Antiviral use among hepatitis B infected patients in a low resource setting in Africa: a case study of West Nile, Uganda

Failure to access antiviral medications is a leading cause of hepatitis B (HBV)-associated morbidity and mortality in sub-Saharan Africa (SSA). Despite guideline availability, SSA is not on course to meet its elimination targets. We characterized factors associated with antiviral medication use and challenges to offering chronic care in a large Ugandan institution. We abstracted HBV care data. 2,175/2,209 (98.5%) had HBV-infection. Most participants were men [1,197 (55%)]; median (IQR) age 27 years (19-35); 388/1689 (23.0%) had cirrhosis by sonography and 141/2175 (6.5%) by the aspartate aminotransferase to platelet ratio index (APRI) score ≥2. Of the eligible, 20/141 (14.2%) with APRI score ≥2 and 24/388 (6.2%) with sonographic evidence of liver cirrhosis were not on antiviral medications. Overall, 1,106 (51%) were on medications though 65.8% had not been fully investigated. In multivariate analysis, age ≥35 years [OR (95% CI) = 1.52 (1.01-2.28), p=0.043], APRI ≥2 [OR (95% CI) =1.79 (1.482.16), p<0.001], hepatitis B viral load >2,000IU/mL [OR (95% CI) = 6.22 (5.08-7.62), p<0.001] were associated with antiviral medications use. Over half of participants in care had not been fully evaluated although on treatment and many eligible patients did not access medications. There is need to bridge these gaps for SSA to realise its HBV elimination goals.

A training for health care workers to integrate hepatitis B care and treatment into routine HIV care in a high HBV burden, poorly resourced region of Uganda: the '2for1' project

INTRODUCTION

The "2for1" project is a demonstration project to examine the feasibility and effectiveness of HBV care integrated into an HIV clinic and service. An initial phase in implementation of this project was the development of a specific training program. Our objective was to describe key features of this integrated training curriculum and evaluation of its impact in the initial cohort of health care workers (HCWs).

METHODS

A training curriculum was designed by experts through literature review and expert opinion. Key distinctive features of this training program (compared to standard HBV training provided in the Government program) were; (i) Comparison of commonalities between HIV and HBV (ii) Available clinic- and community-level infrastructure, and the need to strengthen HBV care through integration (iii) Planning and coordination of sustained service integration. The training was aided by a power-point guided presentation, question and answer session and discussion, facilitated by physicians and hepatologists with expertise in viral hepatitis. Assessment approach used a self-administered questionnaire among a cohort of HCWs from 2 health facilities to answer questions on demographic information, knowledge and attitudes related to HBV and its prevention, before and after the training. Knowledge scores were generated and compared using paired t- tests.

RESULTS

A training curriculum was developed and delivered to a cohort of 44 HCWs including medical and nursing staff from the two project sites. Of the 44 participants, 20 (45.5%) were male, average age (SD) was 34.3 (8.3) with an age range of 22-58 years. More than half (24, 54.5%) had been in service for fewer than 5 years. Mean correct knowledge scores increased across three knowledge domains (HBV epidemiology and transmission, natural history and treatment) post-intervention. However, knowledge related to diagnosis and prevention of HBV did not change.

CONCLUSION

A structured HBV education intervention conducted as part of an HIV/HBV care integration training for health care workers yielded improved knowledge on HBV and identified aspects that require further training. This approach may be replicated in other settings, as a public health strategy to heighten HBV elimination efforts.

Hepatitis C in Uganda: Identification of infected blood donors for micro-elimination

Background

The drive to eliminate viral hepatitis by 2030 is underway. However, locally generated data on active infection is required to focus such efforts. We performed a regionally-inclusive survey to determine prevalence of active HCV, genotypes and related factors among Ugandan blood donors.

Methods

Participants from regional blood banks and blood collection centers were surveyed for information on demographic, clinical and lifestyle factors. Blood was assayed for HCV infection, HCV genotypes and subtypes. Logistic regression was performed to determine factors associated with active HCV infection.

