Daniel J. Kyabayinze

Background: The coronavirus disease 2019 (COVID-19) pandemic significantly impacted health systems worldwide. Aim: This study explored the effects of the COVID-19 cascade on health programmes in Uganda. Setting: This study conducted in-depth interviews with key informants involved in Uganda’s national COVID-19 response. Methods: A cross-sectional exploratory study using qualitative approaches was carried out. A purposive sample of 30 key informants from the Ministry of Health (MoH) and implementing partners were interviewed (May 2023 – June 2023). Interviews were audio recorded and analysed using inductive thematic analysis with NVivo 14 software. Results: Four themes emerged: (1) approaches and opportunities for successful COVID-19 response, (2) negative impacts of the pandemic on health services, (3) barriers to implementing response strategies and (4) suggestions for preparedness for future epidemics. Conclusion: While the pandemic disrupted health programmes and access to care, it also revealed opportunities to strengthen healthcare delivery. Strengthening the dedicated Ministry of Health department for epidemic preparedness and response is recommended. Contribution: This study identifies areas for improvement in Uganda’s health system exposed by the COVID-19 pandemic. It informs public health preparedness efforts in Uganda and other African countries, aligning with the Journal’s focus on strengthening health systems in Africa.

Background: Coronavirus disease 2019 (COVID-19) vaccination is crucial for healthcare workers (HCWs) and understanding their perspectives is vital for promoting vaccine uptake in communities. Aim: This study assessed factors influencing COVID-19 vaccine uptake among HCWs in Kampala, Uganda. Setting: A cross-sectional study was done in seven high-volume health facilities in Kampala. Methods: A questionnaire based on the Behavioural and Social Drivers Model was administered to 200 HCWs. Data were analysed using STATA version 17 to identify associations with vaccination status. Results: Overall vaccination uptake was 65.2% (95% confidence interval [CI]: 58.1, 71.8), with 17.7% (95% CI: 12.6, 23.7) having received a booster dose. Concerns about safety and side effects were the primary reasons for vaccine hesitancy. While HCWs generally believed that getting vaccinated for diseases such as measles and tuberculosis can help prevent sickness or death, with 70.5% (n = 141/200) strongly agreeing, only 48% (n = 96/200) of HCWs strongly agreed that vaccination against COVID-19 can reduce the risk of illness or death. Age, profession and facility type were associated with vaccination status. Conclusion: Healthcare workers in Kampala had high vaccine uptake, but safety concerns remain. Targeted communication strategies from the Ministry of Health are needed to address these concerns and further increase vaccine confidence. Contribution: This study reveals specific reasons for vaccine hesitancy among HCWs in an African urban setting. These insights inform interventions to improve vaccine uptake in this key population.

Background: The World Health Organisation recommends that malaria case management is based on parasite-based diagnosis in all cases. However, currently available tools for clinical use have limitations, including the inability to detect low-level infections. Next-generation highly sensitive rapid diagnostic tests (HS-RDT) for Plasmodium falciparum (Pf) are commercially available but require field-based validation. This study evaluated the performance of the highly sensitive NxTek™ Eliminate Malaria Pf (NxTek) diagnostic test in health facilities and community settings in Mpigi district, Uganda, compared to the conventional rapid diagnostic tests (cRDTs) and evaluated a real-time data capture and transmission tools. Methods: Between April and December 2019, we randomly enrolled symptomatic participants from the outpatient department (OPD), community settings and asymptomatic Antenatal Care (ANC) women. The participants were tested with both cRDTs and an HS-RDT to detect Plasmodium falciparum HRP2 antigen and quality-assured results with qPCR as a reference. All results were transmitted as geo-coded real-time data using a smartphone with custom-designed software. Results: Among symptomatic participants at OPD, HS-RDTs showed 13.1% (110/8418) positive with the P.falciparum compared to 7.1% (612/8585) proportion positive for cRDTs. HS-RDTs detected 11% (384/3,490) positives among asymptomatic pregnant women at ANC. At iCCM testing points 79.7% (2,397/3,009) of the under-five age group were positive for malaria parasites on cRDTs. Follow-up to the homes of confirmed positive index contacts, HS-RDTs resulted in the detection of 21.1% (1,877) asymptomatic positive of different age groups. Acceptability of new technology was observed and demonstrated by the users. All health workers effectively performed HS-RDT testing after a one-day training session and transmitted real-time results through the 'Sympheos Collect' customized Android telephone application provided. Conclusion: Using HS-RDTs increased case findings of low parasite density infections compared to cRDTs in study populations and allowed the elimination of malaria reservoirs through treatments. The introduction of HS-RDTs and Sympheos Collect^TM data collecting systems are feasible, acceptable, easy to use and require minimal additional training. Further evidence is required to demonstrate the wide population impact of HS-RDTs on asymptomatic infections in various age groups.

