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Ogwang R, Osoti V, Wamae K, Ndwiga L, Muteru K, Ningwa A, Tuju J, Kinyanjui S, Osier F, Marsh K, Bejon P, Idro R, Ochola-Oyier LI. A retrospective analysis of P. falciparum drug resistance markers detects an early (2016/17) high prevalence of the k13 C469Y mutation in asymptomatic infections in Northern Uganda. Antimicrob Agents Chemother 2024; 68:e0157623. [PMID: 39136465 PMCID: PMC11382623 DOI: 10.1128/aac.01576-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 07/20/2024] [Indexed: 09/05/2024] Open
Abstract
The emergence of drug-resistant Plasmodium falciparum parasites in sub-Saharan Africa will substantially challenge malaria control. Here, we evaluated the frequency of common drug resistance markers among adolescents from Northern Uganda with asymptomatic infections. We used an established amplicon deep sequencing strategy to screen dried blood spot samples collected from 2016 to 2017 during a reported malaria epidemic within the districts of Kitgum and Pader in Northern Uganda. We screened single-nucleotide polymorphisms within: kelch13 (Pfk13), dihydropteroate synthase (Pfdhps), multidrug resistance-1 (Pfmdr1), dihydrofolate reductase (Pfdhfr), and apical membrane antigen (Pfama1) genes. Within the study population, the median age was 15 years (14.3-15.0, 95% CI), and 54.9% (78/142) were Plasmodium positive by 18S rRNA qPCR, which were subsequently targeted for sequencing analysis. We observed a high frequency of resistance markers particularly for sulfadoxine-pyrimethamine (SP), with no wild-type-only parasites observed for Pfdhfr (N51I, C59R, and S108N) and Pfdhps (A437G and K540E) mutations. Within Pfmdr1, mixed infections were common for NF/NY (98.5%). While for artemisinin resistance, in kelch13, there was a high frequency of C469Y (34%). Using the pattern for Pfama1, we found a high level of polygenomic infections with all individuals presenting with complexity of infection greater than 2 with a median of 6.9. The high frequency of the quintuple SP drug-resistant parasites and the C469Y artemisinin resistance-associated mutation in asymptomatic individuals suggests an earlier high prevalence than previously reported from symptomatic malaria surveillance studies (in 2016/2017). Our data demonstrate the urgency for routine genomic surveillance programs throughout Africa and the value of deep sequencing.
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Affiliation(s)
- Rodney Ogwang
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Makerere University College of Health Sciences, Kampala, Uganda
- Centre of Tropical Neuroscience (CTN), Kitgum Site, Uganda
| | - Victor Osoti
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Kevin Wamae
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Leonard Ndwiga
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Kelvin Muteru
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Albert Ningwa
- Makerere University College of Health Sciences, Kampala, Uganda
- Centre of Tropical Neuroscience (CTN), Kitgum Site, Uganda
| | - James Tuju
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Sam Kinyanjui
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Faith Osier
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Life Sciences, Imperial College London, London, United Kingdom
| | - Kevin Marsh
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Philip Bejon
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Richard Idro
- Makerere University College of Health Sciences, Kampala, Uganda
- Centre of Tropical Neuroscience (CTN), Kitgum Site, Uganda
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Lynette Isabella Ochola-Oyier
- Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
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Catherine N A, Claudia S, Savino A, Edgar MM, Rogers K, Julius LB, Morgan A, Imelda TK, Joel B, Frederick B, Andreas T. Antibiotic resistance of E. coli isolates from different water sources in Mbarara, Uganda. JOURNAL OF WATER AND HEALTH 2024; 22:1579-1593. [PMID: 39340372 DOI: 10.2166/wh.2024.319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 08/11/2024] [Indexed: 09/30/2024]
Abstract
Escherichia coli is widely used as an indicator of recent faecal pollution of water. Most E. coli strains are commensals; however, isolates in water samples have been shown to carry antibiotic resistance determinants. In total, 47 E. coli were isolated from selected drinking water sources in Mbarara, Uganda. The isolates were examined for their susceptibility to seven antibiotics and the presence of nine antibiotic-resistance genes (mostly β-lactamase genes) and class 1 integrons. Isolates showed a high resistance to ampicillin of 55.5% and a high sensitivity to azithromycin and gentamicin at 98 and 96%, respectively. PCR analysis showed the presence of extended-spectrum β-lactamase genes blaCTX-M-32 and blaCMY-2 in 64 and 36% of the isolates. The carbapenemase genes blaOXA-48, blaVIM-2, blaNDM-1, and blaKPC-3 were either not detected or only in a very small number of the isolates, whereas class 1 integrons were present in 68% of the isolates. This study proves that antimicrobial resistance exists in E. coli in water used for drinking purposes in Mbarara city. There is a need for public health actors to improve the surveillance of microbiological quality of drinking water to minimize health risks.
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Affiliation(s)
- Abaasa Catherine N
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara city, Uganda E-mail:
| | - Stange Claudia
- DVGW-Technologiezentrum Wasser, Karlsruher Straße 84, 76139 Karlsruhe, Germany
| | - Ayesiga Savino
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara city, Uganda
| | - Mulogo M Edgar
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara city, Uganda
| | - Kalyetsi Rogers
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara city, Uganda
| | - Lejju B Julius
- Faculty of Science, Mbarara University of Science and Technology, Mbarara city, Uganda
| | - Andama Morgan
- Faculty of Science, Muni University, Mbarara city, Uganda
| | - Tamwesigire K Imelda
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara city, Uganda
| | - Bazira Joel
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara city, Uganda
| | - Byarugaba Frederick
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara city, Uganda
| | - Tiehm Andreas
- DVGW-Technologiezentrum Wasser, Karlsruher Straße 84, 76139 Karlsruhe, Germany
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Mokuolu OA, Bolarinwa OA, Opadiran OR, Ameen HA, Dhorda M, Cheah PY, Amaratunga C, de Haan F, Tindana P, Dondorp AM. A framework for stakeholder engagement in the adoption of new anti-malarial treatments in Africa: a case study of Nigeria. Malar J 2023; 22:185. [PMID: 37330469 DOI: 10.1186/s12936-023-04622-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 06/14/2023] [Indexed: 06/19/2023] Open
Abstract
BACKGROUND Recent reports of artemisinin partial resistance from Rwanda and Uganda are worrisome and suggest a future policy change to adopt new anti-malarials. This is a case study on the evolution, adoption, and implementation of new anti-malarial treatment policies in Nigeria. The main objective is to provide perspectives to enhance the future uptake of new anti-malarials, with an emphasis on stakeholder engagement strategies. METHODS This case study is based on an analysis of policy documents and stakeholders' perspectives drawn from an empirical study conducted in Nigeria, 2019-2020. A mixed methods approach was adopted, including historical accounts, review of programme and policy documents, and 33 qualitative in-depth interviews and 6 focus group discussions. RESULTS Based on policy documents reviewed, the adoption of artemisinin-based combination therapy (ACT) in Nigeria was swift due to political will, funding and support from global developmental partners. However, the implementation of ACT was met with resistance from suppliers, distributors, prescribers, and end-users, attributed to market dynamics, costs and inadequate stakeholder engagement. Deployment of ACT in Nigeria witnessed increased developmental partner support, robust data generation, ACT case-management strengthening and evidence on anti-malarial use in severe malaria and antenatal care management. A framework for effective stakeholder engagement for the future adoption of new anti-malarial treatment strategies was proposed. The framework covers the pathway from generating evidence on drug efficacy, safety and uptake; to making treatment accessible and affordable to end-users. It addresses which stakeholders to engage with and the content of engagement strategies with key stakeholders at different levels of the transition process. CONCLUSION Early and staged engagement of stakeholders from global bodies to community level end-users is critical to the successful adoption and uptake of new anti-malarial treatment policies. A framework for these engagements was proposed as a contribution to enhancing the uptake of future anti-malarial strategies.
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Affiliation(s)
| | | | | | - Hafsat Abolore Ameen
- Department of Epidemiology and Community Health, University of Ilorin, Ilorin, Nigeria
| | - Mehul Dhorda
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Phaik Yeong Cheah
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- The Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Chanaki Amaratunga
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Freek de Haan
- Copernicus Institute of Sustainable Development, Utrecht University, Utrecht, the Netherlands
| | - Paulina Tindana
- Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Angupale JR, Tusiimire J, Ngwuluka NC. A review of efficacy and safety of Ugandan anti-malarial plants with application of RITAM score. Malar J 2023; 22:97. [PMID: 36932389 PMCID: PMC10021060 DOI: 10.1186/s12936-023-04486-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 02/11/2023] [Indexed: 03/19/2023] Open
Abstract
BACKGROUND Malaria, a treatable disease mainly caused by Plasmodium falciparum has remained a health challenge in Africa, a continent that accounted for 96% of total global cases and deaths in 2021. Uganda, a malaria endemic country is experiencing malaria parasite resistance to some of the drugs used in the artemisinin-based combination therapy (ACT). In an effort to prioritize herbal medicines for new product development, this review synthesized the available safety and efficacy literature on the Ugandan anti-malarial plants to suggest most effective herbal plants. METHODS Literature was exhaustively searched using engines and databases, such as Google scholar, Pubmed, and Scopus-indexed journals during the period of June 2020-December 2021. In the first phase, information on ethnobotanical uses of anti-malarial plants in Uganda was gathered and synthetized to generate a list of plants, followed by data on anti-malarial efficacy (both in vitro and in vivo) on each listed plant. Minimum inhibitory concentrations (µg/ml), and % parasite suppression for every plant were scored using The Research Initiative on Traditional and Antimalarial Methods (RITAM) scoring system. The best twenty (20) plants were evaluated for acute safety (LD50) data in rat model, plant parts used, ease of cultivation, presence of clinical studies and other relevant factors for suggesting the best three (3) plants for future anti-malarial product development. RESULTS Over one hundred twenty-six (126) plant species are used in Uganda for treatment of malaria in local communities. Out of these, about 33% (41) have been studied for efficacy and safety, with Artemisia annua and Vernonia amygdalina being the most extensively studied and among the best twenty (20) anti-malarial plants in Uganda. Both are limited by parasite recrudescence in clinical studies. Microglossa pyrifolia, a very potent plant (IC50 = 0.03 - 0.05 µg/ml has potential to penetrate the liver and could ameliorate the challenge of recrudescence if combined with A. annua and V. amygdalina in a polyherbal formulation. CONCLUSION There are many plants with promising potential for malaria treatment in Uganda and a herbal combination of A. annua, V. amydalina and M. pyrifolia could offer the next herbal ACT if carefully studied and developed.