Results

Of 1243 participants, 1041 (83.7%) were male, average age (SD), 27.7 (9.8). Prevalence of active HCV infection was 7.8% and we identified 3 genotypes. Median age (adj. OR (95% CI) = 1.03 (1.01-1.06), p-value = 0.040)), Northern region of birth versus Central or Eastern (adj. OR (95% CI) = 10.25 (2.65-39.68), p-value = 0.001)), Northern residence, versus Central or Eastern (adj. OR (95% CI) = 0.23 (0.08-0.65), p-value = 0.006)), and being married (versus single/divorced) adj. OR 2.49(1.3-4.79), p-value = 0.006 were associated with active HCV infection.

Conclusion

Targeted interventions in at-risk populations coupled with linkage to care and treatment will help achieve the WHO elimination goals in this setting.

Neighborhood greenness and burden of non-communicable diseases in Sub-Saharan Africa: A multi-country cross-sectional study

Population growth, demographic transitions and urbanization in sub-Saharan Africa (SSA) will increase non-communicable disease (NCD) burden. We studied the association between neighborhood greenness and NCDs in a multi-country cross-sectional study. Among 1178 participants, in adjusted models, a 0.11 unit NDVI increase was associated with lower BMI (β: -1.01, 95% CI: -1.35, -0.67), and lower odds of overweight/obesity (aOR: 0.73, 95% CI: 0.62, 0.85), diabetes (aOR: 0.77, 95% CI: 0.62, 0.96), and having ≥3 allostatic load components compared to none (aOR: 0.66, 95% CI: 0.52, 0.85). Except for diabetes, these remained statistically significant after Bonferroni correction. We observed no association between NDVI and hypertension or cholesterol. Our findings are consistent with health benefits of neighborhood greenness reported in other countries, suggesting greening strategies could be considered as part of broader public health interventions for NCDs.

Herbal medicine use among patients with viral and non-viral Hepatitis in Uganda: prevalence, patterns and related factors

Background

There is some evidence that patients with liver diseases commonly use complementary and alternative therapies to address general and liver-disease specific health concerns. The purpose of this study was to assess and describe prevalence, patterns and related factors of herbal medicine use among adults diagnosed with viral and non-viral hepatitis in Kampala, Uganda.

Methods

A cross-sectional study was conducted on 310 adult patients attending the gastrointestinal clinic in Mulago hospital referral hospital in Kampala. Data on prevalence, types and reasons for herbal medicine use was collected using standardized questionnaires and focus group discussions. Modified Poisson regression analyses were used to examine factors related to use.

Results

Usage of various herbal remedies within 12 months prior to April 2018 was reported by 46.1% (143/310) of patients with 27.3% (39/143) of these reporting having used conventional and herbal therapies concurrently. Herbal remedies were used to treat various health conditions including hepatitis. Patients with hepatitis C virus infection (PRR = 1.16, p = 0.02) compared to those with hepatitis B virus infection, and those who believed that it was safe to use herbal and conventional therapies concurrently (PRR = 1.23, p = 0.008) had higher prevalence odds of herbal medicine use. Conversely, patients who had been newly diagnosed with hepatitis (PRR = 0.69, p = 0.03) compared to those who had been diagnosed more than one-year prior, had lower prevalence odds of herbal medicine use. Various types of local herbs were reported as most commonly used however most patients did not know the ingredients of commercially prepared herbal therapies.

Conclusion

A high prevalence of herbal medicine use was found among newly-diagnosed patients and patients with hepatitis C more likely to use herbal remedies after adjusting for other factors. Usage was influenced by the belief that herbal medicine is safe and effective. Health workers need to consistently elicit information about herbal remedy use. Research is needed on benefits, adverse effects and outcomes in patients who use herbal remedies to treat primary liver diseases in order to facilitate evidence of efficacy and product safety.

Hepatitis B virus perceptions and health seeking behaviors among pregnant women in Uganda: implications for prevention and policy

BACKGROUND

With most countries in sub-Saharan Africa (SSA) lagging behind schedule to implement a comprehensive viral hepatitis elimination strategy, several barriers to accurate information and hepatitis B virus (HBV) services still exist, that are unique to different regions. In an obstetric population of a high HBV burden SSA setting without antenatal HBV services, we systematically evaluated perceptions and prevention behavioral intentions in relation to HBV and liver cancer.

