Prevalence, associated factors and clinical features of congenital syphilis among newborns in Mbarara hospital, Uganda.

BACKGROUND: While congenital syphilis is a significant public health problem that can cause severe disabilities, little is known about the situation in Uganda. We describe prevalence, associated factors and clinical presentation of congenital syphilis in Mbarara, Uganda. METHODS: A cross sectional study was carried out among mother- newborn dyads from the postnatal ward of Mbarara Regional Referral Hospital (MRRH). After obtaining informed consent, a structured questionnaire was used to capture data on risk factors for congenital syphilis. A finger prick was performed on the mothers for Treponema Pallidum Haemagglutination Assay (TPHA). If TPHA was positive, a venous blood sample was collected from the mother to confirm active infection using Rapid Plasma Reagin (RPR). Venous blood was drawn from a newborn if the mother tested positive by TPHA and RPR. A newborn with RPR titres 4 times higher than the mother was considered to have congenital syphilis. We fit logistic regression models to determine factors associated with congenital syphilis. RESULTS: Between June and September 2015, we enrolled 2500 mothers and 2502 newborns. Prevalence of syphilis was 3.8% (95% CI 3.1-4.6) among newborn infants and 4.1% (95% CI 3.4-5.0) among their mothers. Maternal age <25 years, past history of genital ulcer, a past history of abnormal vaginal discharge, and not receiving treatment of at least one of genital ulcer, genital itching, lower abdominal pain and abnormal vaginal discharge in the current pregnancy were the risk factors associated with congenital syphilis. The most common clinical feature was hepatosplenomegaly. CONCLUSIONS: We found higher-than-expected syphilis sero-prevalence rates in a high risk population of postnatal mothers and their newborns in Uganda. Bridge populations for syphilis may include mothers not tested during pregnancy, who are usually married and not treated. In accordance with our results, the national policy for syphilis control in Uganda should be strengthened to include universal syphilis screening amongst mother-newborn pairs in postnatal clinics with subsequent partner notification.

Individual, maternal and household risk factors for anaemia among young children in sub-Saharan Africa: a cross-sectional study.

OBJECTIVE: Anaemia affects the majority of children in sub-Saharan Africa (SSA). Previous studies of risk factors for anaemia have been limited by sample size, geography and the association of many risk factors with poverty. In order to measure the relative impact of individual, maternal and household risk factors for anaemia in young children, we analysed data from all SSA countries that performed haemoglobin (Hb) testing in the Demographic and Health Surveys. DESIGN AND SETTING: This cross-sectional study pooled household-level data from the most recent Demographic and Health Surveys conducted in 27 SSA between 2008 and 2014. PARTICIPANTS: 96 804 children age 6-59 months. RESULTS: The prevalence of childhood anaemia (defined as Hb <11 g/dL) across the region was 59.9%, ranging from 23.7% in Rwanda to 87.9% in Burkina Faso. In multivariable regression models, older age, female sex, greater wealth, fewer household members, greater height-for-age, older maternal age, higher maternal body mass index, current maternal pregnancy and higher maternal Hb, and absence of recent fever were associated with higher Hb in tested children. Demographic, socioeconomic factors, family structure, water/sanitation, growth, maternal health and recent illnesses were significantly associated with the presence of childhood anaemia. These risk factor groups explain a significant fraction of anaemia (ranging from 1.0% to 16.7%) at the population level. CONCLUSIONS: The findings from our analysis of risk factors for anaemia in SSA underscore the importance of family and socioeconomic context in childhood anaemia. These data highlight the need for integrated programmes that address the multifactorial nature of childhood anaemia.

Explaining antiretroviral therapy adherence success among HIV-infected children in rural Uganda: a qualitative study.

High adherence is critical for achieving clinical benefits of HIV antiretroviral therapy (ART) and particularly challenging for children. We conducted 35 qualitative interviews with caregivers of HIV-infected Ugandan children who were followed in a longitudinal study of real-time ART adherence monitoring; 18 participants had undetectable HIV RNA, while 17 had detectable virus. Interviews blinded to viral suppression status elicited information on adherence experiences, barriers and facilitators to adherence, and social support. Using an inductive content analytic approach, we identified 'lack of resources,' 'Lazarus effect,' 'caregiver's sense of obligation and commitment,' and 'child's personal responsibility' as categories of influence on adherence, and defined types of caregiver social support. Among children with viral suppression, high hopes for the child's future and ready access to private instrumental support appeared particularly important. These findings suggest clinical counseling should explore caregivers' views of their children's futures and ability to access support in overcoming adherence barriers.

Assessment of HIV antiretroviral therapy adherence by measuring drug concentrations in hair among children in rural Uganda.

