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In Uganda, spirituality is closely associated with traditional healthcare; however, though prevalent, it is considered controversial, mystical, less documented and often misunderstood. There is a paucity of literature on the description of health, illness, disease, and management approaches among traditional spiritual healers. This article examines the perspectives on health, illness, disease, and management approaches among Baganda traditional spiritual healers, the Balubaale, in Central Uganda, who engage ancestral spirits during health care and management. We used a qualitative study design in particular grounded theory. We used semi-structured, qualitative interviews and observation on 12 male and female purposively selected Balubaale in Central Uganda. Data was transcribed, coded, and thematically analyzed using ATLAS ti. 22 Computer software based on an inductive approach. Findings show that the words and concepts describing health, illness, disease, and management approaches are descriptive and contextualized to include the problem, the prospected root-causes, and the therapeutic approaches involved. The words for illness "olumbe", disease "obulwadde" and the management approaches such as divination (kulagula), ritual cleansing (kwambulula), amulets (ensiriba and yirizi), and scarification (kusandaga) have spiritual and social dimensions, contextual meanings and attachments. Further research is recommended among other tribes and larger sample size to compare findings and terminologies to facilitate communication and policy considerations., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Sekagya et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Acute respiratory illness (ARI) is one of the most common reasons children receive antibiotic treatment. Measurement of C-reaction protein (CRP) has been shown to reduce unnecessary antibiotic use among children with ARI in a range of clinical settings. In many resource-constrained contexts, patients seek care outside the formal health sector, often from lay community health workers (CHW). This study's objective was to determine the impact of CRP measurement on antibiotic use among children presenting with febrile ARI to CHW in Uganda., Methods and Findings: We conducted a cross-sectional, stepped wedge cluster randomized trial in 15 villages in Bugoye subcounty comparing a clinical algorithm that included CRP measurement by CHW to guide antibiotic treatment (STAR Sick Child Job Aid [SCJA]; intervention condition) with the Integrated Community Care Management (iCCM) SCJA currently in use by CHW in the region (control condition). Villages were stratified into 3 strata by altitude, distance to the clinic, and size; in each stratum, the 5 villages were randomly assigned to one of 5 treatment sequences. Children aged 2 months to 5 years presenting to CHW with fever and cough were eligible. CHW conducted follow-up assessments 7 days after the initial visit. Our primary outcome was the proportion of children who were given or prescribed an antibiotic at the initial visit. Our secondary outcomes were (1) persistent fever on day 7; (2) development of prespecified danger signs; (3) unexpected visits to the CHW; (4) hospitalizations; (5) deaths; (6) lack of perceived improvement per the child's caregiver on day 7; and (7) clinical failure, a composite outcome of persistence of fever on day 7, development of danger signs, hospitalization, or death. The 65 participating CHW enrolled 1,280 children, 1,220 (95.3%) of whom had sufficient data. Approximately 48% (587/1,220) and 52% (633/1,220) were enrolled during control (iCCM SCJA) and intervention periods (STAR SCJA), respectively. The observed percentage of children who were given or prescribed antibiotics at the initial visit was 91.8% (539/587) in the control periods as compared to 70.8% (448/633) during the intervention periods (adjusted prevalence difference -24.6%, 95% CI: -36.1%, -13.1%). The odds of antibiotic prescription by the CHW were over 80% lower in the intervention as compared to the control periods (OR 0.18, 95% CI: 0.06, 0.49). The frequency of clinical failure (iCCM SCJA 3.9% (23/585) v. STAR SCJA 1.8% (11/630); OR 0.41, 95% CI: 0.09, 1.83) and lack of perceived improvement by the caregiver (iCCM SCJA 2.1% (12/584) v. STAR SCJA 3.5% (22/627); OR 1.49, 95% CI: 0.37, 6.52) was similar. There were no unexpected visits or deaths in either group within the follow-up period., Conclusions: Incorporating CRP measurement into iCCM algorithms for evaluation of children with febrile ARI by CHW in rural Uganda decreased antibiotic use. There is evidence that this decrease was not associated with worse clinical outcomes, although the number of adverse events was low. These findings support expanded access to simple, point-of-care diagnostics to improve antibiotic stewardship in rural, resource-constrained settings where individuals with limited medical training provide a substantial proportion of care., Trial Registration: ClinicalTrials.gov NCT05294510. The study was reviewed and approved by the University of North Carolina Institutional Review Board (#18-2803), Mbarara University of Science and Technology Research Ethics Committee (14/03-19), and Uganda National Council on Science and Technology (HS 2631)., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Ciccone et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Traditional medicinal knowledge and healing practices of indigenous spiritual healers play important roles in health care, and contribute towards achieving Universal Health Care. Traditional spiritual healers (TSHs) are grouped into three categories. One category of Baganda TSHs, Balubaale, engage ancestral spirits during health management. Balubaale are socially significant but not legally accepted. Their initiation and training practices have not been documented in Uganda. The study purpose was to understand and establish the training of traditional spiritual healers. Twelve (10M, 2F); practicing TSHs in Central Uganda were purposively selected and recruited between 15th July 2019 and 29th April 2020, and were prospectively interacted with for 24 months. Transcribed data was coded and thematically analyzed using ATLAS ti. 22 computer software and presented based on an inductive approach. Findings show key areas of TSHs training include connecting with ancestral spirits and the spiritual powers of non-materials and materials such as living and non-living things through rituals. Spiritual healers train in diagnosis and health management based on ancestral spirits and they finally pass out in a communal ceremony witnessed by family and community members. We conclude that TSHs undergo training and are supervised and supported by experienced spiritualists, family and the community. We recommend similar studies among other ethnic groups to contextualize the process of becoming a TSH, compare and harmonize findings to facilitate inter-medical systems communication and policy considerations., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Sekagya et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: In integrated community case management (iCCM) care, community health workers (CHWs) provide home-based management of fever, diarrhea and fast breathing for children aged <5 y. The iCCM protocol recommends that children with danger signs for severe illness are referred by CHWs to health facilities within their catchment area. This study examines the management of danger signs by CHWs implementing iCCM in a rural context., Methods: A retrospective observational study that examined clinical records for all patients with danger signs evaluated by CHWs from March 2014 to December 2018 was conducted., Results: In total, 229 children aged <5 y had been recorded as having a danger sign during 2014-2018. Of these children, 56% were males with a mean age of 25 (SD 16.9) mo, among whom 78% were referred by the CHWs as per the iCCM protocol. The age category of 12 to 35 mo had the highest numbers of prereferred and referred cases (54% and 46%, respectively)., Conclusions: CHWs play a key role in early symptomatic detection, prereferral treatment and early referral of children aged <5 y. Danger signs among children aged <5 y, if left untreated, can result in death. A high proportion of the children with danger signs were referred as per the iCCM protocol. Continuous CHW training is emphasized to reduce the number of referral cases that are missed. More studies need to focus on children aged 12-35 mo and why they are the most referred category. Policymakers should occasionally revise iCCM guidelines to detail the types of danger signs and how CHWs can address these., (© The Author(s) 2023. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.)

