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Abstract Background There is a gradual increase in the number of optometry education programs in Africa yet there is limited knowledge on optometry students’ experiences of their clinical training. Therefore, the purpose of this study was to explore the optometry students’ experiences of their clinical learning environment at a national referral and teaching hospital in Uganda. Methods Between April 2023 and May 2023, face to face in-depth interviews were conducted to explore the experiences of the participants. All 16 optometry students in fourth-year at university were purposefully recruited into the study. Data was collected at the end of the students’ clinical training at the eye clinic of a national referral and teaching hospital. Interviews were audio recorded and transcribed for analysis using an inductive thematic approach. Results Two themes, learning at the eye clinic and organization of the eye clinic, were identified to represent participants’ experiences. Each theme had three sub themes. Conclusion Training optometry students at an eye clinic enhances their clinical skills and knowledge of diagnosing and managing various eye conditions. Future studies should compare optometry students’ experiences in lower-level health units to those in national referral hospitals.

Abstract Background Pneumonia remains the leading cause of mortality among children under 5 years. Poor nutritional status increases pneumonia mortality. Nutritional status assessed by anthropometry alone does not provide information on which body composition element predicts survival. Body composition proxy measures including arm-fat-area (AFA), arm-muscle-area (AMA), and arm-muscle-circumference (AMC) could be useful predictors. Objective To compare the ability of fat and muscle mass indices to predict 6-month survival among children with severe pneumonia. Methods This prospective cohort study was nested in the COAST-Nutrition trial (ISRCTN10829073, 06/06/2018) conducted between June 2020 and October 2022 in Uganda and Kenya. We included children aged 6–59 months hospitalized for severe pneumonia with hypoxemia. Children with severe malnutrition, known chronic lung or cardiac diseases were excluded. Anthropometry and clinical status were assessed at enrolment and at follow-up to day 180. We examined Receiver Operator Characteristic (ROC) curves of fat and muscle mass indices with 6-month survival as the outcome, and compared the areas under the curve (AUCs) using chi-square tests. Cox survival analysis models assessed time-to-mortality. Results We included 369 participants. The median age was 15-months (IQR 9, 26), and 59.4% (219/369) of participants were male. The baseline measurements were: median MUAC 15.0 cm (IQR 14.0,16.0); arm-fat-area 5.6cm2 (IQR 4.7, 6.8); arm-muscle-area 11.4cm2 (IQR 10.0, 12.7); and arm-muscle-circumference 12.2 cm (IQR 11.5, 12.9). Sixteen (4.3%) participants died and 4 (1.1%) were lost-to-follow-up. The AUC for Arm-Fat-Area was not significantly higher than that for Arm-Muscle-Area and Arm-Muscle-Circumference [AUC 0.77 (95%CI 0.64–0.90) vs. 0.61 (95%CI 0.48–0.74), p = 0.09 and 0.63 (95%CI 0.51–0.75), p = 0.16 respectively], but was not statistically different from MUAC (AUC 0.73 (95%CI 0.62–0.85), p = 0.47). Increase in Arm-Fat-Area and Arm-Muscle-Circumference significantly improved survival [aHR 0.40 (95%CI 0.24–0.64), p =

Abstract Background Sub-Saharan Africa bears the highest burden of sickle cell disease (SCD) globally with Nigeria, Democratic Republic of Congo, Tanzania, Uganda being the most affected countries. Uganda reports approximately 20,000 SCD births annually, constituting 6.67% of reported global SCD births. Despite this, there is a paucity of comprehensive data on SCD from the African continent. SCD registries offer a promising avenue for conducting prospective studies, elucidating disease severity patterns, and evaluating the intricate interplay of social, environmental, and genetic factors. This paper describes the establishment of the Sickle Pan Africa Research Consortium (SPARCo) Uganda registry, encompassing its design, development, data collection, and key insights learned, aligning with collaborative efforts in Nigeria, Tanzania, and Ghana SPARCo registries. Methods The registry was created using pre-existing case report forms harmonized from the SPARCo data dictionary and ontology to fit Uganda clinical needs. The case report forms were developed with SCD data elements of interest including demographics, consent, baseline, clinical, laboratory and others. That data was then parsed into a customized REDCap database, configured to suit the optimized ontologies and support retrieval aggregations and analyses. Patients were enrolled from one national referral and three regional referral hospitals in Uganda. Results A nationwide electronic patient-consented registry for SCD was established from four regional hospitals. A total of 5,655 patients were enrolled from Mulago National Referral Hospital (58%), Jinja Regional Referral (14.4%), Mbale Regional Referral (16.9%), and Lira Regional Referral (10.7%) hospitals between June 2022 and October 2023. Conclusion Uganda has been able to develop a SCD registry consistent with data from Tanzania, Nigeria and Ghana. Our findings demonstrate that it’s feasible to develop longitudinal SCD registries in sub-Saharan Africa. These registries will be crucial for facilitating a range of studies, including the analysis of SCD clinical phenotypes and patient outcomes, newborn screening, and evaluation of hydroxyurea use, among others. This initiative underscores the potential for developing comprehensive disease registries in resource-limited settings, fostering collaborative, data-driven research efforts aimed at addressing the multifaceted challenges of SCD in Africa.

Abstract Introduction The long case is used to assess medical students’ proficiency in performing clinical tasks. As a formative assessment, the purpose is to offer feedback on performance, aiming to enhance and expedite clinical learning. The long case stands out as one of the primary formative assessment methods for clinical clerkship in low-resource settings but has received little attention in the literature. Objective To explore the experiences of medical students and faculty regarding the use of the Long Case Study as a formative assessment method at a tertiary care teaching hospital in a low-resource setting. Methodology A qualitative study design was used. The study was conducted at Makerere University, a low-resource setting. The study participants were third- and fifth-year medical students as well as lecturers. Purposive sampling was utilized to recruit participants. Data collection comprised six Focus Group Discussions with students and five Key Informant Interviews with lecturers. The qualitative data were analyzed by inductive thematic analysis. Results Three themes emerged from the study: ward placement, case presentation, and case assessment and feedback. The findings revealed that students conduct their long cases at patients’ bedside within specific wards/units assigned for the entire clerkship. Effective supervision, feedback, and marks were highlighted as crucial practices that positively impact the learning process. However, challenges such as insufficient orientation to the long case, the super-specialization of the hospital wards, pressure to hunt for marks, and inadequate feedback practices were identified. Conclusion The long case offers students exposure to real patients in a clinical setting. However, in tertiary care teaching hospitals, it’s crucial to ensure proper design and implementation of this practice to enable students’ exposure to a variety of cases. Adequate and effective supervision and feedback create valuable opportunities for each learner to present cases and receive corrections.

Abstract Objective Diabetes mellitus predisposes patients to increased incidence and severe forms of periodontal disease. Currently, information on the bacterial diversity of patients with diabetes mellitus and periodontitis in Uganda is scanty. This study set out to describe the bacteria associated with periodontitis in patients with diabetes mellitus in Uganda, as part of a larger study describing the association between periodontal disease and diabetes mellitus. Results This was a case control involving 45 samples of gingival crevicular fluid collected from participants with periodontitis, the cases being 26 participants with diabetes mellitus and controls 19 participants without diabetes mellitus. Sequencing using the 16s Oxford nanopore long read protocol was followed by a bioinformatics analysis pipeline for alpha and beta diversity indices in the two groups. Multivariate tests were done to determine the differences in the bacterial composition in the two groups. Of the 739 Operational Taxonomic Units and 500 phyla identified, 37.9% (280/739) were from participants with diabetes mellitus. Analysis of beta diversity revealed a dissimilarity between the two study groups (CAP score = 0) with a significant association noted between periodontitis and the subgingival bacteria (P = 0.001). Diabetes mellitus reduced the quantity and altered the composition of the subgingival microbiome in the study participants.

Abstract Background Medical schools are called to be socially accountable by medical education and healthcare system stakeholders. Social accountability is a feature of excellent medical education. Medical students are essential to the development of socially accountable medical schools. Therefore, understanding the perceptions and experiences of medical students regarding social accountability is critical for efforts to improve social accountability practices and outcomes. Methods This cross-sectional online questionnaire-based survey used Google Forms and involved medical students in their fourth and fifth years of study at the Makerere University School of Medicine. The survey was conducted between September 2022 and October 2023. We used a study questionnaire and a validated toolkit designed by students as part of The Training for Health Equity Collaborative to gauge a school’s progress towards social accountability in medical schools to collect data on demographics, perceptions and experiences and evaluate social accountability. Results Out of 555 eligible medical students, 426 responded to the online questionnaire. The response rate was 77%. The mean age of the students was 25.24 ± 4.4 years. Almost three fourths of the students were male (71.3%), and slightly less than two thirds were in their fourth year of study (65%). Almost half of the students (48.1%%) evaluated the school as doing well with regard to social accountability. The evaluation items referring to community-based research and positive impact on the community had the highest mean scores. Only 6 (3.6%) students who reported hearing of social accountability had a clear understanding of social accountability. Students receiving career guidance in secondary school was associated with evaluating social accountability in the medical school as strong (p-0.003). Conclusions Medical students evaluated the medical school favorably forsocial accountability despite lacking a clear understanding of social accountability. Receiving career guidance in secondary school was significantly associated with a positive evaluation of social accountability.

