Lymphatic filariasis in Uganda: baseline investigations in Lira, Soroti and Katakwi districts.

Baseline epidemiological investigations on lymphatic filariasis were conducted for the first time in Uganda in 3 communities in the districts of Lira (Alebtong area), Soroti (Lwala area) and Katakwi (Obalanga area), located to the north of Lake Kyoga at an altitude of 1000-1100 m above sea level. Individuals from the communities were examined, in April-August 1998, for Wuchereria bancrofti specific circulating antigen (by ICT card test), microfilaraemia (by counting chamber and stained blood-smear techniques) and chronic clinical manifestations of lymphatic filariasis. Endophilic mosquitoes were sampled and dissected for filarial larvae. Prevalences of circulating filarial antigen positivity were 29%, 18% and 30% in the Alebtong, Lwala and Obalanga communities, respectively. Microfilaria (mf) prevalences were 18%, 9% and 21%, and geometric mean mf intensities among mf-positive individuals were 306, 171 and 402 mf/mL blood, in the same communities. Examination of stained blood smears revealed mf of both W. bancrofti and Mansonella perstans, but more than 80% of mf-positive individuals harboured the first of these parasites. Prevalences of hydrocoele in adult (> or = 20 years) males were 28%, 7% and 17%, and prevalences of limb elephantiasis in adults were 9%, 4% and 4%, in the Alebtong, Lwala and Obalanga communities, respectively. Anopheles gambiae s.l. (mainly An. gambiae s.s.) and An. funestus were common in all 3 communities, and showed W. bancrofti infectivity rates of 1.1-1.7% and 1.3-2.9%, respectively. It is concluded that lymphatic filariasis is highly endemic in these high-altitude areas of Uganda, with An. gambiae s.l. and An. funestus being the main vectors.

The challenge to restoring basic health care in Uganda.

This paper presents the results of a health facility survey conducted in Uganda between June 1992 and December 1993. The survey covered both government and non-government organisation (NGO) facilities from 10 districts in the five regions of the country. The main objective of the survey was to assess resource use, costs and financing of health facilities. The survey found differences between resource levels of NGOs and government facilities. Government facilities were inadequately maintained, and mostly in a state of disrepair. The user fee scheme that had been recently introduced in some government units to meet running costs was not only inadequate, but was not being used to meet the needs of consumers. In addition, most available resources, including human resources, were concentrated in hospitals. As a result, there was heavy demand for hospital services and less use of services in the lower level facilities. And furthermore, staff in government facilities were paid much less than staff working for NGOs, who not only got better pay but also in-kind forms of rewards, which made them better motivated to work. The number of qualified staff, particularly for primary health care, was grossly inadequate, and most of the work in local facilities was being done by unqualified employees, such as ward maids and dressers. In order to alleviate some of the problems identified, particularly in government facilities, there is a need to explore ways in which more can be done with the available resources to improve the efficiency of health services. The user charge system could be effective in improving the resource base of the health facilities, but it must result in visible improvement in the quality of services for consumers to be willing to pay. Collection methods should be standardised, and expenditures supervised. As part of the government's decentralisation programme, districts should be given the power to recruit and fire personnel. Once this authority is in place, the district should consider employing fewer personnel at all levels and aim to pay them a living wage.

The effects of ivermectin on onchocercal skin disease and severe itching: results of a multicentre trial.

OBJECTIVE: To determine the effects of ivermectin in annual, 3-monthly and 6-monthly doses on onchocercal skin p6isease (OSD) and severe itching. METHOD: A multicentre, double-blind placebo controlled trial was conducted among 4072 residents of rural communities in Ghana, Nigeria and Uganda. Baseline clinical examination categorized reactive skin lesions as acute papular onchodermatitis, chronic papular onchodermatitis and lichenified onchodermatitis. Presence and severity of itching was determined by open-ended and probing questions. Clinical examination and interview took place at baseline and each of 5 subsequent 3-monthly follow-up visits. RESULTS: While prevalence and severity of reactive lesions decreased for all 4 arms, those receiving ivermectin maintained a greater decrease in prevalence and severity over time. The difference between ivermectin and placebo groups was significant for prevalence at 9 months and for severity at 3 months. Differences between placebo and ivermectin groups were much more pronounced for itching. From 6 months onward, the prevalence of severe itching was reduced by 40-50% among those receiving ivermectin compared to the trend in the placebo group. CONCLUSION: This is an important effect on disease burden as severe itching is for the affected people the most troubling complication of onchocerciasis. The difference among regimens was not significant, and the recommended regimen of annual treatment for the control of ocular onchocerciasis appears also the most appropriate for onchocerciasis control in areas where the skin manifestations predominate. The final determination of the effect on skin lesions requires a longer period of study.

