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Ronald Olum,1 Frederick Nelson Nakwagala,2 Raymond Odokonyero3 1School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda; 2Mulago National Referral Hospital, Kampala, Uganda; 3Department of Psychiatry, School of Medicine, College of Health Sciences, Makerere University, Kampala, UgandaCorrespondence: Ronald OlumSchool of Medicine, College of Health Sciences, PO Box 7072, Kampala, UgandaTel +256-775-512-540Email olum.ronald@gmail.comBackground: Depression affects about a third of medical students worldwide. There is paucity of data on depression among medical students in Uganda. The purpose of this study was to establish the prevalence and factors associated with depression among medical students at Makerere University College of Health Science (MakCHS), Uganda.Methods: A cross-sectional study was conducted among students pursuing a Bachelor of Medicine and Surgery at MakCHS in May and July 2019. Students were enrolled by consecutive sampling, both online using Google Forms and in person for those unable to access internet. The self-reported Patient Health Questionnaire 9 (PHQ9) was administered to assess depression, defined as a PHQ9 score ≥ 10. Microsoft Excel 2016 and Stata 16 were used for data analysis.Results: Overall, 331 valid responses (mean age 23.1± 3.3 years) were submitted (response rate 93.8%). In a majority of participants, the prevalence of depression was 21.5% (n=71) of which 64.1% had moderate depression (n=50). On bivariate analysis, year of study, worrying about academic performance, and lectures were significantly associated with depression. On multivariate analysis, worrying about academic performance (aOR 2.52, 95% CI 1.50– 4.22; P< 0.001) and lectures (aOR 1.89, 95% CI 1.11– 3.22; P=0.018) were significantly associated with depression.Conclusion: Depression affects a significant number of medical students at MakCHS. About one in five medical students have depression. Year of study and academic performance were significantly associated with depression. Efforts aimed at identification and evaluation of students at risk, administering appropriate interventions, and follow-up of affected students are vital. Analytical studies aimed at establishing the causative factors and the effects of depression on medical students are recommended.Keywords: depression, medical students, risk factors, PHQ9, Uganda

Background: Health care workers (HCWs) are at increased risk of acquiring coronavirus disease 2019 (COVID-19). This study aimed to determine and compare the morbidity and mortality rates due to COVID-19 among the HCWs and the general population (non-HCWs)., Methods: We conducted a retrospective chart review. We accessed electronic database of participants admitted at Mulago National Referral Hospital COVID-19 Treatment Unit (CTU) between March 2020 and September 2021. Participants with missing occupations were excluded., Results: Of 594 eligible participants, 6.4% ( n  = 38) were HCWs. Compared with non-HCWs, HCWs were much younger (48 versus 55 years, p  = 0.020). The proportion of participants with severe disease (73.7% versus 77.6%, p  = 0.442), who had not received COVID-19 vaccine (91.2% versus 94.7%, p  = 0.423), mortality rate (44.7% versus 54.8%, p  = 0.243) and the median length of hospitalization (6 versus 7 days, p  = 0.913) were similar among HCWs and non-HCWs, respectively. A higher proportion of HCWs required oxygen therapy (24.3% versus 9.7%, p  < 0.01). At admission, the presence of cough ( p  = 0.723), breathlessness ( p  = 0.722), fever ( p  = 0.19), sore throat ( p  = 0.133), comorbidities ( p  = 0.403) and headache ( p  = 0.162) were similar across groups. Rhinorrhoea was more common among HCWs (34.4% versus 16.6%, p  = 0.017). Among HCWs, nurses had the highest morbidity (52.6%) and mortality (58.8%)., Conclusion: The morbidity and mortality among HCWs in Uganda were substantial, with a low COVID-19 vaccination rate and a higher requirement for oxygen therapy despite a younger age., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article., (© The Author(s), 2022.)

Several studies have reported inadequate comprehension of informed consent for genomic research. This study aimed to assess research participants' understanding of critical elements of informed consent for genomic research. A cross-sectional survey involving 123 parents/caregivers of children participating in a paediatric genomic TB/HIV study was conducted . Only 47.2% of the participants had adequate understanding of consent information. The mean objective (actual) and subjective (perceived) understanding scores were 78.7% and 91.7% respectively. Participants adequately understood most elements of consent however, some elements were poorly understood including foreseeable risks, protection of confidentiality and compensation for research related injury. Overall there was inadequate comprehension of critical elements of informed consent and there was dissonance between actual and perceived comprehension of informed consent.

