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Bwire G, Chowdhury F, Khan AI, Wamala JF, Orach CG, Qadri F. Adapting existing tools to control and eliminate protracted epidemics and pandemics. Lancet Glob Health 2024; 12:e725-e726. [PMID: 38614621 DOI: 10.1016/s2214-109x(24)00096-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 02/26/2024] [Indexed: 04/15/2024]
Affiliation(s)
- Godfrey Bwire
- Division of Public Health Emergency Preparedness and Response, Ministry of Health, Kampala, Uganda; School of Public Health, Makerere University, Kampala, Uganda.
| | - Fahima Chowdhury
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh
| | - Ashraful Islam Khan
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh
| | | | | | - Firdausi Qadri
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh
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Xu H, Zou K, Dent J, Wiens KE, Malembaka EB, Bwire G, Okitayemba PW, Hampton LM, Azman AS, Lee EC. Enhanced cholera surveillance to improve vaccination campaign efficiency. Nat Med 2024; 30:1104-1110. [PMID: 38443690 PMCID: PMC11031394 DOI: 10.1038/s41591-024-02852-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 01/30/2024] [Indexed: 03/07/2024]
Abstract
Systematic testing for Vibrio cholerae O1 is rare, which means that the world's limited supply of oral cholera vaccines (OCVs) may not be delivered to areas with the highest true cholera burden. Here we used a phenomenological model with subnational geographic targeting and fine-scale vaccine effects to model how expanding V. cholerae testing affected impact and cost-effectiveness for preventive vaccination campaigns across different bacteriological confirmation and vaccine targeting assumptions in 35 African countries. Systematic testing followed by OCV targeting based on confirmed cholera yielded higher efficiency and cost-effectiveness and slightly fewer averted cases than status quo scenarios targeting suspected cholera. Targeting vaccine to populations with an annual incidence rate greater than 10 per 10,000, the testing scenario averted 10.8 (95% prediction interval (PI) 9.4-12.6) cases per 1,000 fully vaccinated persons while the status quo scenario averted 6.9 (95% PI 6.0-7.8) cases per 1,000 fully vaccinated persons. In the testing scenario, testing costs increased by US$31 (95% PI 25-39) while vaccination costs reduced by US$248 (95% PI 176-326) per averted case compared to the status quo. Introduction of systematic testing into cholera surveillance could improve efficiency and reach of global OCV supply for preventive vaccination.
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Affiliation(s)
- Hanmeng Xu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kaiyue Zou
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Juan Dent
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kirsten E Wiens
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Epidemiology and Biostatistics, College of Public Health, Temple University, Philadelphia, PA, USA
| | - Espoir Bwenge Malembaka
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Center for Tropical Diseases and Global Health, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Godfrey Bwire
- Division of Public Health Emergency Preparedness and Response, Ministry of Health, Kampala, Uganda
- Makerere University School of Public Health, Kampala, Uganda
| | - Placide Welo Okitayemba
- Programme National d'Elimination de Choléra et lutte contre les autres Maladies Diarrhéiques, Kinshasa, Democratic Republic of the Congo
| | | | - Andrew S Azman
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Geneva Centre for Emerging Viral Diseases, Geneva University Hospitals, Geneva, Switzerland
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Elizabeth C Lee
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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3
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Xiao S, Abade A, Boru W, Kasambara W, Mwaba J, Ongole F, Mmanywa M, Trovão NS, Chilengi R, Kwenda G, Orach CG, Chibwe I, Bwire G, Stine OC, Milstone AM, Lessler J, Azman AS, Luo W, Murt K, Sack DA, Debes AK, Wohl S. New Vibrio cholerae sequences from Eastern and Southern Africa alter our understanding of regional cholera transmission. medRxiv 2024:2024.03.28.24302717. [PMID: 38585829 PMCID: PMC10996759 DOI: 10.1101/2024.03.28.24302717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Despite ongoing containment and vaccination efforts, cholera remains prevalent in many countries in sub-Saharan Africa. Part of the difficulty in containing cholera comes from our lack of understanding of how it circulates throughout the region. To better characterize regional transmission, we generated and analyzed 118 Vibrio cholerae genomes collected between 2007-2019 from five different countries in Southern and Eastern Africa. We showed that V. cholerae sequencing can be successful from a variety of sample types and filled in spatial and temporal gaps in our understanding of circulating lineages, including providing some of the first sequences from the 2018-2019 outbreaks in Uganda, Kenya, Tanzania, Zambia, and Malawi. Our results present a complex picture of cholera transmission in the region, with multiple lineages found to be co-circulating within several countries. We also find evidence that previously identified sporadic cases may be from larger, undersampled outbreaks, highlighting the need for careful examination of sampling biases and underscoring the need for continued and expanded cholera surveillance across the African continent.