Abstract Background Over two million children and adolescents suffer from chronic kidney disease globally. Early childhood insults such as birth asphyxia could be risk factors for chronic kidney disease in later life. Our study aimed to assess renal function among children aged two to four years, born to women with obstructed labour. Methods We followed up 144 children aged two to four years, born to women with obstructed labor at Mbale regional referral hospital in Eastern Uganda. We used serum creatinine to calculate estimated glomerular filtration rate (eGFR) using the Schwartz formula. We defined decreased renal function as eGFR less than 90 ml/min/1.73m2. Results The mean age of the children was 2.8 years, standard deviation (SD) of 0.4 years. Majority of the children were male (96/144: 66.7%). The mean umbilical lactate level at birth among the study participants was 8.9 mmol/L with a standard deviation (SD) of 5.0. eGFR of the children ranged from 55 to 163 ml/min/1.73m2, mean 85.8 ± SD 15.9. Nearly one third of the children (45/144) had normal eGFR (> 90 ml/Min/1.73m2), two thirds (97/144) had a mild decrease of eGFR (60–89 ml/Min/1.73m2), and only two children had a moderate decrease of eGFR (

Objectives: To determine the incidence of mortality and its predictors among pulmonary tuberculosis (PTB) survivors treated at a rural Ugandan tertiary hospital. Methods: We conducted a retrospective chart review of data between 2013 and 2023. We included all people that met the World Health Organisation's definition of tuberculosis cure and traced them or their next of kin to determine vital status (alive/deceased). We estimated the cumulative incidence of mortality per 1000 population, crude all-cause mortality rate per 1000 person-years, and median years of potential life lost for deceased individuals. Using Cox proportional hazard models, we investigated predictors of mortality. Results: Of 334 PTB survivors enrolled, 38 (11.4%) had died. The cumulative incidence of all-cause mortality was 113.7 per 1000 population, and the crude all-cause mortality rate was 28.5 per 1000 person-years. The median years of potential life lost for deceased individuals was 23.8 years (IQR: 9.6-32.8). Hospitalization (adjusted hazard ratio (aHR): 4.3, 95% CI: 1.1-16.6) and unemployment (aHR: 7.04, 95% CI: 1.5-31.6) at TB treatment initiation predicted mortality. Conclusion: PTB survivors experience post high mortality rates after TB cure. Survivors who were hospitalized and unemployed at treatment initiation were more likely to die after cure. Social protection measures and long-term follow-up of previously hospitalized patients could improve the long-term survival of TB survivors.

Summary: Background: Severe pneumonia in African children results in poor long-term outcomes (deaths/readmissions) with undernutrition as a key risk factor. We hypothesised additional energy/protein-rich Ready-to-Use Therapeutic Foods (RUTF) would meet additional nutritional requirements and improve outcomes. Methods: COAST-Nutrition was an open-label Phase 2 randomised controlled trial in children (aged 6 months-12 years) hospitalised with severe pneumonia (and hypoxaemia, SpO2 99%). By Day 90, there was no significant difference in the composite endpoint (probabilistic index 0.49, 95% CI 0.45–0.53, p = 0.74). Respective 90-day mortality (13/420 3.1% vs 14/421 3.3%) and MUAC increment (0.54 (SD 0.85) vs 0.55 (SD 0.81)) were similar between arms. There was no difference in any anthropometric secondary endpoints to Day 28, 90 or 180 except skinfold thickness at Day 28 and Day 90 was greater in the RUTF arm. Serious adverse events were higher in the RUTF arm (n = 164 vs 108), mainly due to hospital readmission for acute illness (54/387 (14%) vs 37/375 (10%). Interpretation: Our study suggested that nutritional supplementation with RUTF did not improve outcomes to 180 days in children with severe pneumonia. Funding: This trial is part of the EDCTP2 programme (grant number RIA-2016S-1636-COAST-Nutrition) supported by the European Union, and UK Joint Global Health Trials scheme: Medical Research Council, Department for International Development, Wellcome Trust (grant number MR/L004364/1, UK).

Abstract Background Globally, high systolic blood pressure accounts for 10.8 million deaths annually. The deaths are disproportionately higher among black people. The reasons for this disparity are poorly understood, but could include a high burden of perinatal insults such as birth asphyxia. Therefore, we aimed to assess the incidence of elevated blood pressure and to explore associated factors among children born to women with obstructed labour. Methods We followed up children born to women with obstructed labour aged 25 to 44 months at Mbale regional referral hospital that had participated in the sodium bicarbonate trial ( Trial registration number PACTR201805003364421) between October 2021 and April 2022. Our primary outcome was elevated blood pressure defined as blood pressure (either systolic or diastolic or both) ≥ the 90th percentile for age, height, and sex in the reference population based on the clinical practice guideline for screening and management of high blood pressure in children and adolescents. We used logistic regression to estimate odds ratios between selected exposures and elevated blood pressure. Results The incidence of elevated blood pressure was (39/140, 27.9%: 95% (CI: 20.6–36.1)). Participants aged three years and above had twice the odds of elevated blood pressure as those aged less than three years (Adjusted odds ratio (AOR) 2.46: 95% CI (1.01–5.97). Female participants had 2.81 times the odds of elevated blood pressure as their male counterparts (AOR 2.81 95% CI (1.16–6.82). Participants with reduced estimated glomerular filtration rate had 2.85 times the odds of having elevated blood pressure as those with normal estimated glomerular filtration rate (AOR 2.85 95% CI (1.00–8.13). We found no association between arterial cord lactate, stunting, wealth index, exclusive breastfeeding, food diversity and elevated blood pressure. Conclusion Our findings show a high incidence of elevated blood pressure among children. We encourage routine checking for elevated blood pressure in the pediatric population particularly those with known risk factors.

Abstract Objective Every year, an estimated 20 million babies are born with low birthweight and this number is increasing globally. Survivors are at risk of lifelong morbidities like undernutrition. We assessed the growth and nutritional status for children born with low birthweight at Mulago Hospital, Uganda. Methods We conducted a cross sectional study to describe the nutritional status of children aged between 22 and 38 months and born weighing ≤ 2000 g. Anthropometric measurements; weight for height, height for age and weight for age z-scores were generated based on the World Health Organization standards to define wasting, stunting and underweight respectively. Data was collected using a structured questionnaire and analysis was done using STATA version 14. Results Of the 251 children, 129 (51.4%) were male, mean age was 29.7 months SD 4.5) and maternal mean age was 29.9 (SD 5.3). A total of 101(40.2%) had normal nutritional status. The prevalence of wasting, underweight and stunting were: 8 (3.2%), 36 (14.4%) and 106 (42.2%) respectively. Conclusion Six of ten children born with low birthweight were at risk of undernutrition in early childhood: underweight and stunting were higher than the national prevalence. Targeted interventions are needed for children with very low birth weight.

Abstract Background Given that there are hardly any comprehensive frameworks to guide institutions on approaches to use as they implement interprofessional education and collaborative practice during international electives, we developed and piloted a framework to address this gap. The purpose of this study, therefore, was to explore the experiences of faculty and students regarding the use of the developed interprofessional education and collaborative practice framework during international electives. Methods This was an exploratory qualitative study. The study participants included faculty and students from four health training universities in Africa who participated in the pilot of international electives guided by the framework developed. Deductive thematic analysis was used to analyze the data. The codes were categorized as per the major themes. Results The major themes regarding the framework included (1) The Strengths, (2) Weaknesses, (3) Opportunities, and (4) Threats. All participants perceived the framework as useful and appropriate to enable the acquisition of interprofessional education and collaborative practice skills objectives set. The framework’s duration of the elective was seen as a weakness with the need for an increment in the duration. The opportunities the framework presented included: acting as a starting point to structure and implement interprofessional education across various training institutions in Africa, advancing research, and networking opportunities to share the best practices. The main threat included siloed training where the current training curriculum of the students does not have opportunities that allow the students to study with, from, and about each other. Conclusions The framework developed to guide the implementation of interprofessional education and collaborative practice during international electives is feasible and enabled students to achieve the interprofessional education and collaborative practice objectives set while appreciating the transcultural similarities and differences in another country.

Abstract Background The skin is a major route of infection in the neonatal period, especially in low birthweight (LBW) infants. Appropriate and safe neonatal skin care practices are required to reduce this risk. The perceptions and beliefs of mothers and other caregivers towards various neonatal skin care practices in our setting have been documented. Data from Asia suggests that the application of emollient to the skin of LBW infants can promote growth, reduce serious neonatal infections, and potentially reduce mortality. This is the first study to explore the acceptability of emollients and massage as part of neonatal skin care in a low-resource setting in sub-Saharan Africa (SSA) that is representative of the majority of government health facilities in Uganda and many in SSA. Objective To explore perceptions, beliefs, and current practices regarding neonatal skin care and emollient use in eastern Uganda. Methods We conducted a qualitative study consisting of three focus group discussions (30 participants), eight in-depth interviews with mothers/caregivers of preterm and term neonates and 12 key informant interviews with midwives, doctors and community health workers involved in neonatal care, to explore the perceptions and practices surrounding neonatal skin care and emollient use. Data collected were transcribed and analyzed using thematic content analysis. Results Mothers perceived that skin care began in utero. Skincare practices depended on the place of delivery; for deliveries in a health facility the skincare practices were mainly based on the health worker’s advice. Vernix caseosa was often washed off due to its perceived undesirability and was attributed to sexual intercourse in the last trimester. Despite their deleterious attributes found in previous studies, petrolatum-based oils, petrolatum-based jellies and talcum baby powders were the most commonly reported items used in neonatal skin care. In our population, there was high acceptability of emollient therapy use; however, neonatal massage was treated with scepticism as mothers feared damaging the vulnerable neonate. Mothers suggested massage and emollient application be undertaken by health workers, if it becomes an intervention. Conclusions In eastern Uganda, the perceptions and beliefs of mothers/caregivers toward neonatal skincare influenced their practices of which some could potentially be beneficial, and others harmful. Emollient use would be easily accepted if adequate sensitisation is conducted and using the gatekeepers such as health workers.

