The most significant findings were the three waves of COVID-19 in Gulu in Northern Uganda, and these were in May and September of 2020 and July of 2021 (Figure 1, Figure 2, and Figure 3). The third wave of COVID-19 in 2021 was less pronounced (Figure 1, Figure 2, Figure 3). This finding contrasts with the official Ugandan Ministry of Health position on the number of COVID-19 waves Uganda has gone through since the pandemic began in March 2020. The Ugandan Ministry of Health specified two waves of the COVID-19: one in 2020 and another in June 2021. This Ugandan Ministry of Health report is not surprising as regional waves of COVID-19 have been reported in many studies [11, 12, 13, 14]. This finding has implications on how Uganda could respond to the COVID-19 waves as the regional approach to managing and controlling the pandemic has become eminent. The regional occurrence of the COVID-19 wave has advantages in that the Ugandan Ministry of Health could use this information to harness support and allocate resources to effectively manage and control the pandemic at the regional level in different parts of the Country. This may include mass mobilization and sensitization of the population at a regional level to embrace mass vaccination with COVID-19 vaccines now that they are available in the Country. It is expected that this approach could limit the spreading of COVID-19 country-wide and reduce the morbidity and mortality of the coronavirus in Uganda.
Socio-demographic characteristics of the COVID-19 patients
Findings from this study show that most COVID-19 patients treated at the Gulu Regional Referral Hospital were males, 30–39-years-old, Acholi, Catholics with certificates as the highest level of education, civil servants, and from Gulu District (Table 1). These socio-demographic characteristics are comparable to previous studies conducted in Northern Uganda, where the most affected people were males and certificates at their highest level of education (Table 1). What is different in this study population is that the most affected age group is a decade older (Table 1) compared to previous studies in Northern Uganda, where most participants were 20–29-years-old [15, 16].
The age factor could be explained by the susceptibility pattern of the COVID-19 among the older population of Northern Uganda and elsewhere. The aging population appears more vulnerable and susceptible. The overall reasons for the susceptibility in the older people in Northern Uganda may not be known for now but perhaps attributable to lifestyles, exposure to multiple risk factors, comorbidities, and immunity problems of the more aging population. As shown in Table 1, the younger age groups were least affected as per the GRRH COVID-19 treatment center's admission details. However, it could also mean that many of the younger age groups got affected but remained asymptomatic, did not test for COVID-19, did not develop severe disease, and did not get hospitalized with the coronavirus.
Findings from this current study show that nearly one-fourth of the COVID-19 patients treated were asymptomatic, and less than 10% of the patients were below 20 years of age (Table 3). These authors argue that this information was not wholly new. Similar findings in many studies conducted elsewhere in the world show that younger persons were least susceptible to severe COVID-19 and hospitalization [13, 14, 17].
Factors associated with the COVID-19 patients treated at the Gulu Regional Referral Hospital
This report shows that most COVID-19 patients treated for severe COVID-19 and died at the GRRH had comorbidities, for example, Diabetes mellitus, cardiovascular diseases (CVDs) including (Stroke, valvular heart diseases, dysrhythmias, heart failure, and cardiac septal defects), hypertension, and symptomatic cases (Table 2 and Table 3). Many studies have observed similar findings, particularly those with comorbidities [2, 17, 18]. This finding implies that the Ugandan Ministry of Health could adopt the "Enhanced shielding" approach, where persons with comorbidities and the elderly are shielded from the general population to protect them from contracting the COVID-19 virus [12, 19]. These suggestions have implications on the approach the Ugandan health systems could adopt to control the spreading of COVID-19 among the elderly and those with comorbid conditions. The rural structure and relationship between the elderly and younger generation need thorough analysis as the elderly in the rural community live with and together with the young people who provide support and protection to the elderly. The practicality of this approach needs thorough thinking as this new approach may disrupt traditional ways of how people in the African rural communities live. These authors argue that with the lockdown, the economy, and health systems collapsing in many African countries, it is high time government planners came with solutions that allow the economy to be opened but ensure a reduced incidence and prevalence of COVID-19 in communities. One of the recommended approaches was to practice the enhanced shielding approach, which is more favorable to a country's social and economic systems. In addition, there is a need to sensitize and mobilize the population to embrace mass COVID-19 vaccination as vaccines are now available in the country to reduce the incidence of severe diseases which require hospitalization.