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Affiliation(s)
- Shaoming Xiao
- Division of Pediatric Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ahmed Abade
- Ministry of Health, Dar es Salaam, Tanzania
- Field Epidemiology and Laboratory Training Program, Nairobi, Kenya
| | - Waqo Boru
- Field Epidemiology and Laboratory Training Program, Nairobi, Kenya
| | | | - John Mwaba
- Center for Infectious Disease Research, Zambia
- Department of Pathology and Microbiology, University Teaching Hospital, Lusaka, Zambia
| | | | | | | | - Roma Chilengi
- Zambia National Public Health Institute, Lusaka, Zambia
| | | | | | | | | | - O Colin Stine
- University of Maryland School of Medicine, Baltimore, USA
| | - Aaron M Milstone
- Division of Pediatric Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Justin Lessler
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Epidemiology, Gillings School of Public Health, University of North Carolina, Chapel Hill, NC, USA
- Carolina Population Center, University of North Carolina, Chapel Hill, NC, USA
| | - Andrew S Azman
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland
- Geneva Centre for Emerging Viral Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Wensheng Luo
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kelsey Murt
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Biomedical Sciences, School of Health Sciences, University of Zambia, Lusaka, Zambia
| | - David A Sack
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Amanda K Debes
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Shirlee Wohl
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA
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Wiens KE, Xu H, Zou K, Mwaba J, Lessler J, Malembaka EB, Demby MN, Bwire G, Qadri F, Lee EC, Azman AS. Estimating the proportion of clinically suspected cholera cases that are true Vibrio cholerae infections: A systematic review and meta-analysis. PLoS Med 2023; 20:e1004286. [PMID: 37708235 PMCID: PMC10538743 DOI: 10.1371/journal.pmed.1004286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 09/28/2023] [Accepted: 08/25/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Cholera surveillance relies on clinical diagnosis of acute watery diarrhea. Suspected cholera case definitions have high sensitivity but low specificity, challenging our ability to characterize cholera burden and epidemiology. Our objective was to estimate the proportion of clinically suspected cholera that are true Vibrio cholerae infections and identify factors that explain variation in positivity. METHODS AND FINDINGS We conducted a systematic review of studies that tested ≥10 suspected cholera cases for V. cholerae O1/O139 using culture, PCR, and/or a rapid diagnostic test. We searched PubMed, Embase, Scopus, and Google Scholar for studies that sampled at least one suspected case between January 1, 2000 and April 19, 2023, to reflect contemporary patterns in V. cholerae positivity. We estimated diagnostic test sensitivity and specificity using a latent class meta-analysis. We estimated V. cholerae positivity using a random-effects meta-analysis, adjusting for test performance. We included 119 studies from 30 countries. V. cholerae positivity was lower in studies with representative sampling and in studies that set minimum ages in suspected case definitions. After adjusting for test performance, on average, 52% (95% credible interval (CrI): 24%, 80%) of suspected cases represented true V. cholerae infections. After adjusting for test performance and study methodology, the odds of a suspected case having a true infection were 5.71 (odds ratio 95% CrI: 1.53, 15.43) times higher when surveillance was initiated in response to an outbreak than in non-outbreak settings. Variation across studies was high, and a limitation of our approach was that we were unable to explain all the heterogeneity with study-level attributes, including diagnostic test used, setting, and case definitions. CONCLUSIONS In this study, we found that burden estimates based on suspected cases alone may overestimate the incidence of medically attended cholera by 2-fold. However, accounting for cases missed by traditional clinical surveillance is key to unbiased cholera burden estimates. Given the substantial variability in positivity between settings, extrapolations from suspected to confirmed cases, which is necessary to estimate cholera incidence rates without exhaustive testing, should be based on local data.
