Category: Kampala

Mobile Phone Charging Station in Mobile Phone Charging Station in Kabale, Uganda

UGA study using ‘selfies’ to encourage tuberculosis treatment

Researchers from the University of Georgia and Makerere University in Uganda have launched a project leveraging the popularity of selfies to promote tuberculosis (TB) treatment.

The intervention, dubbed DOT Selfie, is one of thirteen mobile health research projects funded by the National Institutes of Health and The Fogarty Center to improve health outcomes, health care services and health research in low- and middle- income countries.

TB is one of the world’s deadliest infectious diseases, and though the disease is treatable, almost one-third of TB patients do not follow prescribed treatment plans.

Non-adherence is a major obstacle to TB control in low- and middle-income countries, says Juliet Sekandi, an assistant professor in the Global Health Institute at UGA’s College of Public Health and lead investigator for DOT Selfie.

But many TB patients in these countries face their own barriers to treatment, she added.

“Major barriers to medication adherence include patient-related factors, such as stigma and lack of overall knowledge about TB, and they include systemic factors, such as the cost of travel to health clinics or long waiting times at health facilities due to high patient to health worker ratios,” said Sekandi.

Adherence challenges are particularly acute in sub-Saharan Africa, where TB rates can be as high as 800 per 100,000 and resources for delivery of health care are limited.

Directly observed therapy (DOT) is acknowledged as the best way to monitor and ensure TB treatment adherence, but this approach proves difficult in areas where there are health care gaps.

In recent years, mobile health tools, including the added video function of a smartphones, have helped overcome some of these barriers to adherence. But there is limited evidence describing the best ways to utilize mobile technologies.

Sekandi’s team is piloting the DOT Selfie project with around 150 TB patients in the Uganda, a country that is estimated to have 45,000 new cases of TB per year. It will be among the first trials to evaluate video DOT in an African setting.

DOT Selfie patients will use their smartphones to record and send time-stamped videos of their daily medication intake. In return, they receive a weekly reward for following their medication regime.

“The need for frequent travel to health facilities is eliminated, which is a big deal,” said Sekandi. “It also offers autonomy to take medications anywhere, anytime, perhaps in a location with more privacy.

Sekandi says she and her team are most excited about the potential impacts of this project to propel health care delivery forward in Uganda and the rest of Africa.

“The successful use of mobile technology will address some critical systemic barriers that persistently lead to poor health outcomes in Africa,” said Sekandi.

UGA GHI receives two NIH grants to fight global TB

The National Institutes of Health (NIH) recently awarded the Global Health Institute (GHI) at the University of Georgia two grants for research projects aimed at decreasing the global burden of tuberculosis.

The first NIH grant, awarded over five years, will study the transmission of M. tuberculosis in an African city. GHI director Dr. Christopher Whalen and associate director Dr. Julie Sekandi, along with their research team at UGA, will collaborate with colleagues at Makerere University and Case Western Reserve University to determine the geographic ‘hotspots’ for transmission in Kampala, Uganda. With this knowledge, public health professionals can design community interventions to reduce transmission of tuberculosis and control the epidemic.

Dr. Sekandi was also awarded a two-year grant from the NIH Fogarty International Center to address the problem of non-adherence with treatment of tuberculosis. Non-adherence is a major obstacle to tuberculosis control because it reduces cure rates, prolongs infectiousness, and promotes drug-resistance. This study will evaluate the benefit of using smartphones to perform video-directed observed therapy – meaning a video selfie to record taking pills – to improve overall adherence and outcomes in treating tuberculosis.

UGA epidemiologist tracks tuberculosis using cellphone records

Tuberculosis is the ninth leading cause of death worldwide, and though the World Health Organization has said the average global burden of disease is on the decline, some areas of the world continue to feel its impact.

Researchers at the University of Georgia have received a $2.6 million grant from the National Institutes of Health to understand the local epidemiology of TB in African urban settings and help these communities develop targeted interventions to reduce transmission.

Led by physician and epidemiologist Christopher Whalen at UGA’s College of Public Health, the team will estimate where TB is being transmitted by combining information about patient movement with genetic information from the bacteria itself. Understanding where transmission is happening is the key to effective control, said Whalen.

The standard approach to tuberculosis control today relies on detection and treatment of tuberculosis disease, but this approach doesn’t work in areas where the disease burden is high.

“By the time a case is diagnosed and treated, the next generation of cases has already been newly infected,” he said.

Whalen has been working with colleagues in Makarere University in Kampala, Uganda, for years trying to discover better ways to limit TB transmission.

