80 women benefit from free fistula repair-no more shame

Christine Katusabe slightly lifts the curtain at her hospital bed to confirm if the morning is here. When the first ray of light shoots through the window, she slowly turns her grey blanket and sky-blue sheets over to the other side, sits up and throws her head into her palms and looks at the other patients.

Her grandmother, having woken up 20 minutes earlier, peers into her 17 year granddaughter’s eyes, probably not seeing the beauty and innocence of a young girl, but trauma and shame. Katusabe passes urine uncontrollably because of an obstetric fistula. 

Christine Katusabe relaxes with her grandmother during the camp

A fistula is a tear between the birth passage and the bladder or rectum caused by obstructed and prolonged labor.  Dr Rose Mukisa Bisoborwa says during this time, the soft tissues of the pelvis are compressed between the baby’s head and the mother’s pelvic bones. The lack of blood flow causes tissue to die, creating a hole between the mother’s vagina and bladder or between the vagina and rectum, or both resulting in leakage.

Although Katusabe survived the fatal child birth experience where she had obstructed labor for a day and a half, she was left with a still born baby and trauma. 

“I would want to go back to school, study and become a nurse but because of my condition, I cannot. I have difficulty in walking and sitting and all the time, I want to eat,” the rather jolly Katusabe, who has borne this condition for two months, says. 

She gets off her bed and slowly motions towards the door. She is slightly bent and keeps her hands tucked in her brown shirt as if hiding something. Outside are more than 100 women crowded with basins, pieces of torn cloth and mats. The smell of the urine in their environs is unmistakable.

Like Katusabe, they too have obstetric fistulas and have come to Hoima Regional Referral Hospital to receive free fistula surgery courtesy of Engender Health and United Nations Population Fund (UNFPA). Engender Health is a global reproductive health organization working to improve the quality of health care with funding from USAID.

Dr Rose Bisoborwa, the country director for Engender Health-Uganda says ordinarily, fistula repair costs $ 400 (Shs 1m). 

Patients line up to receive treatment numbers during the camp

The camp is running for two weeks till 31^st May.

Consequences of damage resulting from obstetric fistula include depression, physical injury where a woman’s birth canal and bladder is ruptured thus frequent passing out of stool or urine or both and mental health dysfunction.

“Left with choric leaking of urine and stool, women with obstetric fistula are abandoned or neglected by their husbands and families, unable to work and ostracized by their communities,” Dr Peter Mukasa Kivunike, an obstetrician with UNFPA says. 

A fistula patient (L) being led to the theater for repair

A fistula patient for 40 years carries her 'weapon'-a basin at the camp where she hopes to be repaired

To contain the leakage, Katusabe uses two scarves interchangeably as pads. But she is met with yet another challenge; that of taking five liters of water daily which she cannot access. Her counselor, Betty Mujenje says this helps reduce the acid in the urine which may injure her skin. 

Counsellor Betty Mujenje(L) counsels Christine Katusabe, a fistula patient

The beginning of her woes;

In an area touched with poverty at every side, Katusabe, an orphan dropped out of school in Senior One at Kigolobya High School after her grandmother could not handle the school expenses any longer.

While working in her friend’s grocery store, she met Robert Amanyire, 29 who lured her into sexual intercourse.

“I knew I was not supposed to sleep with him but it happened accidentally,” she says in a timid voice further explaining that she even moved into his home in Nkondo village.

 But in the ninth month of her pregnancy, she moved back to Kigolobya, her grandmother’s home. Through the first day of her labor, Katusabe suffered a high fever and loss of a lot of blood but the quickest resort was a traditional birth attendant (TBA). Nevertheless, the labor and blood loss persisted that she was rushed to Kigolobya Health Centre IV.

She had a still birth and with little control over her system, she was left wet and dirty. Although she received support from her husband, she is battling depression and contemplating her future, she wonders when she will ever return to school. The day I met her, she was more than ready to undergo the fistula repair surgery after a comforting hour of counseling.

Like Katusabe, any woman is at risk of fistula if not assisted by a skilled health care provider. Young girls are particularly at risk because of pelvic bone immaturity and a small birth canal.