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Affiliation(s)
- Kirsten E. Wiens
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Epidemiology and Biostatistics, College of Public Health, Temple University, Philadelphia, Pennsylvania, United States of America
| | - Hanmeng Xu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Kaiyue Zou
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - John Mwaba
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
- Department of Biomedical Sciences, School of Health Sciences, University of Zambia, Lusaka, Zambia
- Department of Pathology and Microbiology, University Teaching Hospital, Lusaka, Zambia
| | - Justin Lessler
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Espoir Bwenge Malembaka
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- Center for Tropical Diseases and Global Health (CTDGH), Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Maya N. Demby
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Godfrey Bwire
- Division of Public Health Emergency Preparedness and Response, Ministry of Health, Kampala, Uganda
| | - Firdausi Qadri
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Elizabeth C. Lee
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Andrew S. Azman
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- Geneva Centre for Emerging Viral Diseases, Geneva University Hospitals, Geneva, Switzerland
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland
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Bwire G, Kisakye A, Amulen E, Bwanika JB, Badebye J, Aanyu C, Nakirya BD, Okello A, Okello SA, Bukenya JN, Orach CG. Cholera and COVID-19 pandemic prevention in multiple hotspot districts of Uganda: vaccine coverage, adverse events following immunization and WASH conditions survey. BMC Infect Dis 2023; 23:487. [PMID: 37479986 PMCID: PMC10362646 DOI: 10.1186/s12879-023-08462-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 07/13/2023] [Indexed: 07/23/2023] Open
Abstract
BACKGROUND Between March, 2020 and December, 2021 due to cholera and coronavirus disease 2019 (COVID-19) pandemics, there were 1,534 cholera cases with 14 deaths and 136,065 COVID-19 cases with 3,285 deaths reported respectively in Uganda. This study investigated mass vaccination campaigns for the prevention of the two pandemics namely: oral cholera vaccine (OCV) and COVID-19 vaccine coverage; adverse events following immunization (AEFI); barriers and enablers for the vaccine uptake and assessed water, sanitation and hygiene (WASH) conditions in the six cholera and COVID-19 hotspot districts of Uganda. METHODS A household survey was conducted between January and February, 2022 in the six cholera hotspot districts of Uganda which had recently conducted OCV mass vaccination campaigns and had ongoing COVID-19 mass vaccination campaigns. The survey randomly enrolled 900 households with 4,315 persons of whom 2,085 were above 18 years. Data were collected using a data entry application designed in KoBoToolbox and analysed using STATA version 14. Frequencies, percentages, odds ratios, means, confidence intervals and maps were generated and interpreted. RESULTS The OCV coverage for dose one and two were 85% (95% CI: 84.2-86.4) and 67% (95% CI: 65.6-68.4) respectively. Among the 4,315 OCV recipients, 2% reported mild AEFI, 0.16% reported moderate AEFI and none reported severe AEFI. The COVID-19 vaccination coverage for dose one and two were 69.8% (95% CI: 67.8-71.8) and 18.8% (95% CI: 17.1-20.5) respectively. Approximately, 23% (478/2,085) of COVID-19 vaccine recipient reported AEFI; most 94% were mild, 0.6% were moderate and 2 cases were severe. The commonest reason for missing COVID-19 vaccine was fear of the side effects. For most districts (5/6), sanitation (latrine/toilet) coverage were low at 7.4%-37.4%. CONCLUSION There is high OCV coverage but low COVID-19 vaccine and sanitation coverage with high number of moderate cases of AEFI recorded due to COVID-19 vaccines. The low COVID-19 vaccine coverage could indicate vaccine hesitancy for COVID-19 vaccines. Furthermore, incorporation of WASH conditions assessment in the OCV coverage surveys is recommended for similar settings to generate data for better planning. However, more studies are required on COVID-19 vaccine hesitancy.
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Affiliation(s)
- Godfrey Bwire
- School of Public Health, Makerere University, Kampala, Uganda.