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Affiliation(s)
- Jimmy R Angupale
- Department of Pharmaceutical Sciences, Faculty of Medicine, Mbarara University of Science and Technology, P.O Box 1410, Mbarara, Uganda.
- Pharm-Biotechnology and Traditional Medicine Centre, Mbarara University of Science and Technology, P.O Box 1410, Mbarara, Uganda.
| | - Jonans Tusiimire
- Department of Pharmacy, Faculty of Medicine, Mbarara University of Science and Technology, P.O Box 1410, Mbarara, Uganda
| | - Ndidi C Ngwuluka
- Department of Pharmaceutics, Faculty of Pharmaceutical Sciences, University of Jos, Jos, Nigeria
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Ocan M, Ashaba FK, Mwesigwa S, Edgar K, Kamya MR, Nsobya SL. Prevalence of arps10, fd, pfmdr-2, pfcrt and pfkelch13 gene mutations in Plasmodium falciparum parasite population in Uganda. PLoS One 2022; 17:e0268095. [PMID: 35511795 PMCID: PMC9070901 DOI: 10.1371/journal.pone.0268095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 04/21/2022] [Indexed: 11/18/2022] Open
Abstract
In Uganda, Artemether-Lumefantrine and Artesunate are recommended for uncomplicated and severe malaria respectively, but are currently threatened by parasite resistance. Genetic and epigenetic factors play a role in predisposing Plasmodium falciparum parasites to acquiring Pfkelch13 (K13) mutations associated with delayed artemisinin parasite clearance as reported in Southeast Asia. In this study, we report on the prevalence of mutations in the K13, pfmdr-2 (P. falciparum multidrug resistance protein 2), fd (ferredoxin), pfcrt (P. falciparum chloroquine resistance transporter), and arps10 (apicoplast ribosomal protein S10) genes in Plasmodium falciparum parasites prior to (2005) and after (2013) introduction of artemisinin combination therapies for malaria treatment in Uganda. A total of 200 P. falciparum parasite DNA samples were screened. Parasite DNA was extracted using QIAamp DNA mini kit (Qiagen, GmbH, Germany) procedure. The PCR products were sequenced using Sanger dideoxy sequencing method. Of the 200 P. falciparum DNA samples screened, sequencing for mutations in K13, pfmdr-2, fd, pfcrt, arps10 genes was successful in 142, 186, 141, 128 and 74 samples respectively. Overall, we detected six (4.2%, 6/142; 95%CI: 1.4-7.0) K13 single nucleotide polymorphisms (SNPs), of which 3.9% (2/51), 4.4% (4/91) occurred in 2005 and 2013 samples respectively. All four K13 SNPs in 2013 samples were non-synonymous (A578S, E596V, S600C and E643K) while of the two SNPs in 2005 samples, one (Y588N) is non-synonymous and the other (I587I) is synonymous. There was no statistically significant difference in the prevalence of K13 (p = 0.112) SNPs in the samples collected in 2005 and 2013. The overall prevalence of SNPs in pfmdr-2 gene was 39.8% (74/186, 95%CI: 25.1-50.4). Of this, 4.2% (4/95), 76.9% (70/91) occurred in 2005 and 2013 samples respectively. In 2005 samples only one SNP, Y423F (4.2%, 4/95) was found while in 2013, Y423F (38.5%, 35/91) and I492V (38.5%, 35/91) SNPs in the pfmdr-2 gene were found. There was a statistically significant difference in the prevalence of pfmdr-2 SNPs in the samples collected in 2005 and 2013 (p<0.001). The overall prevalence of arps10 mutations was 2.7% (2/72, 95%CI: 0.3-4.2). Two mutations, V127M (4.5%: 1/22) and D128H (4.5%: 1/22) in the arps10 gene were each found in P. falciparum parasite samples collected in 2013. There was no statistically significant difference in the prevalence of arps10 SNPs in the samples collected in 2005 and 2013 (p = 0.238). There were more pfmdr-2 SNPs in P. falciparum parasites collected after introduction of Artemisinin combination therapies in malaria treatment. This is an indicator of the need for continuous surveillance to monitor emergence of molecular markers of artemisinin resistance and its potential drivers in malaria affected regions globally.
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Affiliation(s)
- Moses Ocan
- Department of Pharmacology & Therapeutics, Makerere University, Kampala, Uganda
- * E-mail:
| | | | - Savannah Mwesigwa
- Department of Immunology and Molecular Biology, Makerere University, Kampala, Uganda
| | - Kigozi Edgar
- Makerere University Biomedical Research Center, Kampala, Uganda
| | - Moses R. Kamya
- Infectious Disease Research Collaboration (IDRC), Kampala, Uganda
- Department of Medicine, Makerere University, Kampala, Uganda
| | - Sam L. Nsobya
- Infectious Disease Research Collaboration (IDRC), Kampala, Uganda
- Department of Pathology, Kampala, Uganda
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Boyce RM, Brazeau N, Fulton T, Hathaway N, Matte M, Ntaro M, Mulogo E, Juliano JJ. Prevalence of Molecular Markers of Antimalarial Drug Resistance across Altitudinal Transmission Zones in Highland Western Uganda. Am J Trop Med Hyg 2020; 101:799-802. [PMID: 31436149 DOI: 10.4269/ajtmh.19-0081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
We explored spatial variation in the prevalence of established molecular markers of antimalarial resistance across a geographically diverse, highland region of western Uganda. We identified Plasmodium falciparum CQ resistance transporter 76T mutations in all pools, but there was no evidence of spatial differences across village-based strata defined by either altitude or river valley. In contrast, we identified a significant inverse association between altitude and the prevalence of Plasmodium falciparum multidrug resistance 1 mutations with the largest proportion of Y184F mutations observed in the low-elevation, high-transmission villages. These results demonstrate the substantial heterogeneity in resistance markers observed across geographic settings, even at relatively small scales, but highlight the complex nature of these ecological relationships.
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Affiliation(s)
- Ross M Boyce
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda.,Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Nicholas Brazeau
- Division of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Travis Fulton
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Nick Hathaway
- Program in Bioinformatics and Integrative Biology, University of Massachusetts, Worcester, Massachusetts
| | - Michael Matte
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Moses Ntaro
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Edgar Mulogo
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jonathan J Juliano
- Curriculum in Genetics and Microbiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Division of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Balikagala B, Sakurai-Yatsushiro M, Tachibana SI, Ikeda M, Yamauchi M, Katuro OT, Ntege EH, Sekihara M, Fukuda N, Takahashi N, Yatsushiro S, Mori T, Hirai M, Opio W, Obwoya PS, Anywar DA, Auma MA, Palacpac NMQ, Tsuboi T, Odongo-Aginya EI, Kimura E, Ogwang M, Horii T, Mita T. Recovery and stable persistence of chloroquine sensitivity in Plasmodium falciparum parasites after its discontinued use in Northern Uganda. Malar J 2020; 19:76. [PMID: 32070358 PMCID: PMC7026951 DOI: 10.1186/s12936-020-03157-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 02/09/2020] [Indexed: 11/10/2022] Open
Abstract
Background Usage of chloroquine was discontinued from the treatment of Plasmodium falciparum infection in almost all endemic regions because of global spread of resistant parasites. Since the first report in Malawi, numerous epidemiological studies have demonstrated that the discontinuance led to re-emergence of chloroquine-susceptible P. falciparum, suggesting a possible role in future malaria control. However, most studies were cross-sectional, with few studies looking at the persistence of chloroquine recovery in long term. This study fills the gap by providing, for a period of at least 6 years, proof of persistent re-emergence/stable recovery of susceptible parasite populations using both molecular and phenotypic methods. Methods Ex vivo drug-susceptibility assays to chloroquine (n = 319) and lumefantrine (n = 335) were performed from 2013 to 2018 in Gulu, Northern Uganda, where chloroquine had been removed from the official malaria treatment regimen since 2006. Genotyping of pfcrt and pfmdr1 was also performed. Results Chloroquine resistance (≥ 100 nM) was observed in only 3 (1.3%) samples. Average IC50 values for chloroquine were persistently low throughout the study period (17.4–24.9 nM). Parasites harbouring pfcrt K76 alleles showed significantly lower IC50s to chloroquine than the parasites harbouring K76T alleles (21.4 nM vs. 43.1 nM, p-value = 3.9 × 10−8). Prevalence of K76 alleles gradually increased from 71% in 2013 to 100% in 2018. Conclusion This study found evidence of stable persistence of chloroquine susceptibility with the fixation of pfcrt K76 in Northern Uganda after discontinuation of chloroquine in the region. Accumulation of similar evidence in other endemic areas in Uganda could open channels for possible future re-use of chloroquine as an option for malaria treatment or prevention.