Coronavirus disease-2019 (COVID-19) is the leading cause of death worldwide from a single infectious agent. Whether or not HIV infection affects clinical outcomes in patients with COVID-19 remains inconclusive. This study aimed to compare the clinical outcomes of people living with HIV (PLWH) and non-HIV-infected patients hospitalized during the second wave of the COVID-19 pandemic in Uganda. We retrospectively retrieved data on patients with COVID-19 who were admitted to the Mulago National Referral Hospital in Uganda between April 2021 and mid-July 2021. We performed propensity-score-matching of 1:5 to compare outcomes in COVID-19 patients living with and those without HIV coinfection (controls). We included 31 PLWH and 155 non-HIV controls. The baseline characteristics were similar across groups (all p values > 0.05). PLWH had close to threefold higher odds of having ICU consultation compared to controls (odds ratio [OR]: 2.9, 95% CI: 1.2-6.9, p = 0.015). There was a trend toward having a severe or critical COVID-19 illness among PLWHIH compared to controls (OR: 1.9, 95% CI: 0.8-4.7, p = 0.164). Length of hospitalization was not significantly different between PLWH and non-HIV controls (6 days vs. 7 days, p = 0.184). Seven-day survival was 63% (95% CI: 42%-78%) among PLWH and 72% (95% CI: 61%-82%) among controls while 14-day survival was 50% (95% CI: 28%-69%) among PLWH and 65% (95% CI: 55%-73%) among controls (p = 0.280). There was another trend toward having 1.7-fold higher odds of mortality among PLWH compared to controls (OR: 1.7, 95% CI: 0.8-3.8, p = 0.181). Our data suggest that PLWH may be at an increased risk of severe or critical COVID-19 illness requiring ICU consultation. Further studies with larger sample sizes are recommended., (© 2022 Wiley Periodicals LLC.)

This study aimed to explore experiences and practices of key research team members in obtaining informed consent for pharmacogenetics research and to identify the approaches used for enhancing understanding during the consenting process. Data collection involved 15 qualitative, in-depth interviews with key researchers who were involved in obtaining informed consent from HIV infected individuals in Uganda for participation in pharmacogenetic clinical trials. The study explored two prominent themes: approaches used to convey information and enhance research participants' understanding and challenges faced during the consenting process. Several barriers and facilitators for obtaining consent were identified. Innovative and potentially effective consenting strategies were identified in this study that should be studied and independently verified.

Background: Type 2 diabetes mellitus (T2DM) is one of the most common global diseases of public concern. In developing countries like Uganda, dietary habits and sedentary lifestyle are the major factors for rapidly rising incidence of DM. Therefore, awareness about diabetes dietary practices and life style are paramount in the control of the disease., Methodology: One hundred type 2 diabetic patients were randomly selected and divided into two groups of intervention and control (50 patients in each group) to participate in the study. The intervention consisted of two educational sessions each for 30 min with various learning segments. A conversation map for type 2 diabetes, 24-h dietary recall and glycemic load tables were used. Data were collected using a pre-tested questionnaire before intervention and on monthly basis for a period of four months of intervention. Data were entered and analyzed using SPSS software version 21., Results: There was a significant (p < 0.001) increase in water, vegetables, fruits, and number of meals intake per day coupled with quitting alcohol, soda, and beer among the intervention group. On the other hand, it was revealed that meat and milk consumption significantly reduced by 81.6 and 82.4% respectively among the intervention group. At the end of study period, milk, meat, vegetable, beer, soda, cigarettes intake, and duration of physical activity increased among the control group., Conclusions: Nutrition education improves dietary feeding practices and lifestyle among type 2 diabetes patients within four months of intervention., (© 2021. The Author(s), under exclusive licence to Springer Nature Limited.)