METHODS

Eligible consenting pregnant women were recruited from public health care facilities in the central and northern regions of Uganda, between October 2016 and December 2017. Standardized procedures and instruments based on the health belief model and theory of planned behavior were used to collect data on socio-demographic characteristics, HBV perceptions and behavioral intentions. Descriptive analysis using Chi-square tests was done to obtain distribution of respondents by levels of perceived risk of HBV and liver cancer for themselves, their child under 5 years and their spouse. Modified Poisson regression analyses were used to evaluate relationships between perception variables and different behavioral outcomes (intention to screen, vaccinate and treat HBV).

RESULTS

Perceived risk (PRR = 0.95(0.90-1.00), p = 0.055) was inversely associated with intention to screen for HBV. Conversely, perceived self-efficacy showed a consistent association with intention to screen for HBV (PRR = 1.18(1.10-1.23) p = 0.005), to vaccinate (PRR = 1.20(1.05-1.36) p = 0.006) and to seek treatment for HBV (PRR = 1.40(1.18-1.67) p < 0.001). Women from the north, compared to the central region (PRR = 1.76 (1.13-2.72) p = 0.012), and those who self-identified as Catholic (PRR = 1.85 (0.99-3.56) p = 0.056), and as Protestant, (PRR = 2.22 (1.22-4.04) p = 0.002), were more likely to have higher perceived self-efficacy, compared to Muslims. Age and education were not related to perceived self-efficacy.

CONCLUSION

Women in both regions hold incorrect perceptions of HBV and liver cancer risk, with women from the central reporting higher perceived risk than those from the north. High perceived self-efficacy influenced intention to participate in HBV prevention. Programs and policies geared towards enhancing HBV prevention in this sub-population may consider socio-cultural factors observed to influence prevention behaviors. These findings may guide HBV interventions aimed at improving capacity to seek HBV prevention services, thereby promoting HBV micro-elimination in this sub-population.

Correlates of hepatitis B awareness and disease-specific knowledge among pregnant women in Northern and Central Uganda: a cross-sectional study

Introduction

Countries in sub-Saharan Africa with a high hepatitis B burden also have limited resources to identify underlying drivers of disease among key at-risk populations. To improve prioritization and strengthen prevention of mother to child transmission of HBV, it is imperative to understand disease awareness, knowledge and related factors among pregnant women.

Objectives

This study assessed HBV disease awareness, knowledge and related factors among pregnant women in public health facilities in two regions with diverse HBV disease epidemiology.

Methods

From October 2016 through December 2017, a random sample of 455 pregnant women attending antenatal clinics were surveyed to assess HBV awareness, knowledge and associated factors. Participants responded to an 18-item questionnaire with themes on HBV awareness, knowledge of disease signs and symptoms, transmission, prevention and misconceptions about the disease. Results were analysed in STATA (version 14.0).

Results

Of 455 participants enrolled, about two thirds reported having heard about HBV disease. By region, nearly half (47%) of participants from the central region, compared to only 16% from the north, reported that they had never heard of HBV. Region of residence had a moderating effect on the education- HBV awareness relationship. Only 162/455 (36%) of participants had adequate HBV knowledge. More than half 256/455 (56%) and 242/455 (53%) were not knowledgeable about horizontal and mother to child HBV transmission, respectively. About two thirds 298/455 (66%) and 281/455 (62%) believed HBV was spread via sharing of utensils and mosquito bites respectively. In multiple regression analysis, residing in the north, (PR=1.91(1.53 -2.38), p < 0.001) compared to central region and having a secondary education (PR=1.87(1.37 -2.55), p < 0.001) compared to primary were statistically significantly related to being knowledgeable about HBV.

Conclusion

We demonstrated marked regional differences in HBV disease awareness and knowledge in this high HBV prevalence setting. However, most pregnant women displayed unacceptably low HBV knowledge and a significant proportion still hold misconceptions about HBV. Interventions to improve HBV prevention through antenatal education will need to be tailored to existing differences in comprehensive HBV knowledge.