Background: Surgical management of Hirschsprung disease (HD) in low- and middle-income countries is typically a staged procedure, necessitating multiple hospitalizations and clinic visits increasing family financial burden. Currently, there is limited information on the costs borne by caretakers of children with Hirschsprung disease seeking surgical intervention. This study seeks to measure the costs and economic burden of surgical treatment for Hirschsprung disease in western Uganda., Methods: A cross-sectional study using cost analysis was conducted among caretakers of patients who completed surgical treatment of HD between January 2017 and December 2021 at two hospitals in western Uganda. The average direct and indirect costs incurred by caretakers presenting at a public and private hospital were computed., Results: A total of 69 patients (M: F = 7:1) were enrolled in the study. The median age at diagnosis was 60.5 (IQR 3-151.25) days for children and two-staged pull-through procedure was the common surgery performed. The mean overall cost for treatment was US $960 (SD = $720), with the majority of costs coming from direct medical costs. Nearly half (48%) of participants resorted to distress financing to finance their child's surgical care. The overwhelming majority of patients (n = 64, 93%) incurred catastrophic expenditure from the total costs of surgery for HD, and 97% of participants fell below the international poverty line at the time treatment was completed., Conclusion: Despite the availability of 'free care' from government hospital and non-profit services, this study found that surgical management of Hirschsprung disease imposed substantial cost burden on families with Hirschsprung disease patients., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

In Uganda, children with febrile illness are often treated with antibiotics even though most have self-limiting, likely viral, infections. C-reactive protein (CRP) measurement can help identify those who are more likely to have a bacterial infection and therefore need antibiotic treatment. Implementation of a CRP rapid diagnostic test (RDT) at the point-of-care in resource-constrained settings with minimal laboratory infrastructure could reduce unnecessary antibiotic use. In this study, we evaluated the performance of three semi-quantitative CRP RDTs (Actim, BTNX, Duo) against a reference CRP assay requiring an electrically powered analyzer (Afinion). While both tests demonstrated substantial agreement with Afinion, Actim had slightly higher agreement than BTNX. The sensitivity was higher for the BTNX test, whereas the Actim test had a higher specificity, at cut-offs of 40 mg/L and 80 mg/L. At a cut-off of 20 mg/L, Duo demonstrated substantial agreement with the Afinion test as well. Our results demonstrate the reliability of CRP RDTs when compared to a reference standard. CRP RDTs without the need for a laboratory-based analyzer are promising tools for optimizing antibiotic use in low-resource settings., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Cassidy et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Malaria epidemics result from extreme precipitation and flooding, which are increasing with global climate change. Local adaptation and mitigation strategies will be essential to prevent excess morbidity and mortality., Methods: We investigated the spatial risk of malaria infection at multiple timepoints after severe flooding in rural western Uganda employing longitudinal household surveys measuring parasite prevalence and leveraging remotely sensed information to inform spatial models of malaria risk in the 3 months after flooding., Results: We identified clusters of malaria risk emerging in areas (1) that showed the greatest changes in Normalized Difference Vegetation Index from pre- to postflood and (2) where residents were displaced for longer periods of time and had lower access to long-lasting insecticidal nets, both of which were associated with a positive malaria rapid diagnostic test result. The disproportionate risk persisted despite a concurrent chemoprevention program that achieved high coverage., Conclusions: The findings enhance our understanding not only of the spatial evolution of malaria risk after flooding, but also in the context of an effective intervention. The results provide a "proof of concept" for programs aiming to prevent malaria outbreaks after flooding using a combination of interventions. Further study of mitigation strategies-and particularly studies of implementation-is urgently needed., Competing Interests: Potential conflicts of interest. All authors: No reported conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2023. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Coronavirus disease (COVID-19) vaccine hesitancy is a global challenge. In low- and middle-income countries (LMICs), the problem has persisted despite vaccine availability and decreasing infections. In Uganda, there is still limited information on the extent and predictors of vaccine hesitancy. This study sought to assess the prevalence and predictors of COVID-19 vaccine hesitancy, and the effectiveness of an intervention that involved community pharmacy counseling in combating COVID-19 vaccine hesitancy., Methods: A total of 394 participants were enrolled in a 4-week prospective cohort interventional study. The study was conducted across eight community pharmacies in Mbarara City, between 9:00 AM and 5:00 PM daily. The study personnel ascertained the vaccination status of all clients seeking community pharmacy services. All unvaccinated clients were consecutively assessed for eligibility, and eligible clients were systematically enrolled after receiving the community pharmacy services for which they requested. The study intervention involved structured participant counseling (within the pharmacy premise), follow-up short message service (weekly), and telephone calls (bi-weekly). Only participants who did not accept to receive the COVID-19 vaccine despite counseling were followed up for four weeks, or until they accepted to receive a COVID-19 vaccine. The effectiveness of the community pharmacy counseling intervention was determined as an increase in COVID-19 vaccine acceptance, and desirable attitudinal change towards COVID-19 disease, vaccination exercise, and vaccines. Descriptive analysis was used to summarize data, and multivariate analysis was used to determine the predictors of COVID-19 vaccine hesitancy. A p-value < 0.05 was considered statistically significant., Results: Out of 394 participants, 221 (56%) were hesitant to receive a COVID-19 vaccine. Participants expressed several reasons (mean 2±1) for COVID-19 vaccine hesitancy, mostly concerning vaccine safety (N=160, 47.3%). The overall COVID-19 vaccine acceptance rate increased by 25.4 percent points (43.9 - 69.3 percent points) after the study intervention. Age, religion, level of education, distance from the nearest public health facility, having a friend/family diagnosed with COVID-19, and personal suspicion of contracting COVID-19 were significant predictors of COVID-19 vaccine hesitancy., Conclusion: COVID-19 vaccine hesitancy is a big challenge in Uganda. A mix of sociodemographic and COVID-19 vaccine perceptions are the key predictors of COVID-19 vaccine hesitancy. Although COVID-19 vaccines were not available at the time of the study, this study found that structured counseling interventions can improve COVID-19 vaccine acceptance rates. Larger prospective studies should evaluate the effectiveness of similar interventions in community pharmacies and other healthcare settings., (© 2023. The Author(s).)

In rural Uganda where birth dose vaccination for hepatitis B is not routine, we implemented a pilot program for preventing mother-to-child transmission that effectively identified women with high-risk hepatitis B virus (HBV) infection and started antiviral treatment during pregnancy. Further work is required to enhance antiviral adherence through delivery to ensure effective prevention of vertical HBV transmission., Competing Interests: Potential conflicts of interest. P. T. received funding from the National Institutes of Health (grant K08AI148607), the American Society of Tropical Medicine and Hygiene/Burroughs-Wellcome Fund, and Novavax, outside of the current work, as well as research support from Abbott Laboratories and Gilead Sciences, also outside of the current work., (© The Author(s) 2023. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: Current supply shortages constrain yellow fever vaccination activities, particularly outbreak response. Although fractional doses of all WHO-prequalified yellow fever vaccines have been shown to be safe and immunogenic in a randomised controlled trial in adults, they have not been evaluated in a randomised controlled trial in young children (9-59 months old). We aimed to assess the immunogenicity and safety of fractional doses compared with standard doses of the WHO-prequalified 17D-213 vaccine in young children., Methods: This substudy of the YEFE phase 4 study was conducted at the Epicentre Mbarara Research Centre (Mbarara, Uganda). Eligible children were aged 9-59 months without contraindications for vaccination, without history of previous yellow fever vaccination or infection and not requiring yellow fever vaccination for travelling. Participants were randomly assigned, using block randomisation, 1:1 to standard or fractional (one-fifth) dose of yellow fever vaccine. Investigators, participants, and laboratory personnel were blinded to group allocation. Participants were followed for immunogenicity and safety at 10 days, 28 days, and 1 year after vaccination. The primary outcome was non-inferiority in seroconversion (-10 percentage point margin) 28 days after vaccination measured by 50% plaque reduction neutralisation test (PRNT 50 ) in the per-protocol population. Safety and seroconversion at 10 days and 12-16 months after vaccination (given COVID-19 resctrictions) were secondary outcomes. This study is registered with ClinicalTrials.gov, NCT02991495., Findings: Between Feb 20, 2019, and Sept 9, 2019, 433 children were assessed, and 420 were randomly assigned to fractional dose (n=210) and to standard dose (n=210) 17D-213 vaccination. 28 days after vaccination, 202 (97%, 95% CI 95-99) of 207 participants in the fractional dose group and 191 (100%, 98-100) of 191 in the standard dose group seroconverted. The absolute difference in seroconversion between the study groups in the per-protocol population was -2 percentage points (95% CI -5 to 1). 154 (73%) of 210 participants in the fractional dose group and 168 (80%) of 210 in the standard dose group reported at least one adverse event 28 days after vaccination. At 10 days follow-up, seroconversion was lower in the fractional dose group than in the standard dose group. The most common adverse events were upper respiratory tract infections (n=221 [53%]), diarrhoea (n=68 [16%]), rhinorrhoea (n=49 [12%]), and conjunctivitis (n=28 [7%]). No difference was observed in incidence of adverse events and serious adverse events between study groups., Conclusions: Fractional doses of the 17D-213 vaccine were non-inferior to standard doses in inducing seroconversion 28 days after vaccination in children aged 9-59 months when assessed with PRNT 50 , but we found fewer children seroconverted at 10 days. The results support consideration of the use of fractional dose of yellow fever vaccines in WHO recommendations for outbreak response in the event of a yellow fever vaccine shortage to include children., Funding: Médecins Sans Frontières Foundation., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Malaria risk is not uniform across relatively small geographic areas, such as within a village. This heterogeneity in risk is associated with factors including demographic characteristics, individual behaviours, home construction, and environmental conditions, the importance of which varies by setting, making prediction difficult. This study attempted to compare the ability of statistical models to predict malaria risk at the household level using either (i) free easily-obtained remotely-sensed data or (ii) results from a resource-intensive household survey., Methods: The results of a household malaria survey conducted in 3 villages in western Uganda were combined with remotely-sensed environmental data to develop predictive models of two outcomes of interest (1) a positive ultrasensitive rapid diagnostic test (uRDT) and (2) inpatient admission for malaria within the last year. Generalized additive models were fit to each result using factors from the remotely-sensed data, the household survey, or a combination of both. Using a cross-validation approach, each model's ability to predict malaria risk for out-of-sample households (OOS) and villages (OOV) was evaluated., Results: Models fit using only environmental variables provided a better fit and higher OOS predictive power for uRDT result (AIC = 362, AUC = 0.736) and inpatient admission (AIC = 623, AUC = 0.672) compared to models using household variables (uRDT AIC = 376, Admission AIC = 644, uRDT AUC = 0.667, Admission AUC = 0.653). Combining the datasets did not result in a better fit or higher OOS predictive power for uRDT results (AIC = 367, AUC = 0.671), but did for inpatient admission (AIC = 615, AUC = 0.683). Household factors performed best when predicting OOV uRDT results (AUC = 0.596) and inpatient admission (AUC = 0.553), but not much better than a random classifier., Conclusions: These results suggest that residual malaria risk is driven more by the external environment than home construction within the study area, possibly due to transmission regularly occurring outside of the home. Additionally, they suggest that when predicting malaria risk the benefit may not outweigh the high costs of attaining detailed information on household predictors. Instead, using remotely-sensed data provides an equally effective, cost-efficient alternative., (© 2023. The Author(s).)

