Time to care and factors influencing appropriate Sudan Virus Disease care among case patients in Uganda, September to November 2022

BACKGROUND

Early isolation and care for Ebola Disease patients at Ebola Treatment Units (ETU) curb outbreak spread. We evaluated time to ETU entry and associated factors during the 2022 Sudan virus disease (SVD) outbreak in Uganda.

METHODS

We included persons with RT-PCR-confirmed SVD with onset September 20-November 30, 2022. We categorized days from symptom onset to ETU entry ('delays') as short (≤2), moderate (3-5), and long (≥6); the latter two were 'delayed isolation'. We categorized symptom onset timing as 'earlier' or 'later,' using October 15 as a cut-off. We assessed demographics, symptom onset timing, and awareness of contact status as predictors for delayed isolation. We explored reasons for early vs late isolation using key informant interviews.

RESULTS

Among 118 case-patients, 25 (21%) had short, 43 (36%) moderate, and 50 (43%) long delays. Seventy-five (64%) had symptom onset later in the outbreak. Earlier symptom onset increased risk of delayed isolation [cRR=1∙8, 95%CI (1∙2-2∙8)]. Awareness of contact status and SVD symptoms, and belief that early treatment-seeking was lifesaving facilitated early care-seeking. Patients with long delays reported fear of ETUs and lack of transport as contributors.

CONCLUSION

Delayed isolation was common early in the outbreak. Strong contact tracing and community engagement could expedite presentation to ETUs.

Trends and geospatial distribution of stillbirths in Uganda, 2014-2020

INTRODUCTION

Uganda with 17.8 stillbirths per 1,000 deliveries in 2021, is among the countries with a high burden of stillbirths globally. In 2014, Uganda adopted the World Health Organization Every New-born Action Plan (ENAP), which targets < 10 stillbirths per 1,000 deliveries by 2035. Little is known about the trends of stillbirth burden since ENAP was introduced. We assessed the temporal, and spatial distribution of stillbirths, in Uganda, 2014-2020, to inform programming for safe pregnancies and deliveries.

METHODS

We obtained and analysed stillbirth surveillance data from the District Health Information System, 2014-2020. A stillbirth was defined as the death of a foetus > 28 weeks of pregnancy or weighing > 1000 g before or during birth and reported to a health facility. We calculated annual incidence rates of stillbirths per 1,000 deliveries at district, regional, and national levels. We used logistic regression to determine the significance of trends.

RESULTS

The overall national annual incidence of stillbirths decreased from 24/1,000 deliveries in 2014 to 17/1,000 deliveries in 2020. During the same period, reporting rates declined from 71% in 2014 to 46% in 2020. The central region continuously had the highest incidence rate for the past 5 years despite the largest decline (OR = 0.79; CI = 0.77-0.83, P < 0.001) while the eastern region had the smallest decline (OR = 0.59; CI = 0.57-0.61, P < 0.001). Districts with persistently high annual incidence rates of stillbirths (> 30/1000) included Mubende, Kalangala, Hoima, and Nebbi. There was no difference in the reporting rates of the most- vs. least-affected districts.

CONCLUSION

Even with suboptimal reporting, the incidence of stillbirths remained above the national target. Specific areas in the country appear to have particularly high stillbirth rates. We recommend continuous capacity building in managing pregnant women with an emphasis on the most affected districts, and investigation into the reasons for low reporting.

Performance and impact of contact tracing in the Sudan virus outbreak in Uganda, September 2022-January 2023

BACKGROUND

Contact tracing (CT) is critical for ebolavirus outbreak response. Ideally, all new cases after the index case should be previously-known contacts (PKC) before their onset, and spend minimal time ill in the community. We assessed the impact of CT during the 2022 Sudan Virus Disease (SVD) outbreak in Uganda.

METHODS

We collated anonymized data from the SVD case and contacts database to obtain and analyze data on CT performance indicators, comparing confirmed cases that were PKC and were not PKC (NPKC) before onset. We assessed the effect of being PKC on the number of people infected using Poisson regression.

RESULTS

There were 3844 contacts of 142 confirmed cases (mean: 22 contacts/case). Forty-seven (33%) confirmed cases were PKC. PKCs had fewer median days from onset to isolation (4 vs 6; P<0.007) and laboratory confirmation (4 vs 7; P<0.001) than NPKC. Being a PKC vs NPKC reduced risk of transmitting infection by 84% (IRR=0.16, 95% CI 0.08-0.32).

CONCLUSION

Contact identification was sub-optimal during the outbreak. However, CT reduced the time SVD cases spent in the community before isolation and the number of persons infected in Uganda. Approaches to improve contact tracing, especially contact listing, may improve control in future outbreaks.

Factors associated with acute watery diarrhea among children aged 0-59 months in Obongi District, Uganda, April 2022: A case-control study

Background

Diarrheal diseases, are major concerns for Ugandan children; persistent in Obongi District despite high rotavirus vaccination rates (2019-2021). The district recorded the country's highest annual acute watery diarrhea (AWD) incidence from 2017 to 2021. Our study, conducted in April 2022, assessed AWD risk factors among 0-59-month-old children in Obongi.

Methods

We conducted a 1:2 (193:386) unmatched case-control study. A case was a child (0-59 months) with ≥ 3 loose/liquid stools/day, negative malaria/pneumonia tests, residing in Itula/Parolinya subcounty from 1 to 30 April 2022. Medical records from 10 facilities were reviewed. Simple random sampling identified cases, who were interviewed, and controls were randomly chosen from non-AWD neighboring households. Child health cards provided vaccination details. We used logistic regression to identify factors associated with AWD.

Results

Among 193 cases and 386 controls, 104 (54 %) cases and 183 (47 %) controls were male, 58 (30 %) cases and 127 (33 %) controls were aged 12-23 months, 187 (97 %) cases and 369 (96 %) controls had received at least one dose of rotavirus vaccine, 58 (30 %) cases and 120 (34 %) controls treated drinking water. Comorbidity presence (undernutrition, diabetes, HIV) (AOR = 12; CI: 2.5-53), caregiver's unwashed hands post-toilet (AOR = 3.9; CI: 1.2-13), and borehole vs. piped water (AOR = 4.0; CI: 1.7-9.6) linked to AWD.

Conclusion

Modifiable factors, including failure of caregivers to wash their hands with soap after visiting toilets and use of borehole water were associated with AWD, suggesting that community sensitization on handwashing at critical times, using clean water and soap, and expanded use of piped water could reduce AWD incidence in this area.

Investigation of COVID-19 outbreak at a refugee transit centre, Kisoro District, Uganda, June-July 2022

Due to conflict in the Democratic Republic of Congo (DRC), approximately 34,000 persons arrived at Nyakabande Transit Centre (NTC) between March and June 2022. On June 12, 2022, Kisoro District reported >330 cases of COVID-19 among NTC residents. We investigated the outbreak to assess its magnitude, identify risk factors, and recommend control measures. We defined a confirmed case as a positive SARS-CoV-2 antigen test in an NTC resident during March 1-June 30, 2022. We generated a line list through medical record reviews and interviews with residents and health workers. We assessed the setting to understand possible infection mechanisms. In a case-control study, we compared exposures between cases (persons staying ≥5 days at NTC between June 26 and July 16, 2022, with a negative COVID-19 test at NTC entry and a positive test at exit) and unmatched controls (persons with a negative COVID-19 test at both entry and exit who stayed ≥5 days at NTC during the same period). We used multivariable logistic regression to identify factors associated with contracting COVID-19. Among 380 case-persons, 206 (54.2%) were male, with a mean age of 19.3 years (SD = 12.6); none died. The attack rate was higher among exiting persons (3.8%) than entering persons (0.6%) (p<0.01). Among 42 cases and 127 controls, close contact with symptomatic persons (aOR = 9.6; 95%CI = 3.1-30) increased the odds of infection; using a facemask (aOR = 0.06; 95% CI = 0.02-0.17) was protective. We observed overcrowding in shelters, poor ventilation, and most refugees not wearing face masks. The COVID-19 outbreak at NTC was facilitated by overcrowding and suboptimal use of facemasks. Enforcing facemask use and expanding shelter space could reduce the risk of future outbreaks. The collaborative efforts resulted in successful health sensitization and expanding the distribution of facemasks and shelter space. Promoting facemask use through refugee-led efforts is a viable strategy.

Improving maternal and neonatal outcomes among pregnant women who are HIV-positive or HIV-negative through the Saving Mothers Giving Life initiative in Uganda: An analysis of population-based mortality surveillance data

HIV infection is associated with poor maternal health outcomes. In 2016, the maternal mortality ratio (MMR) in Uganda was 336/100,000, and the neonatal mortality rate (NMR) was 19/1,000. Saving Mothers, Giving Life (SMGL) was a five-year maternal and neonatal health strengthening initiative launched in 2012 in Uganda. We extracted maternal and neonatal data for 2015-2016 from the initiative's population-based mortality surveillance system in 123 health facilities in Western Uganda. We collected data on the facilities, HIV status, antiretroviral drug (ARV) use, death, birth weight, delivery type, parity, Apgar scores, and complications. We compared mother and baby outcomes between HIV-positive or HIV-negative, computed risk ratios (RR) for adverse outcomes, and used the chi-square to test for significance in differences observed. Among 116,066 pregnant women who attended and gave birth at SMGL-implementing facilities during 2015-2016, 8,307 (7.7%) were HIV-positive, of whom 7,809 (94%) used antiretroviral drugs (ARVs) at the time of delivery. During birth, 23,993 (21%) women experienced ≥1 complications. Neonate Apgar scores <7 (8.8%) and maternal haemorrhage during birth (1.6%) were the most common outcomes. Overall facility MMR was 258/100,000 and NMR was 7.6/1,000. HIV infection increased risk of maternal death (RR = 3.6, 95% Confidence Interval (CI) = 2.4-5.5), maternal sepsis (RR = 2.1, 95% CI = 1.3-3.3), and infant birth weight <2,500g (RR = 1.2, 95% CI = 1.1-1.3), but was protective against maternal complications (RR = 0.92, 95% CI = 0.87-0.97) and perinatal death (RR = 0.78, 95% CI = 0.68-0.89). Among the HIV-positive, ARV non-use increased risk of maternal death (RR = 15, 95% CI = 7.1-31) and perinatal death (RR = 2.3, 95% CI = 1.6-3.4). SMGL reduced facility MMR and NMR below national rates. HIV-infection was associated with maternal sepsis and death. Failure to use ARVs among women living with HIV increased the risk of maternal and perinatal death. Use of the SMGL approach and complementary interventions that further strengthen HIV care, may continue to reduce MMR and NMR.

Evaluation of malaria outbreak detection methods, Uganda, 2022

BACKGROUND

Malaria outbreaks are detected by applying the World Health Organization (WHO)-recommended thresholds (the less sensitive 75th percentile or mean + 2 standard deviations [2SD] for medium-to high-transmission areas, and the more sensitive cumulative sum [C-SUM] method for low and very low-transmission areas). During 2022, > 50% of districts in Uganda were in an epidemic mode according to the 75th percentile method used, resulting in a need to restrict national response to districts with the highest rates of complicated malaria. The three threshold approaches were evaluated to compare their outbreak-signaling outputs and help identify prioritization approaches and method appropriateness across Uganda.