Prevalence and risk factor for injury in sub-Saharan Africa: a multicountry study

INTRODUCTION

Injury-related morbidity is a neglected health concern in many low-income and middle-income countries. Most injury data in Africa have been collected from hospital-based studies, and few studies have occurred across multiple countries. Using data from a novel cohort, we examined the prevalence and incidence of serious injuries and associated risk factors across five sites in sub-Saharan Africa (SSA).

METHODS

A common baseline and follow-up survey was administered to participants. The study population included 1316 persons at baseline and 904 persons at follow-up. Frequencies were calculated, and logistic regression models were used to assess risk factors for injury.

RESULTS

A total of 233 (17.7%) persons reported a serious injury at baseline and 60 (6.6%) reported a serious injury 6 months later at follow-up. Sixty-nine per cent of participants responded to the follow-up questionnaire. At baseline and follow-up, the most common cause of serious injury at urban sites was transport related, followed by poison/overdose. In rural Uganda, sharp instruments injuries were most common, followed by transport-related injuries. Living at an urban site was associated with an increased odds for serious injury compared with those at the rural site (OR: 1.83, 95% CI 1.15 to 2.90). Participants who consumed above a moderate amount of alcohol were at a higher risk of serious injury compared with those who did not consume alcohol (OR: 1.86, 95% CI 1.02 to 3.41). High level of education was an important risk factor for injury.

CONCLUSION

At baseline and follow-up, common causes of serious injury were transport related, sharp instrument and poison/overdose. Alcohol consumption, urban location and education are important risk factors for injury. It is feasible to collect longitudinal injury data using a standardised questionnaire across multiples sites in SSA. Longitudinal data collection should be leveraged to obtain robust data on risk factors for injury in SSA.

Urban-rural and geographic differences in overweight and obesity in four sub-Saharan African adult populations: a multi-country cross-sectional study

BACKGROUND

Overweight and obesity are on the rise in developing countries including sub-Saharan Africa. We undertook a four-country survey to show the collective burden of these health conditions as they occur currently in sub-Saharan Africa and to determine the differences between urban and rural populations and other socio-economic factors.

METHODS

Participants were nurses in two hospitals in Nigeria (200), school teachers in South Africa (489) and Tanzania (229), and village residents in one peri-urban (297) and one rural location in Uganda (200) who completed a standardised questionnaire. Their height and weight were measured and body mass index calculated. Factor analysis procedure (Principal component) was used to generate a wealth index. Univariate and multivariate analyses with binary logistic regression models were conducted to examine the associations between potential correlates and the prevalence of overweight and obesity with 95 % confidence intervals.

RESULTS

The prevalence of overweight and obese (combined) was 46 %, 48 %, 68 %, 75 % and 85 % in rural Uganda, peri-urban Uganda, Nigeria, Tanzania and South Africa (SA), respectively. Rural Uganda, Peri- urban Uganda, Nigeria, Tanzania and SA had obesity prevalence of 10 %, 14 %, 31 %, 40 % and 54 %, respectively (p < 0.001). Overall, prevalence of overweight was 374 (31 %) and obesity, 414 (34 %). Female sex was a predictor of overweight and obesity (combined) in peri-urban Uganda [AOR = 8.01; 95 % CI: 4.02, 15.96) and obesity in rural Uganda [AOR = 11.22; 95%CI: 2.27, 55.40), peri-urban Uganda [AOR = 27.80; 95 % CI: 7.13, 108.41) and SA [AOR = 2.17; 95 % CI: 1.19, 4.00). Increasing age was a predictor of BMI > =25 kg/m2 in Nigeria [Age > =45 - AOR = 9.11; 95 % CI: 1.72, 48.16] and SA [AOR = 6.22; 95 % CI: 2.75, 14.07], while marital status was predictor of BMI > =25 kg/m2 only in peri-urban Uganda. [Married - AOR = 4.49; 95 % CI: 1.74, 11.57]. Those in Nigeria [AOR = 2.56; 95 % CI: 1.45, 4.53], SA [AOR = 4.97; 95 % CI: 3.18, 7.78], and Tanzania [AOR = 2.68; 95 % CI: 1.60, 4.49] were more likely to have BMI > =25 kg/m2 compared with the rural and peri-urban sites.