Background: In rural Uganda a significant number of persons afflicted with pre-diabetes are unaware of the condition. This is likely to lead to diabetic complications resulting in catastrophic health expendirure.The burden of prediabetes in rural Isingiro has not previously been determined. This study examined the prevalence of prediabetes and the associated factors among rural community members., Methods: We conducted a cross-sectional survey and enrolled 370 participants aged between 18 and 70 years in the Kabuyanda sub-county, rural Isingiro district in march 2021. Multistage sampling and systematic random sampling were conducted to select eligible households. Data was collected using a pretested WHO STEP-wise protocol questionnaire. The primary outcome was prediabetes (FBG = 6.1mmol/l to 6.9mmol/l), calculated as a proportion. Participants known to be diabetic or on medication were excluded. Chi-square tests and multivariate logistic regression model were performed for data analysis using STATA., Results: The prevalence of prediabetes was 9.19% (95% CI 6.23-12.14). Independent factors significantly associated with pre-diabetes were; advancing age [AOR = 5.7, 95% CI:1.03-32.30], moderate-intensity work [AOR = 2.6,95% CI:1.23-5.63], high level of consumption of a healthy diet [AOR = 5.7, 95% CI:1.67-19.05] and body mass index [AOR = 3.7, 95% CI:1.41-9.20]., Conclusion: Prediabetes is prevalent among adult community members in rural Isingiro, southwestern Uganda. Age and lifestyle factors predict prediabetes in this rural population, suggesting a need for targeted health promotion interventions., (© 2023. The Author(s).)

This article details the study protocol for a double-blind, randomized placebo-controlled trial to determine the effectiveness of permethrin-treated baby wraps to prevent Plasmodium falciparum malaria infection in children 6-24 months of age. Participating mother-infant dyads will be randomized to receive either a permethrin-treated or a sham-treated wrap, known locally as a "lesu." After a baseline home visit, during which time all participants will receive new long-lasting insecticidal nets, participants will attend scheduled clinic visits every two weeks for a period of 24 weeks. In the event of an acute febrile illness or other symptoms that may be consistent with malaria (e.g., poor feeding, headache, malaise), participants will be instructed to present to their respective study clinic for evaluation. The primary outcome of interest is the incidence of laboratory-confirmed, symptomatic malaria in participating children. Secondary outcomes of interest include: (1) change in children's hemoglobin levels; (2) change in children's growth parameters; (3) prevalence of asymptomatic parasitemia in children; (4) hospitalization for malaria in children; (5) change in the mother's hemoglobin level; and (6) clinical malaria in the mother. Analyses will be conducted using a modified intent-to-treat approach, with woman-infant dyads who attend one or more clinic visits analyzed according to the arm to which they were randomly assigned. This is the first use of an insecticide-treated baby wrap for prevention of malaria in children. The study began recruitment in June 2022 and is ongoing. ClinicalTrials.gov Identifier: NCT05391230, Registered 25 May 2022., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Boyce et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The World Health Organization has promoted "test and treat" guidelines for malaria since 2010, recommending all suspected malaria cases be confirmed with a parasitological test, typically a rapid diagnostic test (RDT), prior to treatment with antimalarial medications. However, many fevers at private drug shops in Uganda continue to be treated presumptively as malaria without diagnostic testing., Methods: The purpose of this study was to document private sector malaria case management in rural Uganda through a cross-sectional survey of drug shop clients in Bugoye sub-county. Drug shop vendors ( n = 46) recorded information about sales interactions with clients reporting fever or requesting antimalarials and collected capillary blood samples from clients who purchased medications without an RDT. We estimated the proportion of clients who purchased an RDT, adhered to the RDT result, and received antimalarials without having laboratory-confirmed malaria., Results: Most drug shops were unlicensed (96%) and sold RDTs (98%). Of 934 clients with suspected malaria who visited study drug shops during the data collection period, only 25% bought an RDT. Since some clients reported previous RDTs from the public sector, 40% of clients were aware of their malaria status at the drug shop. Among those with negative tests, 36% still purchased antimalarials. Sixty-five percent of clients who purchased an antimalarial without an RDT subsequently tested negative., Conclusions: Despite national guidelines, drug shop clients who purchase antimalarials from drug shops in Bugoye are often not tested to confirm a malaria diagnosis prior to treatment. Most clients treated presumptively with antimalarials did not have malaria. Interventions are needed to improve malaria case management and rational drug use in the private sector., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Shelus, Mumbere, Mulogo, Barrington, Baguma, Muhindo, Herrington, Emch, Maman and Boyce.)