Abstract Purpose Hypothyroidism has been reported at a prevalence of 6% in children and adolescents with Sickle cell anemia. In this study, we determined the prevalence and factors associated with hypothyroidism among children with Sickle cell anemia attending the Sickle Cell Clinic, in Mulago hospital, Uganda. Methods A cross-sectional study was conducted among children aged 6 months − 17 years with a confirmed diagnosis of Sickle Cell Anemia, with no prior diagnosis of hypothyroidism and in steady state attending the Sickle Cell Clinic in Mulago hospital. Data was collected using a structured questionnaire and a blood sample was used to measure thyroid stimulating hormone and free thyroxine. Results Of the 332 children enrolled, sixty (18.1%) participants had sub-clinical hypothyroidism (95% CI: 14.3 — 22.6). Factors associated with hypothyroidism included constipation [adjusted odds ratio: 3.1, 95% CI:1.0 — 9.0, p = 0.043] and male sex [adjusted odds ratio:2.0, 95% CI:1.1— 3.5, p = 0.025]. Conclusion Approximately 1 in 5 children (18.1%) had sub-clinical hypothyroidism. Males and children who presented with constipation were more likely to have sub-clinical hypothyroidism.

Background: Continuing professional development (CPD) activities relevant to medical doctors and their patients should be informed by current assessed training needs. The CPD provision is expected to improve the quality of professional practice and ethics. However, the Uganda Medical and Dental Practitioners’ Council still receives about 40 reports of malpractice every month. Aim: The study aimed to describe the CPD training needs of doctors working in public primary care facilities in central Uganda. Setting: The district health system of central Uganda comprised 10 General Hospitals (GH) and 37 Health Center IVs (HC IVs) with a staffing norm of six and two doctors, respectively. Methods: This was a cross-sectional survey of 100 doctors working in public primary care facilities using the World Health Organization (WHO) Hennessy-Hicks questionnaire. Descriptive statistics of the importance, current performance, and training need of each skilled activity were calculated. Content analysis was applied to data from the open-ended questions. Results: The response rate was 91%, majority were males, 80 (87.9%) from 7 GHs and 24 HC IVs with an average age of 37.9 years. The domain with the highest CPD training need for the doctors was research and audit, with a mean score (standard deviation [s.d.]) of 1.94 (±1.69), followed by administration 1.58 (±1.61) and clinical tasks 1.28 (±1.29). The clinical tasks domain had the most suggested CPD topics. Conclusion: Research and audit and clinical tasks were identified as important domains for CPD training for doctors in this setting. Contribution: The results give insight into CPD training needs of primary care doctors and guide various CPD providers.

BackgroundInternational electives provide a learning platform where interprofessional education and collaborative practice (IPECP) skills can be cultivated. However, hardly any frameworks to guide the implementation of interprofessional education (IPE) during international electives, especially in the context of low-income settings have been published. To address this gap, this study used the modified Delphi approach to develop an IPE framework guide for international electives to be used by health professions training institutions in Sub-Saharan Africa.MethodsA rapid literature review and a study among students and faculty in four African health professional training institutions were done to inform the process. This was followed by the modified Delphi technique that used three Delphi rounds with a panel of eight experts to build consensus on the final framework for IPE during international electives. The level of consensus was set at ≥70% on each of the statements in all rounds.ResultsOut of the 52 statements in round 1 (n = 37, 71%) reached consensus while (n = 15, 29%) of the statements did not reach consensus and were discussed in round 2. Round 2 led to 42 statements to be utilized for round 3. In round 3, all statements (42) reached a consensus and an IPE framework to guide the implementation of international electives was developed. The framework consists of three sections. Section one highlights the various IPECP competencies to be gained by learners in the areas of teamwork, interprofessional communication, roles and responsibilities of interprofessional collaborative practice, values and ethics of interprofessional collaboration, and reflection and evaluation of oneself and the team. Section two gives guidance on the structuring of the IPE international electives in health professional training institutions. This includes subsections on operational/institutional needs, acculturation considerations, teaching strategies, assessment strategies, mode of delivery, and public health considerations. Section three consists of the various practical guides and approaches that health professional training institutions could use according to what works best in their setting.ConclusionThe modified Delphi technique was an adequate approach to aid the development of an IPE framework to guide implementation during international electives in various health professional training institutions.

# Background Faculty perspectives are key drivers of learning during international electives (IEs). However, in Africa, there is limited literature on these perspectives on interprofessional education and collaborative practice (IPECP) during IEs. Therefore, this study explored faculty perspectives toward IPECP within an international elective context from selected African institutions. # Methods This was an exploratory qualitative study. The study participants included faculty from four health professional training universities in Africa. Thematic analysis was used to analyze the data. Common codes were identified and grouped to create subthemes and major themes. # Results Four themes were identified: (i) The importance of IPECP during IEs, (ii) Approaches to IPECP during IEs, (iii) Perceived key barriers, and (iv) Perceived institutional support for IPECP during IEs. Most of the participants perceived IEs as a platform that can be used to cultivate IPECP with a multicultural perspective while promoting cross-border partnerships to advance health care. Suggested teaching approaches included case studies, joint clinical ward rounds, and simulations, among others, with an openness to having an online, blended, or physical mode of delivery. A framework to guide the implementation of IPECP during IEs was considered important, and most participants thought that their institutions had the infrastructure to support IPECP-IEs. # Conclusions Faculty reported enabling perspectives of IPECP during IEs, emphasizing the need for a framework to guide and structure implementation. IPECP-IEs were perceived as a unique platform to cultivate IPECP skills with a multicultural component.

Abstract Introduction Identification of factors predicting prolonged hospitalization of patients with coronavirus disease (COVID-19) guides the planning, care and flow of patients in the COVID-19 Treatment Units (CTUs). We determined the length of hospital stay and factors associated with prolonged hospitalization among patients with COVID-19 at six CTUs in Uganda. Methods We conducted a retrospective cohort study of patients admitted with COVID-19 between January and December 2021 in six CTUs in Uganda. We conducted generalized linear regression models of the binomial family with a log link and robust variance estimation to estimate risk ratios of selected exposure variables and prolonged hospitalization (defined as a hospital stay for 14 days or more). We also conducted negative binomial regression models with robust variance to estimate the rate ratios between selected exposures and hospitalization duration. Results Data from 968 participants were analyzed. The median length of hospitalization was 5 (range: 1–89) days. A total of 136/968 (14.1%: 95% confidence interval (CI): 11.9–16.4%) patients had prolonged hospitalization. Hospitalization in a public facility (adjusted risk ratio (ARR) = 2.49, 95% CI: 1.65–3.76), critical COVID-19 severity scores (ARR = 3.24: 95% CI: 1.01–10.42), and malaria co-infection (adjusted incident rate ratio (AIRR) = 0.67: 95% CI: 0.55–0.83) were associated with prolonged hospitalization. Conclusion One out of seven COVID-19 patients had prolonged hospitalization. Healthcare providers in public health facilities should watch out for unnecessary hospitalization. We encourage screening for possible co-morbidities such as malaria among patients admitted for COVID-19.

Abstract Background Assessing factors associated with mortality among COVID-19 patients could guide in developing context relevant interventions to mitigate the risk. The study aimed to describe mortality and associated factors among COVID-19 patients admitted at six health facilities in Uganda. Methods We reviewed medical records of patients admitted with COVID-19 between January 1st 2021 and December 31st 2021 in six hospitals in Uganda. Using Stata version 17.0, Kaplan Meier and Cox regression analyses were performed to describe the time to death and estimate associations between various exposures and time to death. Finally, accelerated failure time (AFT) models with a lognormal distribution were used to estimate corresponding survival time ratios. Results Out of the 1040 study participants, 234 (22.5%: 95%CI 12.9 to 36.2%) died. The mortality rate was 30.7 deaths per 1000 person days, 95% CI (26.9 to 35.0). The median survival time was 33 days, IQR (9–82). Factors associated with time to COVID-19 death included; age ≥ 60 years [adjusted hazard ratio (aHR) = 2.4, 95% CI: [1.7, 3.4]], having malaria test at admission [aHR = 2.0, 95% CI:[1.0, 3.9]], a COVID-19 severity score of severe/critical [aHR = 6.7, 95% CI:[1.5, 29.1]] and admission to a public hospital [aHR = 0.4, 95% CI:[0.3, 0.6]]. The survival time of patients aged 60 years or more is estimated to be 63% shorter than that of patients aged less than 60 years [adjusted time ratio (aTR) 0.37, 95% CI 0.24, 0.56]. The survival time of patients admitted in public hospitals was 2.5 times that of patients admitted in private hospitals [aTR 2.5 to 95%CI 1.6, 3.9]. Finally, patients with a severe or critical COVID-19 severity score had 87% shorter survival time than those with a mild score [aTR 0.13, 95% CI 0.03, 0.56]. Conclusion In-hospital mortality among COVID-19 patients was high. Factors associated with shorter survival; age ≥ 60 years, a COVID-19 severity score of severe or critical, and having malaria at admission. We therefore recommend close monitoring of COVID-19 patients that are elderly and also screening for malaria in COVID-19 admitted patients.