- Division of Public Health Emergency Preparedness and Response, Ministry of Health, Kampala, Uganda.
| | | | - Esther Amulen
- School of Public Health, Makerere University, Kampala, Uganda
| | | | - Joan Badebye
- School of Forestry, Environmental and Geographical Sciences, Makerere University, Kampala, Uganda
| | - Christine Aanyu
- School of Public Health, Makerere University, Kampala, Uganda
| | | | - Alfred Okello
- Department of Public Health, St Mary's Hospital Lacor, Gulu, Uganda
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Bwire G, Sack DA, Lunkuse SM, Ongole F, Ngwa MC, Namanya DB, Nsungwa J, Aceng Ocero JR, Mwebesa HG, Muruta A, Nakinsige A, Kisakye A, Kalyebi P, Kemirembe J, Makumbi I, Kagirita A, Ampeire I, Mutegeki D, Matseketse D, Debes AK, Orach CG. Development of a Scorecard to Monitor Progress toward National Cholera Elimination: Its Application in Uganda. Am J Trop Med Hyg 2023; 108:954-962. [PMID: 37037429 PMCID: PMC10160876 DOI: 10.4269/ajtmh.23-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 02/01/2023] [Indexed: 04/12/2023] Open
Abstract
In 2017, the Global Task Force for Cholera Control (GTFCC) set a goal to eliminate cholera from ≥ 20 countries and to reduce cholera deaths by 90% by 2030. Many countries have included oral cholera vaccine (OCV) in their cholera control plans. We felt that a simple, user-friendly monitoring tool would be useful to guide national progress toward cholera elimination. We reviewed cholera surveillance data of Uganda from 2015 to 2021 by date and district. We defined a district as having eliminated cholera if cholera was not reported in that district for at least 4 years. We prepared maps to show districts with cholera, districts that had eliminated it, and districts that had eliminated it but then "relapsed." These maps were compared with districts where OCV was used and the hotspot map recommended by the GTFCC. Between 2018 and 2021, OCV was administered in 16 districts previously identified as hotspots. In 2018, cholera was reported during at least one of the four previous years from 36 of the 146 districts of Uganda. This number decreased to 18 districts by 2021. Cholera was deemed "eliminated" from four of these 18 districts but then "relapsed." The cholera elimination scorecard effectively demonstrated national progress toward cholera elimination and identified districts where additional resources are needed to achieve elimination by 2030. Identification of the districts that have eliminated cholera and those that have relapsed will assist the national programs to focus on addressing the factors that result in elimination or relapse of cholera.
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Affiliation(s)
- Godfrey Bwire
- Department of Community Health, Ministry of Health Uganda, Kampala, Uganda
| | - David A. Sack
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Stella M. Lunkuse
- Division of Surveillance, Knowledge and Information Management, Ministry of Health, Kampala, Uganda
| | - Francis Ongole
- Department of National Health Laboratory and Diagnostic Services, Ministry of Health, Kampala, Uganda
| | - Moise Chi Ngwa
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Jesca Nsungwa
- Department of Maternal and Child Health, Ministry of Health, Kampala, Uganda
| | | | - Henry G. Mwebesa
- Office of the Director General Health Service, Ministry of Health, Kampala, Uganda
| | - Allan Muruta
- Department of Integrated Epidemiology and Public Health Emergencies, Ministry of Health, Kampala, Uganda
| | - Anne Nakinsige
- Division of Public Health Emergency Preparedness and Response, Ministry of Health, Kampala, Uganda
| | | | - Peter Kalyebi
- Department of Environmental Health, Ministry of Health, Kampala, Uganda
| | | | - Issa Makumbi
- Public Health Emergency Operation Centre, Ministry of Health, Kampala, Uganda
| | - Atek Kagirita