From 2012 to 2017, Whalen conducted a study to track how TB moves within communities, but his findings were perplexing. The infection didn’t seem to spread within known social networks. That begged the question, where is transmission occurring?

“Then it dawned on me,” said Whalen. “Everyone is carrying a cellphone. By using archived cellphone records, we would be able to map where TB cases move and measure how much time they spent in different places.”

Whalen’s team collected preliminary data using cellphone records from 15 TB patients, and they found that these patients tended to go to the same spots.

“There are hot spots, or places where TB patients spend a lot of time. With this information, you can target areas with the usual community control strategies, such as TB screening, active case finding, and education. If you collect this cellphone information going forward, you’ll be able to see if your control strategies worked,” explained Whalen.

The new project will expand Whalen’s previous work to include genomic information about the organisms that will reveal the order and timing of TB infection among the cases. When this information is combined with the mobility data, the team will be able map where transmission is occurring at different levels within Kampala.

Whalen hopes this approach will provide an actionable prevention tool for tuberculosis control programs in communities facing a high disease burden.

Child bearing expectations can hinder family planning in rural Uganda

The rate of infant and child deaths is very high in many developing countries, and Uganda is no exception. Some of the issues contributing to this problem are poor child spacing and unplanned pregnancies that occur within the first twelve months after child birth. Though low cost, effective family planning options are widely available, only eight percent of women living in rural Uganda are using them.

A recent study from the University of Georgia sought to identify factors that may discourage women living in rural areas from using one such option, long acting reversible contraceptives (LARC).

Most Ugandans live in rural communities where the culture surrounding family and child bearing is rooted in the land.

“Cultural norms in general surround numbers,” said Juliet Sekandi, an assistant professor in the Global Health Institute at UGA’s College of Public Health, who lead the study. “Strength in numbers,’ they always say, because a large family can cultivate a larger piece of land.”

Family members are part of the labor support for the family in a country that is up to 80 percent agricultural, says Sekandi, so the size of the family directly impacts their economic stability. Having more family members also means the extended family clan can wield more political power in the community.

However, mothers can put their health and the health of their unborn child at risk if they become pregnant again within a year of giving birth. Medical standards recommend a time span of twelve to 24 months for a woman to fully recover from pregnancy.

“There are nutritional gains to make after having a child,” said Sekandi. “If the baby in utero has poor nutritional supply because the mother’s nutrient banks are still depleted, you’re going to see poor growth, which we know is typically an indicator of poor child outcomes.”

The researchers surveyed 400 women from 30 villages, asking a range of questions about their feelings on family planning and using LARCs, as well as demographic variables such as previous childbirths and previous pregnancies.

Overall, LARC use mirrored Uganda’s national average, but they found that many women who reported using LARCs had five or more children.

“Once women reach a certain number of children, they are ready for what’s going to give them the most reliable outcome,” said Sekandi. “I’m beginning to speculate, but it may speak to the fact that the accumulation of wisdom from the many experiences of child bearing brings women to this important decision point.”

Interestingly, most of the respondents said they were willing to use modern contraceptives. Sekandi says their willingness to use contraceptives likely comes from 15 to 20 years of public health messaging and education campaigns surrounding the benefits of family planning.

“The education has been there so that women know they can make choices despite the cultural influences around them,” she said. “They know their lives are at risk.”

The dissonance between desire and use could be explained by another cultural norm. In the rural areas, the husband usually has the control over the finances, which can create challenges for woman seeking contraceptives.

A husband may be less likely to allow his wife to use contraceptives if the couple is still planning to have more children. Sekandi posits that this economic barrier may be a substantial one, which highlights the need for more male participation in family planning education.

“Men need to be at the table,” she said. “If they fully understand the dangers of poor spacing, when decision time comes, it can be a joint decision where the person who’s going to provide the funds will be on board well convinced that this a priority for our family.”

The paper, “High parity predicts use of long-acting reversible contraceptives in the extended postpartum period among women in rural Uganda” was published in Contraception and Reproductive Medicine. It is available online at:

Co-authors include Ronald Anguzu and Hassard Sempeera of Makerere University in Kampala, Uganda.

Test for Latent Tuberculosis Still Accurate in High Burden Communities, UGA Study Finds

Though tuberculosis (TB) is an old disease, with cases dating back 5,000 years, it remains a major global health threat. Accurately detecting latent TB infections, when the disease is still dormant and not actively making a person sick, is key to public health efforts to eliminate TB.

New research from the University of Georgia is the first population-level study to examine whether the primary diagnostic tool for latent TB, a tuberculin skin test, could misidentify individuals as new cases of latent TB in areas where the disease burden is very high.