Current tools for measuring medication adherence have significant limitations, especially among pediatric populations. We conducted a prospective observational study to assess the use of antiretroviral (ARV) drug levels in hair for evaluating antiretroviral therapy (ART) adherence among HIV-infected children in rural Uganda. Three-day caregiver recall, 30-day visual analog scale (VAS), Medication Event Monitoring System (MEMS), and unannounced pill counts and liquid formulation weights (UPC) were collected monthly over a one-year period. Hair samples were collected quarterly and analyzed for nevirapine (NVP) levels, and plasma HIV RNA levels were collected every six months. Among children with at least one hair sample collected, we used univariable random intercept linear regression models to compare log transformed NVP concentrations with each adherence measure, and the child's age, sex, and CD4 count percentage (CD4%). One hundred and twenty-one children aged 2-10 years were enrolled in the study; 74 (61%) provided at least one hair sample, and the mean number of hair samples collected per child was 1.9 (standard deviation [SD] 1.0). Three-day caregiver recall, VAS, and MEMS were found to be positively associated with increasing NVP concentration in hair, although associations were not statistically significant. UPC was found to have a nonsignificant negative association with increasing hair NVP concentration. In conclusion, NVP drug concentrations in hair were found to have nonsignificant, although generally positive, associations with other adherence measures in a cohort of HIV-infected children in Uganda. Hair collection in this population proved challenging, suggesting the need for community education and buy-in with the introduction of novel methodologies.

Adolescent abstinence and unprotected sex in CyberSenga, an Internet-based HIV prevention program: randomized clinical trial of efficacy.

CONTEXT: Cost-effective, scalable programs are urgently needed in countries deeply affected by HIV. METHODS: This parallel-group RCT was conducted in four secondary schools in Mbarara, Uganda. Participants were 12 years and older, reported past-year computer or Internet use, and provided informed caregiver permission and youth assent. The intervention, CyberSenga, was a five-hour online healthy sexuality program. Half of the intervention group was further randomized to receive a booster at four-months post-intervention. The control arm received 'treatment as usual' (i.e., school-delivered sexuality programming). The main outcome measures were: 1) condom use and 2) abstinence in the past three months at six-months' post-intervention. Secondary outcomes were: 1) condom use and 2) abstinence at three-month's post-intervention; and 6-month outcomes by booster exposure. Analyses were intention to treat. RESULTS: All 416 eligible youth were invited to participate, 88% (n = 366) of whom enrolled. Participants were randomized to the intervention (n = 183) or control (n = 183) arm; 91 intervention participants were further randomized to the booster. No statistically significant results were noted among the main outcomes. Among the secondary outcomes: At three-month follow-up, trends suggested that intervention participants (81%) were more likely to be abstinent than control participants (74%; p = 0.08), and this was particularly true among youth who were abstinent at baseline (88% vs. 77%; p = 0.02). At six-month follow-up, those in the booster group (80%) reported higher rates of abstinence than youth in the intervention, no booster (57%) and control (55%) groups (p = 0.15); they also reported lower rates of unprotected sex (5%) compared to youth in the intervention, no booster (24%) and control (21%) groups (p = 0.21) among youth sexually active at baseline. CONCLUSIONS: The CyberSenga program may affect HIV preventive behavior among abstinent youth in the short term and, with the booster, may also promote HIV preventive behavior among sexually active youth in the longer term. TRIAL REGISTRATION: NCT00906178.

Socio-cultural and economic antecedents of adolescent sexual decision-making and HIV-risk in rural Uganda.

With more than half of new infections occurring among youth, HIV/AIDS remains a major contributor to morbidity and mortality in Uganda. Semi-structured interviews were performed with 48 adolescents and 15 adult key informants in a rural Ugandan community to identify influences on adolescent sexual decision-making. Inductive data analytic methods revealed five thematic influences: (1) social pressure, (2) decline of the Senga (a familial figure who traditionally taught female adolescents about how to run a household), (3) cultural barriers to condom use, (4) knowledge of HIV transmission and modes of prevention, and (5) a moral injunction against sex before marriage. Influences were classified as HIV/AIDS risk and protective factors and organized to form an explanatory framework of adolescent sexual risk-taking. Risk factors pull youth toward risky behavior, while protective factors push them away. Predominance of risk over protective influences explains persistent sexual risk-taking by Ugandan youth. HIV prevention programs designed for Ugandan adolescents should take competing factors and sociocultural and economic influences into account.

Interpretation of tuberculin skin-test results in the diagnosis of tuberculosis in children.