METHODS

The three methods were applied as well as adjusted approaches (85th percentile and C-SUM + 2SD) for all weeks in 2022 for 16 districts with good reporting rates ( ≥ 80%). Districts were selected from regions originally categorized as very low, low, medium, and high transmission; district thresholds were calculated based on 2017-2021 data and re-categorized them for this analysis.

RESULTS

Using district-level data to categorize transmission levels resulted in re-categorization of 8/16 districts from their original transmission level categories. In all districts, more outbreak weeks were detected by the 75th percentile than the mean + 2SD method (p < 0.001). For all 9 very low or low-transmission districts, the number of outbreak weeks detected by C-SUM were similar to those detected by the 75th percentile. On adjustment of the 75th percentile method to the 85th percentile, there was no significant difference in the number of outbreak weeks detected for medium and low transmission districts. The number of outbreak weeks detected by C-SUM + 2SD was similar to those detected by the mean + 2SD method for all districts across all transmission intensities.

CONCLUSION

District data may be more appropriate than regional data to categorize malaria transmission and choose epidemic threshold approaches. The 75th percentile method, meant for medium- to high-transmission areas, was as sensitive as C-SUM for low- and very low-transmission areas. For medium and high-transmission areas, more outbreak weeks were detected with the 75th percentile than the mean + 2SD method. Using the 75th percentile method for outbreak detection in all areas and the mean + 2SD for prioritization of medium- and high-transmission areas in response may be helpful.

Trends and spatial distribution of neonatal sepsis, Uganda, 2016-2020

BACKGROUND

In Uganda, sepsis is the third-leading cause of neonatal deaths. Neonatal sepsis can be early-onset sepsis (EOS), which occurs ≤ 7 days postpartum and is usually vertically transmitted from the mother to newborn during the intrapartum period, or late-onset sepsis (LOS), occurring 8-28 days postpartum and largely acquired from the hospital environment or community. We described trends and spatial distribution of neonatal sepsis in Uganda, 2016-2020.

METHODS

We conducted a descriptive incidence study using routinely-reported surveillance data on in-patient neonatal sepsis from the District Health Information System version 2 (DHIS2) during 2016-2020. We calculated incidence of EOS, LOS, and total sepsis as cases per 1,000 live births (LB) at district (n = 136), regional (n = 4), and national levels, as well as total sepsis incidence by health facility level. We used logistic regression to evaluate national and regional trends and illustrated spatial distribution using choropleth maps.

RESULTS

During 2016-2020, 95,983 neonatal sepsis cases were reported, of which 71,262 (74%) were EOS. Overall neonatal sepsis incidence was 17.4/1,000 LB. EOS increased from 11.7 to 13.4 cases/1,000 LB with an average yearly increase of 3% (p < 0.001); LOS declined from 5.7 to 4.3 cases/1,000 LB with an average yearly decrease of 7% (p < 0.001). Incidence was highest at referral hospitals (68/1,000 LB) and lowest at Health Center IIs (1.3/1,000 LB). Regionally, total sepsis increased in Central (15.5 to 23.0/1,000 LB, p < 0.001) and Northern regions (15.3 to 22.2/1,000 LB, p < 0.001) but decreased in Western (23.7 to 17.0/ 1,000 LB, p < 0.001) and Eastern (15.0 to 8.9/1,000, p < 0.001) regions.

CONCLUSION

The high and increasing incidence of EOS in Uganda suggests a major gap in sepsis prevention and quality of care for pregnant women. The heterogenous distribution of neonatal sepsis incidence requires root cause analysis by health authorities in regions with consistently high incidence. Strengthening prevention and treatment interventions in Central and Northern regions, and in the most affected districts, could reduce neonatal sepsis. Employment of strategies which increase uptake of safe newborn care practices and prevent neonatal sepsis, such as community health worker (CHW) home visits for mothers and newborns, could reduce incidence.

Investigation of human tungiasis cases, Sheema District, Uganda, November 2021-February 2022

Introduction

no formal surveillance system exists in Uganda for jiggers (tungiasis); however, outbreaks are frequently reported in the media. On 27th January 2022, a news alert reported a jiggers' outbreak in Sheema District, Southwestern Uganda. We investigated to establish the magnitude of the problem and identify possible exposures associated with infestation to inform control measures.

Methods

we defined a confirmed case as visible Tunga penetrans (T. penetrans) in the skin of a resident of any of 6 villages in Bwayegamba Parish, Sheema District, in February 2022. A suspected case was self-reported T. penetrans infestation during the three months preceding the interview. We visited all households in the 3 most affected villages in Bwayegamba Parish to identify cases and conducted interviews to identify possible exposures. We described cases by person, place, and time. We assessed socioeconomic status, household construction, mitigation measures against jiggers, and observed participants and their environments for hygiene. We conducted 2 case-control studies. One compared case-households (with ≥1 case) with control-households (without any cases). The second compared individual cases (suspected and confirmed) to neighbourhood controls.

Results

among 278 households, we identified 60 case-patients, among whom 34 (57%) were male. Kiyungu West was the most affected village (attack rate=31/1,000). Cases had higher odds of being male (ORMH=2.3, 95% CI=1.3-4.0), <20 years of age (ORMH=2.0, 95%CI=1.1-3.6), unmarried (ORMH=2.97, 95% CI=1.7-5.2), unemployed (ORMH=3.28, 95% CI=1.8-5.8), and having poor personal hygiene (ORMH=3.73, 95% CI=2.0-7.4) than controls. In the household case-control study, case-households had higher odds of having dirty or littered compounds (ORMH=2.3, 95% CI=1.2-4.6) and lower odds of practicing mitigation measures against jiggers (ORMH=0.33, 95% CI=0.1-0.8) than control-households.

Conclusion

males, unemployed persons, and those with poor personal or household hygiene had increased odds of tungiasis in this outbreak. Multi-sectoral, tailored interventions that improve standards of living could reduce risk of tungiasis in this area. Adding tungiasis to national surveillance reporting tools could facilitate early identification of future outbreaks.

Timeliness and completeness of monthly disease surveillance data reporting, Uganda, 2020-2021

Introduction

timely and complete reporting of routine public health information about diseases and public health events are important aspects of a robust surveillance system. Although data on the completeness and timeliness of monthly surveillance data are collected in the District Health Information System-2 (DHIS2), they have not been routinely analyzed. We assessed completeness and timeliness of monthly outpatient department (OPD) data, January 2020-December 2021.

Methods

we analyzed secondary data from all the 15 regions and 146 districts of Uganda. Completeness was defined as the number of submitted reports divided by the number of expected reports. Timeliness was defined as the number of reports submitted by the deadline (15th day of the following month) divided by reports received. Completeness or timeliness score of <80% was regarded incomplete or untimely.

Results

overall, there was good general performance with the median completeness being high in 2020 (99.5%; IQR 97.8-100%) and 2021 (100%; IQR 98.7-100%), as was the median timeliness (2020; 82.8%, IQR 74.6-91.8%; 2021, 94.9%, IQR 86.5-99.1%). Kampala Region was the only region that consistently failed to reach ≥ 80% OPD timeliness (2020: 44%; 2021: 65%). Nakasongola was the only district that consistently performed poorly in the submission of timely reports in both years (2020: 54.4%, 2021: 58.3%).

Conclusion

there was an overall good performance in the submission of complete and timely monthly OPD reports in most districts and regions in Uganda. There is a need to strengthen the good reporting practices exhibited and offer support to regions, districts, and health facilities with timeliness challenges.

Community dialogue meetings among district leaders improved their willingness to receive COVID-19 vaccines in Western Uganda, May 2021

BACKGROUND

Widespread COVID-19 vaccine uptake can facilitate epidemic control. A February 2021 study in Uganda suggested that public vaccine uptake would follow uptake among leaders. In May 2021, Baylor Uganda led community dialogue meetings with district leaders from Western Uganda to promote vaccine uptake. We assessed the effect of these meetings on the leaders' COVID-19 risk perception, vaccine concerns, perception of vaccine benefits and access, and willingness to receive COVID-19 vaccine.

METHODS

All departmental district leaders in the 17 districts in Western Uganda, were invited to the meetings, which lasted approximately four hours. Printed reference materials about COVID-19 and COVID-19 vaccines were provided to attendees at the start of the meetings. The same topics were discussed in all meetings. Before and after the meetings, leaders completed self-administered questionnaires with questions on a five-point Likert Scale about risk perception, vaccine concerns, perceived vaccine benefits, vaccine access, and willingness to receive the vaccine. We analyzed the findings using Wilcoxon's signed-rank test.

RESULTS

Among 268 attendees, 164 (61%) completed the pre- and post-meeting questionnaires, 56 (21%) declined to complete the questionnaires due to time constraints and 48 (18%) were already vaccinated. Among the 164, the median COVID-19 risk perception scores changed from 3 (neutral) pre-meeting to 5 (strong agreement with being at high risk) post-meeting (p < 0.001). Vaccine concern scores reduced, with medians changing from 4 (worried about vaccine side effects) pre-meeting to 2 (not worried) post-meeting (p < 0.001). Median scores regarding perceived COVID-19 vaccine benefits changed from 3 (neutral) pre-meeting to 5 (very beneficial) post-meeting (p < 0.001). The median scores for perceived vaccine access increased from 3 (neutral) pre-meeting to 5 (very accessible) post-meeting (p < 0.001). The median scores for willingness to receive the vaccine changed from 3 (neutral) pre-meeting to 5 (strong willingness) post-meeting (p < 0.001).

CONCLUSION

COVID-19 dialogue meetings led to district leaders' increased risk perception, reduced concerns, and improvement in perceived vaccine benefits, vaccine access, and willingness to receive the COVID-19 vaccine. These could potentially influence public vaccine uptake if leaders are vaccinated publicly as a result. Broader use of such meetings with leaders could increase vaccine uptake among themselves and the community.

Readiness of health facilities to manage individuals infected with COVID-19, Uganda, June 2021

BACKGROUND

The COVID-19 pandemic overwhelmed the capacity of health facilities globally, emphasizing the need for readiness to respond to rapid increases in cases. The first wave of COVID-19 in Uganda peaked in late 2020 and demonstrated challenges with facility readiness to manage cases. The second wave began in May 2021. In June 2021, we assessed the readiness of health facilities in Uganda to manage the second wave of COVID-19.

METHODS

Referral hospitals managed severe COVID-19 patients, while lower-level health facilities screened, isolated, and managed mild cases. We assessed 17 of 20 referral hospitals in Uganda and 71 of 3,107 lower-level health facilities, selected using multistage sampling. We interviewed health facility heads in person about case management, coordination and communication and reporting, and preparation for the surge of COVID-19 during first and the start of the second waves of COVID-19, inspected COVID-19 treatment units (CTUs) and other service delivery points. We used an observational checklist to evaluate capacity in infection prevention, medicines, personal protective equipment (PPE), and CTU surge capacity. We used the "ReadyScore" criteria to classify readiness levels as > 80% ('ready'), 40-80% ('work to do'), and < 40% ('not ready') and tailored the assessments to the health facility level. Scores for the lower-level health facilities were weighted to approximate representativeness for their health facility type in Uganda.