Background: We evaluated clinical outcomes of patients hospitalized with coronavirus disease 2019 (COVID-19) in the second wave of the pandemic in a national COVID-19 treatment unit (CTU) in Uganda., Methods: We conducted a retrospective cohort study of COVID-19 patients hospitalized at the Mulago National Referral Hospital CTU between May 1 and July 11, 2021. We performed Kaplan-Meier analysis to evaluate all-cause in-hospital mortality., Results: Of the 477 participants, 247 (52%) were female, 15 (3%) had received at least 1 dose of the COVID-19 vaccine, and 223 (46%) had at least 1 comorbidity. The median age was 52 (interquartile range, 41-65) years. More than 80% of the patients presented with severe (19%, n=91) or critical (66%, n=315) COVID-19 illness. Overall, 174 (37%) patients died. Predictors of all-cause in-hospital mortality were as follows; age ≥50 years (adjusted odds ratio [aOR], 1.9; 95% confidence interval [CI], 1.2-3.2; P =.011), oxygen saturation at admission of ≥92% (aOR, 0.97; 95% CI, 0.91-0.95; P <.001), and admission pulse rate of ≥100 beats per minute (aOR, 1.01; 95% CI, 1.00-1.02; P =.042). The risk of death was 1.4-fold higher in female participants compared with their male counterparts (hazards ratio, 1.4; 95% CI, 1.0-2.0; P =.025)., Conclusions: In this cohort, where the majority of the patients presented with severe or critical illness, more than one third of the patients hospitalized with COVID-19 at a national CTU died of the illness., (© The Author(s) 2021. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: Immunization is an important strategy for controlling the COVID-19 pandemic. COVID-19 vaccination was recently launched in Uganda, with prioritization to healthcare workers and high-risk individuals. In this study, we aimed to determine the acceptability of COVID-19 vaccine among persons at high risk of COVID-19 morbidity and mortality in Uganda., Methods: Between 29 March and 14 April 2021, we conducted a cross-sectional survey consecutively recruiting persons at high risk of severe COVID-19 (diabetes mellitus, HIV and cardiovascular disease) attending Kiruddu National Referral Hospital outpatient clinics. A trained research nurse administered a semi-structured questionnaire assessing demographics, COVID-19 vaccine related attitudes and acceptability. Descriptive statistics, bivariate and multivariable analyses were performed using STATA 16., Results: A total of 317 participants with a mean age 51.5 ± 14.1 years were recruited. Of this, 184 (60.5%) were female. Overall, 216 (70.1%) participants were willing to accept the COVID-19 vaccine. The odds of willingness to accept COVID-19 vaccination were four times greater if a participant was male compared with if a participant was female [adjusted odds ratio (AOR): 4.1, 95% confidence interval (CI): 1.8-9.4, p  = 0.00]. Participants who agreed (AOR: 0.04, 95% CI: 0.01-0.38, p  = 0.003) or strongly agreed (AOR: 0.04, 95% CI: 0.01-0.59, p  = 0.005) that they have some immunity against COVID-19 were also significantly less likely to accept the vaccine. Participants who had a history of vaccination hesitancy for their children were also significantly less likely to accept the COVID-19 vaccine (AOR: 0.1, 95% CI: 0.01-0.58, p  = 0.016)., Conclusion: The willingness to receive a COVID-19 vaccine in this group of high-risk individuals was comparable to the global COVID-19 vaccine acceptance rate. Increased sensitization, myth busting and utilization of opinion leaders to encourage vaccine acceptability is recommended., Competing Interests: Conflict of interest statement: The authors declare that there is no conflict of interest., (© The Author(s), 2021.)