- Division of Surveillance, Knowledge and Information Management, Ministry of Health, Kampala, Uganda
| | - Immaculate Ampeire
- Uganda National Immunization Programme, Ministry of Health, Kampala, Uganda
| | - David Mutegeki
- Public Health Emergency Operation Centre, Ministry of Health, Kampala, Uganda
| | | | - Amanda Kay Debes
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Bwire G, Sartorius B, Guerin P, Tegegne MA, Okware SI, Talisuna AO. Sudan Ebola virus (SUDV) outbreak in Uganda, 2022: lessons learnt and future priorities for sub-Saharan Africa. BMC Med 2023; 21:144. [PMID: 37055861 PMCID: PMC10099013 DOI: 10.1186/s12916-023-02847-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 03/23/2023] [Indexed: 04/15/2023] Open
Affiliation(s)
- Godfrey Bwire
- Division of Public Health Emergency Preparedness and Response, Ministry of Health, Kampala, Uganda
- Department of Community Health and Behavioural Sciences, Makerere University School of Public Health, Kampala, Uganda
| | - Benn Sartorius
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Philippe Guerin
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
| | - Merawi Aragaw Tegegne
- Division of Emergency Preparedness & Response, Africa Union/Africa CDC, Addis Ababa, Ethiopia
| | - Sam I. Okware
- Uganda National Health Research Organization (UNHRO), Entebbe, Uganda
| | - Ambrose O. Talisuna
- World Health Organization, Liaison Office to the African Union (AU) and the United Nations Economic Commission for Africa (UNECA), Addis Ababa, Ethiopia
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Kiggundu T, Ario AR, Kadobera D, Kwesiga B, Migisha R, Makumbi I, Eurien D, Kabami Z, Kayiwa J, Lubwama B, Okethwangu D, Nabadda S, Bwire G, Mulei S, Harris JR, Dirlikov E, Fitzmaurice AG, Nabatanzi S, Tegegn Y, Muruta AN, Kyabayinze D, Boore AL, Kagirita A, Kyobe-Bosa H, Mwebesa HG, Atwine D, Aceng Ocero JR. Notes from the Field: Outbreak of Ebola Virus Disease Caused by Sudan ebolavirus - Uganda, August-October 2022. MMWR Morb Mortal Wkly Rep 2022; 71:1457-1459. [PMID: 36355610 PMCID: PMC9707349 DOI: 10.15585/mmwr.mm7145a5] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/04/2023]
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Bwire G, Ario AR, Eyu P, Ocom F, Wamala JF, Kusi KA, Ndeketa L, Jambo KC, Wanyenze RK, Talisuna AO. The COVID-19 pandemic in the African continent. BMC Med 2022; 20:167. [PMID: 35501853 PMCID: PMC9059455 DOI: 10.1186/s12916-022-02367-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 04/05/2022] [Indexed: 01/13/2023] Open
Abstract
In December 2019, a new coronavirus, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and associated disease, coronavirus disease 2019 (COVID-19), was identified in China. This virus spread quickly and in March, 2020, it was declared a pandemic. Scientists predicted the worst scenario to occur in Africa since it was the least developed of the continents in terms of human development index, lagged behind others in achievement of the United Nations sustainable development goals (SDGs), has inadequate resources for provision of social services, and has many fragile states. In addition, there were relatively few research reporting findings on COVID-19 in Africa. On the contrary, the more developed countries reported higher disease incidences and mortality rates. However, for Africa, the earlier predictions and modelling into COVID-19 incidence and mortality did not fit into the reality. Therefore, the main objective of this forum is to bring together infectious diseases and public health experts to give an overview of COVID-19 in Africa and share their thoughts and opinions on why Africa behaved the way it did. Furthermore, the experts highlight what needs to be done to support Africa to consolidate the status quo and overcome the negative effects of COVID-19 so as to accelerate attainment of the SDGs.
