuye, D.; Otipa, M.; Vutseme, K.; Lukanda, M.; Boa, E. Occurrence of ‘Candidatus Phytoplasma aurantifolia’ (16SrII group) in cassava and four other species in Uganda. Plant Pathology (2008) 58 (2) 390-390. [DOI: 10.1111/j.1365-3059.2008.01963.x]

Summary: Symptoms of leaf yellowing, chlorosis, shortening of internodes and slight stunting were recently observed in cassava fields in Kawanda, Uganda. Interestingly, some plants of four other species growing nearby, i.e. sticky mallow (Malvaviscus arboreus), croton (Codiaeum variegatum), Chinese hibiscus (Hibiscus rosa-sinensis) and passion fruit (Passiflora edulis), showed little leaf, chlorosis, and leaf yellowing and deformation. Molecular studies showed that the 16S rRNA sequences of phytoplasmas detected in cassava (EU315317) and M. arboreus (EU315318) showed 98% of identity with that of the cactus witches' broom phytoplasma (AJ293216), whilst sequences from C. variegatum (EU315315), H. rosa-sinensis (EU315314), and P. edulis (EU315319) exhibited 99% of identity with that of Catharantus roseus phytoplasma (EU096500). The phylogeny results suggest that two distinct sub-types have been identified in (i) cassava and M. arboreus and in (ii) C. variegatum, H. rosa-sinensis and P. edulis, in plants growing geographically close to each other. This is the first record of phytoplasma group 16SrII, 'Candidatus Phytoplasma aurantifolia', in Uganda.

Drought is a major yield loss factor for rainfed East African highland banana

Tue, 22 May 2012 04:31 GMT

Document Type: Journal Article

Production Year: 2011

Citation: van Asten, P.; Fermont, A.; Taulya, G. Drought is a major yield loss factor for rainfed East African highland banana. Agricultural Water Management (2011) 98 (4) 541-552. [DOI: 10.1016/j.agwat.2010.10.005]

Summary: Although drought stress has been identified among the production constraints of East African highland bananas (Musa spp., AAA-EA genome), no quantitative data were available to support this assumption. This study uses data from three on-station fertilizer trials (5–6 cycles) in Central and Southwest Uganda to quantify the effect of drought stress on banana production and explore possible interactions with nutrient availability. Production data were collected at individual plant basis from 1996 to 2002 in one trial and from 2004 to 2009 in two trials. Cumulative rainfall in the 12 months before harvest (CRF12) was computed per plant from daily rainfall measurements. Average bunch weight ranged from 8.0 to 21.9 kg between trials and cycles and was 8–28% less in dry (CRF12 ≤ 905 mm) than in normal (905 < CRF12 ≤ 1365 mm) rainfall periods. Linear relations were observed between CRF12 and maximum bunch weight over the whole range of observed CRF12 (500–1750 mm), whereby every 100 mm decline in rainfall caused maximum bunch weight losses of 1.5–3.1 kg or 8–10%. Optimum annual rainfall for East African highland bananas may thus be well above 1200–1300 mm yr−1 as suggested earlier. Relative drought-induced yield losses were independent of soil fertility. Absolute losses on fertile/fertilized soils were similar to those recorded in well fertilized irrigation studies in Latin America. Our study suggests that drought-induced yield losses in areas of the East African highlands with annual rainfall < 1100 mm are perhaps as high as 20–65% compared to the wetter areas in this region. To improve productivity of smallholder banana farmers in Africa, more attention should be given to research geared towards improved water/drought stress management.

A systematic review of the evidence of the impact of eliminating school user fees in low-income developing countries.

Fri, 18 May 2012 07:53 GMT

Document Type: Systematic Review
Creator: Morgan, C.; Petrosino, A.; Fronius, A.

Production Year: 2012

Citation: Morgan, C.; Petrosino, A.; Fronius, A. A systematic review of the evidence of the impact of eliminating school user fees in low-income developing countries. EPPI-Centre, Social Science Research Unit, Institute of Education, University of London, London, UK (2012) 116 pp. ISBN 978-1-907345-30-2

Summary:

A systematic review of studies of interventions in low-income developing countries that evaluated the elimination of school user fees paid by households – including the five fee categories identified by the World Bank (tuition, uniforms, textbooks, PTA contributions, other materials/activities) was conducted.

Through extensive literature searches and contact with experts in the field, five rigorous experimental and quasi-experimental evaluations were identified, as well as 31 quantitative and qualitative studies that did not meet the criteria for inclusion in effect size estimates but which were examined to map the extent, types and quality of the evidence base in the topic area and to shed light on possible theory, implementation and context issues. Given the small number of studies that met the inclusion criteria and the variation amongst the studies, the results are provided in a narrative fashion, rather than through meta-analysis. Each of the five included interventions took place in sub-Saharan Africa. Three evaluations took place in Kenya, one in Uganda and one in Malawi.