RESULTS

The median (interquartile range (IQR)) readiness scores were: 39% (IQR: 30, 51%) for all health facilities, 63% (IQR: 56, 75%) for referral hospitals, and 32% (IQR: 24, 37%) for lower-level facilities. Of 17 referral facilities, two (12%) were 'ready' and 15 (88%) were in the "work to do" category. Fourteen (82%) had an inadequate supply of medicines, 12 (71%) lacked adequate supply of oxygen, and 11 (65%) lacked space to expand their CTU. Fifty-five (77%) lower-level health facilities were "not ready," and 16 (23%) were in the "work to do" category. Seventy (99%) lower-level health facilities lacked medicines, 65 (92%) lacked PPE, and 53 (73%) lacked an emergency plan for COVID-19.

CONCLUSION

Few health facilities were ready to manage the second wave of COVID-19 in Uganda during June 2021. Significant gaps existed for essential medicines, PPE, oxygen, and space to expand CTUs. The Uganda Ministry of Health utilized our findings to set up additional COVID-19 wards in hospitals and deliver medicines and PPE to referral hospitals. Adequate readiness for future waves of COVID-19 requires additional support and action in Uganda.

Timeliness and completeness of weekly surveillance data reporting on epidemic prone diseases in Uganda, 2020-2021

INTRODUCTION

Disease surveillance provides vital data for disease prevention and control programs. Incomplete and untimely data are common challenges in planning, monitoring, and evaluation of health sector performance, and health service delivery. Weekly surveillance data are sent from health facilities using mobile tracking (mTRAC) program, and synchronized into the District Health Information Software version 2 (DHIS2). The data are then merged into district, regional, and national level datasets. We described the completeness and timeliness of weekly surveillance data reporting on epidemic prone diseases in Uganda, 2020-2021.

METHODS

We abstracted data on completeness and timeliness of weekly reporting of epidemic-prone diseases from 146 districts of Uganda from the DHIS2.Timeliness is the proportion of all expected weekly reports that were submitted to DHIS2 by 12:00pm Monday of the following week. Completeness is the proportion of all expected weekly reports that were completely filled and submitted to DHIS2 by 12:00pm Wednesday of the following week. We determined the proportions and trends of completeness and timeliness of reporting at national level by year, health region, district, health facility level, and facility ownership.

RESULTS

National average reporting timeliness and completeness was 44% and 70% in 2020, and 49% and 75% in 2021. Eight of the 15 health regions achieved the target for completeness of ≥ 80%; Lango attained the highest (93%) in 2020, and Karamoja attained 96% in 2021. None of the regions achieved the timeliness target of ≥ 80% in either 2020 or 2021. Kampala District had the lowest completeness (38% and 32% in 2020 and 2021, respectively) and the lowest timeliness (19% in both 2020 and 2021). Referral hospitals and private owned health facilities did not attain any of the targets, and had the poorest reporting rates throughout 2020 and 2021.

CONCLUSION

Weekly surveillance reporting on epidemic prone diseases improved modestly over time, but timeliness of reporting was poor. Further investigations to identify barriers to reporting timeliness for surveillance data are needed to address the variations in reporting.

Cholera outbreak associated with drinking contaminated river water in Panyimur and Parombo sub-counties: Nebbi district, Uganda, March 2017

Introduction: On 10thFebruary 2017, Uganda Ministry of Health was notified of a suspected cholera outbreak in Nebbi district. The district experienced numerous cholera outbreaks with the latest in 2016. We investigated to determine the scope, mode of transmission, and exposures. Methods: We defined a suspected case as sudden onset of acute watery diarrhoea in a resident (>5 years) from Parombo or Panyimur subcounties in Nebbi district, during 1 January-9 March 2017. A confirmed case was a suspected case with culture-confirmed Vibrio cholerae from stool. We conducted descriptive epidemiology of case-persons to inform hypothesis generation and a case-control study involving 67 case-persons and 134 control-persons to test the hypothesis. Results: We identified 222 suspected case-persons; samples from two yielded Vibrio cholerae O139. Three case-persons died (CFR=1.4%). The epidemic curve indicated a point-source outbreak. Among 67 cases, 40 (60%) drank river water, compared with 56 (42%) of 134 controls (OR 2.2, 95% CI: 1.2- 4.1). Visual assessment revealed that river water had high turbidity and we observed mass open defecation. Conclusion: This outbreak affected two sub-counties and was associated with drinking contaminated river water. We recommended treating drinking water by the community members and health education on drinking water safety and proper waste disposal in the communities. And for long term, the district water department should increase the number and functionality of boreholes or piped water in the communities.

Improving the effectiveness of Field Epidemiology Training Programs: characteristics that facilitated effective response to the COVID-19 pandemic in Uganda

BACKGROUND

The global need for well-trained field epidemiologists has been underscored in the last decade in multiple pandemics, the most recent being COVID-19. Field Epidemiology Training Programs (FETPs) are in-service training programs that improve country capacities to respond to public health emergencies across different levels of the health system. Best practices for FETP implementation have been described previously. The Uganda Public Health Fellowship Program (PHFP), or Advanced-FETP in Uganda, is a two-year fellowship in field epidemiology funded by the U.S. Centers for Disease Control and situated in the Uganda National Institute of Public Health (UNIPH). We describe how specific attributes of the Uganda PHFP that are aligned with best practices enabled substantial contributions to the COVID-19 response in Uganda.

METHODS

We describe the PHFP in Uganda and review examples of how specific program characteristics facilitate integration with Ministry of Health needs and foster a strong response, using COVID-19 pandemic response activities as examples. We describe PHFP activities and outputs before and during the COVID-19 response and offer expert opinions about the impact of the program set-up on these outputs.

RESULTS

Unlike nearly all other Advanced FETPs in Africa, PHFP is delinked from an academic degree-granting program and enrolls only post-Master's-degree fellows. This enables full-time, uninterrupted commitment of academically-trained fellows to public health response. Uganda's PHFP has strong partner support in country, sufficient technical support from program staff, Ministry of Health (MoH), CDC, and partners, and full-time dedicated directorship from a well-respected MoH staff member. The PHFP is physically co-located inside the UNIPH with the emergency operations center (EOC), which provides a direct path for health alerts to be investigated by fellows. It has recognized value within the MoH, which integrates graduates into key MoH and partner positions. During February 2020-September 2021, PHFP fellows and graduates completed 67 major COVID-related projects. PHFP activities during the COVID-19 response were specifically requested by the MoH or by partners, or generated de novo by the program, and were supervised by all partners.

CONCLUSION

Specific attributes of the PHFP enable effective service to the Ministry of Health in Uganda. Among the most important is the enrollment of post-graduate fellows, which leads to a high level of utilization of the program fellows by the Ministry of Health to fulfill real-time needs. Strong leadership and sufficient technical support permitted meaningful program outputs during COVID-19 pandemic response. Ensuring the inclusion of similar characteristics when implementing FETPs elsewhere may allow them to achieve a high level of impact.

Ownership and use of long-lasting insecticidal nets three months after a mass distribution campaign in Uganda, 2021

BACKGROUND

Uganda conducted its third mass long-lasting insecticidal net (LLIN) distribution campaign in 2021. The target of the campaign was to ensure that 100% of households own at least one LLIN per two persons and to achieve 85% use of distributed LLINs. LLIN ownership, use and associated factors were assessed 3 months after the campaign.

METHODS

A cross-sectional household survey was conducted in 14 districts from 13 to 30 April, 2021. Households were selected using multistage sampling. Each was asked about LLIN ownership, use, duration since received to the time of interview, and the presence of LLINs was visually verified. Outcomes were having at least one LLIN per two household members, and individual LLIN use. Modified Poisson regression was used to assess associations between exposures and outcomes.

RESULTS

In total, 5529 households with 27,585 residents and 15,426 LLINs were included in the analysis. Overall, 95% of households owned ≥ 1 LLIN, 92% of the households owned ≥ 1 LLIN < 3 months old, 64% of households owned ≥ 1 LLIN per two persons in the household. Eighty-seven per cent could sleep under an LLIN if every LLIN in the household were used by two people, but only 69% slept under an LLIN the night before the survey. Factors associated with LLIN ownership included believing that LLINs are protective against malaria (aPR = 1.13; 95% CI  1.04-1.24). Reported use of mosquito repellents was negatively associated with ownership of LLINs (aPR = 0.96; 95% CI 0.95-0.98). The prevalence of LLIN use was 9% higher among persons who had LLINs 3-12 months old (aPR = 1.09; 95% CI  1.06-1.11) and 10% higher among those who had LLINs 13-24 months old (aPR = 1.10; 95% CI  1.06-1.14) than those who had LLINs < 3 months old. Of 3,859 LLINs identified in the households but not used for sleeping the previous night, 3250 (84%) were < 3 months old. Among these 3250, 41% were not used because owners were using old LLINs; 16% were not used because of lack of space for hanging them; 11% were not used because of fear of chemicals in the net; 5% were not used because of dislike of the smell of the nets; and, 27% were not used for other reasons.

CONCLUSION

The substantial difference between the population that had access to LLINs and the population that slept under LLINs indicates that the National Malaria Control Programme (NMCP) may need to focus on addressing the main drivers or barriers to LLIN use. NMCP and/or other stakeholders could consider designing and conducting targeted behaviour change communication during subsequent mass distribution of LLINs after the mass distribution campaign to counter misconceptions about new LLINs.

The potential distribution of Bacillus anthracis suitability across Uganda using INLA

To reduce the veterinary, public health, environmental, and economic burden associated with anthrax outbreaks, it is vital to identify the spatial distribution of areas suitable for Bacillus anthracis, the causative agent of the disease. Bayesian approaches have previously been applied to estimate uncertainty around detected areas of B. anthracis suitability. However, conventional simulation-based techniques are often computationally demanding. To solve this computational problem, we use Integrated Nested Laplace Approximation (INLA) which can adjust for spatially structured random effects, to predict the suitability of B. anthracis across Uganda. We apply a Generalized Additive Model (GAM) within the INLA Bayesian framework to quantify the relationships between B. anthracis occurrence and the environment. We consolidate a national database of wildlife, livestock, and human anthrax case records across Uganda built across multiple sectors bridging human and animal partners using a One Health approach. The INLA framework successfully identified known areas of species suitability in Uganda, as well as suggested unknown hotspots across Northern, Eastern, and Central Uganda, which have not been previously identified by other niche models. The major risk factors for B. anthracis suitability were proximity to water bodies (0-0.3 km), increasing soil calcium (between 10 and 25 cmolc/kg), and elevation of 140-190 m. The sensitivity of the final model against the withheld evaluation dataset was 90% (181 out of 202 = 89.6%; rounded up to 90%). The prediction maps generated using this model can guide future anthrax prevention and surveillance plans by the relevant stakeholders in Uganda.