CONCLUSION

The high prevalence of overweight and obesity in these sub-Saharan African countries and the differentials in prevalence and risk factors further highlights the need for urgent focused intervention to stem this trend, especially among women, professionals and urban dwellers.

Does health-related quality of life among adults with pulmonary tuberculosis improve across the treatment period? A hospital-based cross sectional study in Mbale Region, Eastern Uganda

Background

Most tuberculosis (TB) case management guidelines emphasize microbiological cure as treatment goal without highlighting quality of life outcomes. This study assessed health-related quality of life (HRQoL) and related factors in the pre-treatment, intensive and continuation phases of anti-TB therapy among sputum smear positive pulmonary TB patients in Mbale region, Eastern Uganda.

Methods

In this cross-sectional study, questionnaires and 36-Item Short-Form Health Survey Version 2.0 (UK English SF36v2) forms were administered to 210 participants of whom 64.8 % were males. The mean age was 35.48 ± 12.21 years. For each of the three treatment phases, different patients were studied. Responses were translated into the standard 00–100 scale. Means and standard deviations were used to express HRQoL as physical composite scores (PCS) and mental composite scores (MCS). Analysis of variance was used to compare scores across phases. Multiple linear regression methods were used to model relationships between predictor variables and HRQoL for each treatment phase.

Results

HRQoL scores were different across treatment phases. General health (38.8 ± 17.5) and mental health (52.7 ± 18.6) had the lowest and highest sub-scale scores respectively. Mean PCS scores in pretreatment, intensive and continuation phases were 29.9 ± 19.4, 41.9 ± 14.2 and 62.2 ± 18.8 respectively. Mean MCS scores in the pretreatment, intensive and continuation phases were 38.8 ± 18.3, 49.4 ± 13.1 and 60.6 ± 18.8 respectively. Prior to treatment initiation, having an informal occupation (β = −28.66 (<0.001) was associated with poor HRQoL. Being unmarried (β = 11.94, p = 0.028) and belonging to the highest tertile of socioeconomic status (SES) (β = 14.56, p = 0.007) were associated with good HRQoL in the intensive phase. In the continuation phase, SES (β = 10.83, p = 0.021 for MCS and β = 13.14, p = 0.004 for PCS) predicted good HRQoL. Older age (β = −0.43 p = 0.013 for PCS and β = −0.36 p = 0.040 for MCS) was associated with poor HRQoL.

Conclusions

TB treatment improved patients’ perceived health and having means of income was particularly associated with high HRQoL. Strategies to strengthen treatment support that include income generation and specific close monitoring of older patients may help improve overall TB treatment experience, by sustaining acceptable levels of physical, social and emotional functioning.

Urban and rural prevalence of diabetes and pre-diabetes and risk factors associated with diabetes in Tanzania and Uganda

BACKGROUND

The increase in prevalence of diabetes and pre-diabetes in sub-Saharan Africa underlines the importance of understanding its magnitude and causes in different population groups. We analyzed data from the Africa/Harvard Partnership for Cohort Research and Training (PaCT) studies to determine the prevalence of diabetes and pre-diabetes and risk factors associated with diabetes.

METHODOLOGY

Participants were randomly selected from peri-urban (n=297) and rural (n=200) communities in Uganda, and teachers were recruited from schools (n=229) in urban Tanzania. We used a standardized questionnaire to collect socio-demographic and self-reported disease status including diabetes status. Blood glucose was also measured after participants fasted for 8 h. We used standard protocols for anthropometric and blood pressure measurement.

RESULTS

The overall prevalence of diabetes was 10.1% and was highest in rural Ugandan residents (16.1%) compared to teachers in Tanzania (8.3%) and peri-urban Ugandan residents (7.6%). The prevalence of pre-diabetes was 13.8%. The prevalence of self-reported diabetes was low across all sites, where 68% of participants with diabetes were not captured by self-report. In multivariable logistic regression analysis, family history (OR 2.5, 95% CI: 1.1, 5.6) and hypertension (OR 2.3, 95% CI: 1.1, 5.2) were significantly associated with diabetes.

