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ItemMortality and its predictors among TB patients within two years after TB treatment discharge at Kawaala and Kiswa Health Centre IVs, Kampala City, Uganda(Makerere university, 2026)Background: Tuberculosis (TB) treatment completion is an important indicator of programme success; however, this does not always indicate full recovery, and some patients die after treatment has ended. Evidence on the magnitude, timing and determinants of post-treatment mortality remains limited in routine Ugandan settings. This study assessed mortality among TB patients within two years after treatment discharge at Kawaala and Kiswa Health Centre IVs, Kampala City. Objective: To determine two-year mortality, potential predictors of mortality and time to mortality among TB patients after treatment discharge Methods: An ambispective cohort study included 259 eligible participants from a parent TB-diabetes cohort. Vital status was established from cohort and facility records, telephone follow-up and verbal-autopsy interviews with next of kin. Mortality was summarized as a cumulative proportion and person-time rate. Firth penalised logistic regression assessed potential predictors, while Kaplan–Meier and exploratory Cox proportional-hazards methods assessed survival and time to death Results: Participants contributed 6,036 person-months (503 person-years). Ten deaths occurred, giving a two-year cumulative mortality of 3.9% and a crude mortality rate of 19.9 deaths per 1,000 person-years. Five deaths occurred within 0–6 months and five during 6–12 months; none occurred during 12–24 months. Overall survival was 0.981 at six months and 0.961 at 12 months, remaining unchanged through 24 months. HIV-positive status was the strongest potential predictor of mortality across the Firth models (Model A: AOR 3.34, 95% CI 0.96–11.64; Model B: AOR 3.37, 95% CI 0.97–11.71) and the exploratory Cox model (AHR 3.41, 95% CI 0.98–11.84). Dysglycaemia did not show a clear prognostic relationship with mortality (AHR 1.12, 95% CI 0.23–5.54). All adjusted estimates were imprecise because only 10 deaths occurred Conclusion: Post-treatment mortality was relatively low but was concentrated entirely within the first year. HIV-positive status showed the strongest potential predictor signal, although the estimates remained imprecise. The findings support evaluating structured first-year post-TB follow-up and mortality surveillance, with particular attention to continuity of HIV care among HIV-positive survivors. Larger multicentre prospective studies are needed to confirm predictors of mortality and improve precision and generalizability.
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ItemAssessment of Plasmodium falciparum genetic diversity, multiplicity of infection and algorithms for distinguishing recrudescence from reinfection in antimalarial drug efficacy studies in Uganda(Makerere University, 2025-06-10)Background: Despite renewed control efforts, malaria remains a major public health problem, contributing significantly to morbidity and mortality, especially in endemic countries. Effective control is hindered by several factors, including the high genetic diversity of Plasmodium falciparum, the presence of multiple parasite clones within a single host (referred to as multiplicity of infection (MOI)), and the persistence of parasite strains despite treatment (recrudescence). This PhD study aimed to assess P. falciparum genetic diversity and MOI with in sub-Saharan Africa (SSA), with a specific focus on areas of varying malaria transmission intensity in Uganda. Additionally, we evaluated the performance of different microsatellite markers and genotyping algorithms in distinguishing recrudescence from reinfection, an essential component of antimalarial drug efficacy monitoring. Methods: This study employed a combination of systematic review, meta-analysis, and secondary data analysis using both cross-sectional and longitudinal studies. To evaluate P.falciparum genetic diversity and MOI across different geographical regions in SSA (Objective 1), I conducted a systematic review and meta-analysis of published articles. The review focused on studies using common molecular markers, including genes of merozoite surface protein 1 and 2 (msp-1, msp-2), and microsatellites. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. To determine how P. falciparum genetic diversity and MOI vary by malaria transmission intensity, clinical disease status (asymptomatic versus symptomatic), and over time (Objectives 2, 3, and 4), I performed secondary analyses of data and dried blood spot (DBS) filter paper samples from comprehensive surveillance studies conducted between 2011 and 2017 in areas of varying transmission intensities in Uganda. To assess the performance of microsatellite markers and three genotyping algorithms (3/3 match-counting, ≥2/3 matchxiii counting, and the Bayesian approach) in distinguishing between recrudescence and reinfection (Objective 5), I analyzed data and DBS filter paper samples from a therapeutic efficacy study (TES) conducted between September 2018 and February 2019 at three health centers located in high malaria transmission regions of Uganda. Demographic and clinical data were retrieved from primary study databases, while genetic data were generated through genotyping of P. falciparum isolates using the highly polymorphic markers msp-1, msp-2, and microsatellites. Genomic DNA was extracted from DBS samples using Chelex 100 Resin (Sigma-Aldrich, USA). Genotyping of msp-1, msp-2, and glurp was performed using nested PCR, with amplicon sizing on the QIAxcel Advanced System (QIAGEN). For microsatellites, seven loci (TA1, Poly-α, PfPK2, TA109, 2490, C2M34–313, and C3M69–383) were amplified using fluorescently labeled primers, and allele sizing was conducted via high-resolution capillary electrophoresis on an ABI 3730 Genetic Analyzer. P. falciparum genetic diversity was assessed by calculating allele count, effective allele number, allelic richness, and expected heterozygosity (He). P. falciparum