Malaria outbreak facilitated by increased mosquito breeding sites near houses and cessation of indoor residual spraying, Kole district, Uganda, January-June 2019

BACKGROUND

In June 2019, surveillance data from the Uganda's District Health Information System revealed an outbreak of malaria in Kole District. Analysis revealed that cases had exceeded the outbreak threshold from January 2019. The Ministry of Health deployed our team to investigate the areas and people affected, identify risk factors for disease transmission, and recommend control and prevention measures.

METHODS

We conducted an outbreak investigation involving a matched case-control study. We defined a confirmed case as a positive malaria test in a resident of Aboke, Akalo, Alito, and Bala sub-counties of Kole District January-June 2019. We identified cases by reviewing outpatient health records. Exposures were assessed in a 1:1 matched case-control study (n = 282) in Aboke sub-county. We selected cases systematically from 10 villages using probability proportionate to size and identified age- and village-matched controls. We conducted entomological and environmental assessments to identify mosquito breeding sites. We plotted epidemic curves and overlaid rainfall, and indoor residual spraying (IRS). Case-control exposures were combined into: breeding site near house, proximity to swamp and breeding site, and proximity to swamp; these were compared to no exposure in a logistic regression analysis.

RESULTS

Of 18,737 confirmed case-patients (AR = 68/1,000), Aboke sub-county residents (AR = 180/1,000), children < 5 years (AR = 94/1,000), and females (AR = 90/1,000) were most affected. Longitudinal analysis of surveillance data showed decline in cases after an IRS campaign in 2017 but an increase after IRS cessation in 2018-2019. Overlay of rainfall and case data showed two malaria upsurges during 2019, occurring 35-42 days after rainfall increases. Among 141 case-patients and 141 controls, the combination of having mosquito breeding sites near the house and proximity to swamps increased the odds of malaria 6-fold (OR = 6.6, 95% CI = 2.24-19.7) compared to no exposures. Among 84 abandoned containers found near case-patients' and controls' houses, 14 (17%) had mosquito larvae. Adult Anopheles mosquitoes, larvae, pupae, and pupal exuviae were identified near affected houses.

CONCLUSION

Stagnant water formed by increased rainfall likely provided increased breeding sites that drove this outbreak. Cessation of IRS preceded the malaria upsurges. We recommend re-introduction of IRS and removal of mosquito breeding sites in Kole District.

Uganda National Institute of Public Health: Establishment and Experiences, 2013–2021

Since 2013, the Uganda National Institute of Public Health (UNIPH) has successfully collaborated with partners and secured donor funding as it works toward legal establishment as an autonomous entity eligible for government funding. Countries in Africa and beyond can learn from the process Uganda undertook to develop the UNIPH.

Uganda is an ecological hot spot with porous borders that lies in several infectious disease transmission belts, making it prone to disease outbreaks. To prepare and respond to these public health threats and emergencies in a coordinated manner, Uganda established the Uganda National Institute of Public Health (UNIPH) in 2013.

Using a step-by-step process, Uganda’s Ministry of Health (MOH) crafted a strategy with a vision, mission, goal, and strategic objectives, and identified value additions and key enablers for success. A regulatory impact assessment was then conducted to inform the drafting of principles of the bill for legislation on the Institute.

Despite not yet attaining legal status, the UNIPH has already achieved faster, smarter, and more efficient and effective prevention, detection, and response to public health emergencies. Successes include a more coordinated multisectoral, disciplined, and organized response to emergencies; appropriate, timely, and complete information receipt and sharing; a functional national lab sample and results transportation network that has enabled detection and confirmation of public health events within 48 hours of alert; appropriate response to a confirmed public health event in 24–48 hours; and real-time surveillance of endemic- and epidemic-prone diseases.

In this article, we document success stories, lessons learned, and challenges encountered during the unique staged process used to develop the components of the UNIPH. The creation of an integrated disease control center has proven to yield better collaboration and synergies between different arms of epidemic preparedness and response.

Outbreak of cutaneous anthrax associated with handling meat of dead cows in Southwestern Uganda, May 2018

Background

Anthrax is a zoonotic infection caused by the bacteria Bacillus anthracis. Humans acquire cutaneous infection through contact with infected animals or animal products. On May 6, 2018, three cows suddenly died on a farm in Kiruhura District. Shortly afterwards, a sub-county chief in Kiruhura District received reports of humans with suspected cutaneous anthrax in the same district. The patients had reportedly participated in the butchery and consumption of meat from the dead cows. We investigated to determine the magnitude of the outbreak, identify exposures associated with illness, and suggest evidence-based control measures.

Methods

We conducted a retrospective cohort study among persons whose households received any of the cow meat. We defined a suspected human cutaneous anthrax case as new skin lesions (e.g., papule, vesicle, or eschar) in a resident of Kiruhura District from 1 to 26 May 2018. A confirmed case was a suspected case with a lesion testing positive for B. anthracis by polymerase chain reaction (PCR). We identified cases through medical record review at Engari Health Centre and active case finding in the community.

Results

Of the 95 persons in the cohort, 22 were case-patients (2 confirmed and 20 suspected, 0 fatal cases) and 73 were non-case household members. The epidemic curve indicated multiple point-source exposures starting on May 6, when the dead cows were butchered. Among households receiving cow meat, participating in slaughtering (RR = 5.3, 95% CI 3.2–8.3), skinning (RR = 4.7, 95% CI = 3.1–7.0), cleaning waste (RR = 4.5, 95% CI = 3.1–6.6), and carrying meat (RR = 3.9, 95% CI = 2.2–7.1) increased the risk of infection.

Conclusions

This cutaneous anthrax outbreak was caused by handling infected animal carcasses. We suggested to the Ministry of Agriculture, Animal Industry and Fisheries to strengthen surveillance for possible veterinary anthrax and ensure that communities do not consume carcasses of livestock that died suddenly. We also suggested that the Ministry of Health equip health facilities with first-line antibiotics for community members during outbreaks.

Comparative epidemiologic analysis of COVID-19 patients during the first and second waves of COVID-19 in Uganda

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Hospitalized patients were older in Wave 2 Bthan in Wave 1.

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Hospitalized patients were more likely to be male in Wave 1 than in Wave 2.

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Coronavirus disease 2019 was more severe in Wave 2 than in Wave 1.

Introduction

Methods

Findings

Interpretation

Uganda Public Health Fellowship Program's Contributions to the National HIV and TB Programs, 2015–2020

The Uganda Public Health Fellowship Program has built the capacity of its fellows to address multiple gaps in the Uganda health system as well as to contribute to improving Uganda's ability to prevent, prepare for, and respond to public health emergencies such as HIV and TB.

Despite remarkable progress in controlling HIV and TB, Uganda is one of the 30 high-burden TB/HIV countries. Approximately 53,000 Ugandans had a new HIV diagnosis in 2019, and approximately 88,000 Ugandans had a TB diagnosis in 2020. Fellows in the Uganda Public Health Fellowship Program (UPHFP) work directly with the Ministry of Health AIDS and TB Control Programs, the U.S. Centers for Disease Control and Prevention, UPHFP supervisors, and implementing partners to investigate and evaluate HIV-related and TB-related issues. These activities have contributed to the Uganda HIV and TB programs. UPHFP fellows complete projects in 7 competency domains, including outbreak investigations, surveillance evaluations, and data quality improvement. Priority HIV/AIDS/TB information gaps/topics are identified in consultation with key stakeholders, and fellows complete projects to guide program improvements and policy decisions. During 2015–2020, UPHFP fellows implemented 127 HIV and TB projects covering key program areas in AIDS and TB control programs, including care and treatment (16 projects), TB/HIV (18), prevention of mother-to-child HIV transmission (24), key and priority populations (9), pre-exposure and post-exposure prophylaxis (7), adolescent girls and young women (6), service delivery (13), and diagnosis of TB including drug-resistant TB and TB in high-risk groups (32). These projects have helped improve retention, quality of care, and treatment outcomes for people living with HIV, HIV and TB coinfected patients, and TB patients. They have also contributed to the decrease in pediatric TB and infant HIV positivity rates and improved service delivery for key populations. UPHFP results were disseminated to relevant stakeholders such as government departments, implementing partners, districts, and the general community and guided decision making. UPHFP has significantly improved HIV and TB control in Uganda. Other countries with similar programs could benefit from this approach and utilize program fellows to support HIV and TB control.

Evaluation of public health surveillance systems in refugee settlements in Uganda, 2016-2019: lessons learned

Background

Civil wars in the Great Lakes region resulted in massive displacement of people to neighboring countries including Uganda. With associated disease epidemics related to this conflict, a disease surveillance system was established aiming for timely detection of diseases and rapid response to outbreaks. We describe the evaluation of and lessons learned from the public health surveillance system set up in refugee settlements in Uganda.

Methods

We conducted a cross-sectional survey using the US Centers for Disease Control and Prevention Updated Guidelines for Evaluating Public Health Surveillance Systems and the Uganda National Technical Guidelines for Integrated Disease Surveillance and Response in four refugee settlements in Uganda—Bidibidi, Adjumani, Kiryandongo and Rhino Camp. Using semi-structured questionnaires, key informant and focus group discussion guides, we interviewed 53 health facility leaders, 12 key personnel and 224 village health team members from 53 health facilities and 112 villages and assessed key surveillance functions and attributes.

Results

All health facilities assessed had key surveillance staff; 60% were trained on Integrated Disease Surveillance and Response and most village health teams were trained on disease surveillance. Case detection was at 55%; facilities lacked standard case definitions and were using parallel Implementing Partner driven reporting systems. Recording was at 79% and reporting was at 81%. Data analysis and interpretation was at 49%. Confirmation of outbreaks and events was at 76%. Preparedness was at 72%. Response was at 34%. Feedback was at 82%. Evaluate and improve the system was at 67%. There was low capacity for detection, response and data analysis and interpretation of cases (< 60%).

Conclusion

The surveillance system in the refugee settlements was functional with many performing attributes but with many remaining gaps. There was low capacity for detection, response and data analysis and interpretation in all the refugee settlements. There is need for improvement to align surveillance systems in refugee settlements with the mainstream surveillance system in the country. Implementing Partners should be urged to offer support for surveillance and training of surveillance staff on Integrated Disease Surveillance and Response to maintain effective surveillance functions. Functionalization of district teams ensures achievement of surveillance functions and attributes. Regular supervision of and support to health facility surveillance personnel is essential. Harmonization of reporting improves surveillance functions and attributes and appropriation of funds by government to districts to support refugee settlements is complementary to maintain effective surveillance of priority diseases in the northern and central part of Uganda.

Large outbreak of Jimsonweed (Datura stramonium) poisoning due to consumption of contaminated humanitarian relief food: Uganda, March-April 2019

Background

Jimsonweed (Datura stramonium) contains toxic alkaloids that cause gastrointestinal and central nervous system symptoms when ingested. This can be lethal at high doses. The plant may grow together with leguminous crops, mixing with them during harvesting. On 13 March 2019, more than 200 case-patients were admitted to multiple health centres for acute gastrointestinal and neurologic symptoms. We investigated to determine the cause and magnitude of the outbreak and recommended evidence-based control and prevention measures.