Treatment and complications observed among COVID-19 patients in Gulu Regional Referral Hospital
Findings from this study show that most COVID-19 patients were treated with antibiotics, vitamin C, steroids, Ivermectin, and vitamin D (Table 3, Table 4, Table 5, Table 6, and Table 7) and the outcomes of the treatment have been encouraging as shown by a very high recovery rate at 95.2% and a statistically significant association with steroid and Vitamin D treatment (Table 8).
In the same study, the most typical complications observed among the COVID-19 patients were pneumonia, acute respiratory distress syndrome (ARDS), systemic infections, septic shock, chronic fatigue, depression, and nightmares (Table 4). These authors argue that there were justified reasons for using antibiotics in treating COVID-19 patients at Gulu Regional Referral Hospital, as many cases developed complications treated with antibiotics.
In addition, the role played by the other drugs in the management of COVID-19 was suggested by scholars and academicians across the world and particularly their use as immune system modulators . To come up with a conclusive decision on the beneficial effects of the two drugs for managing COVID-19 patients at GRRH, formal Randomized controlled Trials will be required.
On the mental health complications observed among the COVID-19 patients treated at the Gulu Regional Referral Hospital, the authors recommend comprehensive mental health support for COVID-19 patients and the follow-up after recovery. Effective management of mental health conditions such as depression relieves the ever-increasing sense of depression and isolation experienced by the COVID-19 patients. If the numbers of mental health cases become widespread, a grassroots approach using trained village health teams (VHTs) would be the recommended approach for handling the problem. Notably, the VHTs should be trained and capable of dealing with COVID-19 related Psychosocial symptoms in the community. This idea is supported by studies conducted elsewhere in Africa, which suggest a grass-root approach to mental health problems after the lockdown in African [12, 19].
The independent determinants of COVID-19 cases treated at Gulu Regional Referral Hospital: This study showed that the recovery rate from the COVID-19 treated at the Gulu Regional Referral Hospital was 95.2%, yet 99.5% of the COVID-19 patients were unvaccinated (Table 3). Furthermore, this study found the Adjusted Odds Ratios (AOR) for factors associated with COVID-19 patients’ recovery at GRRH were treatment with steroids AOR=138.835 at 95% CI:12.258-1572.50; p<0.000 and Vitamin D AOR=0.016 at 95% CI:1.902-520.98; p=0.016 (Table 8). Statistically significant associations of Vitamin D and steroids with a positive outcome in the treatment and management of COVID 19 patients in our study have also been observed in previous studies [20, 21]. Could these successes be for this center only, or could this apply to diverse settings worldwide? A formal review study in different locations would be required in the long term to determine the effectiveness of the drugs in managing mild and severe cases of COVID-19. Authors recommend global studies on the two drugs to assess their actual effects on the treatment outcomes of COVID-19 patients.
Circumstances under which the coronavirus infected participants
Findings show that most of the circumstances were unknown 581(87.5%), others were congregated situations such overcrowding at Elegu border and interacting with international truck drivers 50(7.5%), Aswa Dam construction workers 12(1.8%) who lived in dormitories, health facility 2(0.3%), persons who nursed a relative with COVID-19 2(0.3%), bars 1(0.2%) and others 16(2.4%). This finding implies that the known source of the COVID-19 infection in Northern Uganda was from international truck drivers and mainly at the Elegu border point. Other sources such as bars, churches, and markets were fewer. Authors argue that regional controls of COVID-19 would be ideal for the East African region, where there is brisk trade among the countries. Therefore, the management and surveillance of international truck drivers as a regional approach would be suitable for controlling the coronavirus, ensuring that COVID-19 testing and management were conducted as per the international protocols across all the East African countries .
Strengths and limitations of the study
This study was a retrospective review of datasets from the COVID-19 medical records of Gulu Regional Referral Hospital. The period of the evaluation was from March 2020 to October 2021. The study has limitations on how Gulu Hospital handled records and record keeping. In addition, vital information, for example, weight, height, and BMI of COVID-19 patients, was not recorded due to the emergency handling of the cases at the beginning of the pandemic in March 2020. The missing variables in the Gulu Hospital HMIS records excluded some files from participating in this study. In this, authors have suggested a need for a prospective or longitudinal assessment of the COVID-19 cases in the future, ensuring that all data were measured and recorded accordingly.
This data is vital as it is one of the well-documented completed data for over 664 cases of COVID-19 treated in a Regional Referral Hospital in Uganda. Findings from this study show tremendous and good clinical practices at Gulu Regional Referral Hospital despite the challenges faced during the pandemic.
Generalization of the data from this study
These findings should be cautiously interpreted and generalized only to Regional Referral Hospitals in Uganda. However, they could be similarly observed in many hospitals in African countries with low-resource settings.