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Affiliation(s)
- Betty Balikagala
- Department of Tropical Medicine and Parasitology, School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Miki Sakurai-Yatsushiro
- Department of International Affairs and Tropical Medicine, School of Medicine, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Shin-Ichiro Tachibana
- Department of Tropical Medicine and Parasitology, School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Mie Ikeda
- Department of Tropical Medicine and Parasitology, School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Masato Yamauchi
- Department of Tropical Medicine and Parasitology, School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Osbert T Katuro
- Mildmay Uganda, Nazibwa Hill, Lweza, P.O. Box 24985, Kampala, Uganda
| | - Edward H Ntege
- Division of Malaria Research, Proteo-Science Center, Ehime University, 3 Bunkyo-cho, Matsuyama, Ehime, 790-8577, Japan
| | - Makoto Sekihara
- Department of Tropical Medicine and Parasitology, School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Naoyuki Fukuda
- Department of Tropical Medicine and Parasitology, School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Nobuyuki Takahashi
- Department of International Affairs and Tropical Medicine, School of Medicine, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Shouki Yatsushiro
- Health Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), 2217-14 Hayashi-cho, Takamatsu, Kagawa, 761-0395, Japan
| | - Toshiyuki Mori
- Department of Tropical Medicine and Parasitology, School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Makoto Hirai
- Department of Tropical Medicine and Parasitology, School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Walter Opio
- St. Mary's Hospital Lacor, P.O. Box 180, Gulu, Uganda
| | - Paul S Obwoya
- St. Mary's Hospital Lacor, P.O. Box 180, Gulu, Uganda
| | - Denis A Anywar
- Faculty of Science, Gulu University, P.O. Box 166, Gulu, Uganda
| | - Mary A Auma
- St. Mary's Hospital Lacor, P.O. Box 180, Gulu, Uganda
| | - Nirianne M Q Palacpac
- Department of Malaria Vaccine Development, Research Institute for Microbial Diseases, Osaka University, 3 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Takafumi Tsuboi
- Division of Malaria Research, Proteo-Science Center, Ehime University, 3 Bunkyo-cho, Matsuyama, Ehime, 790-8577, Japan
| | | | - Eisaku Kimura
- Institute of Tropical Medicine, Nagasaki University, 1-12-4 Sakamoto, Nagasaki, Nagasaki, 852-8523, Japan
| | - Martin Ogwang
- St. Mary's Hospital Lacor, P.O. Box 180, Gulu, Uganda
| | - Toshihiro Horii
- Department of Malaria Vaccine Development, Research Institute for Microbial Diseases, Osaka University, 3 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Toshihiro Mita
- Department of Tropical Medicine and Parasitology, School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
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Byakika-Kibwika P, Ssenyonga R, Lamorde M, Blessborn D, Tarning J. Piperaquine concentration and malaria treatment outcomes in Ugandan children treated for severe malaria with intravenous Artesunate or quinine plus Dihydroartemisinin-Piperaquine. BMC Infect Dis 2019; 19:1025. [PMID: 31795967 PMCID: PMC6889437 DOI: 10.1186/s12879-019-4647-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 11/22/2019] [Indexed: 12/21/2022] Open
Abstract
Background Treatment for severe malaria must be prompt with effective parenteral antimalarial drugs for at least 24 h to achieve fast parasite clearance, and when the patient can tolerate oral therapy, treatment should be completed with effective artemisinin based combination therapy (ACT) for complete parasite clearance and to prevent recrudescence. We evaluated piperaquine concentration and malaria treatment outcomes among Ugandan children treated for severe malaria with intravenous artesunate (AS) or quinine (QN) plus dihydroartemisinin-piperaquine (DP), in Tororo District Hospital in Eastern Uganda. Methods Capillary blood piperaquine concentration data were obtained from a randomized clinical trial whose objective was to evaluate parasite clearance, 42-day parasitological treatment outcomes and safety, following treatment of severe malaria with intravenous AS or QN, plus artemether-lumefantrine or DP among children in Tororo District Hospital, in Eastern Uganda. Results Piperaquine concentration data from 150 participants who received DP were analyzed. Participants with unadjusted treatment failure had lower median day 7 capillary piperaquine concentration than those with treatment success (34.7 (IQR) (17.9–49.1) vs 66.7 (IQR) (41.8–81.9), p < 0.001), and lower than the recommended day 7 cut off level of 57 ng/mL. There was no difference in median capillary piperaquine concentrations among participants with re-infection and recrudescence (35.3 (IQR) (17.9–55.2) vs 34.8 (IQR) (18.1–45.1), p = 0.847). The risk of treatment failure was two times higher among children with low (< 57 ng/mL) day 7 capillary piperaquine concentration (relative risk: 2.1 CI 1.4–3.1), p < 0.001) compared to children with high day 7 capillary piperaquine concentrations (> 57 ng/mL). Conclusion Considering the low day 7 concentrations of piperaquine reported in the patients studied here, we suggest to adopt the recently recommended higher dose of DP in young children or a prolonged 5-day dosing in children living in malaria endemic areas who have suffered an initial episode of severe malaria in order to achieve adequate drug exposures for effective post-treatment prophylactic effects. Trial registration The study was registered with the Pan African Clinical Trial Registry (PACTR201110000321348). Registered 7th October 2011.
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Affiliation(s)
- Pauline Byakika-Kibwika
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda. .,Infectious Diseases Institute, Kampala, Uganda.
| | - Ronald Ssenyonga
- Clinical Trials Unit, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Daniel Blessborn
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Joel Tarning
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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The Diversity of the Plasmodium falciparum K13 Propeller Domain Did Not Increase after Implementation of Artemisinin-Based Combination Therapy in Uganda. Antimicrob Agents Chemother 2019; 63:AAC.01234-19. [PMID: 31358588 DOI: 10.1128/aac.01234-19] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 07/08/2019] [Indexed: 12/15/2022] Open
Abstract
Artemisinin-based combination therapies (ACTs) are the standard of care to treat uncomplicated falciparum malaria. However, resistance to artemisinins, defined as delayed parasite clearance after therapy, has emerged in Southeast Asia, and the spread of resistance to sub-Saharan Africa could have devastating consequences. Artemisinin resistance has been associated in Southeast Asia with multiple nonsynonymous single nucleotide polymorphisms (NS-SNPs) in the propeller domain of the gene encoding the Plasmodium falciparum K13 protein (K13PD). Some K13PD NS-SNPs have been seen in Africa, but the relevance of these mutations is unclear. To assess whether ACT use has selected for specific K13PD mutations, we compared the K13PD genetic diversity in clinical isolates collected before and after the implementation of ACT use from seven sites across Uganda. We detected K13PD NS-SNPs in 16 of 683 (2.3%) clinical isolates collected between 1999 and 2004 and in 26 of 716 (3.6%) isolates collected between 2012 and 2016 (P = 0.16), representing a total of 29 different polymorphisms at 27 codons. Individual NS-SNPs were usually detected only once, and none were found in more than 0.7% of the isolates. Three SNPs (C469F, P574L, and A675V) associated with delayed clearance in Southeast Asia were seen in samples collected between 2012 and 2016, each in a single isolate. No differences in diversity following implementation of ACT use were found at any of the seven sites, nor was there evidence of selective pressures acting on the locus. Our results suggest that selection by ACTs is not impacting on K13PD diversity in Uganda.
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Achol E, Ochaya S, Malinga GM, Edema H, Echodu R. High prevalence of Pfmdr-1 N86 and D1246 genotypes detected among febrile malaria outpatients attending Lira Regional Referral Hospital, Northern Uganda. BMC Res Notes 2019; 12:235. [PMID: 31014391 PMCID: PMC6480777 DOI: 10.1186/s13104-019-4269-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 04/15/2019] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To determine the prevalence of Plasmodium falciparum multi-drug resistant gene-1 (Pfmdr-1) N86Y and D1246Y genotypes among febrile malaria outpatients attending Lira Regional Referral Hospital, Uganda. RESULTS Overall, 92.3% (n = 48/52) and 90% (n = 45/50) of the parasites detected carried the wild type alleles 1246D and N86, respectively. Only 7.7% (n = 4/52) and 10% (n = 5/50) of these P. falciparum isolates carried the Pfmdr-1 mutant alleles 1246Y and 86Y, respectively. Our results show high prevalence of wild type alleles N86 and D1246 in P. falciparum isolates from Lira Regional Referral Hospital, which could translate to a decreased sensitivity to artemether-lumefantrine. Continued monitoring of prevalence of single nucleotide polymorphisms is warranted to timely inform malaria treatment policies and guidelines.
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Affiliation(s)
- Emmanuel Achol
- Department of Biology, Faculty of Science, Gulu University, P.O. Box 166, Gulu, Uganda.,Gulu University Bioscience Research Laboratories, P.O. Box 166, Gulu, Uganda
| | - Stephen Ochaya
- Department of Immunology and Microbiology, Gulu University, P.O. Box 166, Gulu, Uganda
| | - Geoffrey M Malinga
- Department of Biology, Faculty of Science, Gulu University, P.O. Box 166, Gulu, Uganda.,Department of Environmental and Biological Sciences, University of Eastern Finland, P.O. Box 111, 80101, Joensuu, Finland
| | - Hillary Edema
- Gulu University Bioscience Research Laboratories, P.O. Box 166, Gulu, Uganda
| | - Richard Echodu
- Department of Biology, Faculty of Science, Gulu University, P.O. Box 166, Gulu, Uganda. .,Gulu University Bioscience Research Laboratories, P.O. Box 166, Gulu, Uganda.
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11
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Understanding Unlicensed Drug Vendor Practices Related to Childhood Malaria in One Rural District of Uganda: An Exploratory Study. J Trop Med 2018; 2018:6987435. [PMID: 29623095 PMCID: PMC5830015 DOI: 10.1155/2018/6987435] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 01/16/2018] [Indexed: 11/18/2022] Open
Abstract
This study investigated unlicensed drug outlets' practices for the management of malaria in the rural district of Butaleja, Uganda. A qualitative design using semistructured interviews was used. Interviews were recorded, translated, transcribed, and analyzed using thematic analysis. A total of 75 vendors, representing 85% of the outlets in the study area, were interviewed. Most of the vendors were associated with a drug shop type of outfit. About three-quarters reported having completed some level of postsecondary education, but just one-tenth of the vendors had qualifications that made them eligible to apply for a license to operate a drug shop. While most outlets stocked at least one type of antimalarial, only about one-quarter stocked an artemisinin-based combination therapy (ACT), one-quarter expressed a preference for ACTs, and less than one-tenth attested to firmly adhering to the national malaria treatment guidelines on dispensing ACTs as the first-line option. In contrast, nine out of 10 vendors stocked quinine and well over a third stocked antimalarials no longer recommended, such as chloroquine and sulphadoxine-pyrimethamine. Given the ongoing gap between the national malaria policy and unlicensed drug outlet practices, this study calls for greater engagement of unlicensed vendors to improve the management of childhood malaria.