Methods

We defined a suspected case as sudden onset of confusion, dizziness, convulsions, hallucinations, diarrhoea, or vomiting with no other medically plausible explanations in a resident of Napak or Amudat District from 1 March—30 April 2019. We reviewed medical records and canvassed all villages of the eight affected subcounties to identify cases. In a retrospective cohort study conducted in 17 villages that reported the earliest cases, we interviewed 211 residents about dietary history during 11–15 March. We used modified Poisson regression to assess suspected food exposures. Food samples underwent chemical (heavy metals, chemical contaminants, and toxins), proteomic, DNA, and microbiological testing in one national and three international laboratories.

Results

We identified 293 suspected cases; five (1.7%) died. Symptoms included confusion (62%), dizziness (38%), diarrhoea (22%), nausea/vomiting (18%), convulsions (12%), and hallucinations (8%). The outbreak started on 12 March, 2–12 h after Batch X of fortified corn-soy blend (CSB +) was distributed. In the retrospective cohort study, 66% of 134 persons who ate CSB + , compared with 2.2% of 75 who did not developed illness (RR_adj = 22, 95% CI = 6.0–81). Samples of Batch X distributed 11–15 March contained 14 tropane alkaloids, including atropine (25-50 ppm) and scopolamine (1-10 ppm). Proteins of Solanaceae seeds and Jimsonweed DNA were identified. No other significant laboratory findings were observed.

Conclusion

This was the largest documented outbreak caused by food contamination with tropane alkaloids. Implicated food was immediately withdrawn. Routine food safety and quality checks could prevent future outbreaks.

You cannot find what you are not looking for! detecting malaria outbreaks in Uganda: a case study

Malaria is the leading cause of morbidity and mortality in Uganda, with nearly half of the population becoming infected in any given year. Uganda relies on analyzing high-quality surveillance data to help detect outbreaks, determine which areas or population groups are most affected, and help target resources to where they are most needed. In March 2019, over 300 health facilities from different districts in Uganda reported substantially higher malaria cases than usual. In 13 districts, health facilities reported that the number of malaria cases was so high that they were experiencing stock outs of antimalarial drugs. Although seasonal increases in cases had been expected, districts reported that the number of cases being identified were overwhelming the capacity of the health facilities. Uganda´s National Malaria Control Division tasked a team of epidemiologists to investigate this unprecedented increase in malaria cases. National Malaria Control Division were interested in how malaria epidemiology had been changing in recent years, and whether they had missed something that would have predicted the situation they were facing in 2019. This case study describes the steps taken to conduct a descriptive analysis of routine malaria surveillance data and demonstrates how to detect malaria outbreaks using historical data. It is useful for training Field Epidemiologists and public health officers involved in analysis of surveillance data.

An outbreak of malaria caused by increase in malaria breeding sites in swamps

On 10^th June 2019, routine analysis of malaria surveillance data at the National Malaria Control Division, Ministry of Health in Uganda revealed that there was an unusual increase in the number of malaria cases reported in the Oyam District. On 11^th June 2019, the District Health Officer in Oyam District convened a meeting with the District Health Team (DHT) in which the District Biostatistician confirmed that the number of malaria cases had indeed exceeded the upper limit, starting in epidemic week 24 (approximately the week of June 10). The District Health Officer issued a formal request to the Ministry of Health for assistance in dealing with the malaria outbreak in Oyam. Two field epidemiology residents were assigned to work with the District Health Team to investigate the outbreak. The residents followed the steps in conducting vector borne disease outbreak investigations including preparation for field work, establishment of the existence of an outbreak by analyzing surveillance data, descriptive data analysis, hypothesis generation, conducting environmental and entomological assessments, conducting analytic studies with a focus on the utility of retrospective cohort studies as well as reporting findings. This case study teaches trainees in Field Epidemiology and Laboratory Training Programs, public health students, public health workers who are interested or who may participate in vector borne disease outbreak investigation and response.

Malaria outbreak in Mbale: it´s the pits! a case study

Malaria is a leading cause of morbidity and mortality in Uganda. In June 2019, the Uganda Ministry of Health through routine surveillance data analysis was notified of an increase in malaria cases in Bumbobi and Nyondo Sub-counties, Mbale District, which exceeded the action thresholds. We investigated to assess outbreak magnitude, identify transmission risk factors, and recommend evidence-based control measures. We defined a confirmed case as a positive malaria result using malaria Rapid Diagnostic Test or microscopy from 1 Jan 2019 to 30 Jun 2019 in a resident or visitor of Bumbobi or Nyondo Sub-county, Mbale District. We reviewed medical records to develop a line list for descriptive epidemiology. In a case-control study, we compared exposures between 150 case-persons and 150 age- and village-matched asymptomatic controls. We conducted environmental and entomological assessments on vector dynamics and behavior. We identified 7,891 case-persons (attack rate [AR]=26%). Females (AR=36%) were more affected than males (AR=25%). The 5-18 year age group (AR=26%) was most affected. The epidemic curve showed steady increase in malaria cases from March following intermittent rainfall from January, with short spells of no rainfall up to June. In the matched pair case-control analysis, 95% (143/150) of case-patients and 49% (73/150) of controls had soil erosion control pits near their homes that held stagnant water for several days following rainfall (AOR=18, 95%CI=7-50); Active breeding sites were found near and within homesteads with Anopheles gambiaeas the predominant vector. Increased vector breeding sites due to erosion control pits sustained by the intermittent rainfall caused this outbreak. We recommended draining of pits immediately after the rains and increasing coverage for bed-nets.

Delayed outbreak detection: a wake-up call to evaluate a surveillance system

During May, 83 of the 120 districts in Uganda had reported malaria cases above the upper limit of the normal channel. Across all districts, cases had exceeded malaria normal channel upper limits for an average of six months. Yet no alarms had been raised! Starting in 2000, Uganda adopted the World Health Organization (WHO) Integrated Disease Surveillance and Response (IDSR) strategy for disease reporting, including for malaria. Even early on, however, it was unclear how effectively IDSR and DHIS2 were being used in Uganda. Outbreaks were consistently detected late, but the underlying cause of the late detection was unclear. Suspecting there might be gaps in the surveillance system that were not immediately obvious, the Uganda FETP was asked to evaluate the malaria surveillance system in Uganda. This case study teaches trainees in Field Epidemiology and Laboratory Training Programs, public health students, public health workers who may participate in evaluation of public health surveillance systems, and others who are interested in this topic on reasons, steps, and attributes and uses the surveillance evaluation approach to identify gaps and facilitates discussion of practical solutions for improving a public health surveillance system.

Preparing for the worst: opportunities to prevent trans-boundary disease transmission in Uganda: a case study

On August 1^st, 2018, the Ministry of Health of the Democratic Republic of Congo (DRC) declared its tenth Ebola Virus Disease (EVD) outbreak in history, affecting North Kivu and Ituri provinces. The outbreak response was complicated due to insecurity and armed conflict in the region, and over the next 19 months, thousands of cases and deaths would occur, making this the world´s second-largest outbreak of EVD to date. On 4 August 2018, the Uganda Ministry of Health (MoH) activated the national coordination mechanisms for public health emergencies. The National Rapid Response Team (NRRT) immediately mobilized and embarked on a preparedness assessment and risk mapping to inform the country´s EVD response plan. This case study describes the events that transpired from declaration, activation of the coordination mechanisms, preparedness and response to EVD. The case study is meant to teach rapid responders, Incident Management Team members and the National and District Task Forces on how to prepare and respond to such outbreaks.

Malaria outbreak facilitated by engagement in activities near swamps following increased rainfall and limited preventive measures: Oyam District, Uganda

In April 2019, the District Health Office of Oyam District, Uganda reported an upsurge in malaria cases exceeding expected epidemic thresholds, requiring outbreak response. We investigated the scope of outbreak and identified exposures for transmission to inform control measures. A confirmed case was a positive malaria rapid diagnostic test or malaria microscopy from 1 January-30 June 2019 in a resident or visitor of Acaba Sub-county, Oyam District. We reviewed medical records at health facilities to get case-patients. We conducted entomological and environmental assessments to determine vector density, and identify aquatic Anopheles habitats, conducted a case-control study to determine exposures associated with illness. Of 9,235 case-patients (AR = 33%), females (AR = 38%) were more affected than males (AR = 20%) (p<0.001). Children <18 years were more affected (AR = 37%) than adults (p<0.001). Among 83 case-patients and 83 asymptomatic controls, 65 (78%) case-patients and 33 (40%) controls engaged in activities <500m from a swamp (ORMH = 12, 95%CI 3.6-38); 18 (22%) case-patients and four (5%) controls lived <500m from rice irrigation sites (ORMH = 8.2, 95%CI 1.8-36); and 23 (28%) case-patients and four (5%) controls had water pools <100m from household for 3-5 days after rainfall (ORMH = 7.3, 95%CI 2.2-25). Twenty three (28%) case-patients and four (5%) controls did not sleep under bed nets the previous night (ORMH = 20, 95%CI 2.7-149); 68 (82%) case-patients and 43(52%) controls did not wear long-sleeved clothes during evenings (ORMH = 9.3, 95%CI 2.8-31). Indoor resting vector density was 4.7 female mosquitoes/household/night. All Anopheles aquatic habitats had Anopheles larvae. Weekly rainfall in 2019 was heavier (6.0±7.2mm) than same period in 2018 (1.8±1.8mm) (p = 0.006). This outbreak was facilitated by Anopheles aquatic habitats near homes created by human activities, following increased rainfall compounded by inadequate use of individual preventive measures. We recommended awareness on use of insecticide-treated bed nets, protective clothing, and avoiding creation of Anopheles aquatic habitats.

Cholera outbreak caused by drinking unprotected well water contaminated with faeces from an open storm water drainage: Kampala City, Uganda, January 2019

Background

Kampala city slums, with one million dwellers living in poor sanitary conditions, frequently experience cholera outbreaks. On 6 January 2019, Rubaga Division notified the Uganda Ministry of Health of a suspected cholera outbreak in Sembule village. We investigated to identify the source and mode of transmission, and recommended evidence-based interventions.

Methods

We defined a suspected case as onset of profuse, painless, acute watery diarrhoea in a Kampala City resident (≥ 2 years) from 28 December 2018 to 11 February 2019. A confirmed case was a suspected case with Vibrio cholerae identified from the patient’s stool specimen by culture. We found cases by record review and active community case-finding. We conducted a case–control study in Sembule village, the epi-center of this outbreak, to compare exposures between confirmed case-persons and asymptomatic controls, individually matched by age group. We overlaid rainfall data with the epidemic curve to identify temporal patterns between rain and illnesses. We conducted an environmental assessment, interviewed village local council members, and tested water samples from randomly-selected households and water sources using culture and PCR to identify V. cholerae.