BackgroundWorld Health Organisation recommends that malaria case management be based on parasite-based diagnosis in all cases, but currently available tools for clinical use have limitations, including the inability to detect low-level infections. Currently, next-generation highly sensitive rapid diagnostic tests (hsRDT) for Plasmodium falciparum (Pf) are commercially available, but require field-based validation. This study evaluated the performance of the highly sensitive NxTek™ Eliminate Malaria Pf (NxTek) diagnostic test in health facilities and community settings in Mpigi district, Uganda in comparison to the conventional rapid diagnostic tests (cRDTs).MethodsBetween April and December 2019, symptomatic and asymptomatic participants were randomly enrolled from the Outpatient Department (OPD), Antenatal Care (ANC), and community settings. The participants were tested with both cRDTs and an hsRDT to detect Plasmodium falciparum HRP2 antigen and quality assured results with PCR as a reference. Geo-coded real time data were transmitted by health facility and community-based providers using a smartphone with custom designed software.ResultsAt the OPD, the parasite positivity rate was 13.3% for HS-RDT, compared to 6.4% with cRDT. The HS-RDT detected twice the number of positives compared to cRDT. At ANC, 11% (384/3,490) of the pregnant women were malaria parasite positive. HS-RDT detected more positive cases (10.4%) than cRDT (7.0%). At the community setting, 79.7% (2,397/3,009) of the under-five age group were positive for malaria parasites. Index clients in households resulted in a detection of 21.1% (1,877) asymptomatic positive especially among school going children. Health workers were able to learn how to effectively perform the HS-RDT, from a one-day training session. The additional support supervision was provided for VHTs to enable all to transmit results through the android phones. ConclusionUse of HS-RDTs increased case findings of low parasite density infections compared to cRDTs in study populations and provides the opportunity to eliminate malaria reservoirs through treatments. There were minimal additional training requirements when the HS-RDT kits were introduced. The observed increased positivity rates among school-age children call for integrating targeted interventions into school health programs.

The Uganda National Malaria Control Programme recognizes the importance of minimizing the effect of malaria among pregnant women. Accordingly, strategies including intermittent preventive treatment of malaria in pregnancy using sulfadoxine-pyrimethamine (IPTp-SP) have been scaled up. Uptake of IPTp-SP among pregnant women in Uganda, aged 15–49 years who had had a live birth 2 years preceding the 2016 Uganda Demographic and Health Survey (UDHS) was determined and factors associated with the uptake of optimal IPTp-SP doses were identified. This was a secondary analysis of the UDHS 2016 dataset. The outcome variable was uptake of IPTp-SP doses among women 15–49 years old who had had a live birth 2 years preceding the survey. Independent variables were residence type, age, marital status, education, wealth status, region of residence, parity, number of antenatal care (ANC) attendance, timing to first ANC visit, and exposure to messages through radio. Logistic regression was used to identify factors associated with the uptake of optimal IPTp-SP doses. Uptake of three or more doses of IPTp-SP was 18%. The likelihood of taking optimal doses of IPTp-SP was increased among those who had attained a secondary-level education (aOR: 1.5, 95% CI 1.04–2.15), those who attended ANC ≥ 4 times (aOR: 1.34, 95% CI 1.12–1.60), and those exposed to radio messages (aOR: 1.23, 95% CI 1.02–1.48). Among those in the age category > 34 years (aOR: 0.70, 95% CI 0.53–0.92), and those who attended first ANC in the third trimester of pregnancy (aOR: 0.58, 95% CI 0.38–0.87) the odds of uptake were decreased. Education status, exposure to radio messages about health and frequency of ANC attendance were associated with increased uptake while timing of first ANC attendance and being > 34 years were associated with decreased uptake. The findings suggest a need to strengthen behaviour change communication among women of child-bearing age in order to improve uptake of IPTp-SP during pregnancy.

