NON COMMUNICABLE DISEASES IN UGANDA

NON COMMUNICABLE DISEASES IN UGANDA

Lifestyle issues: Diabetes and Hypertension

Summary of the presentation made by Dr. Roy William Mayega a lecturer at Makerere University School of Public Health at the 3rd Uganda Health Communications Network conference held on 26th -28th June 2019. The conference was themed around Non-Communicable Diseases; Communication, Myths, and Realities. Below Esther Nakkazi summarises Dr. Roy William Mayega presentation;

The rising burden of NCDs
Prevalence of key NCD related risk factors

National NCD risk factor survey:

• 25% of the population have hypertension – equal in rural/urban 
• Overweight at 14%, but with a marked difference between males (9%) and females (20%) 
• Obesity at 5% 
• High bad fats in blood; 11% 
• Only 7% of people with hypertension know 

Local studies

• Iganga: Overweight at 18%; 10% in males and 25% in females 
• Wakiso: About 15% of Ugandans have chronic kidney disease (Kalyesubula et al 2016) 
• Study in peri-urban secondary schools: 11% prevalence of hypertension; high rates of obesity; marked school differences (Nakiriba et al, 2017) An increasing prevalence of risk factors in Uganda 

As an indicator disease: 

• Type 2 Diabetes affects 3% of Ugandans 
• The distribution is not uniform – there are pockets of much higher prevalence e.g. 7% prevalence found in people aged 35-60 years in Iganga 
• Only 51% of people with diabetes are diagnosed 
• In the 1960s, diabetes was very low; however, an upturn since 1980
• Currently, NCDs are responsible for 25% of morbidity 
• 4 major conditions: Cardiovascular diseases, Diabetes, Cancer & Chronic Lung Disease 

Society: The social environment

1. In interrelated changes in population-level factors influenced by globalization (de-Graft Aikins et al. 2010) 
2. Urbanization; peri-urbanization of rural behaviors
3. A rapidly changing food environment: refined foods, sugar, adverting of junk, soda/concentrates, globalization of refined rice/maize/oil, peri-urbanization of diets ,’Rolex’, salting, sharp decline in F&V; traditional starches with high fibre off the dinner table, energy dense pastries taking over the breakfast table even 
4. Changing nature of work: At 95% PA rates, Uganda has been named the most physically active country in the world; however, this mostly works and transport related, and is rapidly changing 
5. Culture of wellness checks 

Health system gaps

1. Health systems in LMICs are not yet ready 
2. The PHC package is mainly oriented towards acute conditions 
3. Care: The vast majority undiagnosed; inadequate treatment; inadequate follow-up and adherence 
4. Prevention: Wellness activities lacking 
5. Other sectors: Not yet on-board 
6. Opportunities: 
7. NCD office established in the MoH to coordinate; various civil society actions 
8. NCDs integrated into minimum health care package; National diet and Physical activity guidelines 
9. MoH Technical Working Group 

A focus on behavioral interventions

Awareness exists but knowledge is low
Iganga: Only 34% of people aged 35-60 were moderately knowledgeable
For effective behavioral strategy, the current messages as they are would be ineffective
Contextually relevant messages have not been developed leading to unrealistic, patchy messages subject to distortion
Challenge: How do we shape the message; what do we say and in a way that is realistic?

Perceptions and practices on lifestyles
“Change means sacrificing a good life...”
To those with diabetes, ‘obesity is sickness’ but to those without diabetes, obesity is ‘success’ and weight loss denotes sickness or a financial crash:
“When someone is big, they think that he has money... They call them ‘omugaiga’; if you are a woman, they call you ‘Hajjati’. “Lose weight and you have HIV”
Gender connotations: “Big is beautiful/Big is big”
Diet: “The things they advise us against are also the tastiest”
Balanced diet unaffordable: “When you have the money you can eat chicken, fish, eggs; you cannot buy half a kilo of meat to serve ten people”
Food environment: The ‘Rolex’, an energy-dense informal snack has been peri-urbanized
Formal physical activity is strange: “Apart from sportsmen, I have never seen anyone running! Maybe the children; but for an adult to run…!” (All laugh)
School environments: Drastic reduction in extra-curricular activities as students are pressurized to learn/space
Peer-driven consumption of very refined foods (e.g. the licking of raw sugar-mixtures)

How people perceive current and future well-being
Attitude change: Most non-ill people have a non-holistic view of wellbeing that focuses on ‘absence of pain and access to basic needs now’: ‘Without pain, risk factors are not viewed as a problem’
People with high blood pressure describe symptoms that mean probable severe disease
People with diabetes seem to have serious psychosocial issues: ‘Diabetes is worse than HIV/AIDS’; ‘Thoughts are more powerful than the disease’;
Lifestyle education only offered to people who already have the disease
Message gap leading to confusing messages e.g. blood group-based diets, concoctions, rigorous activities that substantially reduce the quality of life; herbalists, drug distributors, alternative medicine is predominant information givers
For patients: Support for self-care and autonomy support grossly lacking