Background: In response to COVID-19 pandemic, the Government of Uganda adopted public health measures to contain its spread in the country. Some of the initial measures included refusal to repatriate citizens studying in China, mandatory institutional quarantine, and social distancing. Despite being a public health emergency, the measures adopted deserve critical appraisal using an ethics and human rights approach. The goal of this paper is to formulate an ethics and human rights criteria for evaluating public health measures and use it to reflect on the ethical propriety of those adopted by the government of Uganda to contain the spread of COVID-19., Main Body: We begin by illustrating the value of ethics and human rights considerations for public health measures including during emergencies. We then summarize Uganda's social and economic circumstances and some of the measures adopted to contain the spread of COVID-19. After reviewing some of the ethics and human rights considerations for public health, we reflect upon the ethical propriety of some of Uganda's responses to COVID-19. We use content analysis to identify the measures adopted by the government of Uganda to contain the spread of COVID-19, the ethics and human rights considerations commonly recommended for public health responses and their importance. Our study found that some of the measures adopted violate ethics and human rights principles. We argue that even though some human rights can sometimes be legitimately derogated and limited to meet public health goals during public health emergencies, measures that infringe on human rights should satisfy certain ethics and human rights criteria. Some of these criteria include being effective, strictly necessary, proportionate to the magnitude of the threat, reasonable in the circumstances, equitable, and least restrictive. We reflect on Uganda's initial measures to combat the spread of COVID-19 and argue that many of them fell short of these criteria, and potentially limit their effectiveness., Conclusion: The ethical legitimacy of public health measures is valuable in itself and for enhancing effectiveness of the measures. Such legitimacy depends on the extent to which they conform to ethics and human rights principles recommended for public health measures.

Aims: To determine the prevalence and associated risk factors of diabetic peripheral neuropathy (DPN) among newly diagnosed diabetes mellitus patients in Mulago Hospital., Methods: A cross-sectional study was conducted among 248 newly diagnosed adult diabetic patients. Using the standard Neuropathy Symptom Score (NSS) and Neuropathy Disability Score (NDS) criteria, we screened them for neuropathy. Data on the socio-demographics, age, duration of symptoms and history of diabetic ulcer were analyzed using a multiple logistic regression. A p-value <0.05 was considered significant., Results: The majority of study patients (62.1%) were male. The overall prevalence of DPN was 29.4 %. Nearly sixteen percent had moderate neuropathy and only five percent had severe neuropathy. Age above 60 years was significantly associated with the presence of DPN; (OR 3.72; 95% CI 1.25 - 11.03; p=0.018). The history of ever having a foot ulcer was significantly associated with peripheral neuropathy (OR 2.59; 95% CI: 1.03 - 6.49, p = 0.042)., Conclusion: DPN occurs in 1 in 4 of newly diagnosed diabetic patients in Mulago hospital. Two thirds of these patients had moderate to severe neuropathy. DPN was independently associated with increasing age. Early diagnosis of diabetes mellitus, increased diabetes knowledge and regular blood sugar screenings would play an important role in identifying this problem.

Aims: Glycated haemoglobin (HbA1C) has been suggested to replace glucose tests in identifying diabetes and pre-diabetes. We assessed agreement between fasting plasma glucose (FPG) and HbA1C rapid tests in classifying abnormal glucose regulation (AGR), and their utility for preventive screening in rural Africa., Methods: A population-based survey of 795 people aged 35-60 years was conducted in a mainly rural district in Uganda. FPG was measured using On-Call® Plus glucometers, and classified using World Health Organization (WHO) and American Diabetes Association (ADA) criteria. HbA1C was measured using A1cNow® kits and classified using ADA criteria. Body mass index and blood pressure were measured. Percentage agreement between the two tests was computed., Results: Using HbA1C, 11.3% of participants had diabetes compared with 4.8% for FPG. Prevalence of HbA1C-defined pre-diabetes (26.4%) was 1.2 times and 2.5 times higher than FPG-defined pre-diabetes using ADA (21.8%) and WHO (10.1%) criteria, respectively. With FPG as the reference, agreement between FPG and HbA1C in classifying diabetes status was moderate (Kappa=22.9; Area Under the Curve (AUC)=75%), while that for AGR was low (Kappa=11.0; AUC=59%). However, agreement was high (over 90%) among negative tests and among participants with risk factors for type 2 diabetes (obesity, overweight or hypertension). HbA1C had more procedural challenges than FPG., Conclusions: Although low in the general sample, agreement between HbA1C and FPG is excellent among persons who test negative with either test. A single test can therefore identify the majority at lower risk for type 2 diabetes. Nurses if trained can conduct these tests., (Copyright © 2014 The Authors. Published by Elsevier Ireland Ltd.. All rights reserved.)