Devices to safely transfer fixed amounts of finger prick blood to rapid diagnostic tests (RDTs) pose a significant challenge, especially in non-laboratory settings. Following the success of an “inverted cup device” for transfer of 5 μL blood, a prototype with a conical cup shape was developed for transfer of 20 μL blood, the amount needed for human immunodeficiency virus or human African trypanosomiasis (HAT) RDTs. This study determined the volume of blood transferred by this new blood transfer device (BTD) and compared its ease of use, safety, and acceptability with that of a plastic pipette when used by health workers (HWs) for HAT RDTs in northwestern Uganda. After a half-day training, 48 HWs had used the two BTDs with at least 10 patients. The conical cup BTD effectively transferred a mean of 22.76 μL of blood (standard deviation 3.31 μL). A significantly higher proportion of HWs were able to collect the full amount of blood using the conical cup BTD, as compared with the pipette (92.4% versus 74.2%, P < 0.001). In HW questionnaires, the conical cup BTD scored higher than the pipette in various aspects of ease of use and safety. In addition, HWs preferred the conical cup BTD (79%), indicating that it was easy to handle, made work faster, and increased their confidence in front of the patient. These findings suggest that the design of the conical cup BTD may be adapted for RDTs requiring 20 μL of blood to facilitate safe and accurate blood transfer.

Use of antigen-detecting malaria rapid diagnostic tests (RDTs) has increased exponentially over the last decade. WHO’s Global Malaria Programme, FIND, and other collaborators have established a quality assurance scheme to guide product selection, lot verification, transport, storage, and training procedures. Recent concerns over the quality of buffer packaging and test accessories suggest a need to include these items in product assessments. This paper describes quality problems with buffer and accessories encountered in a project promoting private sector RDT use in five African countries and suggests steps to avoid or more rapidly identify and resolve such problems. Private provider complaints about RDT buffer vials and kit accessories were collected during supervisory visits, and a standard assessment process was developed. Using 100 tests drawn from six different lots produced by two manufacturers, lab technicians visually assessed alcohol swab packaging, blood transfer device (BTD) usability, and buffer appearance, then calculated mean blood volume from 10 BTD transfers and mean buffer volume from 10 individual buffer vials. WHO guided complaint reporting and follow-up with manufacturers. Supervisory visits confirmed user reports of dry alcohol swabs, poorly functioning BTDs, and non-uniform volumes of buffer. Lot testing revealed further evidence of quality problems, leading one manufacturer to replace buffer vials and accessories for 40,000 RDTs. In December 2014, WHO issued an Information Notice for Users regarding variable buffer volumes in single-use vials and recommended against procurement of these products until defects were addressed. Though not necessarily comprehensive or generalizable, the findings presented here highlight the need for extending quality assessment to all malaria RDT test kit contents. Defects such as those described in this paper could reduce test accuracy and increase probability of invalid, false positive, or false negative results. Such deficiencies could undermine provider confidence in RDTs, prompting a return to presumptive treatment or reliance on poor quality microscopy. In partial response to this experience, WHO, FIND, and other project partners have developed guidance on documenting, troubleshooting, reporting, and resolving such problems when they occur.