Fistula Repair and prevention;

Use of the partograph; 

A partograph is a low-tech tool that can substantially reduce the incidence of prolonged labor.

“Through its use, midwives and nurses can be alerted to the need to take action. This has the potential to reduce obstructed labor and its adverse consequences, including fistula,” Dr Odong Emintone Alyena a senior consultant obstetrician and gynecologist at Lacor Hospital explains. 

Immediate Catheterization

If a woman with obstructed labor arrives at the hospital and is believed to be at risk for obstetric fistula, immediate catheterization can help to prevent the fistula from developing. The catheter should remain in place until the end of labor.

Caesarean section (C-Section)

Timely C-Section is critical for women with obstructed labor.

“Doctors performing a Caesarean delivery must be competent so that they create an iatrogenic fistula where the bladder is accidentally cut resulting in an abnormal opening through which urine leaks,” Dr Bisoborwa says.

Community-based prevention

Activities include social mobilization and awareness raising campaigns, dramas and broadcasts about the importance of antenatal care and assisted delivery and support for transportation and referrals.

Sr Stella Kachope a counselor of women suffering with fistulas says there is need to sensitize men to get involved in birth preparedness and the importance of delaying first pregnancy up to 18 years.

The challenges;

The over 100 women at the camp have travelled from as far as Buliisa, Nangwali, Kyankwanzi, Apac, Bugweri and Kiboga that are at least 100 KM and at most 400 KM away from Hoima.

Dr Francis Mulwanyi Wambuzi the director, Hoima Regional Referral Hospital says travelling long distances are a common obstacle for these impoverished communities where proper healthcare and facilities are rare. Therefore many women live with this condition for years. For example Sarah Akugizibwe, 38 has lived with an obstetric fistula for eight years after losing her first set of twins. 

Sr Stella Kachope counselling fitsula patients at Hoima Regional Referral Hospital

Also, the hospital has inadequate emergency capacity in terms of supplies and medical staff compared to the backlog of patients.

“Hoima’s Health Centre IVs do not have doctors and at this hospital, we are only nine doctors and yet we are supposed to be 40 and there is only one senior obstetrician with no consultant in that field,” Dr Mulwanyi says.

Also, Hoima has a big migrant population from DRC and Kabale District who are unfamiliar with where to access medical services and end up facing delays in the community.

Unlike other regions like Masaka District that have private not-for profit, Hoima region does not have one and it is marred with power irregularities.

Fistula burden in Uganda;

The 2011 Uganda Demographic Health Survey (UDHS) estimates that 140,000 to 200,000 women in Uganda have the problem and 1900 new cases every year. Between 1500 and 2000 cases are repaired every year.

 The western region is leading in fistula rates with 5.4%, followed by that north at 3.6%, Central 3.4%, Eastern 1.1% and Karamoja with the least at 0.1%.

UNFPA has however over the past 10 years directly supported over 34000 women and girls to receive surgical treatment for fistula.

Uganda to conduct another HIV vaccine trial

Makerere University Walter Reed Project (MUWRP) is this July launching another third Phase I trial attempt to develop an HIV vaccine since 1999 when the first trial was launched.

Phase I is the first stage in developing a candidate HIV vaccine and involves a small number of uninfected participants at a low risk of acquiring HIV.

This year’s trial, according to the MUWRP’s Executive Director Dr Hannah Kibuuka, will be multisite, including Thailand and U.S.A –with 120 volunteers, 60 of which are Ugandans.

“In continued effort to develop an HIV vaccine, we have to undertake this trial and others until a safe and effective vaccine is found,” Dr Kibuuka said. 

Dr Hannah Kibuuka

Volunteers have to be free of illnesses such as hypertension, sickle cells and diabetes and undergo intense HIV counseling and follow-up during the trial.

Currently, MUWRP is undertaking a vaccine trial involving 42 volunteers from Uganda to determine the body’s immune response and vaccine safety. Other participants in this trial have been recruited from Kenya, Tanzania and USA.

Dr Fatim Jallow, MUWRP’s deputy laboratory director says the lab is well equipped for the July trial.