Barriers continue to limit access to viral load (VL) monitoring across sub-Saharan Africa adversely impacting control of the HIV epidemic. The objective of this study was to determine whether the systems and processes required to realize the potential of rapid molecular technology are available at a prototypical lower-level (i.e., level III) health center in rural Uganda. In this open-label pilot study, participants underwent parallel VL testing at both the central laboratory (i.e., standard of care) and on-site using the GeneXpert HIV-1 assay. The primary outcome was the number of VL tests completed each clinic day. Secondary outcomes included the number of days from sample collection to receipt of result at clinic and the number of days from sample collection to patient receipt of the result. From August 2020 to July 2021, we enrolled a total of 242 participants. The median number of daily tests performed on the Xpert platform was 4, (IQR = 2-7). Time from sample collection to result was 51 days (IQR = 45-62) for samples sent to the central laboratory and 0 days (IQR = 0-0.25) for the Xpert assay conducted at the health center. However, few participants elected to receive results by one of the expedited options, which contributed to similar time-to-patient between testing approaches (89 versus 84 days, p = 0.07). Implementation of a rapid, near point-of-care VL assay at a lower-level health center in rural Uganda appears feasible, but interventions to promote rapid clinical response and influence patient preferences about result receipt require further study. Trial registration: ClinicalTrials.gov Identifier: NCT04517825, Registered 18 August 2020. Available at: https://clinicaltrials.gov/ct2/show/NCT04517825., Competing Interests: Xpert HIV VL cartridges were supplied by Cepheid at no cost to the study. There are no patents, products in development or marketed products associated with this research to declare. This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2023 Boyce et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The World Health Organization recommends all suspected malaria cases be confirmed with a parasitological test, typically a rapid diagnostic test (RDT), prior to treatment. Despite recommendations, many fevers presenting at private drug shops are treated presumptively as malaria without diagnostic testing. The purpose of this qualitative study was to describe community perceptions of RDTs and explore ways to improve malaria case management at drug shops in Bugoye, western Uganda. A total of 63 in-depth interviews were conducted between September and December 2021 with 24 drug shop clients, 19 drug shop vendors, 12 community health workers, and 8 health and community officials. Data was analyzed using thematic content analysis and narrative techniques. While drug shop clients valued RDTs, the cost of the test limited their use. Further, mistrust in negative results and fear about treatment options for conditions other than malaria led to nonadherence to negative RDTs. Improvement with antimalarials after a negative RDT, or no RDT at all, was seen as proof an individual had malaria, reinforcing the acceptability of liberal antimalarial use. Drug shop vendors were knowledgeable about malaria case management but financially conflicted between recommending best practices and losing business. While clients viewed drug shop vendors as trusted health professionals, health officials distrusted them as business owners focused on maximizing profits. Study results suggest public-private partnerships that recognize the essential role of drug shops, better incorporate them into the healthcare system, and leverage the high levels of community trust in vendors, could provide greater opportunities for oversight and training to improve private-sector malaria case management. Interventions that address financial barriers to RDT use, emphasize the financial benefits of malaria testing, increase vendor knowledge about illnesses confused with malaria, and improve the quality of vendor-client counseling could increase RDT uptake and improve adherence to RDT results., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Shelus et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The control of malaria, pneumonia, and diarrhoea is important for the reduction in morbidity and mortality among children under 5 years. Uganda has adopted the Integrated Community Case Management strategy using Community Health Workers (CHWs) to address this challenge. The extent and trend of these three conditions managed by the CHWs are not well documented. This study was done to describe the epidemiology and trends of the three common illnesses treated by the CHWs in Bugoye Sub-County in rural Uganda., Methods: A retrospective review of monthly morbidity data for children less than 5 years of age for the period April 2014-December 2018 for CHWs in rural Bugoye Sub-County in Kasese district, Uganda was done. The total number reviewed was 18,430 records. The data were analysed using STATA version 14., Results: In total male were 50.2% of the sample, pneumonia was the highest cause of illness among the infants (< 1 year), while malaria was the highest among the children 1 year-59 months. Infection with a single illness was the commonest recorded cause of presentation but there were some children recorded with multiple illnesses. All the CHWs were managing the three common illnesses among children under 5 years. The trend of the three common illnesses was changing from malaria to pneumonia being the commonest. Children aged 12-24 months and 25-59 months were at 2.1 times (95% CI 1.7-2.4) and 5.2 times (95% CI 4.6-5.9), respectively, more likely to get malaria but less likely to get pneumonia and diarrhoea., Conclusion: Community Health Workers in rural Uganda are contributing significantly to the management of all the three commonest illnesses among under-5 years-old children. The trend of the commonest illness is changing from malaria to pneumonia. Children under 1 year are at a higher risk of getting pneumonia and diarrhoea and at a lower risk of getting malaria., (© 2022. The Author(s).)

Background: Malaria epidemics are a well-described phenomenon after extreme precipitation and flooding. Yet, few studies have examined mitigation measures to prevent post-flood malaria epidemics., Methods: We evaluated a malaria chemoprevention program implemented in response to severe flooding in western Uganda. Children aged ≤12 years from 1 village were eligible to receive 3 monthly rounds of dihydroartemisinin-piperaquine (DP). Two neighboring villages served as controls. Malaria cases were defined as individuals with a positive rapid diagnostic test result as recorded in health center registers. We performed a difference-in-differences analysis to estimate changes in the incidence and test positivity of malaria between intervention and control villages., Results: A total of 554 children received at least 1 round of chemoprevention, with 75% participating in at least 2 rounds. Compared with control villages, we estimated a 53.4% reduction (adjusted rate ratio [aRR], 0.47; 95% confidence interval [CI]: .34-.62; P < .01) in malaria incidence and a 30% decrease in the test positivity rate (aRR, 0.70; 95% CI: .50-.97; P = .03) in the intervention village in the 6 months post-intervention. The impact was greatest among children who received the intervention, but decreased incidence was also observed in older children and adults (aRR, 0.57; 95% CI: .38-.84; P < .01)., Conclusions: Three rounds of chemoprevention with DP delivered under pragmatic conditions reduced the incidence of malaria after severe flooding in western Uganda. These findings provide a proof-of-concept for the use of malaria chemoprevention to reduce excess disease burden associated with severe flooding., (© The Author(s) 2021. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Background: Despite the availability of a highly effective vaccine, measles remains a substantial public health problem in many countries including Uganda. In this study, conducted between June-August 2020 following a local outbreak, we sought to explore the factors that could affect measles vaccination coverage in rural western Uganda., Methods: We conducted a descriptive study using qualitative data collection approaches in the Kasese district. The research team utilized purposive sampling to identify and select participants from the public health sector and district government. We conducted key informant interviews (KII) and one focus group discussion (FGD). Responses were recorded using portable electronic devices with the FGD and KII guide installed. Interviews were conducted at the health centre and district headquarters. Data was coded and analysed using ATLAS.ti version 8 software through deductive thematic analysis to identify key themes., Results: Barriers to measles vaccination identified in this study were premised around six themes including: (i) availability of supplies and stock management, (ii) health worker attitudes and workload, (iii) financing of vaccination outreach activities, (iv) effectiveness of duty rosters (i.e., health workers' working schedules), (v) community beliefs, and (vi) accessibility of healthcare facilities. Respondents reported frequent vaccine supply disruptions, lack of resources to facilitate transportation of health workers to communities for outreach events, and health centre staffing that did not adequately support supplemental vaccination activities. Furthermore, community dependence on traditional medicine as a substitute for vaccines and long distances traveled by caregivers to reach a health facility were mentioned as barriers to vaccination uptake., Conclusions: Health system barriers limiting vaccination uptake were primarily logistical in nature and reflect inadequate resourcing of immunization efforts. At the same time, local beliefs favouring traditional medicine remain a persistent cultural barrier. These findings suggest an urgent need for more efficient supply management practices and resourcing of immunization outreaches in order to achieve the Uganda Ministry of Health's targets for childhood immunization and the prevention of disease outbreaks., (© 2022. The Author(s).)