MOI was estimated by determining the number of distinct genotypes per infection. Population structure was assessed using multilocus linkage disequilibrium (LD), genetic differentiation, analysis of molecular variance (AMOVA), and clustering analysis. Statistical comparisons were made using the Kruskal–Wallis test, Chi-square test, or Fisher’s exact test, as appropriate. Temporal trends were analyzed using the Jonckheere–Terpstra test, while genotyping algorithm performance was assessed using the Wilcoxon signed-rank test. For all analyses, 95% confidence intervals and/or standard deviations were reported where applicable, with statistical significance set at p < 0.05. Results: The systematic review and meta-analysis showed significant regional variation in P. falciparum genetic diversity and MOI across SSA. The pooled mean He was 0.65 (95% CI: 0.51–0.78), and the pooled mean MOI was 2.09 (CI: 1.88–2.30), with 63% (CI: 56–70%) of cases showing polyclonal infections. When P. falciparum genetic diversity was compared between areas with different malaria transmission intensities in Uganda, no statistically significant variation was observed across sites (p > 0.05), though Kanungu (a low transmission site) showed the highest mean He (0.81 ± 0.14), while the mean He was slightly lower and similar in both Jinja and Tororo (both 0.78 ± 0.16). Regarding MOI, Tororo, a high-transmission site, exhibited a significantly higher mean MOI (2.5 ± 0.5) and polyclonal infection rate (70%) compared to Kanungu (MOI: 2.0 ± 0.05; polyclonal rate: 56%) and Jinja (MOI: 1.9 ± 0.3; polyclonal rate: 58%) (p = 0.004). Genetic structure analysis indicated minimal differentiation (FST: 0.011–0.021). When comparing P. falciparum genetic diversity and MOI between asymptomatic and symptomatic participants, both groups exhibited high genetic diversity (He 0.79–0.81). Polyclonal infections were common in both groups (58.5% in symptomatic and 63% in asymptomatic). Asymptomatic participants had a higher mean MOI (2.10) than symptomatic individuals (1.92), though the difference was not statistically significant (p = 0.33). Temporal analyses showed a slight decline in He from 0.79 to 0.76, with polyclonal infections remaining above 50% throughout the period. Finally, the 3/3 match-counting algorithm identified significantly fewer recrudescence cases compared to the ≥2/3 match-counting and Bayesian algorithms (p < 0.001). Conclusions: This study shows significant regional variation in P. falciparum genetic diversity and MOI within SSA. Within Uganda, genetic diversity of P. falciparum did not differ significantly across sites, although MOI varied significantly by transmission intensity. Persistently high genetic diversity, minimal population differentiation, and sustained polyclonal infections were observed across clinical disease status and time, reflecting ongoing transmission pressures rather than uniform regional variation. Discrepancies in recrudescence classification between match-counting and Bayesian algorithms highlight the need for standardized PCR correction practices. These findings underscore the need for tailored malaria control strategies, including targeted interventions for asymptomatic carriers and continuous molecular surveillance to adapt to evolving transmission dynamics. Furthermore, the study emphasizes the importance of using robust analytical algorithms to accurately distinguish recrudescence from reinfection, an essential component of effective antimalarial drug efficacy monitoring.
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ItemAcceptance of Malaria Vaccine and its Determinants among Caregivers of Children under 5 Years at Mulago National Referral Hospital-a Mixed Methods Study.(Makerere university, 2026-10-11)Background: Malaria remains a major public health challenge in Uganda. Although the malaria vaccine offers a promising additional control measure, its successful uptake depends on caregiver acceptance. There’s a critical gap in understanding caregivers’ willingness to accept the vaccine which poses a challenge in effective vaccine implementation. Objective: To investigate the acceptance, knowledge, and perceptions of the malaria vaccine among caregivers of children under the age of five attending Mulago National Referral Hospital. Methodology: This was a convergent parallel mixed methods cross- sectional study. The quantitative component involved a cross-sectional survey of 385 caregivers of children under five attending the Paediatrics Outpatient Clinic at Mulago National Referral Hospital, selected through systematic sampling. An interviewer administered questionnaire was used to collect data on willingness to accept the malaria vaccine, knowledge and perceptions. The qualitative component comprised in-depth interviews with 24 caregivers, selected purposively. Qualitative data was analysed using thematic content analysis. Results: Vaccine acceptance was high at 86.5% though this fell markedly when a hypothetical fee was introduced. Good vaccine knowledge was the strongest independent predictor of acceptance (aOR 2.658, 95% CI: 1.005-7.033, p=0.049). Health worker contact (aOR 2.984, 95%CI: 1.146-7.775, p=0.025) was the primary independent predictor of knowledge. Caregivers perceived the malaria vaccine as beneficial for immunity and cost reduction but expressed safety concerns and unrealistic expectations. Despite high acceptance driven by high malaria burden and trust in government programs, hesitancy persisted due to fear of side effects and negative experiences from COVID 19 spill over within a contested social environment. Conclusions: Malaria vaccine acceptance was near universal but conditional on free delivery and vulnerable to safety misinformation and cross-vaccine distrust. Knowledge was the most critical modifiable determinant of acceptance and health workers were its most powerful driver. Structured health worker counselling and preservation of cost-free vaccine delivery even in an urban setting are essential to translating high acceptance intent into complete, schedule adherent vaccine uptake.