Results

We identified 50 suspected case-patients, with three deaths (case-fatality rate: 6.0%). Of 45 case-patients with stool samples tested, 22 were confirmed positive for V. cholerae O1, serotype Ogawa. All age groups were affected; persons aged 5–14 years had the highest attack rate (AR) (8.2/100,000). The epidemic curve showed several point-source outbreaks; cases repeatedly spiked immediately following rainfall. Sembule village had a token-operated water tap, which had broken down 1 month before the outbreak, forcing residents to obtain water from one of three wells (Wells A, B, C) or a public tap. Environmental assessment showed that residents emptied their feces into a drainage channel connected to Well C. Drinking water from Well C was associated with illness (OR_M–H = 21, 95% CI 4.6–93). Drinking water from a public tap (OR_M–H = 0.07, 95% CI 0.014–0.304) was protective. Water from a container in one of eight households sampled tested positive for V. cholerae; water from Well C had coliform counts ˃ 900/100 ml.

Conclusions

Drinking contaminated water from an unprotected well was associated with this cholera outbreak. We recommended emergency chlorination of drinking water, fixing the broken token tap, and closure of Well C.

Risk perception and psychological state of healthcare workers in referral hospitals during the early phase of the COVID-19 pandemic, Uganda

Background

Safeguarding the psychological well-being of healthcare workers (HCWs) is crucial to ensuring sustainability and quality of healthcare services. During the COVID-19 pandemic, HCWs may be subject to excessive mental stress. We assessed the risk perception and immediate psychological state of HCWs early in the pandemic in referral hospitals involved in the management of COVID-19 patients in Uganda.

Methods

We conducted a cross-sectional survey in five referral hospitals from April 20–May 22, 2020. During this time, we distributed paper-based, self-administered questionnaires to all consenting HCWs on day shifts. The questionnaire included questions on socio-demographics, occupational behaviors, potential perceived risks, and psychological distress. We assessed risk perception towards COVID-19 using 27 concern statements with a four-point Likert scale. We defined psychological distress as a total score > 12 from the 12-item Goldberg’s General Health Questionnaire (GHQ-12). We used modified Poisson regression to identify factors associated with psychological distress.

Results

Among 335 HCWs who received questionnaires, 328 (98%) responded. Respondents’ mean age was 36 (range 18–59) years; 172 (52%) were male. The median duration of professional experience was eight (range 1–35) years; 208 (63%) worked more than 40 h per week; 116 (35%) were nurses, 52 (14%) doctors, 30 (9%) clinical officers, and 86 (26%) support staff. One hundred and forty-four (44%) had a GHQ-12 score > 12. The most common concerns reported included fear of infection at the workplace (81%), stigma from colleagues (79%), lack of workplace support (63%), and inadequate availability of personal protective equipment (PPE) (56%). In multivariable analysis, moderate (adjusted prevalence ratio, [aPR] = 2.2, 95% confidence interval [CI] 1.2–4.0) and high (aPR = 3.8, 95% CI 2.0–7.0) risk perception towards COVID-19 (compared with low-risk perception) were associated with psychological distress.

Conclusions

Forty-four percent of HCWs surveyed in hospitals treating COVID-19 patients during the early COVID-19 epidemic in Uganda reported psychological distress related to fear of infection, stigma, and inadequate PPE. Higher perceived personal risk towards COVID-19 was associated with increased psychological distress. To optimize patient care during the pandemic and future outbreaks, workplace management may consider identifying and addressing HCW concerns, ensuring sufficient PPE and training, and reducing infection-associated stigma.

Documentation and dissemination of scientific evidence by the Uganda Public Health Fellowship Program: experiences and lessons learnt, 2015-2020

BACKGROUND

During participation in Field Epidemiology Training Programs (FETP) residents/fellows generate scientific evidence from the various public health projects they are engaged in. However, this evidence is not sufficiently disseminated to influence policy and practice. We describe the processes through which evidence is disseminated, and share achievements and lessons learnt during the first 5 years of the Uganda Public Health Fellowship Program (PHFP).

METHODS

The PHFP is a 2-year, full-time, non-degree fellowship, and the first post-masters FETP in Africa for mid-career public health professionals. Fellows gain competencies in seven main domains, which are demonstrated by deliverables while learning through service delivery, 80% of the time within Ministry of Health and related agencies. Generated public health evidence is disseminated immediately through sharing of daily situation reports with the National Task Force for Epidemic Preparedness and Response, as well as regional and district levels. Information is also disseminated on an intermediate to long-term basis through newspaper articles, epidemiological bulletins, abstracts and conference presentations, and publications in scientific journals.

RESULTS

During 2015-2020, PHFP enrolled 80 fellows in seven cohorts, including five of whom who had graduated. Overall, 355 field projects had been implemented. Additionally, PHFP made 287 conference presentations including 108 international and 178 national conferences. Altogether, the Uganda PHFP has received 7 awards, 4 of these for excellent scientific presentations during conferences. By end of 2020, PHFP had written 147 manuscripts at different stages of peer review, including 53 publications; and published 153 epidemiological bulletins. Dissemination performance was limited by delays due to challenges like non-adherence to product clearance guidelines, limited persons to conduct product review, and limited expertise on certain scientific areas, authorship related issues, and competing priorities among fellows, staff, and alumni.

CONCLUSIONS

The PHFP has disseminated public health evidences through various means to a wider range of audiences within Uganda and globally. Manuscript publication and monitoring of actions taken as a result of evidence dissemination is still limited. We recommend putting in place mechanisms to facilitate publication of all scientific evidence and deliberate efforts to ensure and monitor scientific evidence utilization.

Patterns of wasting among pregnant and lactating women in Uganda, 2015-2018: analysis of Nutrition surveillance data

BACKGROUND

Maternal nutrition is closely linked to the survival and development of children during the first 1000 days of life. Maternal wasting, a measure of malnutrition, is measured using the mid-upper arm circumference. However, in 2019, the rate and distribution of wasting among pregnant and lactating women was not known. We described annual trends and distribution of wasting among pregnant and lactating women (PLW), Uganda, 2015-2018, to inform programming on targeted nutritional interventions.

METHODS

We analyzed nutrition surveillance data from the District Health Information System for all PLW from 2015 to 2018. We used the World Health Organization standard thresholds to determine wasting among PLW by year and region, drawing choropleth maps to demonstrate the geographic distribution of wasting among PLW. We used logistic regression to assess wasting trends.

RESULTS

During 2015-2018, 268,636 PLW were wasted (prevalence = 5.5%). Of the 15 regions of Uganda, Karamoja (prevalence = 21%) and Lango (prevalence = 17%) registered the highest prevalence while Toro (prevalence = 2.7%) and Kigezi (prevalence = 2.0%) registered the lowest prevalence. The national annual prevalence of wasting among PLW declined by 31% from 2015 to 2018 (OR = 0.69, p < 0.001). Regions in the north had increasing trends of wasting over the period [Lango (OR = 1.6, p < 0.001) and Acholi (OR = 1.2, p < 0.001)], as did regions in the east [(Bugisu (OR = 3.4, p < 0.001), Bukedi (OR = 1.4, p < 0.001), and Busoga (OR = 1.3, p < 0.001)]. The other 11 regions showed declines.

CONCLUSION

The trend of wasting among PLW nationally declined during the study period. Lango and Acholi regions, both of which were experiencing a nutrition state of emergency during this period, had both high and rising rates of wasting, as did the Karamoja region, which experienced the highest wasting rates. We recommended that the Ministry of Health increases its focus on nutrition monitoring for PLW and conduct an analysis to clearly identify the factors underlying malnutrition specific for PLW in these regions.

The yield of HIV testing during pregnancy and postnatal period, Uganda, 2015-2018: analysis of surveillance data

Background

Uganda has registered a reduction in new HIV infections among children in recent years. However, mother-to-child transmission of HIV still occurs, especially among pregnant women who present late. To eliminate this transmission, all HIV-positive pregnant women should be identified during antenatal HIV testing. We described women newly identified HIV-positive during pregnancy and postnatal period 2015–2018.

Methods

We extracted surveillance data for women identified as HIV-positive during pregnancy and the postnatal period reported through the Health Management Information System from 2015–2018. We calculated proportions newly positive at antenatal, labor, and postnatal periods nationally and at district levels. We disaggregated data into ‘tested early’ (during antenatal care) and ‘tested late’ (during labor or postnatal period) and calculated the proportion positive. We evaluated trends in these parameters at national and district levels.

Results

Overall, 8,485,854 mothers were tested for HIV during this period. Of these, 2.4% tested HIV-positive for the first time. While the total number of mothers tested increased from 1,327,022 in 2015 to 2,514,212 in 2018, the proportion testing HIV-positive decreased from 3.0% in 2015 to 1.7% in 2018 (43% decline over the study period, p < 0.001). Of 6,781,047 tested early, 2.2% tested HIV-positive. The proportion positive among those tested early dropped from 2.5% in 2015 to 1.7% in 2018. Of 1,704,807 tested late, 3.2% tested HIV-positive. The proportion positive among those tested late dropped from 5.2% in 2015 to 1.6% in 2018. At the district level, Kalangala District had the highest proportion testing positive at 13% (909/11,312) in 2015; this dropped to 5.2% (169/3278) in 2018.

Conclusion

The proportion of women newly testing HIV-positive during pregnancy and postnatal declined significantly during 2015–2018. A higher proportion of mothers who tested late vs early were HIV-positive. Failure to identify HIV early represents an increased risk of transmission. Ministry of Health should strengthen Elimination of Mother to Child Transmission (eMTCT) services to sustain this decrease through targeted interventions for poorly-performing districts. It should strengthen community-based health education on antenatal care and HIV testing and enhance the implementation of other primary prevention strategies targeting adolescents and young women.

Epidemiological profile of patients with rifampicin-resistant tuberculosis: an analysis of the Uganda National Tuberculosis Reference Laboratory Surveillance Data, 2014-2018

BACKGROUND

Drug-resistant tuberculosis (DR-TB), including rifampicin-resistant tuberculosis (RR-TB) and multidrug-resistant tuberculosis (MDR-TB, or RR-TB with additional isoniazid resistance), presents challenges to TB control. In Uganda, the GeneXpert test provides point-of-care testing for TB and rifampicin resistance. Patients identified with RR-TB receive culture-based drug susceptibility testing (DST) to identify additional resistance, if any. There are few data on the epidemiological profiles of current DR-TB patients in Uganda. We described patients with RR-TB in Uganda and assessed the trends of RR-TB to inform TB control interventions.

METHODS

We identified patients with RR-TB whose samples were referred for culture and DST during 2014-2018 from routinely-generated laboratory surveillance data at the Uganda National Tuberculosis Reference Laboratory. Data on patient demographics and drug sensitivity profile of Mycobacterium tuberculosis isolates were abstracted. Population data were obtained from the Uganda Bureau of Statistics to calculate incidence. Descriptive epidemiology was performed, and logistic regression used to assess trends.

