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Andrianaivoarimanana V, Savin C, Birdsell DN, Vogler AJ, Le Guern AS, Rahajandraibe S, Brémont S, Rahelinirina S, Sahl JW, Ramasindrazana B, Rakotonanahary RJL, Rakotomanana F, Randremanana R, Maheriniaina V, Razafimbia V, Kwasiborski A, Balière C, Ratsitorahina M, Baril L, Keim P, Caro V, Rasolofo V, Spiegel A, Pizarro-Cerda J, Wagner DM, Rajerison M. Multiple Introductions of Yersinia pestis during Urban Pneumonic Plague Epidemic, Madagascar, 2017. Emerg Infect Dis 2024; 30:289-298. [PMID: 38270131 PMCID: PMC10826772 DOI: 10.3201/eid3002.230759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024] Open
Abstract
Pneumonic plague (PP) is characterized by high infection rate, person-to-person transmission, and rapid progression to severe disease. In 2017, a PP epidemic occurred in 2 Madagascar urban areas, Antananarivo and Toamasina. We used epidemiologic data and Yersinia pestis genomic characterization to determine the sources of this epidemic. Human plague emerged independently from environmental reservoirs in rural endemic foci >20 times during August-November 2017. Confirmed cases from 5 emergences, including 4 PP cases, were documented in urban areas. Epidemiologic and genetic analyses of cases associated with the first emergence event to reach urban areas confirmed that transmission started in August; spread to Antananarivo, Toamasina, and other locations; and persisted in Antananarivo until at least mid-November. Two other Y. pestis lineages may have caused persistent PP transmission chains in Antananarivo. Multiple Y. pestis lineages were independently introduced to urban areas from several rural foci via travel of infected persons during the epidemic.
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Affiliation(s)
| | | | | | - Amy J. Vogler
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Anne-Sophie Le Guern
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Soloandry Rahajandraibe
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Sylvie Brémont
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Soanandrasana Rahelinirina
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Jason W. Sahl
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Beza Ramasindrazana
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Rado Jean Luc Rakotonanahary
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Fanjasoa Rakotomanana
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Rindra Randremanana
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Viviane Maheriniaina
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Vaoary Razafimbia
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Aurelia Kwasiborski
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Charlotte Balière
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Maherisoa Ratsitorahina
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Laurence Baril
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Paul Keim
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Valérie Caro
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - Voahangy Rasolofo
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
| | - André Spiegel
- Institut Pasteur de Madagascar, Antananarivo, Madagascar (V. Andrianaivoarimanana, S. Rahelinirina, B. Ramasindrazana, R.J.L. Rakotonanahary, F. Rakotomanana, R. Randremanana, M. Ratsitorahina, L. Baril, V. Rasolofo, A. Spiegel, M. Rajerison)
- Institut Pasteur, Paris, France (C. Savin, A.-S. Le Guern, S. Brémont, A. Kwasiborski, C. Balière, V. Caro, J. Pizarro-Cerda)
- Northern Arizona University, Flagstaff, Arizona, USA (D.N. Birdsell, A.J. Vogler, J.W. Sahl, P. Keim, D.M. Wagner)
- Madagascar Ministry of Public Health, Antananarivo (S. Rahajandraibe, V. Maheriniaina, V. Razafimbia)
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Kayiwa J, Homsy J, Nelson LJ, Ocom F, Kasule JN, Wetaka MM, Kyazze S, Mwanje W, Kisakye A, Nabunya D, Nyirabakunzi M, Aliddeki DM, Ojwang J, Boore A, Kasozi S, Borchert J, Shoemaker T, Nabatanzi S, Dahlke M, Brown V, Downing R, Makumbi I. Establishing a Public Health Emergency Operations Center in an Outbreak-Prone Country: Lessons Learned in Uganda, January 2014 to December 2021. Health Secur 2022; 20:394-407. [PMID: 35984936 PMCID: PMC10985018 DOI: 10.1089/hs.2022.0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Uganda is highly vulnerable to public health emergencies (PHEs) due to its geographic location next to the Congo Basin epidemic hot spot, placement within multiple epidemic belts, high population growth rates, and refugee influx. In view of this, Uganda's Ministry of Health established the Public Health Emergency Operations Center (PHEOC) in September 2013, as a central coordination unit for all PHEs in the country. Uganda followed the World Health Organization's framework to establish the PHEOC, including establishing a steering committee, acquiring legal authority, developing emergency response plans, and developing a concept of operations. The same framework governs the PHEOC's daily activities. Between January 2014 and December 2021, Uganda's PHEOC coordinated response to 271 PHEs, hosted 207 emergency coordination meetings, trained all core staff in public health emergency management principles, participated in 21 simulation exercises, coordinated Uganda's Global Health Security Agenda activities, established 6 subnational PHEOCs, and strengthened the capacity of 7 countries in public health emergency management. In this article, we discuss the following lessons learned: PHEOCs are key in PHE coordination and thus mitigate the associated adverse impacts; although the functions of a PHEOC may be legalized by the existence of a National Institute of Public Health, their establishment may precede formally securing the legal framework; staff may learn public health emergency management principles on the job; involvement of leaders and health partners is crucial to the success of a public health emergency management program; subnational PHEOCs are resourceful in mounting regional responses to PHEs; and service on the PHE Strategic Committee may be voluntary.