Dr. Juliet Sekandi

The proper identification of new cases using the tuberculin skin test has implications for who is treated, says Juliet Sekandi, an assistant professor in the Global Health Institute at UGA’s College of Public Health and lead author on the study.

Sekandi and colleague Chris Whalen were leading a research team gathering survey data in Kampala, Uganda, when they noticed an unusually high rate of reported latent TB, over 50 percent of the population.

“That’s what triggered this study,” said Sekandi, to determine whether there could be a flaw in the skin test.

Tuberculin skin tests can be susceptible to ‘boosting,’ which can occur when the test triggers an immune response from past exposure to TB bacteria, rather than recent exposure. That can lead to a false positive.

“We don’t want to falsely diagnose latent TB because, by policy, it is supposed to be treated,” said Sekandi. “You treat for six to nine months, so if you’re going to give somebody treatment for nothing when it’s just a boosted reaction, that’s not good.”

In addition to protecting the patient from unnecessary side effects, it can be costly to treat people who don’t need it. It’s estimated that one-third of the world’s population have latent TB infections, but resources to treat it are limited. Public health programs can’t afford to treat a large number of misidentified patients.

Researchers recruited volunteers in Kampala, who agreed to receive two skin tests. If the initial test came back negative for latent TB, a second skin test was performed. Of the 99 participants, only two showed a boosted response.

These findings, says Sekandi, are important to public health prevention programs going forward.

“We can be confident we aren’t doing too much harm,” she said. “The takeaway point here is that in high burden settings like Uganda, most of the people that test positive with a skin test are actual cases of latent TB, not just false positives.”

The study “Low Prevalence of Tuberculin Skin Test Boosting among Community Residents in Uganda” was published in the American Journal of Tropical Medicine and Hygiene. It is available online at

Co-authors include Allan Nkwata, Leo Martinez, Robert Kakaire, Jane Mutanga and Christopher Whalen, with UGA’s College of Public Health; Sarah Zalwango with Makerere University in Kampala, Uganda, and the Department of Health Services; and Noah Kiwanuka with Makerere University.

UGA receives $1.49 million grant for HIV, TB research training in Uganda

Athens, Ga. – Every year, 50,000 people die in East Africa from tuberculosis. Worldwide, 1.5 million people die from the disease. And when HIV infection is added to the mix, TB becomes even more deadly. The University of Georgia is fighting against these numbers with a new $1.49 million grant from the Fogarty International Center of the National Institutes of Health.

UGA is partnering with Makerere University in Kampala, Uganda, to train Ugandan scientists in new and emerging methods increasingly important in understanding the complex transmission dynamics of HIV and Mycobacterium tuberculosis, the bacterium responsible for tuberculosis.

According to the World Health Organization, TB infections now rival HIV/AIDS as a leading cause of death from infectious diseases. Persons co-infected with TB and HIV are estimated to be 27-32 times more likely to develop active TB disease than persons without HIV.

“Infectious diseases do not respect human political borders,” said Dr. Christopher Whalen, the grant’s principal investigator and the Ernest Corn Professor of Infectious Disease Epidemiology in the UGA College of Public Health. “What is in Africa today could be in the U.S. tomorrow. Remember the concern about Ebola? It is better to contain infectious diseases at their source. To do this, you must build capacity in areas where the disease is most serious.”

UGA will use the five-year grant to enhance computational and molecular epidemiology training in tuberculosis and HIV in Uganda. To achieve this goal, the program will train two predoctoral students in molecular and computational epidemiology, offer non-degree technical training in computational epidemiology and bioinformatics, and support a variety of additional research and training activities in Uganda.

Training will be integrated into ongoing research projects Whalen is leading to investigate how social interactions that make up daily life in Uganda contribute to TB transmission in the context of a mature HIV epidemic.

Bioinformatics and computational epidemiology are currently not available in Uganda. “Disease transmission is difficult to study because it involves a community,” Whalen said. “Since it is not possible to study everyone in a community, we use the molecular and computational approaches to infer patterns of transmission within the community.”

The program builds on 25 years of research and training collaborations Whalen has established with public health and academic institutions in Uganda and will further enhance the research capacity needed to address the country’s co-epidemics of TB and HIV.

Key collaborators from Makerere University include Moses Joloba, chair of the department of medical microbiology in the College of Health Sciences; and Noah Kiwanuka, an infectious disease epidemiologist at its School of Public Health.

Andreas Handel, associate professor, and Ming Zhang, assistant professor in the department of epidemiology and biostatistics at the UGA College of Public Health, will also contribute to the program’s training efforts.

The research is being supported by the Fogarty International Center of the National Institutes of Health under award number D43TW010045.

This story was originally published on UGA Today on November 10, 2015.