Quality of oral and parenteral chloroquine in Kampala.

Malaria remains an important public health problem in Uganda. The mainstay of treatment is still chloroquine. However, recently there have been several reports of poor response to chloroquine treatment. We do not know whether the reported poor response is due to true resistance or poor quality of the drug in the market. This study was done to assess the quality of chloroquine dosage forms in Kampala. The study was cross-sectional; end-point designed to assess the amount of the active ingredient in the tablet and injection dosage forms of the drug. The quality assay was based on the BP, 1988 standard, using both visual and potentiometric analysis technique. The study demonstrated that there is a problem with the quality of chloroquine in the market. Upto 30% of the tablet samples and 33% of injection samples contained less than the stated amount of the active ingredient. This may be one of the reasons for the reported poor response of malaria to chloroquine treatment in Uganda. Given that routine laboratory testing of active ingredients in pharmaceuticals is not practised in Uganda, this study has demonstrated the necessity for establishment of a drug quality control laboratory in the country.

Legislatory framework for private medical practice in Uganda.

BACKGROUND: In Uganda the private health sector has expanded dramatically in recent years with a striking proliferation of facilities for private medical practice which is particularly evident in urban areas. OBJECTIVES: The general objective of this study was to analyse the laws and regulations governing the private health sector in order to determine how they affect the operations and development of private medical practice in Uganda. METHODS: Between December 1995 and December 1996, we identified and reviewed all the laws, which affect private medical practice in Uganda. We discussed the contents of the laws with Ministry of Health officials and with representatives of private practitioners. We also made visits to a sample of clinics, which we inspected to ascertain compliance with the laws, and held interviews with managers of the clinics to get their views about the laws. RESULTS: Two categories of laws were identified. The first category includes two laws adopted in 1993, whose purpose is to ensure the availability at all times of efficacious and cost effective drugs in the country. The second category includes three laws, all adopted in 1996, which spell out the licensing procedures, supervision, disciplining and general control of different categories of professionals. The list of health professions, which are permitted to practice privately, was revised to include new categories, which were previously not allowed. We identified what we considered to be barriers to private health sector development, loopholes in the laws and also assessed the enforcement of the laws. The legal barriers include restrictions of drug imports, the requirement for the professionals to renew their practising licenses and to register the premises annually at one central place in the country, long periods of time mandated for acquiring experience before one can be permitted to practice privately and the finding that there are some capable professions which are still not allowed to practice privately. CONCLUSION: We made recommendations to the Ministry of Health to address all these barriers. We also recommended to the Ministry that non-professionals who have the ability to set up clinics should be allowed to register them provided they can engage professionals to operate them.

The challenge to restoring basic health care in Uganda

This paper presents the results of a health facility survey conducted in Uganda between June 1992 and December 1993

Social anthropological aspects of onchocercal skin disease in Nebbi District, Uganda.

In providing health care, the busy medical practitioner often lacks the "I-You" quality of the personal experience of illness. This paper reports the perceptions, beliefs and practices of persons living in a hyperendemic focus of onchocerciasis in Nebbi District, north-western Uganda. The study involved the use of focus group discussion and semi-structured interviews designed to explore the experiences, meanings, and illness-related coping strategies employed by the community. The results indicated that oncherciasis is considered to be a mysterious elusive disease which cannot be treated by local herbs. The disease is often mistaken for measles (odyer), and leprosy (dhobu). Persons who suffer from onchocerciasis believed that the cause of the disease is the small black fly (Kamacur), dirty water or rivers. However, non-affected individuals believed that the condition is caused by poor personal and environmental hygiene, and personal contact with persons affected by onchocerciasis. Affected people recommended public health education to control the disease while non-affected people, recommended the avoidance of personal contact with affected people, ensuring personal hygiene, and the improvement of environmental sanitation and the nutritional status of community. The belief systems of the community are probably responsible for the discriminatory practices of the people against those affected by the condition. The results indicate that onchocerciasis is a serious public health problem which needs to be controlled.

Non-invasive diagnosis of tropical splenomegaly syndrome.