Abstract Background Malaria is one of the leading causes of morbidity and mortality among children under 5 years of age in Uganda. Although Karamoja sub-region has the highest prevalence of malaria, and one of the highest case fatality rates in children under 5 years, information on malaria case management for the sub-region is scarce. The study evaluated the malaria diagnostic and treatment practices, as well as the factors associated with inappropriate care for children under 5 years of age presenting with fever in two public hospitals within the sub-region. Methods A cross-sectional study was conducted amongst 857 children under 5 years of age who presented with fever at Abim and Kaabong general hospitals between February and March 2020. A questionnaire was administered to the primary caregiver during exit/bedside interviews to collect socio-demographic information. The participant clinical notes were reviewed to capture information on laboratory tests conducted, diagnosis given, and treatment prescribed. In addition, a health facility assessment was conducted and information on healthcare workers was collected. The healthcare worker and facility data was linked to the participant’s hospital visit. Main outcome measures were malaria diagnostic and treatment practices. Results Of the 857 children enrolled, 820 (95.7%) had a malaria diagnostic test done and 623 (76.0%) tested positive for malaria. All test positive children received anti-malarial treatment, however, only 424/623 (68.1%) received the recommended anti-malarial drug and 376/424 (88.7%) received the right dose of the treatment. Inappropriate diagnosis/treatment was in 321 (37.5%) of the enrolled participants. Factors associated with inappropriate diagnosis/treatment included: lack of recommended anti-malarials on the day of the visit (Prevalence Ratio [PR] = 2.1, 95% confidence interval [CI] 1.8–2.4), hospital where care was sought (PR = 0.4, 95% CI 0.3–0.5), being managed by a recently supervised health worker (PR = 0.5, 95% CI 0.2–0.9), and health worker cadre (PR = 0.8, 95% CI 0.7–0.9). Conclusion The prevalence of inappropriate malaria diagnosis and treatment in the Karamoja sub-region was high with approximately one in every three children receiving inappropriate care. This was majorly influenced by health system factors, which if improved upon may reduce malaria-related mortalities in the sub-region a vital step in meeting the country’s target of zero deaths from malaria by 2030.

Abstract Background Practice-based learning is crucial in forming appropriate strategies for improving learning among the medical students that support the country’s understaffed health sector. Unsatisfactory learning consequently results in poor performance of students and poor quality of health care workforce in the long run. Exploring the perceptions about the current practice-based learning system and how to improve is thus vital. This study set out to explore the perceptions of Orthopaedic medicine students and their supervisors about practice-based learning at a tertiary training hospital. Methods This was an exploratory phenomenological qualitative study that involved in-depth interviews among 10 Orthopedic students during their rotation in the emergency ward of Mulago hospital and 6 of their supervisors. Interviews were audio-recorded, transcribed, and then imported into Atlas ti 8.3 for analysis. The data were coded and grouped into themes relating to perceptions of practice-based learning, general inductive analysis was used. The general inductive approach involved condensing the raw textual data into a brief and summary format. The summarized format was then analyzed to establish clear links between the perceptions of practice-based learning and the summary findings derived from the raw data. Results The mean age of the students was 23 ± 1.5 years. Four out of the six supervisors were Orthopaedic officers while the remaining two were principal Orthopaedic officers, four out of the six had a university degree while the other two were diploma holders. The main themes arising were hands-on skills, an unconducive learning environment, the best form of learning, and having an undefined training structure. Particularly, the perceptions included the presence of too many students on the wards during the rotation, frequent stock-outs of supplies for learning, and supervisors being overwhelmed caring for a large number of patients. Conclusion Barriers to satisfactory practice-based learning were overcrowding on the wards and insufficient training materials. To improve practice-based learning, adequate learning materials are required and the number of students enrolled needs to be appropriate for the student – supervisor ratio.

Abstract Background Medical schools in Sub-Saharan Africa have adopted competency based medical education (CBME) to improve the quality of graduates trained. In 2015, Makerere University College of Health Sciences (MaKCHS) implemented CBME for the Bachelor of Medicine and Bachelor of Surgery (MBChB) programme in order to produce doctors with the required attributes to address community health needs. However, no formal evaluation of the curriculum has been conducted to determine whether all established competencies are being assessed. Objective To evaluate whether assessment methods within the MBChB curriculum address the stated competencies. Methods The evaluation adopted a cross-sectional study design in which the MBChB curriculum was evaluated using an Essential Course Evidence Form (ECEF) that was developed to collect information about each assessment used for each course. Information was collected on: (1) Assessment title, (2) Description, (3) Competency domain (4) Sub-competency addressed, (5) Student instructions, and (6) Grading method/details. Data were entered into a structured Access data base. In addition, face-to-face interviews were conducted with faculty course coordinators. Results The MBChB curriculum consisted of 62 courses over 5 years, focusing on preclinical skills in years 1–2 and clinical skills in years 3–5. Fifty-nine competencies were identified and aggregated into 9 domains. Fifty-eight competencies were assessed at least one time in the curriculum. Faculty cited limited training in assessment as well as large student numbers as hindrances to designing robust assessments for the competencies. Conclusion CBME was successfully implemented evidenced by all but one of the 59 competencies within the nine domains established being assessed within the MBChB curriculum at MaKCHS. Faculty interviewed were largely aware of it, however indicated the need for more training in competency-based assessment to improve the implementation of CBME.

Abstract Background Children with sickle cell anemia (SCA) are at increased risk of acute kidney injury (AKI) that may lead to death or chronic kidney disease. This study evaluated AKI prevalence and risk factors in children with SCA hospitalized with a vaso-occlusive crisis (VOC) in a low-resource setting. Further, we evaluated whether modifications to the Kidney Disease: Improving Global Outcomes (KDIGO) definition would influence clinical outcomes of AKI in children with SCA hospitalized with a VOC. Methods We prospectively enrolled 185 children from 2 – 18 years of age with SCA (Hemoglobin SS) hospitalized with a VOC at a tertiary hospital in Uganda. Kidney function was assessed on admission, 24–48 h of hospitalization, and day 7 or discharge. Creatinine was measured enzymatically using an isotype-dilution mass spectrometry traceable method. AKI was defined using the original-KDIGO definition as ≥ 1.5-fold change in creatinine within seven days or an absolute change of ≥ 0.3 mg/dl within 48 h. The SCA modified-KDIGO (sKDIGO) definition excluded children with a 1.5-fold change in creatinine from 0.2 mg/dL to 0.3 mg/dL. Results Using KDIGO, 90/185 (48.7%) children had AKI with 61/185 (33.0%) AKI cases present on admission, and 29/124 (23.4%) cases of incident AKI. Overall, 23 children with AKI had a 1.5-fold increase in creatinine from 0.2 mg/dL to 0.3 m/dL. Using the sKDIGO-definition, 67/185 (36.2%) children had AKI with 43/185 (23.2%) cases on admission, and 24/142 (16.9%) cases of incident AKI. The sKDIGO definition, but not the original-KDIGO definition, was associated with increased mortality (0.9% vs. 7.5%, p = 0.024). Using logistic regression, AKI risk factors included age (aOR, 1.10, 95% CI 1.10, 1.20), hypovolemia (aOR, 2.98, 95% CI 1.08, 8.23), tender hepatomegaly (aOR, 2.46, 95% CI 1.05, 5.81), and infection (aOR, 2.63, 95% CI 1.19, 5.81) (p

Tuberculosis (TB), caused by Mycobacterium tuberculosis (Mtb), remains a leading cause of pediatric morbidity and mortality. Young children are at high risk of TB following Mtb exposure, and this vulnerability is secondary to insufficient host immunity during early life. Our primary objective was to compare CD4+ and CD8+ T-cell production of proinflammatory cytokines IFN-gamma, IL-2, and TNF-alpha in response to six mycobacterial antigens and superantigen staphylococcal enterotoxin B (SEB) between Ugandan adults with confirmed TB (n = 41) and young Ugandan children with confirmed (n = 12) and unconfirmed TB (n = 41), as well as non-TB lower respiratory tract infection (n = 39). Flow cytometry was utilized to identify and quantify CD4+ and CD8+ T-cell cytokine production in response to each mycobacterial antigen and SEB. We found that the frequency of CD4+ and CD8+ T-cell production of cytokines in response to SEB was reduced in all pediatric cohorts when compared to adults. However, T-cell responses to Mtb-specific antigens ESAT6 and CFP10 were equivalent between children and adults with confirmed TB. In contrast, cytokine production in response to ESAT6 and CFP10 was limited in children with unconfirmed TB and absent in children with non-TB lower respiratory tract infection. Of the five additional mycobacterial antigens tested, PE3 and PPE15 were broadly recognized regardless of TB disease classification and age. Children with confirmed TB exhibited robust proinflammatory CD4+ and CD8+ T-cell responses to Mtb-specific antigens prior to the initiation of TB treatment. Our findings suggest that adaptive proinflammatory immune responses to Mtb, characterized by T-cell production of IFN-gamma, IL-2, and TNF-alpha, are not impaired during early life.