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Affiliation(s)
- Godfrey Bwire
- grid.415705.2Department of Integrated Epidemiology Surveillance and Public Health Emergencies, Ministry of Health, P.O Box 7272, Kampala, Uganda
- grid.11194.3c0000 0004 0620 0548School of Public Health, Makerere University, P.O. Box 7072, Kampala, Uganda
| | | | - Patricia Eyu
- Uganda National Institute of Public Health, Kampala, Uganda
| | - Felix Ocom
- Uganda National Institute of Public Health, Kampala, Uganda
| | | | - Kwadwo A. Kusi
- grid.8652.90000 0004 1937 1485Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Latif Ndeketa
- grid.419393.50000 0004 8340 2442Malawi-Liverpool-Wellcome Programme (MLW), Blantyre, Malawi
| | - Kondwani C. Jambo
- grid.419393.50000 0004 8340 2442Malawi-Liverpool-Wellcome Programme (MLW), Blantyre, Malawi
- grid.48004.380000 0004 1936 9764Liverpool School of Tropical Medicine, Liverpool, UK
| | - Rhoda K. Wanyenze
- grid.11194.3c0000 0004 0620 0548School of Public Health, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Ambrose O. Talisuna
- grid.463718.f0000 0004 0639 2906Epidemic Preparedness and Response Cluster, World Health Organization, Regional Office for Africa, Brazzaville, Congo
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Orishaba P, Opollo MS, Nalwadda C, Muruta A, Makumbi I, Kabali K, Nakinsige A, Lotee P, Okware SI, Bwire G. Cholera epidemic amidst the COVID-19 pandemic in Moroto district, Uganda: Hurdles and opportunities for control. PLOS Glob Public Health 2022; 2:e0000590. [PMID: 36962556 PMCID: PMC10022206 DOI: 10.1371/journal.pgph.0000590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 09/20/2022] [Indexed: 11/07/2022]
Abstract
INTRODUCTION On 21st March 2020, the first COVID-19 case was detected in Uganda and a COVID-19 pandemic declared. On the same date, a nationwide lockdown was instituted in response to the pandemic. Subsequently, more cases were detected amongst the returning international travelers as the disease continued to spread across the country. On May 14th, 2020, a cholera epidemic was confirmed in Moroto district at a time when the district had registered several COVID-19 cases and was in lockdown. This study aimed to describe the cholera epidemic and response activities during the COVID-19 pandemic as well as the hurdles and opportunities for cholera control encountered during the response. MATERIALS AND METHODS In a cross-sectional study design, we reviewed Moroto district's weekly epidemiological records on cholera and COVID-19 from April to July 2020. We obtained additional information through a review of the outbreak investigation and control reports. Data were analyzed and presented in frequencies, proportions, attack rates, case fatality rates, graphs, and maps. RESULTS As of June 28th, 2020, 458 cases presenting with severe diarrhea and/or vomiting were line listed in Moroto district. The most affected age group was 15-30 years, 30.1% (138/458). The females, 59.0% [270/458], were the majority. The Case Fatality Rate (CFR) was 0.4% (2/458). Whereas home use of contaminated water following the vandalization of the only clean water source in Natapar Kocuc village, Moroto district, could have elicited the epidemic, implementing COVID-19 preventive and control measures presented some hurdles and opportunities for cholera control. The significant hurdles were observing the COVID-19 control measures such as social distancing, wearing of masks, and limited time in the community due to the need to observe curfew rules starting at 6.00 pm. The opportunities from COVID-19 measures complementary to cholera control measures included frequent hand washing, travel restrictions within the district & surrounding areas, and closure of markets. CONCLUSION COVID-19 preventive and control measures such as social distancing, wearing of masks, and curfew rules may be a hurdle to cholera control whereas frequent hand washing, travel restrictions within the district & surrounding areas, and closure of markets may present opportunities for cholera control. Other settings experiencing concurrent cholera and COVID-19 outbreaks can borrow lessons from this study.
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Affiliation(s)
- Philip Orishaba
- The Centre for Rapid Evidence Synthesis, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Integrated Epidemiology, Surveillance and Public Health Emergencies, Ministry of Health, Kampala, Uganda
| | - Marc Sam Opollo
- Department of Public Health, Faculty of Health Sciences, Lira University, Lira, Uganda
| | - Christine Nalwadda
- Department of Community Health and Behavioral Sciences, Makerere University School of Public Health, Kampala, Uganda
| | - Allan Muruta
- Department of Integrated Epidemiology, Surveillance and Public Health Emergencies, Ministry of Health, Kampala, Uganda
| | - Issa Makumbi
- Emergency Operation Centre (EOC), Ministry of Health, Kampala, Uganda
| | - Kenneth Kabali
- World Health Organization, Karamoja Regional Office, Moroto, Uganda
| | - Anne Nakinsige
- Department of Integrated Epidemiology, Surveillance and Public Health Emergencies, Ministry of Health, Kampala, Uganda
| | - Phillip Lotee
- Department of Health, Moroto District Local Government, Moroto, Uganda