The findings of this systematic review highlight the need for more rigorous empirical research to investigate the effects of various types of school fees elimination policies in low-income developing nations – particularly on the effectiveness of targeting policies to the most vulnerable groups – accompanying trade offs in education quality, and the extent to which fees abolition policies can be sustained over time without undue donor dependency. Research in this area is complicated by the fact that many countries have already implemented universal free school tuition policies for all primary children, so an appropriate control group is difficult to identify and include in an evaluation. One possible solution to this challenge may involve utilising an interrupted time series design involving a single group. In addition, because UPE policies often do not eliminate all household contributions to schooling, additional impact evaluations of nongovernmental or government-supported programmes targeting fees elimination for specific groups can shed more light on the true costs of education for households and the degree to which eliminating these costs can improve schooling and other outcomes for the most vulnerable groups. Longitudinal studies are needed to elucidate the longer-term impacts of fees elimination, including whether initial surges in enrolment are sustained over time and what the policies mean for future educational attainment, employment and other outcomes.

Research to determine the full household costs of education (including opportunity costs for boys and girls) for different socio-economic groups is key, as well as determining how much of the full cost of education households are willing and able to bear, given an acceptable level of education quality. Experimentation with different innovations, such as user fees on a sliding scale based on household ability to pay would be informative and could be researched empirically. Studies such as these can provide valuable information to countries that are considering abolishing school fees and can inform strategies for advance planning and targeting of reforms, including planning for efficient allocation of resources at the local level.

Understanding the incremental cost of increasing access to maternal health care services: Perspectives from a Voucher Scheme in Eastern Uganda

Tue, 15 May 2012 03:30 GMT

Document Type: PowerPoint Presentation
Creator: Mayora, C.; Ekirapa-Kiracho, E.; Ssengooba, F.; Baine, S.O.; Okui, O.

Production Year: 2011

Citation: Mayora, C.; Ekirapa-Kiracho, E.; Ssengooba, F.; Baine, S.O.; Okui, O. Understanding the incremental cost of increasing access to maternal health care services: Perspectives from a Voucher Scheme in Eastern Uganda. Presented at iHEA's 8th World Congress on Health Economics, Toronto, Canada, 11 July 2011. (2011) 19 pp.

Summary: Chrispus Mayora of the Makerere University School of Public Health looks at the incremental costs of implementing a voucher scheme for ante-natal, delivery and post-natal care in several districts in Uganda.

Increasing access to institutional deliveries using demand and supply side incentives: early results from a quasi-experimental study

Tue, 15 May 2012 02:08 GMT

Document Type: Journal Article
Creator: Ekirapa-Kiracho, E.; Waiswa, P.; Rahman, M.H.; Makumbi, F.; Kiwanuka, N.; Okui, O.; Rutebemberwa, E.; Bua, J.; Mutebi, A.; Nalwadda, G.; Serwadda, D.; Pariyo, G.W.; Peters, D.H.

Production Year: 2011

Citation: Ekirapa-Kiracho, E.; Waiswa, P.; Rahman, M.H.; Makumbi, F.; Kiwanuka, N.; Okui, O.; Rutebemberwa, E.; Bua, J.; Mutebi, A.; Nalwadda, G.; Serwadda, D.; Pariyo, G.W.; Peters, D.H. Increasing access to institutional deliveries using demand and supply side incentives: early results from a quasi-experimental study. BMC International Health and Human Rights (2011) 11 (Suppl 1) S11. [DOI: 10.1186/1472-698X-11-S1-S11]

Summary: Background Geographical inaccessibility, lack of transport, and financial burdens are some of the demand side constraints to maternal health services in Uganda, while supply side problems include poor quality services related to unmotivated health workers and inadequate supplies. Most public health interventions in Uganda have addressed only selected supply side issues, and universities have focused their efforts on providing maternal services at tertiary hospitals. To demonstrate how reforms at Makerere University College of Health Sciences (MakCHS) can lead to making systemic changes that can improve maternal health services, a demand and supply side strategy was developed by working with local communities and national stakeholders.

Methods This quasi-experimental trial is conducted in two districts in Eastern Uganda. The supply side component includes health worker refresher training and additions of minimal drugs and supplies, whereas the demand side component involves vouchers given to pregnant women for motorcycle transport and the payment to service providers for antenatal, delivery, and postnatal care. The trial is ongoing, but early analysis from routine health information systems on the number of services used is presented.

Results Motorcyclists in the community organized themselves to accept vouchers in exchange for transport for antenatal care, deliveries and postnatal care, and have become actively involved in ensuring that women obtain care. Increases in antenatal, delivery, and postnatal care were demonstrated, with the number of safe deliveries in the intervention area immediately jumping from <200 deliveries/month to over 500 deliveries/month in the intervention arm. Voucher revenues have been used to obtain needed supplies to improve quality and to pay health workers, ensuring their availability at a time when workloads are increasing.

Conclusions Transport and service vouchers appear to be a viable strategy for rapidly increasing maternal care. MakCHS can design strategies together with stakeholders using a learning-by-doing approach to take advantage of community resources.