BackgroundMineral bone disorders (MBD) are common in sickle cell anemia (SCA). Frequent vaso-occlusive crises (VOC) further impact MBD in children with SCA. We evaluated the prevalence of markers of SCA-related MBD (sMBD) in hospitalized children and assessed the relationship between sMBD and individual mineral abnormalities with kidney disease.MethodsWe prospectively recruited 185 children with SCA hospitalized with a VOC. Serum measures of mineral bone metabolism (calcium, phosphate, parathyroid hormone, 25-hydroxy vitamin D, FGF23, osteopontin) were measured at enrollment. The primary outcome was markers of sMBD defined as a composite of hypocalcemia, hyperphosphatemia, hyperparathyroidism, or deficiency in 25-OH vitamin D. Secondary outcomes included individual abnormalities in mineral metabolism. The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines were used to define SCA-associated acute kidney injury (AKI). AKI was further assessed using urine NGAL as a marker of tubular injury. Acute kidney disease (AKD) was defined as a composite of AKI, an eGFR

BackgroundIn Uganda, approximately 170,000 confirmed COVID-19 cases and 3,630 deaths have been reported as of January 2023. At the start of the second COVID-19 wave, the Ugandan health system was overwhelmed with a sudden increase in the number of COVID-19 patients who needed care, and the Ministry of Health resorted to home-based isolation and care for patients with mild to moderate disease. Before its rollout, the COVID-19 home-based care strategy had neither been piloted nor tested in Uganda.ObjectiveTo explore the experiences of COVID-19 patients managed at home in Uganda.MethodsThis was a qualitative study that was conducted to explore the lived experiences of COVID-19 patients managed at home. The study was carried out among patients who presented to three hospitals that were designated for treating COVID-19 patients in Uganda. COVID-19 patients diagnosed at these hospitals and managed at home were followed up and contacted for in-depth telephone interviews. The data were analysed using thematic content analysis with the aid of NVIVO 12.0.0 (QRS International, Cambridge, MA).ResultsParticipants experienced feelings of fear and anxiety: fear of death, fear of losing jobs, fear of infecting loved ones and fear of adverse events such as loss of libido. Participants also reported feelings of loneliness, hopelessness and depression on top of the debilitating and sometimes worsening symptoms. In addition to conventional medicines, participants took various kinds of home remedies and herbal concoctions to alleviate their symptoms. Furthermore, COVID-19 care resulted in a high economic burden, which persisted after the COVID-19 illness. Stigma was a major theme reported by participants. Participants recommended that COVID-19 care should include counselling before testing and during and after the illness to combat the fear and stigma associated with the diagnosis. Another recommendation was that health workers should carry out home visits to patients undergoing home-based care and that COVID-19 treatment should be free of charge.ConclusionCOVID-19 home-based care was associated with fear, anxiety, loneliness, depression, economic loss and stigma. Policymakers should consider various home-based follow-up strategies and strengthen counselling of COVID-19 patients at all stages of care.

BackgroundRheumatic and musculoskeletal disorders (RMDs) are associated with cardiovascular diseases (CVDs), with hypertension being the most common. We aimed to determine the prevalence of high blood pressure (HBP), awareness, treatment, and blood pressure control among patients with RMDs seen in a Rheumatology clinic in Uganda.MethodsWe conducted a cross-sectional study at the Rheumatology Clinic of Mulago National Referral Hospital (MNRH), Kampala, Uganda. Socio-demographic, clinical characteristics and anthropometric data were collected. Multivariable logistic regression was performed using STATA 16 to determine factors associated with HBP in patients with RMDs.ResultsA total of 100 participants were enrolled. Of these, majority were female (84%, n = 84) with mean age of 52.1 (standard deviation: 13.8) years and median body mass index of 28 kg/m2 (interquartile range (IQR): 24.8 kg/m2-32.9 kg/m2). The prevalence of HBP was 61% (n = 61, 95% CI: 51.5-70.5), with the majority (77%, n = 47, 95% CI: 66.5-87.6) being aware they had HTN. The prevalence of HTN was 47% (n = 47, 37.2-56.8), and none had it under control. Factors independently associated with HBP were age 46-55years (adjusted prevalence ratio (aPR): 2.5, 95% confidence interval (CI): 1.06-5.95), 56-65 years (aPR: 2.6, 95% CI: 1.09-6.15), >65 years (aPR: 2.5, 95% CI: 1.02-6.00), obesity (aPR: 3.7, 95% CI: 1.79-7.52), overweight (aPR: 2.7, 95% CI: 1.29-5.77).ConclusionThere was a high burden of HBP among people with RMDs in Uganda with poor blood pressure control, associated with high BMI and increasing age. There is a need for further assessment of the RMD specific drivers of HBP and meticulous follow up of patients with RMDs.

BackgroundCancer morbidity and mortality is rising in sub-Saharan Africa. Given this rise, family caregivers play an integral role in provision of quality cancer care services. This study explored the family caregivers (FCGs)/relatives' experiences of caring for patients with advanced cancer (stage 3 or stage 4) in Uganda.MethodsThis was a descriptive qualitative study exploring the lived experiences of FCGs of patients with advanced cancer attending care at the Uganda cancer institute. We purposively recruited twelve FCGs and conducted face-to-face in-depth interviews using an interviewer-guided semi-structured questionnaire. Data were analyzed by thematic analysis.ResultsThe age range of participants was 19 to 49 years. Most participants were children of the patients (n = 7), had attained tertiary education (n = 7), and had taken care of their loved ones for at least one year (n = 10). Six themes emerged from data analysis; (i) caring roles, (ii) caring burdens, (iii) role conflict, (iv) health system tensions, (v) support and motivation, (vi) caring benefits, lessons and recommendations.ConclusionStudy findings highlight the fundamental role of FCGs in the care of their loved ones, and illuminate the neglected physical, psychological and social challenges of family caregivers amidst health system tensions and conflicting roles. The needs of family caregivers should be embedded within cancer care, prevention and control programs particularly in low resource settings.

Abstract Background Dental health is often neglected by the majority of the population and has contributed to the global burden of oral diseases. We assessed awareness, utilization and barriers to seeking oral health care among adults in Nebbi District, Uganda. Methods A community-based, cross sectional study was conducted in the central division, Nebbi District in Uganda among adults between the age of 18 years or older. An interviewer-administered, semi-structured questionnaire was used for data collection on socio-demographic characteristics, oral health awareness, oral health utilization, associated factors and barriers. Results A total of 400 adults with a median age of 32 years (interquartile range 24–43) years were enrolled. More than half (57.5%, n = 230) of the participants were female. Participants identified smoking (42.8%, n = 171) and consumption of sugary foodstuffs (29.0%, n = 116) as risk factors for oral disease. Not brushing was also identified by 260 participants (65.0%) as the cause of tooth decay and 95.8% (n = 383) believed brushing one’s teeth could prevent tooth decay. Of the 51.5% (n = 206) who had experienced a toothache or discomfort 12 months prior to the study but only about half (52%, n = 106) had sought healthcare from a dental clinic or facility. About 89.5% (n = 94) of the participants were able to see a dentist during their last visits. Dental carries (76.6%, n = 70) and gum bleeding (14.9%, n = 14) were the most frequent reasons for visiting a dental clinic, and 73.7% (n = 70) had their tooth extracted. Barriers to seeking oral healthcare were cost of treatment (47.5%, n = 190), and long waiting time (18.5%, n = 74). The odds of seeking oral healthcare was 2.8-fold higher in participants who were being married (Odds ratio (OR): 2.8, 95% CI 1.3–6.3, p = 0.011) and 3.5-fold higher among housewives (COR: 3.5, 95% CI 1.1–11.4, p = 0.040). Conclusion About half of the participants had sought healthcare following a dental condition. Cost of treatment seems to be an important factor affecting utilization of oral health services. Optimization of costs, and creating awareness regarding benefits of utilizing preventive dental services are recommended.