RESULTS

We identified 1474 patients whose mean age was 36 ± 17 years. Overall incidence was 3.8/100,000 population. Males were more affected by RR-TB than females (4.9 vs. 2.7/100,000, p ≤ 0.01). Geographically, Northern Uganda was the most affected region (IR = 6.9/100,000) followed by the Central region (IR = 5.01/100,000). The overall population incidence of RR-TB increased by 20% over the evaluation period (OR = 1.2; 95% CI 1.15-1.23); RR-TB in new TB cases increased by 35% (OR = 1.35; 95% CI 1.3-1.4) and by 7% in previously-treated cases (OR = 1.07; 95% CI 1.0-1.1). Of the 1474 patients with RR-TB, 923 (63%) were culture-positive of whom 670 (72%) had full DST available. Based on the DST results, 522/670 (78%) had MDR-TB.

CONCLUSION

Between 2014 and 2018, the incidence of RR-TB increased especially among newly-diagnosed TB patients. We recommend intensified efforts and screening for early diagnosis especially among previously treated patients. Mechanisms should be in put to ensure that all patients with RR-TB obtain DST.

Early cases of SARS-CoV-2 infection in Uganda: epidemiology and lessons learned from risk-based testing approaches - March-April 2020

BACKGROUND

On March 13, 2020, Uganda instituted COVID-19 symptom screening at its international airport, isolation and SARS-CoV-2 testing for symptomatic persons, and mandatory 14-day quarantine and testing of persons traveling through or from high-risk countries. On March 21, 2020, Uganda reported its first SARS-CoV-2 infection in a symptomatic traveler from Dubai. By April 12, 2020, 54 cases and 1257 contacts were identified. We describe the epidemiological, clinical, and transmission characteristics of these cases.

METHODS

A confirmed case was laboratory-confirmed SARS-CoV-2 infection during March 21-April 12, 2020 in a resident of or traveler to Uganda. We reviewed case-person files and interviewed case-persons at isolation centers. We identified infected contacts from contact tracing records.

RESULTS

Mean case-person age was 35 (±16) years; 34 (63%) were male. Forty-five (83%) had recently traveled internationally ('imported cases'), five (9.3%) were known contacts of travelers, and four (7.4%) were community cases. Of the 45 imported cases, only one (2.2%) was symptomatic at entry. Among all case-persons, 29 (54%) were symptomatic at testing and five (9.3%) were pre-symptomatic. Among the 34 (63%) case-persons who were ever symptomatic, all had mild disease: 16 (47%) had fever, 13 (38%) reported headache, and 10 (29%) reported cough. Fifteen (28%) case-persons had underlying conditions, including three persons with HIV. An average of 31 contacts (range, 4-130) were identified per case-person. Five (10%) case-persons, all symptomatic, infected one contact each.

CONCLUSION

The first 54 case-persons with SARS-CoV-2 infection in Uganda primarily comprised incoming air travelers with asymptomatic or mild disease. Disease would likely not have been detected in these persons without the targeted testing interventions implemented in Uganda. Transmission was low among symptomatic persons and nonexistent from asymptomatic persons. Routine, systematic screening of travelers and at-risk persons, and thorough contact tracing will be needed for Uganda to maintain epidemic control.

A prolonged cholera outbreak caused by drinking contaminated stream water, Kyangwali refugee settlement, Hoima District, Western Uganda: 2018

Background

On 23 February 2018, the Uganda Ministry of Health (MOH) declared a cholera outbreak affecting more than 60 persons in Kyangwali Refugee Settlement, Hoima District, bordering the Democratic Republic of Congo (DRC). We investigated to determine the outbreak scope and risk factors for transmission, and recommend evidence-based control measures.

Methods

We defined a suspected case as sudden onset of watery diarrhoea in any person aged ≥ 2 years in Hoima District, 1 February–9 May 2018. A confirmed case was a suspected case with Vibrio cholerae cultured from a stool sample. We found cases by active community search and record reviews at Cholera Treatment Centres. We calculated case-fatality rates (CFR) and attack rates (AR) by sub-county and nationality. In a case-control study, we compared exposure factors among case- and control-households. We estimated the association between the exposures and outcome using Mantel-Haenszel method. We conducted an environmental assessment in the refugee settlement, including testing samples of stream water, tank water, and spring water for presence of fecal coliforms. We tested suspected cholera cases using cholera rapid diagnostic test (RDT) kits followed by culture for confirmation.

Results

We identified 2122 case-patients and 44 deaths (CFR = 2.1%). Case-patients originating from Demographic Republic of Congo were the most affected (AR = 15/1000). The overall attack rate in Hoima District was 3.2/1000, with Kyangwali sub-county being the most affected (AR = 13/1000). The outbreak lasted 4 months, which was a multiple point-source. Environmental assessment showed that a stream separating two villages in Kyangwali Refugee Settlement was a site of open defecation for refugees. Among three water sources tested, only stream water was feacally-contaminated, yielding > 100 CFU/100 ml. Of 130 stool samples tested, 124 (95%) yielded V. cholerae by culture. Stream water was most strongly associated with illness (odds ratio [OR] = 14.2, 95% CI: 1.5–133), although tank water also appeared to be independently associated with illness (OR = 11.6, 95% CI: 1.4–94). Persons who drank tank and stream water had a 17-fold higher odds of illness compared with persons who drank from other sources (OR = 17.3, 95% CI: 2.2–137).

Conclusions

Our investigation demonstrated that this was a prolonged cholera outbreak that affected four sub-counties and two divisions in Hoima District, and was associated with drinking of contaminated stream water. In addition, tank water also appears to be unsafe. We recommended boiling drinking water, increasing latrine coverage, and provision of safe water by the District and entire High Commission for refugees.

Low proportion of women who came knowing their HIV status at first antenatal care visit, Uganda, 2012-2016: a descriptive analysis of surveillance data

Background

HIV testing is the cornerstone for HIV care and support services, including Prevention of Mother to Child Transmission of HIV (PMTCT). Knowledge of HIV status is associated with better reproductive health choices and outcomes for the infant’s HIV status. We analyzed trends in known current HIV status among pregnant women attending the first antenatal care (ANC) visit in Uganda, 2012–2016.

Methods

We conducted secondary data analysis using District Health Information Software2 data on all pregnant women who came for ANC visit during 2012–2016. Women who brought documented HIV negative test result within the previous 4 weeks at the first ANC visit or an HIV positive test result and/or own HIV care card were considered as knowing their HIV status.

We calculated proportions of women with known current HIV status at first ANC visit, and described linear trends both nationally and regionally. We tested statistical significance of the trend using modified Poisson regression with generalized linear models. For known HIV positive status, we only analyzed data for years 2015–2016 because this is when this data became available.

Results

There was no significant difference in the number of women that attended first ANC visits over years 2012–2016. The proportion of women that came with known HIV status increased from 4.4% in 2012 to 6.9% in 2016 and this increase was statistically significant (p < 0.001). Most regions had an increase in trend except the West Nile and Mid-Eastern (p < 0.001). The proportion of women that came knowing their HIV positive status at first ANC visit was slightly higher than that of women that were newly tested HIV positive at first ANC visit in 2015 and 2016.

Conclusion

Although the gap in women that come at first ANC visit without knowing their HIV positive status might be reducing, a large proportion of women who were infected with HIV did not know their status before the first ANC visit indicating a major public health gap. We recommend advocacy for early ANC attendance and hence timely HIV testing and innovations to promptly identify HIV positive women of reproductive age so that timely PMTCT interventions can be made.

Measles outbreak amplified in a pediatric ward: Lyantonde District, Uganda, August 2017

Background

Measles is a highly infectious viral disease. In August 2017, Lyantonde District, Uganda reported a measles outbreak to Uganda Ministry of Health. We investigated the outbreak to assess the scope, factors facilitating transmission, and recommend control measures.

Methods

We defined a probable case as sudden onset of fever and generalized rash in a resident of Lyantonde, Lwengo, or Rakai Districts from 1 June-30 September 2017, plus ≥1 of the following: coryza, conjunctivitis, or cough. A confirmed case was a probable case with serum positivity of measles-specific IgM. We conducted a neighborhood- and age-matched case-control study to identified exposure factors, and used conditional logistic regression to analyze the data. We estimated vaccine effectiveness and vaccination coverage.

Results

We identified 81 cases (75 probable, 6 confirmed); 4 patients (4.9%) died. In the case-control study, 47% of case-patients and 2.3% of controls were hospitalized at Lyantonde Hospital pediatric department for non-measles conditions 7–21 days before case-patient’s onset (OR_adj = 34, 95%CI: 5.1–225). Estimated vaccine effectiveness was 95% (95%CI: 75–99%) and vaccination coverage was 76% (95%CI: 68–82%). During the outbreak, an “isolation” ward was established inside the general pediatric ward where there was mixing of both measles and non-measles patients.

Conclusions

This outbreak was amplified by nosocomial transmission and facilitated by low vaccination coverage. We recommended moving the isolation ward outside of the building, supplemental vaccination, and vaccinating pediatric patients during measles outbreaks.

Investigation of a Cluster of Severe Respiratory Disease Referred from Uganda to Kenya, February 2017

On February 22, 2017, Hospital X-Kampala and US CDC-Kenya reported to the Uganda Ministry of Health a respiratory illness in a 46-year-old expatriate of Company A. The patient, Mr. A, was evacuated from Uganda to Kenya and died. He had recently been exposed to dromedary camels (MERS-CoV) and wild birds with influenza A (H5N6). We investigated the cause of illness, transmission, and recommended control. We defined a suspected case of severe acute respiratory illness (SARI) as acute onset of fever (≥38°C) with sore throat or cough and at least one of the following: headache, lethargy, or difficulty in breathing. In addition, we looked at cases with onset between February 1 and March 31 in a person with a history of contact with Mr. A, his family, or other Company A employees. A confirmed case was defined as a suspected case with laboratory confirmation of the same pathogen detected in Mr. A. Influenza-like illness was defined as onset of fever (≥38°C) and cough or sore throat in a Uganda contact, and as fever (≥38°C) and cough lasting less than 10 days in a Kenya contact. We collected Mr. A's exposure and clinical history, searched for cases, and traced contacts. Specimens from the index case were tested for complete blood count, liver function tests, plasma chemistry, Influenza A(H1N1)pdm09, and MERS-CoV. Robust field epidemiology, laboratory capacity, and cross-border communication enabled investigation.

Uganda's experience in Ebola virus disease outbreak preparedness, 2018-2019

BACKGROUND

Since the declaration of the 10th Ebola Virus Disease (EVD) outbreak in DRC on 1st Aug 2018, several neighboring countries have been developing and implementing preparedness efforts to prevent EVD cross-border transmission to enable timely detection, investigation, and response in the event of a confirmed EVD outbreak in the country. We describe Uganda's experience in EVD preparedness.