INTRODUCTION: The tuberculin skin test is one of the most valuable tests for demonstrating tuberculous infection in both symptomatic and asymptomatic children. However, its application is often undermined by difficulties in interpretation of results arising from its low sensitivity and specificity. OBJECTIVES: This review aimed to use the concept of induration distribution analysis to estimate the induration size demarcating positive from negative results in a group of children with suspected tuberculosis, and to compare this cut-off with available guidelines for interpretation of the Mantoux test in the diagnosis of tuberculosis in children. METHODS: The results of Mantoux tests of children presenting with suspected tuberculosis over a 12-month period were retrospectively reviewed and plotted on a frequency distribution curve. The distribution was used to define a demarcation between positive and negative reactions. The resultant cut-off was compared with currently published guidelines for interpretation of the Mantoux test. RESULTS: Two hundred (200) Mantoux results were analysed out of 202 records reviewed. Induration sizes ranged from 0 to 60 mm, with a mean of 9.4 mm. The induration distribution showed a bimodal pattern, with 103 patients showing no reaction (0 mm), and 96 (48%) patients with an induration size of (3) 5 mm, with the second mode at 15-19 mm. The demarcating antimode was at 5 mm. CONCLUSIONS: The induration distribution showed that a cut-off induration size of 5 mm was appropriate for this group of patients. This was in agreement with currently published guidelines for the interpretation of the Mantoux test in the diagnosis of tuberculosis in children.

Tuberculosis in children at Mbarara University Teaching Hospital, Uganda: diagnosis and outcome of treatment.

BACKGROUND: The diagnosis of tuberculosis in children is difficult particularly in HIV infected children. The poor outcome following antituberculosis treatment usually reported in HIV infected children might be due, in part, to other HIV-related chronic diseases wrongly diagnosed as TB. OBJECTIVE: The study examines the impact of HIV infection on the clinical features and diagnosis of children presenting with suspected tuberculosis in Mbarara University Teaching Hospital. It also examines the effect of various factors on the outcome of anti-TB treatment. METHODS: Children presenting with suspected TB were prospectively enrolled. Clinical data were recorded and investigations included Mantoux test, chest X-ray, HIV test and Z-N staining of various specimens for AAFBs where available. Patients were treated with standard, short-course anti-TB therapy, and followed-up for six months. They were then classified as "good outcome" if they improved and "poor outcome" if they deteriorated or died whilst on treatment. RESULTS: A total of 128 children were enrolled over an 18-month period. Four patients (3.1%) had a diagnosis of confirmed TB, 82 (64.1%) with "probable TB" and 42 (32.8%) with "suspected TB". Of 88 patients tested 43 (48.9%) were HIV positive. HIV positive patients had a higher frequency of failure to thrive, digital clubbing, enlarged lymph nodes and hepatomegaly; and a lower frequency of positive Mantoux tests. HIV positive patients were less likely to be classified as "confirmed or probable TB" (chi2 = 5.02, p = 0.025). Fifty six patients had a good outcome, 12 had a poor outcome and 60 defaulted before completing six months of treatment. HIV positive children were more likely to have a poor outcome (relative risk = 9.58, 95% CI 1.32 - 69.46). A diagnosis of "confirmed or probable TB" was associated with a good outcome (relative risk for poor outcome = 0.14, 95% CI 0.05 - 0.36). CONCLUSION: HIV positive children with suspected TB frequently have signs that suggest the presence of other diseases such as Lymphocystic Interstitial Pneumonitis (LIP) and chronic bronchiectasis; and are less likely to have a diagnosis of "probable or confirmed TB" after investigations. Patients with an uncertain diagnosis of TB are less likely to improve on anti-TB therapy.

Childhood bacterial meningitis in Mbarara Hospital; Uganda: antimicrobial susceptibility and outcome of treatment

The recommended antibiotic treatment of bacterial meningitis has come under scrutiny following frequent reports of in-vitro resistance by the common causative organisms to penecillin and chloramphenicol. Objective: the study recorded the causative organisms; antibiotic sensitivity patterns and outcome of treatment of bacterial meningitis in children and examined the impact of various factors on the recorded outcome. Design: this was a retrospective review of all case records of patients treated for bacterial meningitis over a one-year period. Setting: The study was set in the paediatric wards of Mbarara University Teaching Hospital; in South Western Uganda. Results: A total of 77 patients were treated. Among 56 patients with available CSF results the frequency of bacterial causes was as follows: H.influenzae 13(23.2); coliforms 7(12.5); uncultured Gram-negative bacilli 7)12.5); S. pneumoniae 5(8.9) and N. meningitids 3(5.4). Most isolates tested were resistant to both penicillin and chloramphenicol; but all were sensitive to ciptofloxacin and perfloxacin. Twenty eight (36.8) patients died; 22(28.9) survived with sequelae and 15(19.7) improved without sequaelae. 14/18 who received perfloxacin and/or ciprofloxacin survived comapred with 23/47 who did not : p=0.04). Conclusions: The high case-fatality rates and the high frequency of resistance to penicillin and chloramphenicol make a case for a review of the currently recommended antibiotic treatment of bacterial meningitis in this region. Fluoroquinolones need further evaluation as potential alternatives to chloramphenicol in the treatment of bacterial meningitis