On going activity at the MUWRP lab where the trial will be held

Stages of Hiv vaccine trials;

At the early stages of development, Phase I and II trials, scientists test to find out how the body responds to the vaccine. After a person is vaccinated, their blood is sent to the laboratory to identify whether his/ her body has generated a response that can fight HIV.

“The only way to identify if the vaccines actually protect against HIV/Aids is in a large Phase III trial with thousands of volunteers who are at risk of HIV infection,” Dr Francis Kiweewa, head of research and scientific affairs at MUWRP said.

Phase III trials can last three to five years.

Currently the World Health Organization (WHO) and UNAIDS are working to facilitate trials in African countries through the African AIDS Vaccine Programme (AAVP), an initiative adopted in 2001 by African Heads of State at the African Summit on HIV/Aids, Tuberculosis and Malaria in Abuja, Nigeria.

Challenges;

Currently, one of the challenges is developing a single vaccine that will effectively deal with the different HIV subtypes. There are at least nine Hiv subtypes circulating in the world.

Most research to date has focused on a vaccine for Hiv subtype B, which is the main subtype in the Americas, Australia, Japan and Western Europe.

“There is still a challenge for a common vaccine that will prevent Hiv among all the strains especially A, C, D and E common in sub-Saharan Africa and Asia,” Dr Kibuuka said.

Earlier trials in Uganda

In 1999, Uganda launched Africa’s first Hiv vaccine trial, a small Phase I safety study involving 50 volunteers at the Joint Clinical Research Clinic (JCRC). However, this generated massive public criticism with misconceptions that the vaccine would trigger new infections and debate whether volunteers would be compensated in case of harm.

In 2003, Uganda launched its second vaccine trial with support of the International Aids Vaccine Initiative (IAVI). This was also a Phase I study which tested a combination of two vaccines based on the Hiv subtype A. The study enrolled 50 volunteers and ran until February 2005.  

A researcher displays preserved blood samples collected from volunteers at the MUWRP laboratory

Trials worldwide

In 2009, a Phase III trial vaccine RV-144 in Thailand yielded modest results of a 31% efficacy meaning that it reduced the risk of acquiring HIV by 31%.

This is the first study that indicated that it that a vaccine could work.

But in the latest trial failures, researchers in the US according to an article in the Los Angeles Times, ‘HIV vaccine trial shut down’ have stopped a trial after the experimental vaccine failed to both prevent HIV transmission and to reduce viral load in those who contracted the virus.

The article, published on April 25 2013 reports that the trial started in 2009 and enrolled 2,504 men who have sex with men (MSM) and transgendered people who have sex with men in 21 sites in 19 U.S. cities. Of the 1,250 participants who received the experimental vaccine 27 became HIV positive during the study.

HIV/Aids burden in Uganda

According to the 2011 Uganda Aids Indicator Survey (UAIS), about 7.3% (about 1,390,000 Ugandans) of adults aged 15 to 49 are living with Hiv. There is an estimated 20,000 to 25,000 pediatric HIV infections annually and currently new infections are about 145,000 up from 124, 000 in 2009 and 128,000 in 2010.

Treatment options

Current treatment in Uganda involves the use of several antiretroviral drugs, termed Highly Active Antiretroviral Therapy (HAART), which can extend the life expectancy of people living with Hiv and decrease viral load without eradicating the virus.

Other treatment options include safe male circumcision, Option B+ one of the four prongs of the elimination of mother to child transmission (EMTCT), pre and post exposure Prophylaxis.

With giant steps being made in research and development of a vaccine, scientists hope to develop a feasible vaccine to reduce risk of acquiring the virus.

Tobacco-related illnesses will cost you Shs 5m every 3weeks

Born and raised in tobacco-growing district of Arua, Emmanuel Ojapi learnt how to smoke at 17.

Now 38, Ojapi smokes between 26 and 30 sticks of locally woven tobacco daily – which is probably why his teeth are steadily changing colour from white to deep yellow.

When he smiles, the change is evident with the teeth of his lower jaw. Ojapi has easy access to tobacco because he works on tobacco farms for a living.