Objective: Integrated community case management (iCCM) of childhood illness in Uganda involves protocol-based care of malaria, pneumonia and diarrhoea for children under 5 years old. This study assessed volunteer village health workers' (VHW) ability to provide correct iCCM care according to the national protocol and change in their performance over time since initial training., Setting: VHWs affiliated with the Ugandan national programme provide community-based care in eight villages in Bugoye Subcounty, a rural area in Kasese District. The first cohort of VHWs began providing iCCM care in March 2013, the second cohort in July 2016., Participants: All children receiving iCCM care in 18 430 clinical encounters occurring between April 2014 and December 2018., Primary and Secondary Outcome Measures: The descriptive primary outcome measure was the proportion of patients receiving overall correct care, defined as adherence to the iCCM protocol for the presenting condition (hereafter quality of care). The analytic primary outcome was change in the odds of receiving correct care over time, assessed using logistic regression models with generalised estimating equations. Secondary outcome measures included a set of binary measures of adherence to specific elements of the iCCM protocol. Preplanned and final measures were the same., Results: Overall, VHWs provided correct care in 74% of clinical encounters. For the first cohort of VHWs, regression modelling demonstrated a modest increase in quality of care until approximately 3 years after their initial iCCM training (OR 1.022 per month elapsed, 95% CI 1.005 to 1.038), followed by a modest decrease thereafter (OR 0.978 per month, 95% CI 0.970 to 0.986). For the second cohort, quality of care was essentially constant over time (OR 1.007 per month, 95% CI 0.989 to 1.025)., Conclusion: Quality of care was relatively constant over time, though the trend towards decreasing quality of care after 3 years of providing iCCM care requires further monitoring., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Progress against malaria has stalled and may even be slipping backwards in high-burden countries. This is due to a range of factors including insecticide resistance and mosquito feeding behaviours that limit contact with widely-employed interventions including long-lasting insecticidal nets and indoor-residual spraying. Thus, further innovations in malaria control are urgently needed., Methods: The pilot was a randomized, placebo-controlled pilot study of permethrin-treated baby wraps-known locally as lesus-in children 6-18 months of age at a single site in rural western Uganda. Fifty mother-infant pairs were assigned to permethrin-treated or untreated lesus in a 1:1 allocation. Participants and clinical staff were blinded to group assignments through use of sham treatment and re-treatment of lesus. Participants attended scheduled clinic visits every 2 weeks for a total 12 weeks. The primary outcome of interest was the safety of the intervention, assessed as changes in the frequency of use, rates of discontinuation, and incidence of adverse events, such as skin rash. Secondary outcomes included acceptability and feasibility of the intervention as measured through participant satisfaction and completion of study activities, respectively., Results: Overall, rates of retention and participation were relatively high with 86.0% (43 of 50) of participants completing all scheduled visits, including 18 (75.0%) and 25 (96.2%) in the intervention and control arms respectively. By the conclusion of the 12-week follow-up period, one adverse event (0.35 events per 100 person-weeks, one-sided 95% CI 0.0-1.65) was reported. Satisfaction with the lesu was high in both groups. In each study arm, there were five incident RDT positive results, but the only PCR-positive results were observed in the control group (n = 2)., Conclusions: Permethrin-treated baby wraps were well-tolerated and broadly acceptable. Adverse events were infrequent and mild. These findings support future trials seeking to determine the efficacy of treated wraps to prevent P. falciparum malaria infection in young children as a complementary tool to existing household-based interventions., Trial Registration: ClinicalTrials.gov Identifier: NCT04102592, Registered 25 September 2019. Available at: https://clinicaltrials.gov/ct2/show/NCT04102592., (© 2022. The Author(s).)

Globally, billions of people still lack access to safe water, including basic drinking water services, particularly in sub-Saharan Africa. We analyzed water quality for improved water sources and associated factors in Kibuku district, Eastern Uganda. The mixed-methods study employed included; water quality analysis, a questionnaire survey, and key informant interviews conducted in the months of April-June 2020. A total of 249 improved water sources were sampled for analysis of bacteriological quality, pH, and electrical conductivity. This was followed by a sanitary and people's attitudes survey at all the water sources visited. Among the water sources, 62.3% deep boreholes, 63.5% public tap stands, 14.3% rain-water harvesting tanks, and 28.6% protected springs had zero thermotolerant coliforms with 63.8% having acceptable pH levels (6.5-8.5) and 35.3% having acidic levels (less than 6.4). Furthermore, 96.3% deep boreholes, 99.1% public tap stands, all (100%) rain-water harvesting tanks, and 50% protected springs had their turbidity levels in the acceptable range (less than 5NTUs). Additionally, only 22.1% of improved water sources had electrical conductivity in the acceptable range (less than 300 microSiemens). Among the 249 participants, majority (91.2%) had low knowledge levels about various methods that can be used in improving the quality of water. Generally, water sources had poor quality of water which was attributed to agricultural activities, dirty water collection containers, and poor attitude to water chlorination. The Ministry of Health, Ministry of Water and Environment, and other agencies need to design sustainable and feasible models for water treatment for low resourced setting., Competing Interests: Conflict of interestAll authors declare no competing interests., (© The Author(s), under exclusive licence to Springer Nature Switzerland AG 2022.)

Background: Malaria, pneumonia and diarrhoea continue to be the leading causes of death in children under the age of five years (U5) in Uganda. To combat these febrile illnesses, integrated community case management (iCCM) delivery models utilizing community health workers (CHWs) or drug sellers have been implemented. The purpose of this study is to compare the cost-effectiveness of delivering iCCM interventions via drug sellers versus CHWs in rural Uganda., Methods: This study was a cost-effectiveness analysis to compare the iCCM delivery model utilizing drug sellers against the model using CHWs. The effect measure was the number of appropriately treated U5 children, and data on effectiveness came from a quasi-experimental study in Southwestern Uganda and the inSCALE cross-sectional household survey in eight districts of mid-Western Uganda. The iCCM interventions were costed using the micro-costing (ingredients) approach, with costs expressed in US dollars. Cost and effect data were linked together using a decision tree model and analysed using the Amua modelling software., Results: The costs per 100 treated U5 children were US$591.20 and US$298.42 for the iCCM trained-drug seller and iCCM trained-CHW models, respectively, with 30 and 21 appropriately treated children in the iCCM trained-drug seller and iCCM trained-CHW models. When the drug seller arm (intervention) was compared to the CHW arm (control), an incremental effect of 9 per 100 appropriately treated U5 children was observed, as well as an incremental cost of US$292.78 per 100 appropriately treated children, resulting in an incremental cost-effectiveness ratio (ICER) of US$33.86 per appropriately treated U5 patient., Conclusion: Since both models were cost-effective compared to the do-nothing option, the iCCM trained-drug seller model could complement the iCCM trained-CHW intervention as a strategy to increase access to quality treatment., (© 2021. The Author(s).)

Background: Long-lasting insecticidal nets (LLINs) remain a cornerstone of malaria control, but strategies to sustain universal coverage and high rates of use are not well-defined. A more complete understanding of context-specific factors, including transmission intensity and access to health facilities, may inform sub-district distribution approaches and tailored messaging campaigns., Methods: A cross-sectional survey of 2190 households was conducted in a single sub-county of western Uganda that experiences highly variable malaria transmission intensity. The survey was carried out approximately 3 years after the most recent mass distribution campaign. At each household, study staff documented reported LLIN use and source among children 2 to 10 years of age and performed a malaria rapid diagnostic test. Elevation and distance to the nearest health facility was estimated for each household. Associations between parasite prevalence and LLIN use were estimated from log binomial regression models with elevation and distance to clinic being the primary variables of interest., Results: Overall, 6.8% (148 of 2170) of children age 2-10 years of age had a positive RDT result, yielding a weighted estimate of 5.8% (95% confidence interval [CI] 5.4-6.2%). There was substantial variability in the positivity rates among villages, with the highest elevation villages having lower prevalence than lowest-elevation villages (p < .001). Only 64.7% (95% CI 64.0-65.5%) of children were reported to have slept under a LLIN the previous night. Compared to those living < 1 km from a health centre, households at ≥ 2 km were less likely to report the child sleeping under a LLIN (RR 0.86, 95% CI 0.83-0.89, p < .001). Households located farther from a health centre received a higher proportion of LLINs from government distributions compared to households living closer to health centres., Conclusions: LLIN use and sourcing was correlated with household elevation and estimated distance to the nearest health facility. The findings suggest that current facility-based distribution strategies are limited in their reach. More frequent mass distribution campaigns and complementary approaches are likely required to maintain universal LLIN coverage and high rates of use among children in rural Uganda.

We enrolled 250 febrile children in western Uganda to compare the results of malaria rapid diagnostic tests (RDTs) when using capillary vs venous blood. Participants were tested with 4 different RDT types. Polymerase chain reaction testing was performed as the reference standard. Sensitivity and specificity were broadly similar across RDT types and sampling method. Agreement between sample type was high, ranging from 0.95 to 0.99. When following the manufacturer's recommended interpretation, only 5 tests would have resulted in a different clinical diagnosis. These results demonstrate that malaria RDTs perform similarly when using capillary or venous blood in febrile children with Plasmodium falciparum malaria., (© The Author(s) 2021. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Background: Measles outbreaks are prevalent throughout sub-Saharan Africa despite the preventive measures like vaccination that target under five-year-old children and health systems strengthening efforts like prioritizing the supply chain for supplies. Measles immunization coverage for Kasese district and Bugoye HC III in 2018 was 72 and 69%, respectively. This coverage has been very low and always marked red in the Red categorization (below the national target/poor performing) on the national league table indicators. The aim of this study was to assess the scope of the 2018-2019 measles outbreak and the associated risk factors among children aged 0-60 months in Bugoye sub-county, Kasese district, western Uganda., Methods: We conducted a retrospective unmatched case-control study among children aged 0-60 months with measles (cases) who had either a clinical presentation or a laboratory confirmation (IgM positivity) presenting at Bugoye Health Centre III (BHC) or in the surrounding communities between December 2018 and October 2019.. Caregivers of the controls (whose children did not have measles) were selected at the time of data collection in July 2020. A modified CDC case investigation form was used in data collection. Quantitative data was collected and analyzed using Microsoft excel and STATA version 13. The children's immunization cards and health registers at BHC were reviewed to ascertain the immunization status of the children before the outbreak., Results: An extended measles outbreak occurred in Bugoye, Uganda occured between December 2018 and October 2019. All 34 facility-based measles cases were documented to have had maculopapular rash, conjunctivitis, and cough. Also, the majority had fever (97%), coryza (94.1%), lymphadenopathy (76.5%), arthralgias (73.5%) and Koplik Spots (91.2%) as documented in the clinical registers. Similar symptoms were reported among 36 community-based cases. Getting infected even after immunized, low measles vaccination coverage were identified as the principal risk factors for this outbreak., Conclusion: Measles is still a significant problem. This study showed that this outbreak was associated with under-vaccination. Implementing a second routine dose of measles-rubella vaccine would not only increase the number of children with at least one dose but also boost the immunity of those who had the first dose.