A study of 41 clinically diagnosed cases of possible tropical splenomegaly syndrome (TSS) was undertaken in Mulago Hospital, Kampala, Uganda, to determine the appropriateness of liver ultrasonography in confirming a diagnosis of TSS. Definitive diagnosis of TSS was made on liver biopsy in 35 (85%) cases. Abdominal ultrasound showed that 30 of the confirmed cases of TSS had normal liver echo-texture and portal vein diameter, and five had abnormally increased liver echo-texture. The combination of massive splenomegaly and hepatomegaly, together with normal ultrasound features of the liver was highly suggestive of TSS. The sensitivity of this criterion was 86% and the specificity was 83%. This non-invasive approach to the diagnosis of TSS is associated with less hazards than liver biopsy, and a normal echogram could be used to make the diagnosis in over 80% of cases, in the field where histopathology may be lacking.

Social and psychological aspects of onchocercal skin disease in Nebbi district, Uganda.

Onchocerciasis affects 7% of Uganda's population and 1.5 million more people are at risk of infection with Onchocerca volvulus, the nematode that causes the disease. This paper reports the results of part of a multi-centre study whose objective was to determine the prevalence of onchocercal skin disease and its associated psychosocial importance in Uganda. The study employed a standardised clinical dermatological survey method along with the use of structured questionnaires, focus group discussions and key informant interviews. Out of a total of 993 persons examined to determine the prevalence of onchocercal skin lesions 253 persons were interviewed to determine the psychosocial importance of the disease. The results indicate that onchocercal skin disease is associated with a variety of psychosocial, physical and economic effects. The disease also leads to stigmatisation of affected persons and their families. It is suggested that dermatological effects of onchocerciasis should be recognised as an important cause of morbidity in Uganda.

Dermatological problems of onchocerciasis in Nebbi District, Uganda.

A cross-sectional survey of 770 subjects in onchocerciasis hyperendemic villages and 223 subjects from a control community in Nebbi District in the West Nile region of Uganda revealed a high prevalence of onchocercal skin disease of 48% in endemic villages. The most common skin problem was troublesome itching (40%); and the prevalent skin lesions were chronic papular onchodermatitis (16%), depigmentation (4%), lichenified onchodermatitis (2%) and acute papular onchodermatitis (1%). Other typical varieties of onchocercal skin diseases such as, hanging groin, lymphoedema and marked lymphadenopathy were infrequent, and considered rare. Pityriasis vergicolor was the most common non-onchocercal skin lesion in both control and endemic communities, accounting for 37% of all non-onchocercal skin lesions. These skin lesions were associated with a variety of psycho-social and economic impact; and there was a positive correlation between the prevalence of troublesome itching and the prevalence of modules (correlation coefficient r = 0.62, p = 0.00). Given the prospects of onchocerciasis control based on mass ivermectin distribution in communities where blindness is common, we recommend that treatment be extended to communities where blindness is less common, but skin disease known to be predominant.

Dermatological problems of onchocerciasis in Nebbi District; Uganda

A cross-sectional survey of 770 subjects in onchocerciasis hyperendemic villages and 223 subjects from a control community in Nebbi District in the West Nile Region of Uganda revealed a high prevalence of onchocercial skin disease of 48in endemic villages. The most chronic skin problem was troublesome itching (40); and the prevalent skin lesions were chronic popular onchodermatitis (16); depigmentation (4); lichenifield onchodermatitis (2) and acute popular onchodermatitis (1). Other typical varieties of onchocercal skin diseases such as; hanging groin; lymphoedema and marked lymphadenopathy were infrequent; and considered rare. Pityriasis vergicolor was the most common non-onchocercal skin lesion in both control and endemic communities; accounting for 37of all non-onchocercal skin lesions. These skin lesions were associated with a variety of psycho-social and economic impact; and there was a positive correlation between the prevalence of troublesome itching and the prevalence of modules (correlation coefficient r=0.62; p=0.00). Given the prospects of onchorcerciasis control based on mass ivermectin distribution in communities where blindness is less common; but skin disease known to be predominant

Tropical splenomegaly syndrome: who gets oesophageal varices?

Of sixty eight patients with tropical splenomegaly syndrome (TSS), 12 had asymptomatic oesophageal varices (OV). All 12 had massive splenomegaly (Hackett's stage 4 or 5). Eight of the 12 were multiparous females, mainly of Rwandese origin. Endoscopic appearance of the varices suggested that TSS varices were not likely to bleed. None of the patients with the varices had abdominal collaterals belonging to the portal system.

Resource utilization patterns in patients with acquired immunodeficiency syndrome (AIDS).