“I have worked on these farms since I was a child. It took me less than a month to learn how to chew the leaf and my friends taught me how to smoke,” he confidently says as he goes about his daily routines on a tobacco farm in Maracha district.

He is, however, oblivious of the health – and cost – implications of smoking and chewing tobacco.

Dr Fred Okuku, a medical oncologist at the Uganda Cancer Institute (UCI), says there are various types of cancer and other diseases associated with smoking that are costly to treat.

For example, cigarette smoking is a major risk factor for developing small cell lung cancer (SCLC), the commonest lung cancer associated with smoking.

This is treated using chemotherapy, with anti-cancer drugs injected into the vein or taken orally.

“We administer chemotherapy in cycles and these generally last about 3 to 4 weeks. Initial treatment is in four to six cycles, which costs about Shs 5m to Shs 6m,” Dr Okuku says.

Each cycle costs Shs 700,000 to 800,000. And all the six cycles are a prerequisite because SCLC spreads fast to the brain and liver.

Before undergoing chemotherapy, other money-drenching tests are conducted such as a CT scan of the chest, which costs about Shs 200,000, blood, Hepatitis B, urine and abdomen tests which cost a minimum of Shs1m.

Meanwhile, lobectomy, where a section (lobe) of the lung is removed is another treatment option although it is rarely used as the main form of treatment. This costs Shs 25m. Other operations cost Shs 10m to Shs 15m.

Dr Okuku says of the 50 patients admitted to the institute with SCLC, only five benefit from the treatment options because majority come when the cancer is in its advanced stages.

According to an article titled “Do you know tobacco?” by the Centre for Addiction and Mental Health, when tobacco is burned, a dark sticky “tar” is formed from a combination of hundreds of chemicals, including poisons that cause cancers and bronchial disorders. 

Tar is released in tobacco smoke in tiny particles that damage the lungs and airways and stain teeth and fingers. Tar is the main cause of lung and throat cancers.

Globally, the World Health Organisation estimates that tobacco causes about 71% of lung cancer, 42% of chronic respiratory diseases, 20% of global tuberculosis incidence and nearly 10% of cardiovascular diseases.

Smoking is also associated with Chronic Obstructive Pulmonary Disease (COPD) where lungs lose their elasticity, making it difficult to breathe. Coughing up mucus is often the first sign of COPD.

“When one is diagnosed with COPD, you spend a minimum of shs 300,000 a week for treatment and when it becomes severe, one needs oxygen for life,” Dr Okuku says.

TOBACCO BURDEN

Currently, Uganda loses an estimated 13,000 people to tobacco-related illnesses annually. Statistics also indicate that 75% of the cancer patients at Mulago hospital have had a history of smoking (actively or passively) between two and 33 years. Currently, UCI needs Shs102bn annually to treat patients.

Last year the anti-smoking lobby made some progress, moving the Tobacco Control Bill that seeks to increase taxes on tobacco products, bans tobacco advertising and prohibits the sale and importation of duty free tobacco products among others.

Pneumonia is leading infection among children afflicted with HIV

Recently, Uganda launched the new 10-valent pneumococcal vaccine (PCV 10) that is expected to protect 1.5m children below one year against pneumonia infections by end of the year. I interviewed Seth Berkley, the Global Alliance for Vaccine Initiative (GAVI) CEO about the new vaccine. GAVI is channelling over 5m doses of the new vaccine to Uganda. 

Below are the excerpts of the interview.

What are pneumococcal diseases and what is their impact?

Pneumococcal disease (PD) is caused by the bacterium Streptococcus pneumoniae, also known as pneumococcus, and is the number one vaccine preventable cause of death in children under 5 years of age globally. Pneumococcus is the most common cause of fatal pneumonia in children. In Uganda, it is estimated that pneumonia is responsible of 17% of the deaths in children under 5.

What are the symptoms of pneumococcal disease?

Pneumococcus is the most common cause of fatal pneumonia in children. Other life-threatening pneumococcal infections include meningitis and sepsis.

What complications arise from pneumococcal disease?