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12
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Lynch CA, Pearce R, Pota H, Egwang C, Egwang T, Bhasin A, Cox J, Abeku TA, Roper C. Travel and the emergence of high-level drug resistance in Plasmodium falciparum in southwest Uganda: results from a population-based study. Malar J 2017; 16:150. [PMID: 28415996 PMCID: PMC5392983 DOI: 10.1186/s12936-017-1812-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 04/08/2017] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND The I164L mutation on the dhfr gene confers high level resistance to sulfadoxine-pyrimethamine (SP) but it is rare in Africa except in a cluster of reports where prevalence >10% in highland areas of southwest Uganda and eastern Rwanda. The occurrence of the dhfr I164L mutation was investigated in community surveys in this area and examined the relationship to migration. METHODS A cross-sectional prevalence survey was undertaken in among villages within the catchment areas of two health facilities in a highland site (Kabale) and a highland fringe site (Rukungiri) in 2007. Sociodemographic details, including recent migration, were collected for each person included in the study. A total of 206 Plasmodium falciparum positive subjects were detected by rapid diagnostic test; 203 in Rukungiri and 3 in Kabale. Bloodspot samples were taken and were screened for dhfr I164L. RESULTS Sequence analysis confirmed the presence of the I164L mutations in twelve P. falciparum positive samples giving an estimated prevalence of 8.6% in Rukungiri. Of the three parasite positive samples in Kabale, none had I164L mutations. Among the twelve I164L positives three were male, ages ranged from 5 to 90 years of age. None of those with the I164L mutation had travelled in the 8 weeks prior to the survey, although three were from households from which at least one household member had travelled during that period. Haplotypes were determined in non-mixed infections and showed the dhfr I164L mutation occurs in both as a N51I + S108N + I164L haplotype (n = 2) and N51I + C59R + S108N + I164L haplotype (n = 5). Genotyping of flanking microsatellite markers showed that the I164L occurred independently on the triple mutant (N51I, C59R + S108N) and double mutant (N51I + S108N) background. CONCLUSIONS There is sustained local transmission of parasites with the dhfr I164L mutation in Rukungiri and no evidence to indicate its occurrence is associated with recent travel to highly resistant neighbouring areas. The emergence of a regional cluster of I164L in SW Uganda and Rwanda indicates that transmission of I164L is facilitated by strong drug pressure in low transmission areas potentially catalysed in those areas by travel and the importation of parasites from relatively higher transmission settings.
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Affiliation(s)
- Caroline A Lynch
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.
| | - Richard Pearce
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Hirva Pota
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Amit Bhasin
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Jonathan Cox
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Cally Roper
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
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Caregivers' treatment-seeking behaviors and predictors of whether a child received an appropriate antimalarial treatment: a household survey in rural Uganda. BMC Infect Dis 2016; 16:478. [PMID: 27600604 PMCID: PMC5012054 DOI: 10.1186/s12879-016-1815-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 09/01/2016] [Indexed: 11/20/2022] Open
Abstract
Background This study responds to a rural community’s concern that, despite national initiatives, malaria management in young children falls short of national guidelines in their district. This study aimed to: (1) describe caregivers’ treatment-seeking behaviors in the rural district of Butaleja, (2) estimate the percentage of children who received an appropriate antimalarial, and (3) determine factors that maximized the likelihood of receiving an appropriate antimalarial. Appropriate antimalarial in this study is defined as having received only the Uganda’s age-specific first-line malaria treatment for uncomplicated and severe malaria during the course of the febrile illness. Methods A household survey design was used in 2011 to interview 424 caregivers with a child aged five and under who had fever within the two weeks preceding the survey. The survey evaluated factors that included: knowledge about malaria and its treatment, management practices, decision-making, and access to artemisinin combination therapy (ACT) and information sources. Bivariate analysis, followed by logistic regression, was used to determine predictors of the likelihood of receiving an appropriate antimalarial. Results Home management was the most common first action, with most children requiring a subsequent action to manage their fever. Overall, 20.9 % of children received a blood test, 68.4 % received an antimalarial, and 41.0 % received an ACT. But closer inspection showed that only 31.6 % received an appropriate antimalarial. These results confirm that ACT usage and receipt of an appropriate antimalarial in Butaleja remain well below the 2010/2015 target of 85 %. While nine survey items differentiated significantly whether a child had or had not received an appropriate antimalarial, our logistic regression model identified four items as independent predictors of likelihood that a child would receive an appropriate antimalarial: obtaining antimalarials from regulated outlets (OR = 14.99); keeping ACT in the home for future use (OR = 6.36); reporting they would select ACT given the choice (OR = 2.31); and child’s age older than four months (OR = 5.67). Conclusions Few children in Butaleja received malaria treatment in accordance with national guidelines. This study highlighted the importance of engaging the full spectrum of stakeholders in the management of malaria in young children - including licensed and unlicensed providers, caregivers, and family members. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-1815-5) contains supplementary material, which is available to authorized users.
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14
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Ocan M, Bwanga F, Okeng A, Katabazi F, Kigozi E, Kyobe S, Ogwal-Okeng J, Obua C. Prevalence of K13-propeller gene polymorphisms among Plasmodium falciparum parasites isolated from adult symptomatic patients in northern Uganda. BMC Infect Dis 2016; 16:428. [PMID: 27543172 PMCID: PMC4992308 DOI: 10.1186/s12879-016-1777-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 08/11/2016] [Indexed: 11/16/2022] Open
Abstract
Background In the absence of an effective vaccine, malaria treatment and eradication is still a challenge in most endemic areas globally. This is especially the case with the current reported emergence of resistance to artemisinin agents in Southeast Asia. This study therefore explored the prevalence of K13-propeller gene polymorphisms among Plasmodium falciparum parasites in northern Uganda. Methods Adult patients (≥18 years) presenting to out-patients department of Lira and Gulu regional referral hospitals in northern Uganda were randomly recruited. Laboratory investigation for presence of plasmodium infection among patients was done using Plasmodium falciparum exclusive rapid diagnostic test, histidine rich protein-2 (HRP2) (Pf). Finger prick capillary blood from patients with a positive malaria test was spotted on a filter paper Whatman no. 903. The parasite DNA was extracted using chelex resin method and sequenced for mutations in K13-propeller gene using Sanger sequencing. PCR DNA sequence products were analyzed using in DNAsp 5.10.01software, data was further processed in Excel spreadsheet 2007. Results A total of 60 parasite DNA samples were sequenced. Polymorphisms in the K13-propeller gene were detected in four (4) of the 60 parasite DNA samples sequenced. A non-synonymous polymorphism at codon 533 previously detected in Cambodia was found in the parasite DNA samples analyzed. Polymorphisms at codon 522 (non-synonymous) and codon 509 (synonymous) were also found in the samples analyzed. The study found evidence of positive selection in the Plasmodium falciparum population in northern Uganda (Tajima’s D = −1.83205; Fu and Li’s D = −1.82458). Conclusions Polymorphism in the K13-propeller gene previously reported in Cambodia has been found in the Ugandan Plasmodium falciparum parasites. There is need for continuous surveillance for artemisinin resistance gene markers in the country. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-1777-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Moses Ocan
- Department of Pharmacology & Therapeutics, Makerere University, P. O. Box 7072, Kampala, Uganda.
| | - Freddie Bwanga
- Department of Medical Microbiology, Makerere University, P. O. Box 7072, Kampala, Uganda
| | - Alfred Okeng
- MBN Clinical Laboratories, P. O. Box 35135, Kampala, Uganda
| | - Fred Katabazi
- Department of Medical Microbiology, Makerere University, P. O. Box 7072, Kampala, Uganda
| | - Edgar Kigozi
- Department of Medical Microbiology, Makerere University, P. O. Box 7072, Kampala, Uganda
| | - Samuel Kyobe
- Department of Medical Microbiology, Makerere University, P. O. Box 7072, Kampala, Uganda
| | | | - Celestino Obua
- Mbarara University of Science and Technology, P. O. Box 1410, Mbarara, Uganda
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15
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Kassam R, Sekiwunga R, MacLeod D, Tembe J, Liow E. Patterns of treatment-seeking behaviors among caregivers of febrile young children: a Ugandan multiple case study. BMC Public Health 2016; 16:160. [PMID: 26883506 PMCID: PMC4755008 DOI: 10.1186/s12889-016-2813-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Accepted: 02/02/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The vast majority of malaria deaths in Uganda occur in children five and under and in rural areas. This study's exploratory case study approach captured unique situations to illustrate special attributes and aspects of treatment-seeking during a malaria episode. METHODS During August 2010, a qualitative exploratory study was conducted in seven of Butaleja District's 12 sub-counties. Multiple case study methodology consisting of loosely-structured interviews were carried out with eight caregivers of children five and under in the local dialect. Caregivers were geographically distant and not known to each other. Interviews were translated into English and transcribed the same day. Data were analyzed using content analysis. RESULTS Of the eight cases, children recovered fully in three instances, survived but with deficits in three, and died in two. Common to all outcomes were (1) triggers to illness recognition, (2) similar treatment sequences and practices, (3) factors which influenced caregivers' treatment-seeking decisions, (4) challenges encountered while seeking care at public health facilities, (5) cost burdens associated with managing malaria, (6) life burdens resulting from negative outcomes from malaria, (7) variations in caregiver knowledge about artemisinin combination therapy, and (8) varying perspectives how malaria management could be improved. CONCLUSIONS Despite the reality that caregivers in Butaleja District generally share similar practices, experiences and challenges, very few children ever receive treatment in accordance with the Uganda's national guidelines. To bring national practice into conformance with policy, three advances must occur: (1) All key stakeholders (those affiliated with the formal health system--public facilities and licensed private outlets, unlicensed drug vendors, and caregivers of young children) must concur on the need and the means to improve malaria management, (2) all health providers (formal and unlicensed) need to be engaged in training and certification to improve timely access to affordable treatment irrespective of a region's remoteness or low population density, and (3) future public health interventions need to improve caregivers' capacity to take the necessary actions to best manage malaria in young children.
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Affiliation(s)
- Rosemin Kassam
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada.
| | - Richard Sekiwunga
- Child Health and Development Centre, School of Medicine, Makerere University, Kampala, P.O.Box 7062, Uganda.
| | - Duncan MacLeod
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada.
| | | | - Eric Liow
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada.