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ItemWomen's experiences of emergency post-abortion care at Kawempe National Referral Hospital, Uganda(Makerere University, 2026)Post-abortion care (PAC) encompasses emergency treatment, counselling, contraceptive services, and referral linkages. The emergency component of PAC, which is Emergency post-abortion care (EPAC), is a life-saving service for women presenting with acute abortion-related complications such as haemorrhage, sepsis, retained products of conception, and severe pain. In Uganda, where abortion is legally restricted and socially stigmatised, women’s experiences of care are shaped not only by clinical urgency but also by fear, moral vulnerability, provider interactions, and structural health system constraints. While EPAC is essential for survival, there is limited evidence on how women interpret and evaluate their care experiences in referral hospital settings in Uganda. To explore women's experiences of emergency post-abortion care at Kawempe National Referral Hospital, Uganda. A qualitative phenomenological design was employed. Eligible participants varied in age, parity, education, and socio-economic background. Sixteen in-depth interview transcripts from women who had received EPAC at KNRH in March and April 2026 were analysed thematically. The transcripts were analysed thematically using an inductive approach. The Socio-Ecological Model guided interpretation across individual, interpersonal, and facility levels. Rigour was ensured through iterative coding, constant comparison, and close engagement with participants’ narratives. Women’s experiences of EPAC were complex and often contradictory. Six themes were identified: (1) survival and physical relief as the immediate measure of good care; (2) pain, fear, and emotional distress during treatment; (3) reassurance and support as buffers against vulnerability; (4) dignity under pressure: communication and privacy in EPAC; (5) structural barriers across the pathway of care; and (6) experiences beyond discharge: incomplete recovery and uncertainty. Care was frequently evaluated through the lens of survival and physical relief, with many participants describing rapid stabilisation, supportive providers, and timely intervention. Although many participants described survival and physical stabilisation positively, these accounts frequently coexisted with intense procedural pain, fear of death, dismissive communication, compromised privacy, delays, financial burden, and inadequate follow-up after discharge. Experiences extended beyond discharge, with ongoing physical symptoms, uncertainty about recovery and fertility, and variable follow-up support. EPAC at KNRH was experienced not only as a clinical intervention but as a complex encounter shaped by bodily vulnerability, interpersonal dynamics, and system-level constraints. While lifesaving care was often delivered successfully, women’s experiences of care were evaluated through a broader lens that included dignity, communication, pain management, timeliness, and continuity of care. Strengthening EPAC, therefore, requires a shift toward more consistent, patient-centred approaches that integrate clinical effectiveness with respectful care, improved triage, enhanced counselling, and clearer post-discharge support systems/mechanisms.
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ItemMs(Makerere University, 2026-08-04)Introduction, In Uganda, leukaemia and lymphoma contribute to 33% and 13% of all childhood cancers, respectively, with improving survival rates. However, data on quality of life (QoL) among adolescents who have achieved remission remain limited. The objective of this study was to determine the quality of life (QoL) among adolescents who were in remission from liquid cancers at Mulago National Referral Hospital (MNRH). Methods A cross-sectional study design was used to determine the prevalence of QoL measured as a composite indicator constituted of four domains (Physical, Emotional, Social, and Environmental) using the Pediatric Quality of Life Inventory. Each domain was scored based on a Likert scale ranging from 0(good) to 5(bad), then reverse scored (100 = 0, 0 = 5) and summed for all questions across all 5 domains. An average score was then calculated. QoL was categorised as good (> 70) or poor (<70). Data on explanatory variables (demographics, clinical, social, and lifestyle) were collected. The prevalence of QoL was reported as a percentage, and the modified Poisson regression model was used to determine the factors associated with QoL.Results, The prevalence of Good QoL was 62.6% (95% CI: 53.3 – 71.9). Factors associated with good QoL included being in a relationship (aPR 1.43, 95 % 0.98-2.09, p-value 0.049) and engagement in extracurricular activities (aPR 2.04, 95% CI 1.00-4.14, p-value 0.048). The presence of comorbidities (aPR 0.21, 95% CI 0.21-1.14, p-value 0.043) and persistence of treatment side effects (aPR 0.26, 95% CI 0.13-0.52, p-value 0.000) were associated with poor QoL. The median scores (IQR) per domain were: 78.1 (60.7-93.8), 80 (65-90), 80 (70-100), and 75 (60-85) for Physical, Emotional, Social, and School/work domains, respectively. Conclusion. Prevalence of good QoL was modest, calling for intervention targeting domains with poor functioning, like school and physical domains should be prioritized. Inclusion of survivorship programs into management of adolescents with liquid cancers in remission should be considered.