The pneumococcus is the most common cause of invasive (serious) bacterial infections in children, including meningitis, bacteremia (infection of the blood), and pneumonia (infection of the lungs). The pneumococcus is also the most common bacterial cause of acute middle ear infections in children

How is pneumococcal disease transmitted?

The bacterium spreads from person-to-person via respiratory droplets - if the infected person coughs or sneezes in close proximity to other people, the other people may become infected.

Why is pneumococcal disease a health problem in Uganda and the world?

It is one of the major causes of under-5 children’s deaths. Of children under five with suspected pneumonia in Uganda, only 73% are taken to an appropriate health care provider, and 47% receive antibiotics. About 60% of infants less than 6 months are exclusively breastfed.

Who is at risk of acquiring pneumococcal disease?

While persons of any age can acquire pneumococcal disease, young children, particularly infants, are most vulnerable. Immunity-weakening conditions such as malnutrition, HIV/ AIDS, low birth weight, and non-exclusive breastfeeding put children at greater risk for pneumococcal disease.

How can pneumococcal disease be prevented?

The Global Action Plan for Prevention and Control of Pneumonia (GAPP), issued by WHO and UNICEF, recommends a three-pronged approach to address child pneumonia that includes protection (exclusive breastfeeding and improved nutrition), prevention efforts (including routine use of measles, Hepatitis B and pneumococcal vaccines), and treatment (appropriate antibiotics). GAPP estimates that scaling up coverage of these key interventions to 90% could help prevent more than two-thirds of childhood pneumonia deaths worldwide.

What pneumococcal vaccines has GAVI made available to Uganda and other countries?

Pneumococcus comes in 90 varieties or “serotypes.” Three existing pneumococcal conjugate vaccines (PCVs) protect against 7, 10, and 13 of the most common serotypes. The 10- and 13-valent pneumococcal vaccines cover more than 70% of the invasive pneumococcal disease (IPD) causing serotypes afflicting African children. Uganda introduced the 10-valent pneumococcal vaccine (PCV 10).

Which new vaccines are currently in development and why are new vaccines needed?

New vaccines are needed to protect against additional serotypes of pneumococcus to better protect children. Also, efforts are been made to find less expensive vaccines.

Are there people who should not be vaccinated? If yes, why?

PCV are considered safe in all target groups for vaccination, including immuno-compromised individuals.

How and when should the PCV be administered?

The PCV-10 should be given in three doses. The minimum age at first dose is 6 weeks, with a minimum interval of four weeks between the subsequent doses - e.g., 6, 10 and 14 weeks. Ideally, PCV-10 should be given simultaneously with other childhood vaccinations: DTP (for Diphtheria), Hib (Hepatitis B) and Oral Polio Vaccine administration.

Should HIV positive individuals receive the PCV?

Yes, pneumococcal vaccination is recommended in HIV infection to help reduce invasive pneumococcal disease. Studies have shown that children with HIV/AIDS are 9-40 times more likely to contract pneumococcal disease than HIV-negative children, and may also be more likely to contract antibiotic-resistant strains of the disease. In fact, pneumonia is the most common infection leading to hospitalization among HIV-infected children. In Uganda, there are an estimated 1.4 million people currently living with HIV/AIDS, about 190,000 of whom are children under age of 15.

 Do adults need the PCV?  How often, if at all?

The GAVI supports immunization in children, because most complications arise in young children. PCVs for immunization of older populations and the potential use of such vaccines for immunization in pregnancy to protect new born babies are currently not considered sufficient by the World Health Organization (WHO) to make policy recommendations.

Does the PCV have any side effects, mild or otherwise?  Which ones?

The safety of pneumococcal conjugate vaccines for children has been well demonstrated in clinical trials and confirmed after the distribution of more than 198 million doses worldwide. Post-licensure surveillance has found that the use of childhood pneumococcal vaccine also protects unvaccinated children and adults by reducing transmission.

What impact has the PCV had in countries where it has been introduced?

Immunization with PCV7 in the United States, the first country that introduced broadly the vaccination, has led to profound reductions in the disease burden among adults in the first 7 years of the program. The impact of PCV in GAVI eligible countries is being carefully monitored as part of routine sentinel surveillance.