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Roberts DA, Ng M, Ikilezi G, Gasasira A, Dwyer-Lindgren L, Fullman N, Nalugwa T, Kamya M, Gakidou E. Benchmarking health system performance across regions in Uganda: a systematic analysis of levels and trends in key maternal and child health interventions, 1990-2011. BMC Med 2015; 13:285. [PMID: 26631048 PMCID: PMC4668680 DOI: 10.1186/s12916-015-0518-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 11/03/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Globally, countries are increasingly prioritizing the reduction of health inequalities and provision of universal health coverage. While national benchmarking has become more common, such work at subnational levels is rare. The timely and rigorous measurement of local levels and trends in key health interventions and outcomes is vital to identifying areas of progress and detecting early signs of stalled or declining health system performance. Previous studies have yet to provide a comprehensive assessment of Uganda's maternal and child health (MCH) landscape at the subnational level. METHODS By triangulating a number of different data sources - population censuses, household surveys, and administrative data - we generated regional estimates of 27 key MCH outcomes, interventions, and socioeconomic indicators from 1990 to 2011. After calculating source-specific estimates of intervention coverage, we used a two-step statistical model involving a mixed-effects linear model as an input to Gaussian process regression to produce regional-level trends. We also generated national-level estimates and constructed an indicator of overall intervention coverage based on the average of 11 high-priority interventions. RESULTS National estimates often veiled large differences in coverage levels and trends across Uganda's regions. Under-5 mortality declined dramatically, from 163 deaths per 1,000 live births in 1990 to 85 deaths per 1,000 live births in 2011, but a large gap between Kampala and the rest of the country persisted. Uganda rapidly scaled up a subset of interventions across regions, including household ownership of insecticide-treated nets, receipt of artemisinin-based combination therapies among children under 5, and pentavalent immunization. Conversely, most regions saw minimal increases, if not actual declines, in the coverage of indicators that required multiple contacts with the health system, such as four or more antenatal care visits, three doses of oral polio vaccine, and two doses of intermittent preventive therapy during pregnancy. Some of the regions with the lowest levels of overall intervention coverage in 1990, such as North and West Nile, saw marked progress by 2011; nonetheless, sizeable disparities remained between Kampala and the rest of the country. Countrywide, overall coverage increased from 40% in 1990 to 64% in 2011, but coverage in 2011 ranged from 57% to 70% across regions. CONCLUSIONS The MCH landscape in Uganda has, for the most part, improved between 1990 and 2011. Subnational benchmarking quantified the persistence of geographic health inequalities and identified regions in need of additional health systems strengthening. The tracking and analysis of subnational health trends should be conducted regularly to better guide policy decisions and strengthen responsiveness to local health needs.
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Affiliation(s)
- D Allen Roberts
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 60, Seattle, WA, 98121, USA.
| | - Marie Ng
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 60, Seattle, WA, 98121, USA.
| | - Gloria Ikilezi
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 60, Seattle, WA, 98121, USA. .,Infectious Diseases Research Collaboration, Mulago Hospital Complex, Kampala, Uganda.
| | | | - Laura Dwyer-Lindgren
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 60, Seattle, WA, 98121, USA.
| | - Nancy Fullman
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 60, Seattle, WA, 98121, USA.
| | - Talemwa Nalugwa
- Infectious Diseases Research Collaboration, Mulago Hospital Complex, Kampala, Uganda.
| | - Moses Kamya
- Infectious Diseases Research Collaboration, Mulago Hospital Complex, Kampala, Uganda. .,School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.
| | - Emmanuela Gakidou
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 60, Seattle, WA, 98121, USA.
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Kamau RW, Juma BF, Baraza LD. Antimicrobial compounds from root, stem bark and seeds of Melia volkensii. Nat Prod Res 2015; 30:1984-7. [PMID: 26517430 DOI: 10.1080/14786419.2015.1101104] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Three compounds, toosendanin (1), kulactone (2) and scopoletin (3), were isolated from either the root bark and/or the stem bark of Melia volkensii. Their structures were determined on the basis of spectroscopic data generated and by comparison with data from the literature. 1 and 2, isolated for the first time from M. volkensii, exhibited significant (p < 0.05) activity against Escherichia coli with minimum inhibitory concentration of 12.5 μg/mL, close to that of neomycin (6.25 μg/mL). The compounds also exhibited high activity against Aspergillus niger (MIC 6.25 μg/mL compared to 2.5 μg/mL for clotrimazole). Dichloromethane and methanol seed, hexane stem bark and methanol root bark extracts exhibited activities towards Escherichia coli, Staphylococcus aureus, Aspergillus niger and Plasmodium falciparum, respectively. Antimicrobial activity of the plant towards A. niger, P. falciparum and S. aureus is reported for the first time in the current work.
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Affiliation(s)
- Rahab W Kamau
- a Department of Pure and Applied Chemistry , Masinde Muliro University of Science and Technology , Kakamega , Kenya
| | - Benard F Juma
- a Department of Pure and Applied Chemistry , Masinde Muliro University of Science and Technology , Kakamega , Kenya
| | - Lilechi D Baraza
- a Department of Pure and Applied Chemistry , Masinde Muliro University of Science and Technology , Kakamega , Kenya
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Talisuna AO, Noor AM, Okui AP, Snow RW. The past, present and future use of epidemiological intelligence to plan malaria vector control and parasite prevention in Uganda. Malar J 2015; 14:158. [PMID: 25888989 PMCID: PMC4399081 DOI: 10.1186/s12936-015-0677-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 04/04/2015] [Indexed: 11/30/2022] Open
Abstract
Background An important prelude to developing strategies to control infectious diseases is a detailed epidemiological evidence platform to target cost-effective interventions and define resource needs. Methods A review of published and un-published reports of malaria vector control and parasite prevention in Uganda was conducted for the period 1900–2013. The objective was to provide a perspective as to how epidemiological intelligence was used to design malaria control before and during the global malaria eradication programme (GMEP) and to contrast this with the evidence generated in support of the Roll Back Malaria (RBM) initiative from 1998 to date. Results During the GMEP era, comprehensive investigations were undertaken on the effectiveness of vector and parasite control such as indoor residual house-spraying (IRS) and mass drug administration (MDA) at different sites in Uganda. Nationwide malariometric surveys were undertaken between 1964 and 1967 to provide a profile of risk, epidemiology and seasonality leading to an evidence-based national cartography of risk to characterize the diversity of malaria transmission in Uganda. At the launch of the RBM initiative in the late 1990s, an equivalent level of evidence was lacking. There was no contemporary national evidence-base for the likely impact of insecticide-treated nets (ITN), no new malariometric data, no new national cartography of malaria risk or any evidence of tailored intervention delivery based on variations in the ecology of malaria risk in Uganda. Discussion Despite millions of dollars of overseas development assistance over the last ten years in ITN, and more recently the resurrection of the use of IRS, the epidemiological impact of vector control remains uncertain due to an absence of nationwide basic parasite and vector-based field studies. Conclusion Readily available epidemiological data should become the future business model to maximize malaria funding from 2015. Over the next five to ten years, accountability, impact analysis, financial business cases supported by a culture of data use should become the new paradigm by which malaria programmes, governments and their development partners operate.
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Affiliation(s)
- Ambrose O Talisuna
- INFORM Project, Department of Public Health Research, KEMRI-Welcome Trust Research Programme, Nairobi, Kenya. .,Centre for Tropical Medicine & Global Health, Nuffield Department of Clinical Medicine, University of Oxford, CCVTM, Oxford, UK. .,Uganda Malaria Surveillance Programme (UMSP), Kampala, Uganda.
| | - Abdisalan M Noor
- INFORM Project, Department of Public Health Research, KEMRI-Welcome Trust Research Programme, Nairobi, Kenya. .,Centre for Tropical Medicine & Global Health, Nuffield Department of Clinical Medicine, University of Oxford, CCVTM, Oxford, UK.
| | - Albert P Okui
- Ministry of Health, National Malaria Control Programme, Plot 6 Lourdel Road Nakasero, Kampala, Uganda.
| | - Robert W Snow
- INFORM Project, Department of Public Health Research, KEMRI-Welcome Trust Research Programme, Nairobi, Kenya. .,Centre for Tropical Medicine & Global Health, Nuffield Department of Clinical Medicine, University of Oxford, CCVTM, Oxford, UK.
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Nabyonga-Orem J, Mijumbi R. Evidence for informing health policy development in Low-income Countries (LICs): perspectives of policy actors in Uganda. Int J Health Policy Manag 2015; 4:285-93. [PMID: 25905479 DOI: 10.15171/ijhpm.2015.52] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 03/03/2015] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Although there is a general agreement on the benefits of evidence informed health policy development given resource constraints especially in Low-Income Countries (LICs), the definition of what evidence is, and what evidence is suitable to guide decision-making is still unclear. Our study is contributing to filling this knowledge gap. We aimed to explore health policy actors' views regarding what evidence they deemed appropriate to guide health policy development. METHODS Using exploratory qualitative methods, we conducted interviews with 51 key informants using an in-depth interview guide. We interviewed a diverse group of stakeholders in health policy development and knowledge translation in the Uganda health sector. Data were analyzed using inductive content analysis techniques. RESULTS Different stakeholders lay emphasis on different kinds of evidence. While donors preferred international evidence and Ministry of Health (MoH) officials looked to local evidence, district health managers preferred local evidence, evidence from routine monitoring and evaluation, and reports from service providers. Service providers on the other hand preferred local evidence and routine monitoring and evaluation reports whilst researchers preferred systematic reviews and clinical trials. Stakeholders preferred evidence covering several aspects impacting on decision-making highlighting the fact that although policy actors look for factual information, they also require evidence on context and implementation feasibility of a policy decision. CONCLUSION What LICs like Uganda categorize as evidence suitable for informing policy encompasses several types with no consensus on what is deemed as most appropriate. Evidence must be of high quality, applicable, acceptable to the users, and informing different aspects of decision-making.