A survey in 1991 of resource use patterns and factors affecting the cost of care for the acquired immunodeficiency syndrome (AIDS) in Mulago Hospital, Kampala, Uganda, revealed that drugs constitute 97% of the mean cost of care of affected individuals in the outpatient and 37% in hospitalized patients. The cost of drugs per treatment episode was Ug.Sh.5785.00 in the outpatient and Ug.Sh.8309.00 for inpatients. (The exchange rate for 1991 was US$ = Ug.Sh.910.00). Analysis of an attempt to provide essential drugs for the growing number of AIDS subjects shows that drugs alone could consume the entire health budget of the Ministry of Health in Uganda. There is therefore need to critically consider options to control the high cost for drugs in AIDS care.

PIP: A study was conducted in Kampala, Uganda, to assess drug utilization by AIDS patients. The study on AIDS resource use patterns was carried out in the general wards and outpatient clinic for AIDS patients at Mulago Hospital, a tertiary care university teaching hospital. 740 admissions for AIDS and 1074 AIDS outpatient clinic visits were included during March-October 1991. Hospital resource utilization including the use of drugs by AIDS patients was assessed and the cost of various service categories estimated using a standard resource cost list. The mean cost of care per episode of AIDS admission was Ugandan Shilling 22,580.00. In the outpatient the mean cost of care per episode of clinic visit was Ug.Sh. 5952.00. The top drugs used in the hospital were: cotrimoxazole, metronidazole (Flagyl), ketoconazole, chlorpromazine, chloroquine, aspirin or paracetamol, codeine, calamine lotion, and petroleum jelly. Drugs constituted the single most important service category of care in the outpatient clinic, accounting for 97% of outpatient service costs. The mean cost of drugs per outpatient visit was Ug.Sh. 5785.00, while the remainder of the other service categories in the outpatient had a combined mean cost of Ug.Sh. 167.00 (3% of the total). Similarly, for inpatients drugs also constituted the most expensive category of care, accounting for 37% of the mean cost of care compared to 19% for laboratory services and 15% for hotel costs. The mean cost of drugs per treatment episode for inpatients was Ug.Sh. 8309.00. The mean cost of the commonly used drugs per treatment episodes ranged from Ug.Sh. 240.00 to 8000.00 in the outpatient, and 240.00 to 9600.00 in hospitalized patients. The top drugs associated with the highest mean cost per treatment episode were: ketoconazole, cotrimoxazole and metronidazole used for the treatment of oral candida and gastrointestinal symptoms.

Resource utilization patterns in patients with acquired immunodeficiency syndrome (AIDS)

A survey in 1991 of resource use patterns and factors affecting the cost of care for acquired immunodeficiency syndrome (AIDS) in Mulago Hospital; Kampala; Uganda; revealed that drugs constitute 97of the mean cost of care of affected individuals in the outpatient and 37in hospitalised patients. The cost of drugs per treatment episode was Ug.Sh. 5785.00 in the outpatient and Ug.sh. 8.309.00 for inpatients. (The exchange rate for 1991 was US$ = Ug. 910.00). Analysis of an attempt to provide essential drugs for the growing number of AIDS subjects shows that drugs alone could consume the entire health budget of the Ministry of Health in Uganda. There is therefore need to critically consider options to control the high cost for drugs in AIDS care

Absence of bacteremia with Mycobacterium avium-intracellulare in Ugandan patients with AIDS.

Disseminated infection with Mycobacterium avium-intracellulare is the most common systemic bacterial infection in American patients with the acquired immunodeficiency syndrome. Blood cultures for mycobacteria were obtained from 50 severely ill Ugandan patients fulfilling the World Health Organization criteria for AIDS and considered late in the course of their illness; 98% had antibody to HIV by ELISA. All blood cultures were negative. These data suggest that disseminated infection with M. avium-intracellulare is infrequent in Ugandan patients with AIDS, if it occurs at all.

Absence of bacteremia with Mycobacterium avium-intracellulare in Ugandan patients with AIDS

Disseminated infection with Mycobacterium avium-intracellulare is the most common systemic bacterial infection in American patients with the acquired immunodeficiency syndrome. Blood cultures for mycobacteria were obtained from 50 severely ill Ugandan patients fulfilling the World Health Organization criteria for AIDS and considered late in the course of their illness; 98pc had antibody to HIV by ELISA. All blood cultures were negative. These data suggest that disseminated infection with M. avium-intracellulare is infrequent in Ugandan patients with AIDS; if it occurs at all