Background: Our aim was to estimate the prevalence of abnormal glucose regulation (AGR) (i.e. diabetes and pre-diabetes) and its associated factors among people aged 35-60 years so as to clarify the relevance of targeted screening in rural Africa., Methods: A population-based survey of 1,497 people (786 women and 711 men) aged 35-60 years was conducted in a predominantly rural Demographic Surveillance Site in eastern Uganda. Participants responded to a lifestyle questionnaire, following which their Body Mass Index (BMI) and Blood Pressure (BP) were measured. Fasting plasma glucose (FPG) was measured from capillary blood using On-Call® Plus (Acon) rapid glucose meters, following overnight fasting. AGR was defined as FPG ≥6.1 mmol L⁻¹ (World Health Organization (WHO) criteria or ≥5.6 mmol L⁻¹ (American Diabetes Association (ADA) criteria. Diabetes was defined as FPG >6.9 mmol L⁻¹, or being on diabetes treatment., Results: The mean age of participants was 45 years for men and 44 for women. Prevalence of diabetes was 7.4% (95%CI 6.1-8.8), while prevalence of pre-diabetes was 8.6% (95%CI 7.3-10.2) using WHO criteria and 20.2% (95%CI 17.5-22.9) with ADA criteria. Using WHO cut-offs, the prevalence of AGR was 2 times higher among obese persons compared with normal BMI persons (Adjusted Prevalence Rate Ratio (APRR) 1.9, 95%CI 1.3-2.8). Occupation as a mechanic, achieving the WHO recommended physical activity threshold, and higher dietary diversity were associated with lower likelihood of AGR (APRR 0.6, 95%CI 0.4-0.9; APRR 0.6, 95%CI 0.4-0.8; APRR 0.5, 95%CI 0.3-0.9 respectively). The direct medical cost of detecting one person with AGR was two US dollars with ADA and three point seven dollars with WHO cut-offs., Conclusions: There is a high prevalence of AGR among people aged 35-60 years in this setting. Screening for high risk persons and targeted health education to address obesity, insufficient physical activity and non-diverse diets are necessary.

Introduction: Early identification of Tuberculosis (TB) treatment failure using cost effective means is urgently needed in developing nations. The study set out to describe affordable predictors of TB treatment failure in an African setting., Objective: To determine the predictors of treatment failure among patients with sputum smear positive pulmonary TB at Mulago hospital. The study was carried out in the TB clinic of Mulago hospital Kampala, Uganda. This was an unmatched case control study where fifty patients with a diagnosis of TB treatment failure (cases) and 100 patients declared cured after completing anti TB treatment (controls) were recruited into the study. Cases were compared with controls to determine predictors of treatment failure., Results: Significant predictors of treatment failure in this study included a positive sputum smear at 2 months of TB treatment (OR 20.63, 95%CI 5.42- 78.41) and poor adherence to anti TB treatment (OR 14.59, 95%CI 3.04-70.15)., Conclusion: This study identified a treatment related and a simple laboratory predictor of TB treatment failure in Mulago hospital which may be used in resource limited settings for early recognition of those at risk and early intervention.

This essay describes and critically evaluates a co-operative educational program to train Ugandan health care workers in bioethics. It describes one "bottom-up" effort, a week-long intensive workshop in bioethics provided by the authors to health care professionals in a developing country-Uganda. We will describe the background and circumstances that led to the organization of the workshop, and review its planning, design, curriculum, and outcome. We will focus especially on measures taken to make the workshop relevant for the audience of Ugandan professionals, and describe lessons learned after two presentations of the workshop. Finally, we will discuss the strengths and weaknesses of such a format, and its potential value in raising bioethical expertise in developing countries.

The safety and immunogenicity of plasmid pTHr DNA, modified vaccinia virus Ankara (MVA) human immunodeficiency virus type 1 (HIV-1) vaccine candidates were evaluated in four Phase I clinical trials in Kenya and Uganda. Both vaccines, expressing HIV-1 subtype A gag p24/p17 and a string of CD8 T-cell epitopes (HIVA), were generally safe and well-tolerated. At the dosage levels and intervals tested, the percentage of vaccine recipients with HIV-1-specific cell-mediated immune responses, assessed by a validated ex vivo interferon gamma (IFN-gamma) ELISPOT assay and Cytokine Flow Cytometry (CFC), did not significantly differ from placebo recipients. These trials demonstrated the feasibility of conducting high-quality Phase 1 trials in Africa.