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Affiliation(s)
- Joshua Kayiwa
- Joshua Kayiwa, MSc, is a Plans Chief and Information Analyst, Public Health Emergency Operations Center, Ministry of Health, Kampala, Uganda
| | - Jaco Homsy
- Jaco Homsy, MD, MPH, is an Associate Clinical Professor, Epidemiology and Biostatistics, Institute for Global Health Sciences, University of California San Francisco School of Medicine, San Francisco, CA
| | - Lisa J Nelson
- Lisa J. Nelson, MD, MPH, MSc, is a Medical Officer and Uganda Country Director, US Centers for Disease Control and Prevention (CDC) Country Office, Kampala, Uganda
| | - Felix Ocom
- Felix Ocom, MD, is Deputy Director, Public Health Emergency Operations Center, Ministry of Health, Kampala, Uganda
| | - Juliet N Kasule
- Juliet N. Kasule, MSc, is an Early Warning Specialist, US Centers for Disease Control and Prevention (CDC) Country Office, Kampala, Uganda
| | - Milton M Wetaka
- Milton M. Wetaka is a Logistics Chief and Laboratory Specialist, Public Health Emergency Operations Center, Ministry of Health, Kampala, Uganda
| | - Simon Kyazze
- Simon Kyazze, MSc, is an Operations Chief, Public Health Emergency Operations Center, Ministry of Health, Kampala, Uganda
| | - Wilbrod Mwanje
- Wilbrod Mwanje, MPH, is an Epidemiologist, Public Health Emergency Operations Center, Ministry of Health, Kampala, Uganda
| | - Anita Kisakye
- Anita Kisakye, MSc, is a Monitoring and Evaluation Specialist, Public Health Emergency Operations Center, Ministry of Health, Kampala, Uganda
| | - Dorothy Nabunya
- Dorothy Nabunya is an Administrative Specialist, Public Health Emergency Operations Center, Ministry of Health, Kampala, Uganda
| | - Margaret Nyirabakunzi
- Margaret Nyirabakunzi is an Administrative Assistant, Public Health Emergency Operations Center, Ministry of Health, Kampala, Uganda
| | - Dativa Maria Aliddeki
- Dativa Maria Aliddeki, MSc, is an Epidemiologist, Public Health Emergency Operations Center, Ministry of Health, Kampala, Uganda
| | - Joseph Ojwang
- Joseph Ojwang, MPH, is an Epidemiologist, US Centers for Disease Control and Prevention (CDC) Country Office, Kampala, Uganda
| | - Amy Boore
- Amy Boore, PhD, is Director, Division of Global Health Protection, US Centers for Disease Control and Prevention (CDC) Country Office, Kampala, Uganda
| | - Sam Kasozi
- Sam Kasozi is a Systems Developer, Health Information Systems Program Uganda, Kampala, Uganda
| | - Jeff Borchert
- Jeff Borchert, MSc, is a Public Health Advisor, Division of Vector-Borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), US CDC, Fort Collins, CO
| | - Trevor Shoemaker
- Trevor Shoemaker, PhD, is an Epidemiologist, Division of High-Consequence Pathogens and Pathology, NCEZIDUS CDC, Atlanta, GA
| | - Sandra Nabatanzi
- Sandra Nabatanzi, MSc, is an Epidemiologist, Monitoring and Evaluation Technical Support Program, Makerere University School of Public Health, Kampala, Uganda
| | - Melissa Dahlke
- Melissa Dahlke, MSc, is an Epidemiologist, Global Immunization Division, Center for Global Health, US CDC, Atlanta, GA
| | - Vance Brown
- Vance Brown, MA, is a Public Health Advisor, Division of Global Health Protection, NCEZID, US CDC, Atlanta, GA
| | - Robert Downing
- Robert Downing, PhD, is a Laboratory Specialist, Uganda Virus Research Institute, Ministry of Health, Entebbe, Uganda
| | - Issa Makumbi
- Issa Makumbi, MSc, is Director, Public Health Emergency Operations Center, Ministry of Health, Kampala, Uganda
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