CONCLUSIONS

The prevalence of diabetes and pre-diabetes in Uganda and Tanzania is high, differs markedly between population groups, and remains undiagnosed in an alarmingly high proportion of individuals. These findings highlight the need for large-scale, prospective studies to accurately quantify the burden and identify effective intervention and treatment strategies across diverse African populations.

Feasibility of a large cohort study in sub-Saharan Africa assessed through a four-country study

BACKGROUND

Large prospective epidemiologic studies are vital in determining disease etiology and forming national health policy. Yet, such studies do not exist in sub-Saharan Africa (SSA) notwithstanding the growing burden of chronic diseases.

OBJECTIVE

We explored the feasibility of establishing a large-scale multicountry prospective study at five sites in four sub-Saharan countries.

DESIGN

Based on country-specific considerations of feasibility, Nigeria enrolled health care professionals, South Africa and Tanzania enrolled teachers, and Uganda enrolled village residents at one rural and one periurban site each. All sites used a 6-month follow-up period but different approaches for data collection, namely standardized questionnaires filled out by participants or face-to-face interviews.

RESULTS

We enrolled 1415 participants from five sites (range 200-489) with a median age of 41 years. Approximately half had access to clean-burning cooking fuel and 70% to piped drinking water, yet 92% had access to a mobile phone. The prevalence of chronic diseases was 49% among 45- to 54-year-olds and was dominated by hypertension (21.7% overall) - ranging from 4.5 to 31.2% across sites - and a serious injury in the past 12 months (12.4% overall). About 80% of participants indicated willingness to provide blood samples. At 6-month follow-up, 68% completed a questionnaire (45 to 96% across sites) with evidence that mobile phones were particularly useful.

CONCLUSIONS

Our pilot study indicates that a large-scale prospective study in SSA is feasible, and the burden of chronic disease in SSA may already be substantial necessitating urgent etiologic research and primary prevention.

Acceptability of treatment of latent tuberculosis infection in newly HIV-infected young women in Uganda

We studied the acceptability of isoniazid preventive therapy (IPT) in newly human immunodeficiency virus (HIV) infected Ugandan women. Women were followed in an out-patient clinic where they received HIV care including IPT. Of 52 women who were purified protein derivative-positive, 48 were eligible for IPT and 39 (81%) completed therapy. This completion rate was higher than reported in similar observational studies.

Oropharyngeal colonization by Streptococcus pneumoniae among HIV-infected adults in Uganda: assessing prevalence and antimicrobial susceptibility

OBJECTIVES

To evaluate characteristics of Streptococcus pneumoniae associated with oropharyngeal colonization in the Ugandan adult HIV population.

METHODS

We conducted a cross-sectional study at the outpatient HIV clinic at the Joint Clinical Research Centre in Kampala, Uganda between July 2004 and February 2005. Six hundred HIV-infected individuals were interviewed and had oropharyngeal specimens collected. Pneumococci were isolated from these specimens and antimicrobial susceptibility patterns determined using standard microdilution methods. Serotypes of the pneumococcal isolates were evaluated by capsular swelling reaction with commercial antisera.

RESULTS

The prevalence of oropharyngeal colonization with pneumococci was 18% (108/600). Thirty-two different pneumococcal serotypes were identified, and the most common were serotypes 3 (14.7%), 19F (6.4%), 23F (6.4%), and 16 (5.5%). Seventy-two percent of the isolates were penicillin (PCN) intermediate (MICs 0.12-1 microg/mL), the remainder all being PCN susceptible, and >99% were trimethoprim-sulfamethoxazole (TMP-SMX) resistant. Novel PCN intermediate serotypes included 7, 11, 16, 20, 22, 24, and 34. Only one isolate was resistant to macrolides, and resistance to other antibiotics was rare.

CONCLUSIONS

HIV-infected adults in Uganda are colonized with pneumococci that exhibit a high degree of TMP-SMX and PCN non-susceptibility, with several unique PCN non-susceptible serotypes that are not included in current vaccine preparations.