Background: In Integrated Community Case Management (iCCM), village health workers (VHW) assess and treat malaria, pneumonia and diarrhea using a clinical algorithm. Study objectives included: 1) Compare VHWs' performance on case scenario exercises to record review data; 2) assess impact of formal education on performance in the case scenario exercises., Methods: 36 VHWs in Bugoye Subcounty, Uganda completed the case scenarios exercise, which included video case scenarios and brief oral case vignettes, between July 2017 and February 2018. We obtained clinical records for all iCCM encounters in the same time period., Results: In the video case scenarios, 45% of mock patients received all correct management steps (including all recommended education), while 94% received all critical management steps. Based on the level of data available from record review, 74% of patients in the record review dataset received overall correct management compared to 94% in the video case scenarios. In the case scenarios, VHWs with primary school education performed similarly to those with some or all secondary school education., Conclusions: The case scenarios produced higher estimates of quality of care than record review. VHWs often omitted recommended health education topics in the case scenarios. Level of formal education did not appear to influence performance in the case scenarios., (© The Author(s) 2020. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.)

Background: CRISPR-based diagnostics are a new class of highly sensitive and specific assays with multiple applications in infectious disease diagnosis. SHERLOCK, or Specific High-Sensitivity Enzymatic Reporter UnLOCKing, is one such CRISPR-based diagnostic that combines recombinase polymerase pre-amplification, CRISPR-RNA base-pairing, and LwCas13a activity for nucleic acid detection., Methods: We developed SHERLOCK assays capable of detecting all Plasmodium species known to cause human malaria and species-specific detection of P. vivax and P. falciparum, the species responsible for the majority of malaria cases worldwide. We further tested these assays using a diverse panel of clinical samples from the Democratic Republic of the Congo, Uganda, and Thailand and pools of Anopheles mosquitoes from Thailand. In addition, we developed a prototype SHERLOCK assay capable of detecting the dihydropteroate synthetase (dhps) single nucleotide variant A581G associated with P. falciparum sulfadoxine resistance., Findings: The suite of Plasmodium assays achieved analytical sensitivities ranging from 2•5-18•8 parasites per reaction when tested against laboratory strain genomic DNA. When compared to real-time PCR, the P. falciparum assay achieved 94% sensitivity and 94% specificity during testing of 123 clinical samples. Compared to amplicon-based deep sequencing, the dhps SHERLOCK assay achieved 73% sensitivity and 100% specificity when applied to a panel of 43 clinical samples, with false-negative calls only at lower parasite densities., Interpretation: These novel SHERLOCK assays demonstrate the versatility of CRISPR-based diagnostics and their potential as a new generation of molecular tools for malaria diagnosis and surveillance., Funding: National Institutes of Health (T32GM007092, R21AI148579, K24AI134990, R01AI121558, UL1TR002489, P30CA016086)., Competing Interests: Declaration of Competing Interest JBP reports research support from Gilead Sciences and non-financial support from Abbott Laboratories for providing reagents and laboratory testing in-kind for studies of viral hepatitis and financial support from the World Health Organization, outside the scope of the current work., (Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: In some areas of Uganda, village health workers (VHW) deliver Integrated Community Case Management (iCCM) care, providing initial assessment of children under 5 years of age as well as protocol-based treatment of malaria, pneumonia, and diarrhoea for eligible patients. Little is known about community perspectives on or satisfaction with iCCM care. This study examines usage of and satisfaction with iCCM care as well as potential associations between these outcomes and time required to travel to the household's preferred health facility., Methods: A cross-sectional household survey was administered in a rural subcounty in western Uganda during December 2016, using a stratified random sampling approach in villages where iCCM care was available. Households were eligible if the household contained one or more children under 5 years of age., Results: A total of 271 households across 8 villages were included in the final sample. Of these, 39% reported that it took over an hour to reach their preferred health facility, and 73% reported walking to the health facility; 92% stated they had seen a VHW for iCCM care in the past, and 55% had seen a VHW in the month prior to the survey. Of respondents whose households had sought iCCM care, 60% rated their overall experience as "very good" or "excellent," 97% stated they would seek iCCM care in the future, and 92% stated they were "confident" or "very confident" in the VHW's overall abilities. Longer travel time to the household's preferred health facility did not appear to be associated with higher propensity to seek iCCM care or higher overall satisfaction with iCCM care., Conclusions: In this setting, community usage of and satisfaction with iCCM care for malaria, pneumonia, and diarrhoea appears high overall. Ease of access to facility-based care did not appear to impact the choice to access iCCM care or satisfaction with iCCM care.

Background: Stocks of yellow fever vaccine are insufficient to cover exceptional demands for outbreak response. Fractional dosing has shown efficacy, but evidence is limited to the 17DD substrain vaccine. We assessed the immunogenicity and safety of one-fifth fractional dose compared with standard dose of four WHO-prequalified yellow fever vaccines produced from three substrains., Methods: We did this randomised, double-blind, non-inferiority trial at research centres in Mbarara, Uganda, and Kilifi, Kenya. Eligible participants were aged 18-59 years, had no contraindications for vaccination, were not pregnant or lactating, had no history of yellow fever vaccination or infection, and did not require yellow fever vaccination for travel. Eligible participants were recruited from communities and randomly assigned to one of eight groups, corresponding to the four vaccines at standard or fractional dose. The vaccine was administered subcutaneously by nurses who were not masked to treatment, but participants and other study personnel were masked to vaccine allocation. The primary outcome was proportion of participants with seroconversion 28 days after vaccination. Seroconversion was defined as post-vaccination neutralising antibody titres at least 4 times pre-vaccination measurement measured by 50% plaque reduction neutralisation test (PRNT 50 ). We defined non-inferiority as less than 10% decrease in seroconversion in fractional compared with standard dose groups 28 days after vaccination. The primary outcome was measured in the per-protocol population, and safety analyses included all vaccinated participants. This trial is registered with ClinicalTrials.gov, NCT02991495., Findings: Between Nov 6, 2017, and Feb 21, 2018, 1029 participants were assessed for inclusion. 69 people were ineligible, and 960 participants were enrolled and randomly assigned to vaccine manufacturer and dose (120 to Bio-Manguinhos-Fiocruz standard dose, 120 to Bio-Manguinhos-Fiocruz fractional dose, 120 to Chumakov Institute of Poliomyelitis and Viral Encephalitides standard dose, 120 to Chumakov Institute of Poliomyelitis and Viral Encephalitides fractional dose, 120 to Institut Pasteur Dakar standard dose, 120 to Institut Pasteur Dakar fractional dose, 120 to Sanofi Pasteur standard dose, and 120 to Sanofi Pasteur fractional dose). 49 participants had detectable PRNT 50 at baseline and 11 had missing PRNT 50 results at baseline or 28 days. 900 were included in the per-protocol analysis. 959 participants were included in the safety analysis. The absolute difference in seroconversion between fractional and standard doses by vaccine was 1·71% (95% CI -2·60 to 5·28) for Bio-Manguinhos-Fiocruz, -0·90% (-4·24 to 3·13) for Chumakov Institute of Poliomyelitis and Viral Encephalitides, 1·82% (-2·75 to 5·39) for Institut Pasteur Dakar, and 0·0% (-3·32 to 3·29) for Sanofi Pasteur. Fractional doses from all four vaccines met the non-inferiority criterion. The most common treatment-related adverse events were headache (22·2%), fatigue (13·7%), myalgia (13·3%) and self-reported fever (9·0%). There were no study-vaccine related serious adverse events., Interpretation: Fractional doses of all WHO-prequalified yellow fever vaccines were non-inferior to the standard dose in inducing seroconversion 28 days after vaccination, with no major safety concerns. These results support the use of fractional dosage in the general adult population for outbreak response in situations of vaccine shortage., Funding: The study was funded by Médecins Sans Frontières Foundation, Wellcome Trust (grant no. 092654), and the UK Department for International Development. Vaccines were donated in kind., (Copyright © 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Village health workers (VHWs) in Bugoye subcounty, Uganda, provide integrated community case management (iCCM) care to children younger than 5 years for malaria, pneumonia, and diarrhea. We assessed the longevity of VHWs' skills in performing and reading malaria rapid diagnostic tests (RDTs) 4 years after initial training, comparing VHWs who had completed initial iCCM training 1 year before the study with VHWs who had completed training 4 years before the study. Both groups received quarterly refresher trainings. Trained interviewers observed 36 VHWs reading six mock RDTs each and performing an RDT as part of a larger skills assessment exercise. VHWs read 97% of mock RDTs correctly; of the 36 VHWs, 86% read all six mock RDTs correctly. Most VHWs scored either 12/13 or 13/13 on the RDT checklist (39% and 36%, respectively), with 25% scoring 11/13 or lower. For reading mock RDTs, VHWs in the first group (initial training 4 years before study) read 97% of mock RDTs correctly, whereas those in the second group (initial training 1 year before study) read 96% of mock RDTs correctly; the first group had a mean of 5.83 RDTs read correctly, compared with 5.77 RDTs read correctly in the second group ( P = 0.83). For performing an RDT, the first group completed a mean of 12.0 steps correctly, compared with a mean of 12.2 correct steps in the second group ( P = 0.60). Overall, VHWs demonstrated proficiency in reading RDTs accurately and performing RDTs according to protocol at least 4 years after initial iCCM training.