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

ABSTRACT: OBJECTIVE: To determine the effect of contact tracing on the treatment outcomes of index tuberculosis (TB) cases in Uganda. METHODS: We evaluated TB cases registered at an urban public health facility in Uganda in 2015–2020. We extracted data from the unit's TB and contact tracing registers. Treatment outcomes were classified as cure, loss to follow-up, death and treatment failure. Treatment success was the sum of cure and treatment completion. RESULTS: Among 778 TB cases, contact tracing was conducted for 455 (58.5%). Compared with cases without contract tracing (n=323), cases with contract tracing (n=455) had higher treatment success (92.5% vs 79.3%) and cure rates (57.1% vs 39.9%) and lower loss to follow-up (3.5% vs 9.3%), treatment failure (0.4% vs 1.6%) and death (3.5% vs 9.9%) (P

Abstract Background Severe anaemia (haemoglobin

Abstract Background Uganda has an imbalanced distribution of the health workforce, which may be influenced by the specialty career preferences of medical students. In spite of this, there is inadequate literature concerning the factors influencing specialty career preferences. We aimed to determine the specialty career preferences and the factors influencing the preferences among fifth year medical students in the School of Medicine, Makerere University College of Health Sciences (MakCHS). Methods A sequential explanatory mixed methods study design with a descriptive cross-sectional study followed by a qualitative study was used. A total of 135 final year medical students in MakCHS were recruited using consecutive sampling. Self-administered questionnaires and three focus group discussions were conducted. Quantitative data was analysed in STATA version 13 (StataCorp, College Station, Tx, USA) using descriptive statistics, chi-square tests and logistic regression. Qualitative data was analysed in NVIVO version 12 (QRS International, Cambridge, MA) using content analysis. Results Of 135 students 91 (67.4%) were male and their median age was 24 years (IQR: 24, 26). As a first choice, the most preferred specialty career was obstetrics and gynecology (34/135, 25.2%), followed by surgery (27/135, 20.0%), pediatrics (18/135, 13.3%) and internal medicine (17/135, 12.6%). Non-established specialties such as anesthesia and Ear Nose and Throat (ENT) were not selected as a first choice by any student. Female students had 63% less odds of selecting surgical related specialties compared to males (aOR = 0.37, 95%CI: 0.17–0.84). The focus group discussions highlighted controlled lifestyle, assurance of a good life through better financial remuneration and inspirational specialists as facilitators for specialty preference. Bad experience during the clinical rotations, lack of career guidance plus perceived poor and miserable specialists were highlighted as barriers to specialty preference. Conclusion Obstetrics and Gynecology, Surgery, Pediatrics and Internal Medicine are well-established disciplines, which were dominantly preferred. Females were less likely to select surgical disciplines as a career choice. Therefore, there is a need to implement or establish career guidance and mentorship programs to attract students to the neglected disciplines.

Rotavirus genotypes are species specific. However, interspecies transmission is reported to result in the emergence of new genotypes. A cross-sectional study of 242 households with 281 cattle, 418 goats, 438 pigs, and 258 humans in Uganda was undertaken between 2013 and 2014. The study aimed to determine the prevalence and genotypes of rotaviruses across co-habiting host species, as well as potential cross-species transmission. Rotavirus infection in humans and animals was determined using NSP3 targeted RT-PCR and ProSpecT Rotavirus ELISA tests, respectively. Genotyping of rotavirus-positive samples was by G- and P-genotype specific primers in nested RT-PCR assays while genotyping of VP4 and VP7 proteins for the non-typeable human positive sample was done by Sanger sequencing. Mixed effect logistic regression was used to determine the factors associated with rotavirus infection in animals. The prevalence of rotavirus was 4.1% (95% CI: 3.0–5.5%) among the domestic animals and 0.8% (95% CI: 0.4–1.5%) in humans. The genotypes in human samples were G9P[8] and P[4]. In animals, six G-genotypes, G3(2.5%), G8(10%), G9(10%), G11(26.8%), G10(35%), and G12(42.5%), and nine P-genotypes, P[1](2.4%), P[4](4.9%), P[5](7.3%), P[6](14.6%), P[7](7.3%), P[8](9.8%), P[9](9.8%), P[10](12.2%), and P[11](17.1%), were identified. Animals aged 2 to 18 months were less likely to have rotavirus infection in comparison with animals below 2 months of age. No inter-host species transmission was identified.

Abstract Background Neonatal hypoglycemia is the most common endocrine abnormality in children, which is associated with increased morbidity and mortality. The burden and risk factors of neonatal hypoglycemia in rural communities in sub-Saharan Africa are unknown. Objective To determine the prevalence and risk factors for neonatal hypoglycemia in Lira District, Northern Uganda. Methods This was a community-based cross-sectional study, nested in a cluster randomized controlled trial designed to promote health facility births and newborn care practices in Lira District, Northern Uganda. This study recruited neonates born to mothers in the parent study. Random blood glucose was measured using an On Call® Plus glucometer (ACON Laboratories, Inc., 10125 Mesa Road, San Diego, CA, USA). We defined hypoglycemia as a blood glucose of < 47 mg/dl. To determine the factors associated with neonatal hypoglycemia, a multivariable linear regression mixed-effects model was used. Results We examined 1416 participants of mean age 3.1 days (standard deviation (SD) 2.1) and mean weight of 3.2 kg (SD 0.5). The mean neonatal blood glucose level was 81.6 mg/dl (SD 16.8). The prevalence of a blood glucose concentration of < 47 mg/dl was 2.2% (31/1416): 95% CI 1.2%, 3.9%. The risk factors for neonatal hypoglycemia were delayed breastfeeding initiation [adjusted mean difference, − 2.6; 95% CI, − 4.4, − 0.79] and child age of 3 days or less [adjusted mean, − 12.2; 95% CI, − 14.0, − 10.4]. Conclusion The incidence of neonatal hypoglycemia was low in this community and was predicted by delay in initiating breastfeeding and a child age of 3 days or less. We therefore suggest targeted screening and management of neonatal hypoglycemia among neonates before 3 days of age and those who are delayed in the onset of breastfeeding.

Abstract Background Mentorship has become a routine part of undergraduate training in health professions education. Although many health professions training institutions have successfully incorporated faculty-student mentorship in their formal training, many others especially in Sub-Saharan Africa have not fully embraced this. Institutionalized mentorship programmes are effective methods of enhancing student learning experiences. Faculty, who are the mentors have an active role to play in driving the mentorship agenda and ensure that students benefit from this important activity. The aim of this study was to explore the knowledge, attitudes and practices of faculty about student mentorship at Makerere University College of Health Sciences. Methods It was an exploratory qualitative study using interviewer-administered semi-structured questionnaires. The study participants included faculty at Makerere University College of Health Sciences. Thematic analysis was used to analyse the data using pre-determined themes. Results Four themes were identified: 1) Knowledge of mentorship, 2) Attitude towards mentorship, 3) Practice of mentorship and 4) Improving the mentorship process. Majority of the faculty reported being less knowledgeable on mentorship regardless of seniority. The level of knowledge seemed to influence the practice of mentorship. Despite the observed knowledge gap, all faculty demonstrated a positive attitude to participate in mentoring. Conclusion Faculty demonstrated a positive attitude towards mentorship despite the knowledge gap of mentorship identified. Continuous faculty development in mentorship as well as using peer mentorship were identified as key in sustaining the mentorship programme.

BackgroundGroup antenatal care (G-ANC), an alternative to focused ANC (F-ANC), involves grouping mothers by gestational and maternal age. In high-income countries, G-ANC has been associated with improved utilization of health care services like Prevention of Mother to Child Transmission (PMTCT) of HIV services. Some low-resource countries with poor utilization of health care services have piloted G-ANC. However, there is limited evidence of its efficiency. We, therefore, compared G-ANC versus F-ANC with regards to optimal utilization of PMTCT of HIV services and assessed associated factors thereof among adolescent mothers in eastern Uganda. We defined optimal utilization of PMTCT of HIV services as the adolescent being up to date with HIV counseling and testing. If found HIV negative, subsequent timely re-testing. If found HIV positive, initiation of antiretroviral therapy (ART) under option B plus for the mother. While for the infant, it entailed safe delivery, testing, feeding, and appropriate HIV chemotherapy.MethodsFrom February to April 2020, we conducted a cross-sectional study among 528 adolescent mothers in four sites in eastern Uganda. We assessed the optimal utilization of PMTCT of HIV services among adolescent mothers that had attended G-ANC versus F-ANC at the post-natal care or immunization clinics. We also assessed the factors associated with optimal utilization of PMTCT of HIV services among these mothers.ResultsOptimal utilization of PMTCT was higher among those in G-ANC than in F-ANC (74.7% vs 41.2, p-0.0162). There was a statistically significant association between having attended G-ANC and optimal utilization of PMTCT [PR = 1.080, 95%CI (1.067-1.093)]. Other factors independently associated with optimal utilization were; having a partner that tested for HIV [PR = 1.075, 95%CI (1.048-1.103)], trimester of first ANC visit: second trimester [PR = 0.929, 95%CI (0.902-0.957)] and third trimester [PR = 0.725, 95%CI (0.616-0.853)], and the health facility attended: Bugembe HCIV [PR = 1.126, 95%CI (1.113-1.139)] and Jinja regional referral hospital [PR = 0.851, 95%CI (0.841-0.861].ConclusionsAdolescent mothers under G-ANC had significantly higher optimal utilization of PMTCT of HIV services compared to those under F-ANC. We recommend that the Ministry of Health considers widely implementing G-ANC, especially for adolescent mothers.

Background: To prevent poor long-term outcomes (deaths and readmissions) the integrated global action plan for pneumonia and diarrhoea recommends under the ‘Treat’ element of Protect, Prevent and Treat interventions the importance of continued feeding but gives no specific recommendations for nutritional support. Early nutritional support has been practiced in a wide variety of critically ill patients to provide vital cell substrates, antioxidants, vitamins, and minerals essential for normal cell function and decreasing hypermetabolism. We hypothesise that the excess post-discharge mortality associated with pneumonia may relate to the catabolic response and muscle wasting induced by severe infection and inadequacy of the diet to aid recovery. We suggest that providing additional energy-rich, protein, fat and micronutrient ready-to-use therapeutic feeds (RUTF) to help meet additional nutritional requirements may improve outcome. Methods: COAST-Nutrition is an open, multicentre, Phase II randomised controlled trial in children aged 6 months to 12 years hospitalised with suspected severe pneumonia (and hypoxaemia, SpO2

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.