Exploring new health markets: experiences from informal providers of transport for maternal health services in Eastern Uganda

Tue, 15 May 2012 01:57 GMT

Document Type: Journal Article
Creator: Pariyo, G.W.; Mayora, C.; Okui, O.; Ssengooba, F.; Peters, D.H.; Serwadda, D.; Lucas, H.; Bloom, G.; Rahman, M.H.; Ekirapa-Kiracho, E.

Production Year: 2011

Citation: Pariyo, G.W.; Mayora, C.; Okui, O.; Ssengooba, F.; Peters, D.H.; Serwadda, D.; Lucas, H.; Bloom, G.; Rahman, M.H.; Ekirapa-Kiracho, E. Exploring new health markets: experiences from informal providers of transport for maternal health services in Eastern Uganda. BMC International Health and Human Rights (2011) 11 (Suppl 1) S10. [DOI: 10.1186/1472-698X-11-S1-S10]

Summary: Background Although a number of intermediate transport initiatives have been used in some developing countries, available evidence reveals a dearth of local knowledge on the effect of these rural informal transport mechanisms on access to maternal health care services, the cost of implementing such schemes and their scalability. This paper, attempts to provide insights into the functioning of the informal transport markets in facilitating access to maternal health care. It also demonstrates the role that higher institutions of learning can play in designing projects that can increase the utilization of maternal health services.

Objectives To explore the use of intermediate transport mechanisms to improve access to maternal health services, with emphasis on the benefits and unintended consequences of the transport scheme, as well as challenges in the implementation of the scheme.

Methods This paper is based on the pilot phase to inform a quasi experimental study aimed at increasing access to maternal health services using demand and supply side incentives. The data collection for this paper included qualitative and quantitative methods that included focus group interviews, review of project documents and facility level data.

Results There was a marked increase in attendance of antenatal, and delivery care services, with the contracted transporters playing a leading role in mobilizing mothers to attend services. The project also had economic spill-over effects to the transport providers, their families and community generally. However, some challenges were faced including difficulty in setting prices for paying transporters, and poor enforcement of existing traffic regulations.

Conclusions and implications The findings indicate that locally existing resources such as motorcycle riders, also known as “boda boda” can be used innovatively to reduce challenges caused by geographical inaccessibility and a poor transport network with resultant increases in the utilization of maternal health services. However, care must be taken to mobilize the resources needed and to ensure that there is enforcement of laws that will ensure the safety of clients and the transport providers themselves.

Research translation to inform national health policies: learning from multiple perspectives in Uganda

Tue, 15 May 2012 01:41 GMT

Document Type: Journal Article
Creator: Ssengooba, F.; Atuyambe, L.; Kiwanuka, S.N.; Puvanachandra, P.; Glass, N.; Hyder, A.A.

Production Year: 2011

Citation: Ssengooba, F.; Atuyambe, L.; Kiwanuka, S.N.; Puvanachandra, P.; Glass, N.; Hyder, A.A. Research translation to inform national health policies: learning from multiple perspectives in Uganda. BMC International Health and Human Rights (2011) 11 (Suppl 1) S13. [DOI: 10.1186/1472-698X-11-S1-S13]

Summary: Background Research and evidence can have an impact on policy and practice, resulting in positive outcomes. However, research translation is a complex, dynamic and non-linear process. Although universities in Africa play a major role in generating research evidence, their strategic approaches to influence health policies and decision making are weak. This study was conducted with the aim of understanding the process of translating research into policy in order to guide the strategic direction of Makerere University College of Health Sciences (MakCHS) and similar institutions in their quest to influence health outcomes nationally and globally.

Methods A case study approach using 30 in-depth interviews with stakeholders involved in two HIV prevention research project was purposively selected. The study sought to analyze the research-to-policy discourses for the prevention of mother-to-child transmission (PMTCT) and safe male circumcision (SMC). The analysis sought to identify entry points, strengths and challenges for research-to-policy processes by interviewing three major groups of stakeholders in Uganda – researchers (8), policy makers (12) and media practitioners (12).

Results Among the factors that facilitated PMTCT policy uptake and continued implementation were: shared platforms for learning and decision making among stakeholders, implementation pilots to assess feasibility of intervention, the emerging of agencies to undertake operations research and the high visibility of policy benefits to child survival. In contrast, SMC policy processes were stalled for over two years after the findings of the Uganda study was made public. Among other factors, policy makers demanded additional research to assess implementation feasibility of SMC within ordinary health system context. High level leaders also publicly contested the SMC evidence and the underlying values and messages – a situation that reduced the coalition of policy champions.

Conclusions This study shows that effective translation of PMTCT and SMC research results demanded a "360 degree" approach to assembling additional evidence to inform the implementation feasibility for these two HIV prevention interventions. MakCHS and similar institutions should prioritize implementation research to guide the policy processes about the feasibility of implementing new and effective innovations (e.g. PMTCT or SMC) at a large scale in contexts that may be different from the research environments.