Background: The spatial distribution and burden of dengue in sub-Saharan Africa remains highly uncertain, despite high levels of ecological suitability. The goal of this study was to describe the epidemiology of dengue among a cohort of febrile children presenting to outpatient facilities located in areas of western Uganda with differing levels of urbanicity and malaria transmission intensity., Methods: Eligible children were first screened for malaria using rapid diagnostic tests. Children with a negative malaria result were tested for dengue using a combination NS1/IgM/IgG rapid test (SD Bioline Dengue Duo). Confirmatory testing by RT-PCR was performed in a subset of participants. Antigen-capture ELISA was performed to estimate seroprevalence., Results: Only 6 of 1416 (0.42%) children had a positive dengue rapid test, while none of the RT-PCR results were positive. ELISA testing demonstrated reactive IgG antibodies in 28 (2.2%) participants with the highest prevalence seen at the urban site in Mbarara (19 of 392, 4.9%, p < 0.001)., Conclusions: Overall, these findings suggest that dengue, while present, is an uncommon cause of non-malarial, pediatric febrile illness in western Uganda. Further investigation into the eocological factors that sustain low-level transmission in urban settings are urgently needed to reduce the risk of epidemics.

Background: Control of Rubella and Congenital Rubella Syndrome using vaccination has shown great success in the America's. Uganda is due to introduce the Rubella vaccine however the magnitude of transmission is not well documented. Therefore this study was done to determine IgM sero-prevalance for Rubella in order to help monitor vaccine effectiveness post introduction of the vaccine in routine vaccination programme., Methods: A retrospective review of suspected measles cases data for the reporting period January 2007 to December 2016 in Uganda was Done. rubella IgM testing was done on 15,296 of the cases and the data was analyzed using STATA version 13., Results: In total 15,296 cases were tested and 4255 (27.8%) tested positive and among females aged 15-49 years 88 out of 322 (27%) tested positive. The age distribution range was 0-80 years, rubella IgM positivity was reported in all the 15 regions of Uganda and throughout the ten year period in every month. Age group 5-15 years had OR 2.5 p-value < 0.001 of being rubella IgM positive compared to age < 5 years and testing measles IgM negative OR 6.3 p-value < 0.001., Conclusion: Rubella is endemic in Uganda and although rubella IgM positivity is highest in the age 5-15 years even the younger, older and women of reprodutive age are affected. This means the risk of Congenital Rubella Syndrome is high hence the need to introduce the rubella vaccine for infants and pregnant mothers and continued surveillance to enhance its control.

There is a paucity of information on the state of water, sanitation, and hygiene (WASH) at health care facilities in Uganda. A survey on WASH service availability was conducted at 50 health care facilities across 4 districts of rural southwestern Uganda between September and November 2015. The main water points at the majority (94%) of the health care facilities were improved sources, while improved toilets were available at 96% of the health care facilities visited. Hospitals had the poorest toilet to patient ratio (1 : 63). Only 38% of the health care facilities had hand washing facilities at the toilets. The lack of hand washing facilities was most prominent at the level IV health centre toilets (71%). Hand washing facilities were available at other points within most (76%) of the health care facilities. However, both water and soap were present at only 24% of these health care facilities. The poor toilet to patient/caregiver ratios particularly in the high volume health care facilities calls for the provision of cheaper options for improved sanitation in these settings. Priority should also be given to the sustainable provision of hygiene amenities such as soap for hand washing particularly the high patient volume health care facilities, in this case the level IV health centres and hospitals.

Objective: To determine frequency of palatal fistula following primary cleft palate repair and the associated factors as a measure of cleft palate repair outcome and its challenges at a cleft centre in Uganda., Results: Between May and December 2016, 54 children with cleft palate were followed up at Comprehensive Rehabilitation services of Uganda (CoRSU) hospital, from time of primary cleft palate repair until at least 3 months postoperative to determine whether they developed palatal fistula or not. Frequency of palatal fistula was 35%. Factors associated with increased fistula formation were cleft width wider than 12 mm (p = 0.006), palatal index greater than 0.4 (p = 0.046), presence of malnutrition at initial outpatient assessment (p = 0.0057) and at time of surgery (p = 0.008), two-stage palate repair (p = 0.005) and postoperative infection (p = 0.003). Severe clefting (palatal index greater than 0.4) was seen in 74% of patients and malnutrition (Low weight for age) seen in 48% of patients. Palatal fistula rates at our institution were high compared to reports in literature. The high proportions of severe clefting and malnutrition observed in our population that was also poor and unable to afford feeding supplements increased likelihood of fistula formation and posed challenges to achieving low fistula rates in our setting.

Background: Treatment completion among tuberculosis patients remains low across various regions of Uganda, despite implementation of directly observed treatment short course. This study evaluated the determinants of treatment completion in a rural health sub-district of south western Uganda., Methods: In April 2012, health facility records were reviewed to identify tuberculosis patients who had been initiated on treatment between June 2008 and May 2011, in Rwampara Health Sub-District, south-western Uganda. Out of the 162 patients identified, 128 (79%) were traced and subsequently interviewed during a survey conducted in June 2012. Eleven (6.8%) of the 162 patients died, while 23 (14.2%) could not be traced. A review of records showed that 17 of those that could not be traced completed treatment while the other six did not have definitive records., Results: Treatment completion among the 128 patients interviewed was 89.8%. Pre-treatment counselling (aOR = 24.3, 95% CI: 1.4-26.6, P = 0.03), counselling at the time of submission of sputum during follow up (aOR = 6.8, 95% CI: 1.4-33.7, P = 0.02), and refill of drugs on the exact appointment date (aOR = 13.4, 95% CI: 1.9-93.0, P = 0.01), were independently associated with treatment completion., Conclusions: The level of treatment completion was higher than the national average, with service- related determinants identified as being critical for ensuring treatment completion. These data provide further evidence for the need to provide ongoing counselling support to tuberculosis patients. Enhancing the opportunities for counselling of tuberculosis patients should therefore be rigorously promoted as an approach to increase treatment completion in rural settings.

