BackgroundMultidrug resistant and extensively drug resistant tuberculosis (TB) have become major threats to control of tuberculosis globally. The rates of anti-TB drug resistance in Uganda are not known. We conducted a national drug resistance survey to investigate the levels and patterns of resistance to first and second line anti-TB drugs among new and previously treated sputum smear-positive TB cases.MethodsSputum samples were collected from a nationally representative sample of new and previously treated sputum smear-positive TB patients registered at TB diagnostic centers during December 2009 to February 2011 using a weighted cluster sampling method. Culture and drug susceptibility testing was performed at the national TB reference laboratory.ResultsA total of 1537 patients (1397 new and 140 previously treated) were enrolled in the survey from 44 health facilities. HIV test result and complete drug susceptibility testing (DST) results were available for 1524 (96.8%) and 1325 (85.9%) patients, respectively. Of the 1209 isolates from new cases, resistance to any anti-TB drug was 10.3%, 5% were resistant to isoniazid, 1.9% to rifampicin, and 1.4% were multi drug resistant. Among the 116 isolates from previously treated cases, the prevalence of resistance was 25.9%, 23.3%, 12.1% and 12.1% respectively. Of the 1524 patients who had HIV testing 469 (30.7%) tested positive. There was no association between anti-TB drug resistance (including MDR) and HIV infection.ConclusionThe prevalence of anti-TB drug resistance among new patients in Uganda is low relative to WHO estimates. The higher levels of MDR-TB (12.1%) and resistance to any drug (25.3%) among previously treated patients raises concerns about the quality of directly observed therapy (DOT) and adherence to treatment. This calls for strengthening existing TB control measures, especially DOT, routine DST among the previously treated TB patients or periodic drug resistance surveys, to prevent and monitor development and transmission of drug resistant TB.

BackgroundUganda is a low income country that continues to experience disease outbreaks caused by emerging and re-emerging diseases such as cholera, meningococcal meningitis, typhoid and viral haemorrhagic fevers. The Integrated Disease Surveillance and Response (IDSR) strategy was adopted by WHO-AFRO in 1998 as a comprehensive strategy to improve disease surveillance and response in WHO Member States in Africa and was adopted in Uganda in 2000. To address persistent inconsistencies and inadequacies in the core and support functions of IDSR, Uganda initiated an IDSR revitalisation programme in 2012. The objective of this evaluation was to assess IDSR core and support functions after implementation of the revitalised IDSR programme.MethodsThe evaluation was a cross-sectional survey that employed mixed quantitative and qualitative methods. We assessed IDSR performance indicators, knowledge acquisition, knowledge retention and level of confidence in performing IDSR tasks among health workers who underwent IDSR training. Qualitative data was collected to guide the interpretation of quantitative findings and to establish a range of views related to IDSR implementation.ResultsBetween 2012 and 2016, there was an improvement in completeness of monthly reporting (69 to 100%) and weekly reporting (56 to 78%) and an improvement in timeliness of monthly reporting (59 to 93%) and weekly reporting (40 to 68%) at the national level. The annualised non-polio AFP rate increased from 2.8 in 2012 to 3.7 cases per 100,000 population < 15 years in 2016. The case fatality rate for cholera decreased from 3.2% in 2012 to 2.1% in 2016. All districts received IDSR feedback from the national level. Key IDSR programme challenges included inadequate numbers of trained staff, inadequate funding, irregular supervision and high turnover of trained staff. Recommendations to improve IDSR performance included: improving funding, incorporating IDSR training into pre-service curricula for health workers and strengthening support supervision.ConclusionThe revitalised IDSR programme in Uganda was associated with improvements in performance. However in 2016, the programme still faced significant challenges and some performance indicators were still below the target. It is important that the documented gains are consolidated and challenges are continuously identified and addressed as they emerge.

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Rationale: Tuberculosis case-detection rates are below internationally established targets in high-burden countries. Real-time monitoring and evaluation of adherence to widely endorsed standards of tuberculosis care might facilitate improved case finding. Objectives: To monitor and evaluate the quality of tuberculosis casedetection and management services in a low-income country with a high incidence of tuberculosis. Methods: We prospectively evaluated tuberculosis diagnostic services at five primary health-care facilities in Uganda for 1 year, after introducing a real-time, electronic performance-monitoring system. We collected data on every clinical encounter, and measured quality using indicators derived from the International Standards of Tuberculosis Care. Measurements and Main Results: In 2009, there were 62,909 adult primary-care visits. During the first quarter of 2009, clinicians referred only 21% of patients with cough greater than or equal to 2 weeks for sputum smear microscopy and only 71% of patients with a positive sputum examination for tuberculosis treatment. These proportions increased to 53% and 84%, respectively, in the fourth quarter of 2009. The cumulative probability that a smear-positive patient with cough greater than or equal to 2 weeks would be appropriately evaluated and referred for treatment rose from 11% to 34% (P 5 0.005). The quarterly number of tuberculosis cases identified and prescribed treatment also increased four-fold, from 5 to 21. Conclusions: Poor adherence to internationally accepted standards of tuberculosis care improved after introduction of real-time performance monitoring and was associated with increased tuberculosis case detection. Real-time monitoring and evaluation can strengthen health systems in low-income countries and facilitate operational research on the effectiveness and sustainability of interventions to improve tuberculosis case detection.

BackgroundDrug resistance among tuberculosis patients in sub-Saharan Africa is increasing, possibly due to association with HIV infection. We studied drug resistance and HIV infection in a representative sample of 533 smear-positive tuberculosis patients diagnosed in Kampala, Uganda.Methods/Principal FindingsAmong 473 new patients, multidrug resistance was found in 5 (1.1%, 95% CI 0.3–2.5) and resistance to any drug in 57 (12.1%, 9.3–15.3). Among 60 previously treated patients this was 7 (11.7%, 4.8–22.6) and 17 (28.3%; 17.5–41.4), respectively. Of 517 patients with HIV results, 165 (31.9%, 27.9–36.1) tested positive. Neither multidrug (adjusted odds ratio (ORadj) 0.7; 95% CI 0.19–2.6) nor any resistance (ORadj 0.7; 0.43–1.3) was associated with HIV status. Primary resistance to any drug was more common among patients who had worked in health care (ORadj 3.5; 1.0–12.0).Conclusion/SignificanceAnti-tuberculosis drug resistance rates in Kampala are low and not associated with HIV infection, but may be associated with exposure during health care.