RESULTS

On 4 August 2018, the Uganda Ministry of Health (MoH) activated the Public Health Emergency Operations Centre (PHEOC) and the National Task Force (NTF) for public health emergencies to plan, guide, and coordinate EVD preparedness in the country. The NTF selected an Incident Management Team (IMT), constituting a National Rapid Response Team (NRRT) that supported activation of the District Task Forces (DTFs) and District Rapid Response Teams (DRRTs) that jointly assessed levels of preparedness in 30 designated high-risk districts representing category 1 (20 districts) and category 2 (10 districts). The MoH, with technical guidance from the World Health Organisation (WHO), led EVD preparedness activities and worked together with other ministries and partner organisations to enhance community-based surveillance systems, develop and disseminate risk communication messages, engage communities, reinforce EVD screening and infection prevention measures at Points of Entry (PoEs) and in high-risk health facilities, construct and equip EVD isolation and treatment units, and establish coordination and procurement mechanisms.

CONCLUSION

As of 31 May 2019, there was no confirmed case of EVD as Uganda has continued to make significant and verifiable progress in EVD preparedness. There is a need to sustain these efforts, not only in EVD preparedness but also across the entire spectrum of a multi-hazard framework. These efforts strengthen country capacity and compel the country to avail resources for preparedness and management of incidents at the source while effectively cutting costs of using a "fire-fighting" approach during public health emergencies.

Uganda public health fellowship program's contribution to building a resilient and sustainable public health system in Uganda

Background: Low-income countries with relatively weak-health systems are highly vulnerable to public health threats. Effective public health system with a workforce to investigate outbreaks can reduce disease impact on livelihoods and economic development. Building effective public health partnerships is critical for sustainability of such a system. Uganda has made significant progress in responding to emergencies during the past quarter century, but its public health workforce is still inadequate in number and competency.

Objectives: To reinforce implementation of priority public health programs in Uganda and cultivate core capacities for compliance with International Health Regulations.

Methods: To develop a competent workforce to manage epidemics and improve disease surveillance, Uganda Ministry of Health (MoH) established an advanced-level Field Epidemiology Training Program, called Public Health Fellowship Program (PHFP); closely modelled after the US CDC’s Epidemic Intelligence Service. PHFP is a 2-year, full-time, non-degree granting program targeting mid-career public health professionals. Fellows spend 85% of their field time in MoH placements learning through service delivery and gaining competencies in major domains.

Results: During 2015–2018, PHFP enrolled 41 fellows, and graduated 30. Fellows were placed in 19 priority areas at MoH and completed 235 projects (91 outbreaks, 12 refugee assessments, 50 surveillance, and 60 epidemiologic studies, 3 cost analysis and 18 quality improvement); made 194 conference presentations; prepared 63 manuscripts for peer-reviewed publications (27 published as of December 2018); produced MoH bulletins, and developed three case studies. Projects have resulted in public health interventions with improvements in surveillance systems and disease control.

Conclusion: During the 4 years of existence, PHFP has contributed greatly to improving real-time disease surveillance and outbreak response core capacities. Enhanced focus on evidence-based targeted approaches has increased effectiveness in outbreak response and control, and integration of PHFP within MoH has contributed to building a resilient and sustainable health system in Uganda.

Fatal cases associated with eating chapatti contaminated with organophosphate in Tororo District, Eastern Uganda, 2015: case series

BACKGROUND

Few cases of organophosphate poisoning in developing countries have been investigated using clinical and epidemiological methods. On 30 October 2015, 3 students at Mukuju School, Tororo District, Uganda, died soon after eating chapatti (locally-made flat bread) from the same food stand. Ministry of Health investigated to identify the cause and recommend prevention measures.

METHODS

We defined a case as onset during 30-31 October 2015 in a resident of Mukuju Town of ≥1 of the following symptoms: excessive saliva, profuse sweating, dizziness, low blood pressure, constricted pupils or loss of consciousness. We reviewed medical/police records and interviewed survivors, healthcare workers, and police officers. We collected samples of implicated food for toxicological analysis. Autopsies were performed on decedents to identify the cause of death.

RESULTS

We identified 7 cases with 3 deaths (case-fatality ratio = 43%). Clinical manifestations included acute onset of confusion (100%), constricted pupils (43%), excessive saliva (43%), and low blood pressure (43%). All 7 cases had onset from 16:00-18:00 h on 30 October, with a point-source exposure pattern. Of the 7 cases, 86% (6/7) were men; the mean age was 24 (range: 20-32) years. The 3 decedents each ate a whole chapatti while the other 4 cases ate half or less. Autopsy findings of the 3 decedents indicated organophosphate poisoning. Toxicological analysis found high levels of malathion in leftover foods (266 mg/L in dough and 258 mg/L in chapatti) and malaoxon (a highly toxic malathion derivative) in decedents' postmortem specimens (mean levels of 19 mg/L in the blood and 22 mg/L in the gastric contents). There was a delay of 4 h before the patients received appropriate treatment. Police investigations revealed that flour used to make the chapatti was intentionally contaminated with an organophosphate pesticide.

CONCLUSION

This fatal outbreak of organophosphate poisoning was associated with consumption of roadside-vended chapatti made of flour contaminated with pesticide. Clinicians should be aware of symptoms of organophosphate poisoning and prepared to treat it quickly. Street vendors should carefully consider the source of their ingredients. An in-depth surveillance review of such poisonings in Uganda would guide policymakers in reducing access by criminals and accidental exposures for the public.

A cholera outbreak caused by drinking contaminated river water, Bulambuli District, Eastern Uganda, March 2016

BACKGROUND

A cholera outbreak started on 29 February in Bwikhonge Sub-county, Bulambuli District in Eastern Uganda. Local public health authorities implemented initial control measures. However, in late March, cases sharply increased in Bwikhonge Sub-county. We investigated the outbreak to determine its scope and mode of transmission, and to inform control measures.

METHODS

We defined a suspected case as sudden onset of watery diarrhea from 1 March 2016 onwards in a resident of Bulambuli District. A confirmed case was a suspected case with positive stool culture for V. cholerae. We conducted descriptive epidemiologic analysis of the cases to inform the hypothesis on mode of transmission. To test the hypothesis, we conducted a case-control study involving 100 suspected case-patients and 100 asymptomatic controls, individually-matched by residence village and age. We collected seven water samples for laboratory testing.

RESULTS

We identified 108 suspected cases (attack rate: 1.3%, 108/8404), including 7 confirmed cases. The case-control study revealed that 78% (78/100) of case-patients compared with 51% (51/100) of control-persons usually collected drinking water from the nearby Cheptui River (OR_MH = 7.8, 95% CI = 2.7-22); conversely, 35% (35/100) of case-patients compared with 54% (54/100) of control-persons usually collected drinking water from borehole pumps (OR_MH = 0.31, 95% CI = 0.13-0.65). The index case in Bwikhonge Sub-county had onset on 29 February but the outbreak had been on-going in the neighbouring sub-counties in the previous 3 months. V. cholera was isolated in 2 of the 7 river water samples collected from different locations.

CONCLUSIONS

We concluded that this cholera outbreak was caused by drinking contaminated water from Cheptui River. We recommended boiling and/or treating drinking water, improved sanitation, distribution of chlorine tablets to the affected villages, and as a long-term solution, construction of more borehole pumps. After implementing preventive measures, the number of cases declined and completely stopped after 6th April.

Multidrug-resistant tuberculosis outbreak associated with poor treatment adherence and delayed treatment: Arua District, Uganda, 2013-2017

BACKGROUND

In August 2017, the Uganda Ministry of Health was notified of increased cases of multidrug-resistant tuberculosis (MDR-TB) in Arua District, Uganda during 2017. We investigated to identify the scope of the increase and risk factors for infection, evaluate health facilities' capacity to manage MDR-TB, and recommend evidence-based control measures.

METHODS

We defined an MDR-TB case-patient as a TB patient attending Arua Regional Referral Hospital (ARRH) during 2013-2017 with a sputum sample yielding Mycobacterium tuberculosis resistant to at least rifampicin and isoniazid, confirmed by an approved drug susceptibility test. We reviewed clinical records from ARRH and compared the number of MDR-TB cases during January-August 2017 with the same months in 2013-2016. To identify risk factors specific for MDR-TB among cases with secondary infection, we conducted a case-control study using persons with drug-susceptible TB matched by sub-county of residence as controls. We observed infection prevention and control practices in health facilities and community, and assessed health facilities' capacity to manage TB.

RESULTS

We identified 33 patients with MDR-TB, of whom 30 were secondary TB infection cases. The number of cases during January-August 2017 was 10, compared with 3-4 cases in January-August from 2013 to 2016 (p = 0.02). Men were more affected than women (6.5 vs 1.6/100,000, p < 0.01), as were cases ≥18 years old compared to those < 18 years (8.7 vs 0.21/100,000, p < 0.01). In the case-control study, poor adherence to first-line anti-TB treatment (aOR = 9.2, 95% CI: 2.3-37) and initiating treatment > 15 months from symptom onset (aOR = 11, 95% CI: 1.5-87) were associated with MDR-TB. All ten facilities assessed reported stockouts of TB commodities. All 15 ambulatory MDR-TB patients we observed were not wearing masks given to them to minimize community infection. The MDR-TB ward at ARRH capacity was 4 patients but there were 11 patients.

CONCLUSION

The number of cases during January-August in 2017 was significantly higher than during the same months in 2013-2016. Poor adherence to TB drugs and delayed treatment initiation were associated with MDR-TB infection. We recommended strengthening directly-observed treatment strategy, increasing access to treatment services, and increasing the number of beds in the MDR-TB ward at ARRH.

Strengthening Global Health Security Through Africa's First Absolute Post-Master's Fellowship Program in Field Epidemiology in Uganda

Uganda is prone to epidemics of deadly infectious diseases and other public health emergencies. Though significant progress has been made in response to emergencies during the past 2 decades, system weaknesses still exist, including lack of a robust workforce with competencies to identify, investigate, and control disease outbreaks at the source. These deficiencies hamper global health security broadly. To address need for a highly competent workforce to combat infectious diseases, the Uganda Ministry of Health established the Public Health Fellowship Program (PHFP), the advanced-level Field Epidemiology Training Program (FETP), closely modeled after the CDC's Epidemic Intelligence Service (EIS) program. The 2-year, full-time, non-degree granting program is the first absolute post-master's FETP in Africa for mid-career public health professionals. Fellows gain competencies in 7 main domains, which are demonstrated by deliverables, while learning through service delivery 80% of the time in the ministry of health. During 2015-2017, PHFP enrolled 3 cohorts of 31 fellows. By January 2018, PHFP had graduated 2 cohorts (2015 and 2016) of 19 fellows. Fellows were placed in 17 priority areas of the ministry of health. They completed 153 projects (including 60 outbreak investigations, 12 refugee assessments, 40 surveillance projects, and 31 applied epidemiologic studies), of which 49 involved potential bioterrorism agents or epidemic-prone diseases. They made 132 conference presentations, prepared 40 manuscripts for peer-reviewed publication (17 published as of December 2017), and produced 3 case studies. Many of these projects have resulted in public health interventions that led to improvements in disease control and surveillance systems. The program has produced 19 issues of ministry of health bulletins. One year after graduation, graduates have been placed in key public health decision-making positions. Within 3 years, PHFP has strengthened global health security through improvement in public health emergency response; identification, investigation and control of outbreaks at their sources; and documentation and dissemination of findings to inform decision making by relevant stakeholders.