Implications for behavior change communication strategies in a typical low-income country
Fill the gap: Nationwide health promotion targeting lifestyles integrated into all sectors with simple, contextualized messages and materials
Develop realistic messages: That promotes a holistic view: linking current and future health, disbanding myths, incorporating gender, attitudes, emphasis on solutions within the household environment
Coaching and autonomy support as novel education strategies to a lifestyle change
School health is foundational to build a resilient generation
For affected people, treatment is life-long: Life-conditions NOT always disease
Taxes on unhealthy food (cooking oil for example)

Childhood Cancer at the UCI: Burden and challenges

Summary presentation made by Dr. Joyce Balagadde Kambugu; Consultant paediatric oncologist, Head paediatric oncology, Uganda Cancer Institute at the 3rd Uganda Health Communications Network 26th -28th June 2019. The conference was themed around Non-Communicable Diseases; Communication, Myths, and Realities. Below Esther Nakkazi summarises Dr. Joyce Balagadde Kambugu presentation;

Status of cancer at UCI

• The number of new children has increased from 250 in 2013 to 582 in 2018 
• Acute leukaemia and lymphoma the most common cancers
• The prevalence of HIV is 6% 
• Kaposi's sarcoma (KS) is the most common HIV associated cancer
• Brain tumours are becoming increasingly common (5%)
• Rhabdomyosarcoma and wilms tumor are the most common solid tumours

Challenges of paediatric cancer care at the UCI
Insufficient Human resource
Misdiagnosis
Delayed presentation
Abandoned treatment
Lack of consistent adherence to treatment
Drug shortages
Treatment-related death
Use of reduced intensity treatment regimens to facilitate tolerability also contribute to treatment failure and excess relapse.

Ultimately these impact negatively on cure

A. Large Patient numbers
The service received almost 600 new patients from all parts of Uganda and parts of the neighbouring countries
Human resource and the infrastructure is strained
Increases risk of treatment abandonment
Increases risk of poor treatment adherence

This will partially be addressed by making operational the regional cancer centres: Mbarara,  Arua Mbale, Gulu
Improving psychosocial support
UCCF
Kawempe home care
Bless a child foundation

B. Late presentation
Early diagnosis of cancer is a fundamental goal
Allows an opportunity for timely treatment while disease burden is still in its earliest stages
Then prognosis may improve, and a cure can be attained with minimal side or late effects.
Delayed diagnosis is associated with more refractory disease and excess relapse
Increases the costs and morbidity of treatment and in turn, increases treatment abandonment

C. Drug shortages

1. Insufficient drug budget to purchase requisite quantities of drugs 
2. Stagnant drug budget despite increasing patient numbers 
3. 7B UGX from 2013/14 till 2017/18 when increased to 8.8B 
4. Currently, drug-availability is at 65% 
5. No access to newer more efficacious therapies with fewer side effects like the Mabs and Nibs 
6. Autonomy from NMS has afforded 2 things 
7. Optimizing of the available budget by enabling direct dealing with the manufactures; Norvatis, Sandos, Roche, Pfizer, Medac 
8. The unit cost of drugs came down so drug availability is now 65% from 30% 
9. The Institute is more in control of assurance of drug quality 

D. Treatment-related death (With compliments from Dr. Margaret Lubwama-Microbiology Phd student)

1. Sepsis 
2. Treatment regimens are intense 
3. Insufficient capacity to investigate 
4. Increasing prevalence of drug-resistant microbes 
5. Inadequate access to antimicrobials 

Access to blood products
UCI gets only 1/3 of requisite blood product demand even though UCI gets more blood products than any other Institution
Treatment-related marrow suppression
Sepsis (increases risk of bleeding)

Time period Jan 2018 to April 2019

Of 87 patients with haematologic malignancy with at least one episode of febrile neutropaenia 38 were paediatric
15 of the 38 children (39% ) had documented bacteremia
Of 22 gram-negative bacterial isolates from the 15 children, 16 (73 %) were multidrug resistant (to more than 3 classes) b-lactams, gentamicin, ciprofloxacin, carbapenems
Of the resistant bacteria l isolates (n=16 ) 50% (n=8) displayed the ESBL phenotype (were susceptible to carbapenems)

E. Need to use reduced intensity treatment regimes
To facilitate tolerability
Malnutrition and Sepsis contribute to treatment failure and excess relapse.
BL in HIC has a cure rate of almost 90% but with very high-intensity treatment regimens

The best survival rate in Uganda for BL is 50% at 2 years
This is the rationale for the rituximab clinical trial that is starting at the UCI in paediatrics in 2020/2021