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Affiliation(s)
| | - Rhona Mijumbi
- Regional East African Community Health (REACH) Policy Initiative, Uganda.,College of Health Sciences, Makerere University Medical School, Kampala, Uganda
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Nabyonga-Orem J, Nanyunja M, Marchal B, Criel B, Ssengooba F. The roles and influence of actors in the uptake of evidence: the case of malaria treatment policy change in Uganda. Implement Sci 2014; 9:150. [PMID: 25294279 PMCID: PMC4193992 DOI: 10.1186/s13012-014-0150-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Accepted: 09/22/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Uganda changed its malaria treatment policy in response to evidence of resistance to commonly used antimalarials. The use of evidence in policy development--also referred to as knowledge translation (KT)--is crucial, especially in resource-limited settings. However, KT processes occur amidst a complex web of stakeholder interactions. Stakeholder involvement in evidence generation and in KT activities is essential. In the present study, we explored how stakeholders impacted the uptake of evidence in the malaria treatment policy change in Uganda. METHODS We employed a qualitative case study methodology involving interviews with key informants and review of documents. A timeline of events was developed, which guided the purposive sampling of respondents and identification of relevant documents. Data were analysed using inductive content analysis techniques. RESULTS Stakeholders played multiple roles in evidence uptake in the malaria treatment policy change. Donors, the Ministry of Health (MoH), service providers, and researchers engaged in the role of evidence generation. The MoH, parliamentarians, and opinion leaders at the national and local levels engaged in dissemination of evidence. The donors, MoH, researchers, and service providers engaged in the uptake of evidence in policy development and implementation. Stakeholders exerted varying levels of support and influence for different reasons. It is noteworthy that all of the influential stakeholders were divided regarding the best antimalarial alternative to adopt. CONCLUSION Our results showed a diverse group of stakeholders who played multiple roles, with varying levels of support and influence on the uptake of evidence in the malaria treatment policy change. For a given KT processes, mapping the relevant stakeholders and devising mechanism for their engagement and for how to resolve conflicts of interest and disagreements a priori will enhance uptake of evidence in policy development.
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Nabyonga-Orem J, Ssengooba F, Macq J, Criel B. Malaria treatment policy change in Uganda: what role did evidence play? Malar J 2014; 13:345. [PMID: 25179532 PMCID: PMC4164770 DOI: 10.1186/1475-2875-13-345] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 08/26/2014] [Indexed: 01/22/2023] Open
Abstract
Background Although increasing attention is being paid to knowledge translation (KT), research findings are not being utilized to the desired extent. The present study explores the role of evidence, barriers, and factors facilitating the uptake of evidence in the change in malaria treatment policy in Uganda, building on previous work in Uganda that led to the development of a middle range theory (MRT) outlining the main facilitatory factors for KT. Application of the MRT to a health policy case will contribute to refining it. Methods Using a case study approach and mixed methods, perceptions of respondents on whether evidence was available, had been considered and barriers and facilitatory factors to the uptake of evidence were explored. In addition, the respondents’ rating of the degree of consistency between the policy decision and available evidence was assessed. Data collection methods included key informant interviews and document review. Qualitative data were analysed using content thematic analysis, whereas quantitative data were analysed using Excel spreadsheets. The two data sets were eventually triangulated. Results Evidence was used to change the malaria treatment policy, though the consistency between evidence and policy decisions varied along the policy development cycle. The availability of high-quality and contextualized evidence, including effective dissemination, Ministry of Health institutional capacity to lead the KT process, intervention of the WHO and a regional professional network, the existence of partnerships for KT with mutual trust and availability of funding, tools, and inputs to implement evidence, were the most important facilitatory factors that enhanced the uptake of evidence. Among the barriers that had to be overcome were resistance from implementers, the health system capacity to implement evidence, and financial sustainability. Conclusion The results agree with facilitatory factors identified in the earlier developed MRT, though additional factors emerged. These results refine the earlier MRT stating that high-quality and contextualized evidence will be taken up in policies, leading to evidence-informed policies when the MoH leads the KT process, partnerships are in place for KT, the WHO and regional professional bodies play a role, and funding, tools, and required inputs for implementing evidence are available. Electronic supplementary material The online version of this article (doi:10.1186/1475-2875-13-345) contains supplementary material, which is available to authorized users.
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Mutero CM, Kramer RA, Paul C, Lesser A, Miranda ML, Mboera LEG, Kiptui R, Kabatereine N, Ameneshewa B. Factors influencing malaria control policy-making in Kenya, Uganda and Tanzania. Malar J 2014; 13:305. [PMID: 25107509 PMCID: PMC4249611 DOI: 10.1186/1475-2875-13-305] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 08/04/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Policy decisions for malaria control are often difficult to make as decision-makers have to carefully consider an array of options and respond to the needs of a large number of stakeholders. This study assessed the factors and specific objectives that influence malaria control policy decisions, as a crucial first step towards developing an inclusive malaria decision analysis support tool (MDAST). METHODS Country-specific stakeholder engagement activities using structured questionnaires were carried out in Kenya, Uganda and Tanzania. The survey respondents were drawn from a non-random purposeful sample of stakeholders, targeting individuals in ministries and non-governmental organizations whose policy decisions and actions are likely to have an impact on the status of malaria. Summary statistics across the three countries are presented in aggregate. RESULTS Important findings aggregated across countries included a belief that donor preferences and agendas were exerting too much influence on malaria policies in the countries. Respondents on average also thought that some relevant objectives such as engaging members of parliament by the agency responsible for malaria control in a particular country were not being given enough consideration in malaria decision-making. Factors found to influence decisions regarding specific malaria control strategies included donor agendas, costs, effectiveness of interventions, health and environmental impacts, compliance and/acceptance, financial sustainability, and vector resistance to insecticides. CONCLUSION Malaria control decision-makers in Kenya, Uganda and Tanzania take into account health and environmental impacts as well as cost implications of different intervention strategies. Further engagement of government legislators and other policy makers is needed in order to increase funding from domestic sources, reduce donor dependence, sustain interventions and consolidate current gains in malaria.
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Affiliation(s)
- Clifford M Mutero
- Centre for Sustainable Malaria Control and School of Health Systems and Public Health, University of Pretoria, Private Bag 323, Pretoria, 0001, South Africa.
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Mbogo GW, Nankoberanyi S, Tukwasibwe S, Baliraine FN, Nsobya SL, Conrad MD, Arinaitwe E, Kamya M, Tappero J, Staedke SG, Dorsey G, Greenhouse B, Rosenthal PJ. Temporal changes in prevalence of molecular markers mediating antimalarial drug resistance in a high malaria transmission setting in Uganda. Am J Trop Med Hyg 2014; 91:54-61. [PMID: 24799371 DOI: 10.4269/ajtmh.13-0647] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Standard therapy for malaria in Uganda changed from chloroquine to chloroquine + sulfadoxine-pyrimethamine in 2000, and artemether-lumefantrine in 2004, although implementation of each change was slow. Plasmodium falciparum genetic polymorphisms are associated with alterations in drug sensitivity. We followed the prevalence of drug resistance-mediating P. falciparum polymorphisms in 982 samples from Tororo, a region of high transmission intensity, collected from three successive treatment trials conducted during 2003-2012, excluding samples with known recent prior treatment. Considering transporter mutations, prevalence of the mutant pfcrt 76T, pfmdr1 86Y, and pfmdr1 1246Y alleles decreased over time. Considering antifolate mutations, the prevalence of pfdhfr 51I, 59R, and 108N, and pfdhps 437G and 540E were consistently high; pfdhfr 164L and pfdhps 581G were uncommon, but most prevalent during 2008-2010. Our data suggest sequential selective pressures as different treatments were implemented, and they highlight the importance of genetic surveillance as treatment policies change over time.