Abstract Background African children hospitalised with severe febrile illness have a high risk of mortality. The Fluid Expansion As Supportive Therapy (FEAST) trial (ISCRTN 69856593) demonstrated increased mortality risk associated with fluid boluses, but the temporal relationship to bolus therapy and underlying mechanism remains unclear. Methods In a post hoc retrospective analysis, flexible parametric models were used to compare change in mortality risk post-randomisation in children allocated to bolus therapy with 20–40 ml/kg 5% albumin or 0.9% saline over 1–2 h or no bolus (control, 4 ml/kg/hour maintenance), overall and for different terminal clinical events (cardiogenic, neurological, respiratory, or unknown/other). Results Two thousand ninety-seven and 1041 children were randomised to bolus vs no bolus, of whom 254 (12%) and 91 (9%) respectively died within 28 days. Median (IQR) bolus fluid in the bolus groups received by 4 h was 20 (20, 40) ml/kg and was the same at 8 h; total fluids received in bolus groups at 4 h and 8 h were 38 (28, 43) ml/kg and 40 (30, 50) ml/kg, respectively. Total fluid volumes received in the control group by 4 h and 8 h were median (IQR) 10 (6, 15) ml/kg and 10 (10, 26) ml/kg, respectively. Mortality risk was greatest 30 min post-randomisation in both groups, declining sharply to 4 h and then more slowly to 28 days. Maximum mortality risk was similar in bolus and no bolus groups; however, the risk declined more slowly in the bolus group, with significantly higher mortality risk compared to the no bolus group from 1.6 to 101 h (4 days) post-randomisation. The delay in decline in mortality risk in the bolus groups was most pronounced for cardiogenic modes of death. Conclusions The increased risk from bolus therapy was not due to a mechanism occurring immediately after bolus administration. Excess mortality risk in the bolus group resulted from slower decrease in mortality risk over the ensuing 4 days. Thus, administration of modest bolus volumes appeared to prevent mortality risk declining at the same rate that it would have done without a bolus, rather than harm associated with bolus resulting from a concurrent increased risk of death peri-bolus administration. Trial registration ISRCTN69856593. Date of registration 15 December 2008.

Abstract Background Children with sickle cell anemia (SCA) are highly susceptible to stroke and other manifestations of pediatric cerebral vasculopathy. Detailed evaluations in sub-Saharan Africa are limited. Methods We aimed to establish the frequency and types of pediatric brain injury in a cross-sectional study at a large SCA clinic in Kampala, Uganda in a randomly selected sample of 265 patients with HbSS ages 1–12 years. Brain injury was defined as one or more abnormality on standardized testing: neurocognitive impairment using an age-appropriate test battery, prior stroke by examination or transcranial Doppler (TCD) velocities associated with stroke risk in children with SCA (cerebral arterial time averaged mean maximum velocity ≥ 170 cm/second). Results Mean age was 5.5 ± 2.9 years; 52.3% were male. Mean hemoglobin was 7.3 ± 1.01 g/dl; 76.4% had hemoglobin

Given the dearth need for healthcare workers in the control of the ongoing COVID-19 pandemic, e-learning has been adopted in many settings to hasten the continuation of medical training. However, there is a paucity of data in low resource settings on the plausibility of online learning platforms to support medical education. We aimed to assess the awareness, attitudes, preferences, and challenges to e-learning among Bachelor of Medicine and Bachelor of Surgery (MBChB) and Bachelor of Nursing (B.NUR) students at Makerere University, Uganda. An online cross-sectional study was conducted between July and August 2020. Current MBChB and B.NUR students aged 18 years or older constituted the study population. Using Google forms, a web-based questionnaire was administered through the Makerere University mailing list and WhatsApp messenger. The questionnaire was developed using validated questions from previously published studies. Overall, 221 participants responded (response rate = 61%). Of the 214 valid responses, 195 (92.1%) were Ugandans, 123 (57.5% were male, and 165 (77.1%) were pursuing the MB ChB program. The median age was 23 (18 to 40) years. Ownership of computers, smartphones, and email addresses were at 131 (61.2%), 203 (94.9%), and 208 (97.2%), respectively. However, only 57 (26.6%) respondents had access to high or very high quality internet access. Awareness and self-reported usage of e-learning (MUELE) platforms were high among 206 (96.3%) and 177 (82.7%) respondents, respectively. However, over 50% lacked skills in using the Makerere University e-learning (MUELE) platform. About half (n = 104, 49%) of the students believed that e-learning reduces the quality of knowledge attained and is not an efficient method of teaching. Monthly income ( P = .006), internet connectivity quality ( P < .001), computer ownership ( P = .015) and frequency of usage of academic websites or applications ( P = .006) significantly affected attitudes towards e-learning. Moreover, internet costs and poor internet connectivity were the most important barriers to e-learning reported by 199 (93%) and 179 (84%) students, respectively. Sensitization and training of students and faculty on e-learning and use of existing learning platforms are important to improve the attitude and use of e-learning. Blended online and use of offline downloadable learning materials would overcome the challenges related to the variable quality of internet access in the country.

MR1-restricted T (MR1T) cells are defined by their recognition of metabolite antigens presented by the monomorphic MHC class 1-related molecule, MR1, the most highly conserved MHC class I related molecule in mammalian species. Mucosal-associated invariant T (MAIT) cells are the predominant subset of MR1T cells expressing an invariant TCR α-chain, TRAV1-2. These cells comprise a T cell subset that recognizes and mediates host immune responses to a broad array of microbial pathogens, including Mycobacterium tuberculosis. Here, we sought to characterize development of circulating human MR1T cells as defined by MR1-5-OP-RU tetramer labeling and of the TRAV1-2+ MAIT cells defined by expression of TRAV1-2 and high expression of CD26 and CD161 (TRAV1-2+CD161++CD26++ cells). We analyzed postnatal expansion, maturation, and functionality of peripheral blood MR1-5-OP-RU tetramer+ MR1T cells in cohorts from three different geographic settings with different tuberculosis (TB) vaccination practices, levels of exposure to and infection with M. tuberculosis. Early after birth, frequencies of MR1-5-OP-RU tetramer+ MR1T cells increased rapidly by several fold. This coincided with the transition from a predominantly CD4+ and TRAV1-2− population in neonates, to a predominantly TRAV1-2+CD161++CD26++ CD8+ population. We also observed that tetramer+ MR1T cells that expressed TNF upon mycobacterial stimulation were very low in neonates, but increased ~10-fold in the first year of life. These functional MR1T cells in all age groups were MR1-5-OP-RU tetramer+TRAV1-2+ and highly expressed CD161 and CD26, markers that appeared to signal phenotypic and functional maturation of this cell subset. This age-associated maturation was also marked by the loss of naïve T cell markers on tetramer+ TRAV1-2+ MR1T cells more rapidly than tetramer+TRAV1-2− MR1T cells and non-MR1T cells. These data suggest that neonates have infrequent populations of MR1T cells with diverse phenotypic attributes; and that exposure to the environment rapidly and preferentially expands the MR1-5-OP-RU tetramer+TRAV1-2+ population of MR1T cells, which becomes the predominant population of functional MR1T cells early during childhood.

Abstract Background Neonatal sepsis is one of the most important causes of mortality in developing countries and yet the most preventable. In developing countries clinical algorithms are used to diagnose clinical neonatal sepsis because of inadequate microbiological services. Most information on incidence and risk factors of neonatal sepsis are from hospital studies which may not be generalized to communities where a significant proportion of mothers do not deliver from health facilities. This study, conducted in urban Uganda, sought to determine the community based incidence of clinical neonatal sepsis and the factors associated. Methods This was a cohort of mother-neonate pairs in Kampala, Uganda from March to May 2012. The enrolled neonates were assessed for clinical sepsis and factors associated, and followed up till the end of the neonatal period. STATA version 10 was used to analyse the data. Results The community based incidence of neonatal sepsis was 11% (95% CI: 7.6–14.4). On bivariate analysis, lack of financial support from the father (OR 4.09, 95% CI 1.60–10.39) and prolonged rupture of membranes more than 18 h prior to delivery (OR 11.7, 95% CI 4.0–31.83) were significantly associated with neonatal sepsis. Maternal hand washing prior to handling the baby was found to be protective of neonatal sepsis (OR 0.41, 95% CI 0.18–0.94). Of the 317 infants who completed the follow up period, one died within the neonatal period giving a neonatal mortality of 0.003%. Conclusion The high incidence of clinical neonatal sepsis in this urban community with high rates of antenatal care attendance and health facility delivery places a demand on the need to improve the quality of antenatal, perinatal and postnatal care in health facilities with regards to infection prevention including promoting simple practices like hand washing. The astoundingly low mortality rate is most likely because this was a low risk cohort. However it may also suggest that the neonatal mortality in developing countries may be reduced with promotion of simple low cost interventions like community follow up of neonates using village health teams or domiciliary care.