Background: In Uganda, geographical distribution of blood groups and Rhesus (D) factor varies across the country. The aim of this study was to examine the distribution of these groups among voluntary blood donors in rural southwestern Uganda., Results: Twenty-three thousand five hundred four (23,504) blood donors were included in the study. The donors had a mean age of 21 years (SD ± 5.7) and were mainly male (73%). The distribution of ABO blood group was; blood group O (50.3%); blood group A (24.6%); blood group B (20.7%) and blood group AB (4.5%). The proportions of Rhesus (D) positive and Rhesus (D) negative were 98 and 2% respectively. The proportion of non-adult donors (<18 years) was significantly higher among the female than the male donors (p value <0.001). A significantly higher proportion of males than females were Rhesus (D) negative (p-value <0.001). No significant relationship was found between age and blood group distribution., Conclusion: The sequence of ABO distribution among the rural population in southwestern Uganda is; O > A > B > AB, with males as the predominant donors. The frequency of Rhesus (D) negative is very low in rural southwestern Ugandan and is mainly among males. The blood bank services in southwestern Uganda need to develop innovative strategies targeting female donors who are more likely to boost blood stocks in the region.

Home-based human immunodeficiency virus (HIV) voluntary counseling and testing (VCT) in Uganda is being promoted to increase coverage, in addition to main stay approach of service provision through health facilities. The aim of this study was to compare self reported risk reduction behavior among clients receiving facility and home-based HIV VCT within a rural context. Pre-post intervention client surveys were conducted in November 2007 (baseline) and March 2008 (follow up) in southwestern Uganda. The facility-based VCT intervention was provided to 500 clients and home-based VCT to 494 clients at baseline, in 2 different sub-counties. A total of 76% (759/994) of these clients were interviewed at the follow up visit. The respondents who received facility-based VCT were more likely to report abstinence (adjusted Odds Ratio [aOR]=1.47, 95% CI 1.074, 2.02), reducing multi sexual relationships (aOR=3.23, 95% CI 2.02, 5.16) and more frequent use of condoms (aOR=3.14, 95% CI 1.60, 6.18). However, they were less likely to report, discussing HIV (aOR=0.63, 95% CI 0.46, 0.85) with their sexual partner/s and having sex with only one partner (aOR=0.72, 95% CI 0.519-0.99). While facility-based VCT appears to promote abstinence and condom use home-based VCT on the other hand promotes faithfulness and disclosure. VCT services should, therefore, be provided through both models in a complementary relationship and not as surrogates within given settings.

Background: In Uganda, public human immunodeficiency virus (HIV) Voluntary Counseling and Testing (VCT) services are mainly provided through the facility based model, although the home based approach is being promoted as a strategy for improving access to VCT. However the uptake of VCT varies according to service delivery model and is influenced by a number of factors. The aim of this study therefore, was to compare predictors for uptake of facility and home based VCT in a rural context., Methods: A longitudinal study with cross-sectional investigative phases was conducted at two sites (Rugando and Kabingo) in southwestern Uganda between November 2007 (baseline) and March 2008 (follow up). During the baseline visit, facility based VCT was offered at the main health centre in Rugando while home based VCT was offered at the household level in Kabingo and a mixed survey questionnaire administered to the respondents. The results presented in this paper are derived from only the baseline data., Results: Nine hundred ninety four (994) respondents were interviewed, of whom 500 received facility based VCT in Rugando and 494 home based VCT in Kabingo during the baseline visit. The respondents had a mean age of 32.2 years (SD 10.9) and were mainly female (68 percent). Clients who received facility based VCT were less likely to be residents of the more rural households (adjusted Odds Ratio (aOR)=0.14, 95% CI 0.07, 0.22). The clients who received home based VCT were less likely to report having an STI symptom (aOR=0.63, 95% CI 0.46, 0.86), and more likely to be worried about discrimination if they contracted AIDS (aOR=1.78, 95% CI 1.22, 2.61)., Conclusion: The uptake of VCT provided through either the facility or home based models is influenced by client characteristics such as proximity to service delivery points, HIV related symptoms, and fear of discrimination in rural Uganda. Interventions that seek to improve uptake of VCT should provide potential clients with both facility and home based VCT options within a given setting. The clients are then able to select a model for VCT that best fits their characteristics. This is likely to have positive implications for both service coverage and uptake by different sub-groups within particular communities.

Background: Despite the need for oral health morbidity surveys to aid in reviewing of the oral health services, dental data of Ugandan children is scanty., Objectives: To describe the magnitude and distribution of selected oral health conditions among primary school children in Mbarara, Uganda., Methods: A stratified two-stage cluster sample of 437 children aged 5-6, 8-9 and 11-12 was enrolled. The selected conditions included: dental caries, plaque, calculus, gingivitis, fluorosis and malocclusion (maxillary overjet). These conditions were diagnosed and scored in accordance with World Health Organisation (WHO) criteria., Results: The mean decayed, missing, filled permanent teeth (DMFT) was 1.5(±0.8 SD). Females had higher DMFT (1.6±0.8SD) than males (1.3±0.8SD). Decayed, filled milk teeth (dt) was 2.7(±1.8SD) but more in males 3.1(±2.1SD) than in females 2.4(±1.6SD). Children in private schools were likely to have more caries in both permanent teeth (DMFT: 1.6±0.9SD) and milk teeth (dt: 3.0±1.9SD). Day-scholars were likely to have more caries in permanent teeth (DFMT: 1.50.8SD). Those in boarding were likely to have more caries in milk teeth (dt: 3±2.2SD). Milk teeth caries decreased with age (p<0.0001). Eight (1.8%) had very mild to moderate fluorosis. Nine (2%) lost permanent canines due to practice of "nylon teeth mutilation." Majority 325(75%) had dental plaque, which increased with age (p<0.0001). Males significantly had plaque. Children in private schools were associated with less plaque (OR: 0.6, 95%CI: 0.4-0.9), as were those in boarding schools. Some 113(25.9%) had calculus that increased with age (p<0.0001). Calculus was more prevalent in males, government schools, and among day-scholars. Females were less likely to have maxillary overjet (OR: 0.5, 95% CI: 0.3-0.8). Day-scholars were 2 times more likely to have maxillary overjet (OR: 1.9, 95%CI: 1.1-3.5). None had severe gingivitis., Conclusion: The oral hygiene of school children was poor with high plaque prevalence demonstrating a lack of established oral hygiene practices. A comprehensive community-focused oral health care intervention that includes oral health education in homes and the strengthening of school health programme is needed to improve the oral health status of children in Mbarara.

Despite current efforts to combat HIV/AIDS through behavioural change, ingrained socio-cultural practices such as widow inheritance in south-western Uganda has not changed. Low education, unemployment, dowry, widows' socioeconomic demands and the inheritor's greed for the deceased's wealth, influence widow inheritance. Voluntary counselling and testing is needed for the widows and their inheritors; formal dowry should be removed from marriage and widow inheritance stripped of its sexual component.

The purpose of this study was to explore the knowledge, attitudes and barriers to use of postpartum care service among rural communities in Uganda. Study was a part of a larger reproductive health evaluation project, and was cross-sectional in nature utilizing qualitative research methods using the narrative inquiry. Two matched rural communities were used in this study; Semuto in Luwero district, and Lwamaggwa in Rakai district. Fifty key informants who were purposefully selected from each study site were interviewed. They included community leaders, political leaders, health care providers, women leaders and community members. One-on-one interviews were conducted with key community informants using an interview guide. The purpose of the interview was explained to each participant, and written informed consent was obtained before the start of the interview. Respondents were allowed to express their views, opinions and observations on several health issues including postpartum health care services. There was a low level of knowledge about postpartum care services among the respondents of the two communities. There was lack of awareness about postpartum care and it's benefits. The main barriers to use of services were; misconceptions regarding the importance of postpartum care, distance to health facilities, poverty, and health system factors notably; poor facilities, lack of essential drugs, and poor attitudes of health workers. In the effort to improve reproductive health care services, there is an urgent need to improve postpartum services, and make them more accessible and user friendly. The training of providers at all levels is essential, in addition to educating families on the importance of postpartum care services.