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Affiliation(s)
- George W Mbogo
- Infectious Diseases Research Collaboration, Kampala, Uganda; Le Tourneau University, Longview, Texas; Global AIDS Program, Centers for Disease Control and Prevention, Atlanta, Georgia; London School of Hygiene and Tropical Medicine, United Kingdom; University of California, San Francisco, California
| | - Sheila Nankoberanyi
- Infectious Diseases Research Collaboration, Kampala, Uganda; Le Tourneau University, Longview, Texas; Global AIDS Program, Centers for Disease Control and Prevention, Atlanta, Georgia; London School of Hygiene and Tropical Medicine, United Kingdom; University of California, San Francisco, California
| | - Stephen Tukwasibwe
- Infectious Diseases Research Collaboration, Kampala, Uganda; Le Tourneau University, Longview, Texas; Global AIDS Program, Centers for Disease Control and Prevention, Atlanta, Georgia; London School of Hygiene and Tropical Medicine, United Kingdom; University of California, San Francisco, California
| | - Frederick N Baliraine
- Infectious Diseases Research Collaboration, Kampala, Uganda; Le Tourneau University, Longview, Texas; Global AIDS Program, Centers for Disease Control and Prevention, Atlanta, Georgia; London School of Hygiene and Tropical Medicine, United Kingdom; University of California, San Francisco, California
| | - Samuel L Nsobya
- Infectious Diseases Research Collaboration, Kampala, Uganda; Le Tourneau University, Longview, Texas; Global AIDS Program, Centers for Disease Control and Prevention, Atlanta, Georgia; London School of Hygiene and Tropical Medicine, United Kingdom; University of California, San Francisco, California
| | - Melissa D Conrad
- Infectious Diseases Research Collaboration, Kampala, Uganda; Le Tourneau University, Longview, Texas; Global AIDS Program, Centers for Disease Control and Prevention, Atlanta, Georgia; London School of Hygiene and Tropical Medicine, United Kingdom; University of California, San Francisco, California
| | - Emmanuel Arinaitwe
- Infectious Diseases Research Collaboration, Kampala, Uganda; Le Tourneau University, Longview, Texas; Global AIDS Program, Centers for Disease Control and Prevention, Atlanta, Georgia; London School of Hygiene and Tropical Medicine, United Kingdom; University of California, San Francisco, California
| | - Moses Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda; Le Tourneau University, Longview, Texas; Global AIDS Program, Centers for Disease Control and Prevention, Atlanta, Georgia; London School of Hygiene and Tropical Medicine, United Kingdom; University of California, San Francisco, California
| | - Jordan Tappero
- Infectious Diseases Research Collaboration, Kampala, Uganda; Le Tourneau University, Longview, Texas; Global AIDS Program, Centers for Disease Control and Prevention, Atlanta, Georgia; London School of Hygiene and Tropical Medicine, United Kingdom; University of California, San Francisco, California
| | - Sarah G Staedke
- Infectious Diseases Research Collaboration, Kampala, Uganda; Le Tourneau University, Longview, Texas; Global AIDS Program, Centers for Disease Control and Prevention, Atlanta, Georgia; London School of Hygiene and Tropical Medicine, United Kingdom; University of California, San Francisco, California
| | - Grant Dorsey
- Infectious Diseases Research Collaboration, Kampala, Uganda; Le Tourneau University, Longview, Texas; Global AIDS Program, Centers for Disease Control and Prevention, Atlanta, Georgia; London School of Hygiene and Tropical Medicine, United Kingdom; University of California, San Francisco, California
| | - Bryan Greenhouse
- Infectious Diseases Research Collaboration, Kampala, Uganda; Le Tourneau University, Longview, Texas; Global AIDS Program, Centers for Disease Control and Prevention, Atlanta, Georgia; London School of Hygiene and Tropical Medicine, United Kingdom; University of California, San Francisco, California
| | - Philip J Rosenthal
- Infectious Diseases Research Collaboration, Kampala, Uganda; Le Tourneau University, Longview, Texas; Global AIDS Program, Centers for Disease Control and Prevention, Atlanta, Georgia; London School of Hygiene and Tropical Medicine, United Kingdom; University of California, San Francisco, California
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Conrad MD, LeClair N, Arinaitwe E, Wanzira H, Kakuru A, Bigira V, Muhindo M, Kamya MR, Tappero JW, Greenhouse B, Dorsey G, Rosenthal PJ. Comparative impacts over 5 years of artemisinin-based combination therapies on Plasmodium falciparum polymorphisms that modulate drug sensitivity in Ugandan children. J Infect Dis 2014; 210:344-53. [PMID: 24610872 DOI: 10.1093/infdis/jiu141] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Artemisinin-based combination therapies, including artemether-lumefantrine (AL) and dihydroartemisinin-piperaquine (DP), are recommended to treat uncomplicated falciparum malaria. Sensitivities to components of AL and DP are impacted by polymorphisms in pfmdr1 and pfcrt. We monitored changes in prevalences of polymorphisms in Tororo, Uganda, from 2008 to 2012. METHODS Polymorphic loci in pfmdr1 and pfcrt were characterized in samples from 312 children randomized to AL or DP for each episode of uncomplicated malaria (50 samples per arm for each 3-month interval) utilizing a fluorescent microsphere assay. Treatment outcomes and impacts of prior therapies were also characterized. RESULTS Prevalence increased significantly over time for pfmdr1 N86 (AL: odds ratio [OR], 2.08 [95% confidence interval {CI}, 1.83-2.38]; DP: 1.41 [95% CI, 1.25-1.57]), pfmdr1 D1246 (AL: 1.46 [95% CI, 1.29-1.64]; DP: 1.36 [95% CI, 1.23-1.50]), and pfcrt K76 (AL: 3.37 [95% CI, 1.85-6.16]; DP: 5.84 [95% CI, 1.94-17.53], and decreased for pfmdr1 Y184 (AL: 0.78 [95% CI, .70-.86]; DP: 0.84 [95% CI, .76-1.50]); changes were consistently greater in the AL arm. Recent AL treatment selected for pfmdr1 N86, D1246, and 184F in subsequent episodes; DP selected for the opposite alleles. CONCLUSIONS Genotypes with decreased sensitivity to AL components increased over time. This increase was greater in children receiving AL, suggesting that the choice of treatment regimen can profoundly influence parasite genetics and drug sensitivity. CLINICAL TRIALS REGISTRATION NCT00527800.
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Affiliation(s)
| | - Norbert LeClair
- Department of Medicine, University of California, San Francisco
| | | | | | | | | | | | - Moses R Kamya
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Jordan W Tappero
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Grant Dorsey
- Department of Medicine, University of California, San Francisco
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Mori AT, Kaale EA, Ngalesoni F, Norheim OF, Robberstad B. The role of evidence in the decision-making process of selecting essential medicines in developing countries: the case of Tanzania. PLoS One 2014; 9:e84824. [PMID: 24416293 PMCID: PMC3885598 DOI: 10.1371/journal.pone.0084824] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 11/20/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Insufficient access to essential medicines is a major health challenge in developing countries. Despite the importance of Standard Treatment Guidelines and National Essential Medicine Lists in facilitating access to medicines, little is known about how they are updated. This study aims to describe the process of updating the Standard Treatment Guidelines and National Essential Medicine List in Tanzania and further examines the criteria and the underlying evidence used in decision-making. METHODS This is a qualitative study in which data were collected by in-depth interviews and document reviews. Interviews were conducted with 18 key informants who were involved in updating the Standard Treatment Guidelines and National Essential Medicine List. We used a thematic content approach to analyse the data. FINDINGS The Standard Treatment Guidelines and National Essential Medicine List was updated by committees of experts who were recruited mostly from referral hospitals and the Ministry of Health and Social Welfare. Efficacy, safety, availability and affordability were the most frequently utilised criteria in decision-making, although these were largely based on experience rather than evidence. In addition, recommendations from international guidelines and medicine promotions also influenced decision-making. Cost-effectiveness, despite being an important criterion for formulary decisions, was not utilised. CONCLUSIONS Recent decisions about the selection of essential medicines in Tanzania were made by committees of experts who largely used experience and discretionary judgement, leaving evidence with only a limited role in decision-making process. There may be several reasons for the current limited use of evidence in decision-making, but one hypothesis that remains to be explored is whether training experts in evidence-based decision-making would lead to a better and more explicit use of evidence.
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Affiliation(s)
- Amani Thomas Mori
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- School of Pharmacy, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Eliangiringa Amos Kaale
- School of Pharmacy, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Frida Ngalesoni
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Ministry of Health and Social Welfare, Dar es Salaam, Tanzania
| | - Ole Frithjof Norheim
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Bjarne Robberstad
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
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Mohammed A, Ndaro A, Kalinga A, Manjurano A, Mosha JF, Mosha DF, van Zwetselaar M, Koenderink JB, Mosha FW, Alifrangis M, Reyburn H, Roper C, Kavishe RA. Trends in chloroquine resistance marker, Pfcrt-K76T mutation ten years after chloroquine withdrawal in Tanzania. Malar J 2013; 12:415. [PMID: 24225406 PMCID: PMC3830541 DOI: 10.1186/1475-2875-12-415] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 11/11/2013] [Indexed: 12/22/2022] Open
Abstract
Background Plasmodium falciparum resistance to anti-malarial drugs remains a major obstacle to the control of malaria. In 2001 Tanzania replaced chloroquine (CQ) with sulphadoxine-pyrimethamine (SP) as first-line drug, which in turn was replaced by artemisinin combination therapy in 2006. SP has however, continued to be used in intermittent preventive treatment of malaria in pregnancy (IPTp) despite reports of high levels of resistance to SP due to the lack of alternatives to SP for IPTp. Recent reports have indicated recovery of CQ-susceptibility in Malawi, Kenya, Mozambique, and Tanzania based on the prevalence of wild types at codon 76 of the Pfcrt gene in indigenous P. falciparum populations. The current prevalence of this Pfcrt-76 CQ resistance marker from six regions of Tanzania mainland is hereby reported. Methods DNA extracted from filter-paper dried blood spots and rapid diagnostics kit strips collected from finger-prick blood were used to genotype the Pfcrt-76 resistance marker using PCR-RFLP. Data from previously published studies were used to generate CQ susceptibility recovery trends using logistic regression model. Results Seven hundred and forty one (741) samples were genotyped. The current frequency of the CQ-susceptible Pfcrt-K76 was above 92% and did not differ between regions in Tanzania (χ2 = 2.37; p = 0.795). The K76 allelic prevalence was between 85.7 and 93% in regions (χ2 = 7.88, p = 0.163). The CQ resistance recovery trends showed regional variability that may be caused by differences in malaria transmission intensity, but overall the trends converge as the susceptibility levels in all regions approach >90%. Conclusions CQ withdrawal in Tanzania has resulted into >90% recovery of susceptibility in ten years of withdrawal. These findings are in support of the search for CQ-based combination drugs as a possible future alternative to SP for IPTp in places where full recovery of CQ-susceptibility will be evident.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Reginald A Kavishe
- Kilimanjaro Christian Medical University College and Kilimanjaro Clinical Research Institute, Moshi, Tanzania.
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Nabyonga Orem J, Marchal B, Mafigiri D, Ssengooba F, Macq J, Da Silveira VC, Criel B. Perspectives on the role of stakeholders in knowledge translation in health policy development in Uganda. BMC Health Serv Res 2013; 13:324. [PMID: 23958173 PMCID: PMC3751734 DOI: 10.1186/1472-6963-13-324] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Accepted: 08/15/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Stakeholder roles in the application of evidence are influenced by context, the nature of the evidence, the policy development process, and stakeholder interactions. Past research has highlighted the role of stakeholders in knowledge translation (KT) without paying adequate attention to the peculiarities of low-income countries. Here we identify the roles, relations, and interactions among the key stakeholders involved in KT in Uganda and the challenges that they face. METHODS This study employed qualitative approaches to examine the roles of and links among various stakeholders in KT. In-depth interviews were conducted with 21 key informants and focused on the key actors in KT, their perceived roles, and challenges. RESULTS Major stakeholders included civil society organizations with perceived roles of advocacy, community mobilization, and implementation. These stakeholders may ignore unconvincing evidence. The community's role was perceived as advocacy and participation in setting research priorities. The key role of the media was perceived as knowledge dissemination, but respondents noted that the media may misrepresent evidence if it is received in a poorly packaged form. The perceived roles of policy makers were evidence uptake, establishing platforms for KT and stewardship; negative roles included ignoring or even misrepresenting evidence that is not in their favor. The roles of parliamentarians were perceived as advocacy and community mobilization, but they were noted to pursue objectives that may not be supported by the evidence. The researchers' main role was defined as evidence generation, but focusing disproportionately on academic interests was cited as a concern. The donors' main role was defined as funding research and KT, but respondents were concerned about the local relevance of donor-supported research. Respondents reported that links among stakeholders were weak due to the absence of institutionalized, inclusive platforms. Challenges facing the stakeholders in the process of KT were identified. CONCLUSIONS Our investigation revealed the need to consider the roles that various stakeholders are best placed to play. Links and necessary platforms must be put in place to achieve synergy in KT. Relevant capacities need to be built to overcome the challenges faced by the various stakeholders.