Abstract Background Hyperlactataemia (HL) is a biomarker of disease severity that predicts mortality in patients with sepsis and malaria. Lactate clearance (LC) during resuscitation has been shown to be a prognostic factor of survival in critically ill adults, but little data exist for African children living in malaria-endemic areas. Methods In a secondary data analysis of severely ill febrile children included in the Fluid Expansion as Supportive Therapy (FEAST) resuscitation trial, we assessed the association between lactate levels at admission and LC at 8 h with all-cause mortality at 72 h (d72). LC was defined as a relative lactate decline ≥ 40% and/or lactate normalisation (lactate

Abstract Background In most medical schools, graduate students, sometimes referred to as graduate teaching assistants, often participate in the training of undergraduate students. In developing countries like Uganda, are typically involved in undergraduate training. However, prior to this study there were no standard guidelines for this involvement. At the same time, the views and experiences of the graduate students in their role as educators had not been documented. Therefore, the aim of this study was to explore the views and experiences of graduate students about their involvement in undergraduate training in three Ugandan medical schools. The findings of this study will contribute to the development of policies for training in Ugandan medical schools. Methods This was a qualitative study in which thirty in-depth-interviews were conducted among second and third year graduate students in three Ugandan medical schools in the MESAU consortium (Medical Education Services to all Ugandans) including Mbarara University of Science and Technology, Makerere College of Health Sciences and Kampala International University, Western Campus. Results All graduate students from all the three medical schools viewed their involvement in undergraduate training as important. The study also revealed that graduate students increase available human resources and often compensate for the teaching missed when senior educators were absent. The graduate students expressed important views that need to be considered in the design of educational programs where they are to be involved. The respondents also reported a number of challenges in this undertaking that included lack of motivation, lack of orientation and having heavy workloads. The presence and commitment of senior educators to guide and support the graduate students in teaching activities was viewed as one significant intervention that would increase the effectiveness of their educational contributions. Conclusions Graduate students enjoy their involvement in the training of undergraduate students despite the various challenges they face. In some departments, the involvement of postgraduate trainees is critical to the viability of undergraduate medical training.

Abstract Background The aim of mentorship is to build the mentees capacity, enhance their skills and improve their ability to produce desired outcomes. However, the mentoring relationship is vulnerable to a number of challenges that may undermine its effectiveness and sustainability. We aimed to explore the experiences and perceptions of student and junior faculty mentees and senior faculty mentors at the Makerere University College of Health Sciences and identify the key factors defined by mentees and mentors as necessary for a successful mentorship program. Methods A qualitative design involving focus group discussions (FGDs) and key informant interviews (KII) was used. A total of eight KII and four FGDs were conducted, audio recorded and transcribed verbatim. Open coding of the transcripts was performed, and major themes were identified through multiple readings based on thematic analysis. Results Six key themes were shared by the mentees and mentors including: 1) defining the role of the mentor; 2) desired characteristics of a mentor and a mentoring relationship, with an emphasis on mutual trust and respect; 3) overlapping roles of mentors and supervisors; 4) issues with the process for identifying mentors, including the benefits and drawbacks of the mentee selecting mentor vs. being assigned a mentor; 5) current barriers to mentoring, including lack of knowledge about current program, lack of formal structure, uncertainly about who should initiate relationship, and unclear roles and expectations and 6) recommendations for the future development of mentoring programme, including the need for a formalized programme, and training adapted to the local context. Conclusions The mentees and mentors described the role of the mentor and desired characteristics of mentors and a mentoring relationship similarly. Most concerns about mentoring occurred when current mentoring programmes and practices were not well aligned with these desired characteristics. Recommendations for future development of mentoring included greater formalization of mentoring with mentoring programmes based on shared expectations and adapted to the local context.

Summary: Background: Severe anaemia is a leading cause of paediatric admission to hospital in Africa; post-discharge outcomes remain poor, with high 6-month mortality (8%) and re-admission (17%). We aimed to investigate post-discharge interventions that might improve outcomes. Methods: Within the two-stratum, open-label, multicentre, factorial randomised TRACT trial, children aged 2 months to 12 years with severe anaemia, defined as haemoglobin of less than 6 g/dL, at admission to hospital (three in Uganda, one in Malawi) were randomly assigned, using sequentially numbered envelopes linked to a second non-sequentially numbered set of allocations stratified by centre and severity, to enhanced nutritional supplementation with iron and folate-containing multivitamin multimineral supplements versus iron and folate alone at treatment doses (usual care), and to co-trimoxazole versus no co-trimoxazole. All interventions were administered orally and were given for 3 months after discharge from hospital. Separately reported randomisations investigated transfusion management. The primary outcome was 180-day mortality. All analyses were done in the intention-to-treat population; follow-up was 180 days. This trial is registered with the International Standard Randomised Controlled Trial registry, ISRCTN84086586, and follow-up is complete. Findings: From Sept 17, 2014, to May 15, 2017, 3983 eligible children were randomly assigned to treatment, and followed up for 180 days. 164 (4%) were lost to follow-up. 1901 (95%) of 1997 assigned multivitamin multimineral supplement, 1911 (96%) of 1986 assigned iron and folate, and 1922 (96%) of 1994 assigned co-trimoxazole started treatment. By day 180, 166 (8%) children in the multivitamin multimineral supplement group versus 169 (9%) children in the iron and folate group had died (hazard ratio [HR] 0·97, 95% CI 0·79–1·21; p=0·81) and 172 (9%) who received co-trimoxazole versus 163 (8%) who did not receive co-trimoxazole had died (HR 1·07, 95% CI 0·86–1·32; p=0·56). We found no evidence of interactions between these randomisations or with transfusion randomisations (p>0·2). By day 180, 489 (24%) children in the multivitamin multimineral supplement group versus 509 (26%) children in the iron and folate group (HR 0·95, 95% CI 0·84–1·07; p=0·40), and 500 (25%) children in the co-trimoxazole group versus 498 (25%) children in the no co-trimoxazole group (1·01, 0·89–1·15; p=0·85) had had one or more serious adverse events. Most serious adverse events were re-admissions, occurring in 692 (17%) children (175 [4%] with at least two re-admissions). Interpretation: Neither enhanced supplementation with multivitamin multimineral supplement versus iron and folate treatment or co-trimoxazole prophylaxis improved 6-month survival. High rates of hospital re-admission suggest that novel interventions are urgently required for severe anaemia, given the burden it places on overstretched health services in Africa. Funding: Medical Research Council and Department for International Development.

IntroductionUnder five mortality rates (UFMR) remain high for children in low- and middle-income countries (LMICs) in the developing world. Education for practitioners in these environments is a key factor to improve outcomes that will address United Nations Sustainable Development Goals 3 and 10 (good health and well being and reduced inequalities). In order to appropriately contextualize a curriculum using simulation, it is necessary to first conduct a needs assessment of the target learner population. The World Health Organization (WHO) has published a tool to assess capacity for emergency and surgical care in LMICs that is adaptable to this goal.Materials and methodsThe WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care was modified to assess pediatric resuscitation capacity in clinical settings in two LMICs: Uganda and Myanmar. Modifications included assessment of self-identified learning needs, current practices, and perceived epidemiology of disease burden in each clinical setting, in addition to assessment of pediatric resuscitation capacity in regard to infrastructure, procedures, equipment, and supplies. The modified tool was administered to 94 respondents from the two settings who were target learners of a proposed simulation-based curriculum in pediatric and neonatal resuscitation.ResultsInfectious diseases (respiratory illnesses and diarrheal disease) were cited as the most common causes of pediatric deaths in both countries. Self-identified learning needs included knowledge and skill development in pediatric airway/breathing topics, as well as general resuscitation topics such as CPR and fluid resuscitation in shock. Equipment and supply availability varied substantially between settings, and critical shortages were identified in each setting. Current practices and procedures were often limited by equipment availability or infrastructural considerations.Discussion and conclusionEpidemiology of disease burden reported by respondents was relatively consistent with WHO country-specific UFMR statistics in each setting. Results of the needs assessment survey were subsequently used to refine goals and objectives for the simulation curriculum and to ensure delivery of pragmatic educational content with recommendations that were contextualized for local capacity and resource availability. Effective use of the tool in two different settings increases its potential generalizability.

Background: In Africa, the clinical syndrome of pneumonia remains the leading cause of morbidity and mortality in children in the post-neonatal period. This represents a significant burden on in-patient services. The targeted use of oxygen and simple, non-invasive methods of respiratory support may be a highly cost-effective means of improving outcome, but the optimal oxygen saturation threshold that results in benefit and the best strategy for delivery are yet to be tested in adequately powered randomised controlled trials. There is, however, an accumulating literature about the harms of oxygen therapy across a range of acute and emergency situations that have stimulated a number of trials investigating permissive hypoxia. Methods: In 4200 African children, aged 2 months to 12 years, presenting to 5 hospitals in East Africa with respiratory distress and hypoxia (oxygen saturation < 92%), the COAST trial will simultaneously evaluate two related interventions (targeted use of oxygen with respect to the optimal oxygen saturation threshold for treatment and mode of delivery) to reduce shorter-term mortality at 48-hours (primary endpoint), and longer-term morbidity and mortality to 28 days in a fractional factorial design, that compares: Liberal oxygenation (recommended care) compared with a strategy that permits hypoxia to SpO2 > or = 80% (permissive hypoxia); and High flow using AIrVO2TM compared with low flow delivery (routine care). Discussion: The overarching objective is to address the key research gaps in the therapeutic use of oxygen in resource-limited setting in order to provide a better evidence base for future management guidelines. The trial has been designed to address the poor outcomes of children in sub-Saharan Africa, which are associated with high rates of in-hospital mortality, 9-10% (for those with oxygen saturations of 80-92%) and 26-30% case fatality for those with oxygen saturations