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Affiliation(s)
- Juliet Nabyonga Orem
- WHO Uganda office, Health systems and services cluster, P. O. Box 24578, Kampala, Uganda.
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Sears D, Kigozi R, Mpimbaza A, Kakeeto S, Sserwanga A, Staedke SG, Chang M, Kapella BK, Rubahika D, Kamya MR, Dorsey G. Anti-malarial prescription practices among outpatients with laboratory-confirmed malaria in the setting of a health facility-based sentinel site surveillance system in Uganda. Malar J 2013; 12:252. [PMID: 23870515 PMCID: PMC3723425 DOI: 10.1186/1475-2875-12-252] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Accepted: 07/14/2013] [Indexed: 11/11/2022] Open
Abstract
Background Most African countries have adopted artemisinin-based combination therapy (ACT) as the first-line treatment for uncomplicated malaria. The World Health Organization now recommends limiting anti-malarial treatment to those with a positive malaria test result. Limited data exist on how these policies have affected ACT prescription practices. Methods Data were collected from all outpatients presenting to six public health facilities in Uganda as part of a sentinel site malaria surveillance programme. Training in case management, encouragement of laboratory-based diagnosis of malaria, and regular feedback were provided. Data for this report include patients with laboratory confirmed malaria who were prescribed anti-malarial therapy over a two-year period. Patient visits were analysed in two groups: those considered ACT candidates (defined as uncomplicated malaria with no referral for admission in patients ≥ 4 months of age and ≥ 5 kg in weight) and those who may not have been ACT candidates. Associations between variables of interest and failure to prescribe ACT to patients who were ACT candidates were estimated using multivariable logistic regression. Results A total of 51,355 patient visits were included in the analysis and 46,265 (90.1%) were classified as ACT candidates. In the ACT candidate group, 94.5% were correctly prescribed ACT. Artemether-lumefantrine made up 97.3% of ACT prescribed. There were significant differences across the sites in the proportion of patients for whom there was a failure to prescribe ACT, ranging from 3.0-9.3%. Young children and woman of childbearing age had higher odds of failure to receive an ACT prescription. Among patients who may not have been ACT candidates, the proportion prescribed quinine versus ACT differed based on if the patient had severe malaria or was referred for admission (93.4% vs 6.5%) or was below age or weight cutoffs for ACT (41.4% vs 57.2%). Conclusions High rates of compliance with recommended ACT use can be achieved in resource-limited settings. The unique health facility-based malaria surveillance system operating at these clinical sites may provide a framework for improving appropriate ACT use at other sites in sub-Saharan Africa.
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Affiliation(s)
- David Sears
- Department of Medicine, San Francisco General Hospital, University of California-San Francisco, 1001 Potrero Avenue, San Francisco, CA 94143, USA.
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Nabyonga Orem J, Mugisha F, Okui AP, Musango L, Kirigia JM. Health care seeking patterns and determinants of out-of-pocket expenditure for malaria for the children under-five in Uganda. Malar J 2013; 12:175. [PMID: 23721217 PMCID: PMC3680323 DOI: 10.1186/1475-2875-12-175] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 05/25/2013] [Indexed: 11/24/2022] Open
Abstract
Background The objectives of this study were to assess the patterns of treatment seeking behaviour for children under five with malaria; and to examine the statistical relationship between out-of-pocket expenditure (OOP) on malaria treatment for under-fives and source of treatment, place of residence, education and wealth characteristics of Uganda households. OOP expenditure on health care is now a development concern due to its negative effect on households’ ability to finance consumption of other basic needs. Methods The 2009 Uganda Malaria Indicator Survey was the source of data on treatment seeking behaviour for under-five children with malaria, and patterns and levels of OOP expenditure for malaria treatment. Binomial logit and Log-lin regression models were estimated. In logit model the dependent variable was a dummy (1=incurred some OOP, 0=none incurred) and independent variables were wealth quintiles, rural versus urban, place of treatment, education level, sub-region, and normal duty disruption. The dependent variable in Log-lin model was natural logarithm of OOP and the independent variables were the same as mentioned above. Results Five key descriptive analysis findings emerge. First, malaria is quite prevalent at 44.7% among children below the age of five. Second, a significant proportion seeks treatment (81.8%). Third, private providers are the preferred option for the under-fives for the treatment of malaria. Fourth, the majority pay about 70.9% for either consultation, medicines, transport or hospitalization but the biggest percent of those who pay, do so for medicines (54.0%). Fifth, hospitalization is the most expensive at an average expenditure of US$7.6 per child, even though only 2.9% of those that seek treatment are hospitalized. The binomial logit model slope coefficients for the variables richest wealth quintile, Private facility as first source of treatment, and sub-regions Central 2, East central, Mid-eastern, Mid-western, and Normal duties disrupted were positive and statistically significant at 99% level of confidence. On the other hand, the Log-lin model slope coefficients for Traditional healer, Sought treatment from one source, Primary educational level, North East, Mid Northern and West Nile variables had a negative sign and were statistically significant at 95% level of confidence. Conclusion The fact that OOP expenditure is still prevalent and private provider is the preferred choice, increasing public provision may not be the sole answer. Plans to improve malaria treatment should explicitly incorporate efforts to protect households from high OOP expenditures. This calls for provision of subsidies to enable the private sector to reduce prices, regulation of prices of malaria medicines, and reduction/removal of import duties on such medicines.
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Kalyango JN, Rutebemberwa E, Karamagi C, Mworozi E, Ssali S, Alfven T, Peterson S. High adherence to antimalarials and antibiotics under integrated community case management of illness in children less than five years in eastern Uganda. PLoS One 2013; 8:e60481. [PMID: 23555980 PMCID: PMC3612059 DOI: 10.1371/journal.pone.0060481] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 02/26/2013] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Development of resistance to first line antimalarials led to recommendation of artemisinin based combination therapies (ACTs). High adherence to ACTs provided by community health workers (CHWs) gave reassurance that community based interventions did not increase the risk of drug resistance. Integrated community case management of illnesses (ICCM) is now recommended through which children will access both antibiotics and antimalarials from CHWs. Increased number of medicines has been shown to lower adherence. OBJECTIVE To compare adherence to antimalarials alone versus antimalarials combined with antibiotics under ICCM in children less than five years. METHODS A cohort study was nested within a cluster randomized trial that had CHWs treating children less than five years with antimalarials and antibiotics (intervention areas) and CHWs treating children with antimalarials only (control areas). Children were consecutively sampled from the CHWs' registers in the control areas (667 children); and intervention areas (323 taking antimalarials only and 266 taking antimalarials plus antibiotics). The sampled children were visited at home on day one and four of treatment seeking. Adherence was assessed using self reports and pill counts. RESULTS Adherence in the intervention arm to antimalarials alone and antimalarials plus antibiotics arm was similar (mean 99% in both groups) but higher than adherence in the control arm (antimalarials only) (mean 96%). Forgetfulness (38%) was the most cited reason for non-adherence. At adjusted analysis: absence of fever (OR = 3.3, 95%CI =1.6-6.9), seeking care after two or more days (OR = 2.2, 95%CI = 1.3-3.7), not understanding instructions given (OR = 24.5, 95%CI = 2.7-224.5), vomiting (OR = 2.6, 95%CI = 1.2-5.5), and caregivers' perception that the child's illness was not severe (OR = 2.0, 95%CI = 1.1-3.8) were associated with non-adherence. CONCLUSIONS Addition of antibiotics to antimalarials did not lower adherence. However, caregivers should be adequately counseled to understand the dosing regimens; continue with medicines even when the child seems to improve; and re-administer doses that have been vomited.
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Affiliation(s)
- Joan N Kalyango
- Department of Public Health Sciences, Global Health, Karolinska Institutet, Stockholm, Sweden.
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Nabyonga Orem J, Bataringaya Wavamunno J, Bakeera SK, Criel B. Do guidelines influence the implementation of health programs?--Uganda's experience. Implement Sci 2012; 7:98. [PMID: 23068082 PMCID: PMC3534441 DOI: 10.1186/1748-5908-7-98] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Accepted: 10/09/2012] [Indexed: 11/19/2022] Open
Abstract
Background A guideline contains processes and procedures intended to guide health service delivery. However, the presence of guidelines may not guarantee their implementation, which may be a result of weaknesses in the development process. This study was undertaken to describe the processes of developing health planning, services management, and clinical guidelines within the health sector in Uganda, with the goal of understanding how these processes facilitate or abate the utility of guidelines. Methods Qualitative and quantitative research methods were used to collect and analyze data. Data collection was undertaken at the levels of the central Ministry of Health, the district, and service delivery. Qualitative methods included review of documents, observations, and key informant interviews, as well as quantitative aspects included counting guidelines. Quantitative data were analyzed with Microsoft Excel, and qualitative data were analyzed using deductive content thematic analysis. Results There were 137 guidelines in the health sector, with programs related to Millennium Development Goals having the highest number (n = 83). The impetus for guideline development was stated in 78% of cases. Several guidelines duplicated content, and some conflicted with each other. The level of consultation varied, and some guidelines did not consider government-wide policies and circumstances at the service delivery level. Booklets were the main format of presentation, which was not tailored to the service delivery level. There was no framework for systematic dissemination, and target users were defined broadly in most cases. Over 60% of guidelines available at the central level were not available at the service delivery level, but there were good examples in isolated cases. There was no framework for systematic monitoring of use, evaluation, and review of guidelines. Suboptimal performance of the supervision framework that would encourage the use of guidelines, assess their utilization, and provide feedback was noted. Conclusions Guideline effectiveness is compromised by the development process. To ensure the production of high-quality guidelines, efforts must be employed at the country and regional levels. The regional level can facilitate pooling resources and expertise in knowledge generation, methodology development, guideline repositories, and capacity building. Countries should establish and enforce systems and guidance on guideline development.
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Affiliation(s)
- Juliet Nabyonga Orem
- Health systems and services cluster, WHO Uganda office, P.O. Box 24578, Kampala, Uganda.
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