| | - Samuel I Okware
- Uganda National Health Research Organization (UNHRO), Entebbe, Uganda
| | - Godfrey Bwire
- Department of Integrated Epidemiology, Surveillance and Public Health Emergencies, Ministry of Health, Kampala, Uganda
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Sack DA, Debes AK, Ateudjieu J, Bwire G, Ali M, Ngwa MC, Mwaba J, Chilengi R, Orach CC, Boru W, Mohamed AA, Ram M, George CM, Stine OC. Contrasting Epidemiology of Cholera in Bangladesh and Africa. J Infect Dis 2021; 224:S701-S709. [PMID: 34549788 PMCID: PMC8687066 DOI: 10.1093/infdis/jiab440] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
In Bangladesh and West Bengal cholera is seasonal, transmission occurs consistently annually. By contrast, in most African countries, cholera has inconsistent seasonal patterns and long periods without obvious transmission. Transmission patterns in Africa occur during intermittent outbreaks followed by elimination of that genetic lineage. Later another outbreak may occur because of reintroduction of new or evolved lineages from adjacent areas, often by human travelers. These then subsequently undergo subsequent elimination. The frequent elimination and reintroduction has several implications when planning for cholera's elimination including: a) reconsidering concepts of definition of elimination, b) stress on rapid detection and response to outbreaks, c) more effective use of oral cholera vaccine and WASH, d) need to readjust estimates of disease burden for Africa, e) re-examination of water as a reservoir for maintaining endemicity in Africa. This paper reviews major features of cholera's epidemiology in African countries which appear different from the Ganges Delta.
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Affiliation(s)
- David A Sack
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Amanda K Debes
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jerome Ateudjieu
- Meilleur Acces aux Soins de Sante, and Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, and Clinical Research Unit, Division of Health Operations Research, Cameroon Ministry of Public Health, Yaoundé, Cameroon
| | - Godfrey Bwire
- Department of Integrated Epidemiology, Surveillance, and Public Health Emergencies, Ministry of Health, Kampala, Uganda
| | - Mohammad Ali
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Moise Chi Ngwa
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - John Mwaba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Roma Chilengi
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Christopher C Orach
- Department of Community Health and Behavioural Sciences, Makerere University School of Public Health, Kampala, Uganda
| | - Waqo Boru
- Ministry of Health and Field Epidemiology and Laboratory Training Program, Nairobi, Kenya
| | - Ahmed Abade Mohamed
- Tanzania Field Epidemiology and Laboratory Training Program, Dar-es-Salaam, Tanzania
| | - Malathi Ram
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Christine Marie George
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - O Colin Stine
- Department of Epidemiology and Public Health, School of Medicine, University of Maryland, Baltimore, Maryland, USA
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Bwire G, Waniaye JB, Otim JS, Matseketse D, Kagirita A, Orach CG. Cholera risk in cities in Uganda: understanding cases and contacts centered strategy (3CS) for rapid cholera outbreak control. Pan Afr Med J 2021; 39:193. [PMID: 34603574 PMCID: PMC8464210 DOI: 10.11604/pamj.2021.39.193.27794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 06/26/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction in the recent past, cities in sub-Saharan Africa have reported serious cholera outbreaks that last for several months. Uganda is one of the African countries where cities are prone to cholera outbreaks. Studies on cholera in Bangladesh show increased risk of cholera for the immediate household members (contacts) yet the control interventions mainly target cases with little or no focus on contacts. This study aimed to describe the rapid control of cholera outbreaks in Kampala and Mbale cities, Uganda, using, “Cases and Contacts Centered Strategy (3CS)” that consisted of identification and treatment of cases, promotion of safe water, sanitation, hygiene (WaSH) and selective chemoprophylaxis for the contacts. Methods a cross-sectional study was conducted in 2015-2016 in the Kampala and Mbale cities during cholera outbreaks. Cholera cases were treated and 816 contacts from 188 households were listed and given cholera preventive packages. Data were collected, cleaned, analysed and stored in spreadsheet. Comparison of categories was done using Chi-Square test. Results a total of 58 and 41 confirmed cholera cases out of 318 and 153 suspected cases were recorded in Kampala and Mbale cities respectively. The outbreaks lasted for 41 days in both cities. Case fatality rates were high; 12.1% (5/41) for Mbale city and 1.7% (1/58) for Kampala city. Fifty-five percent (210/379) of stool samples were tested by culture to confirm V. choleraeO1. No contacts listed and given cholera preventive package developed cholera. Both sexes and all age groups were affected. In Kampala city, the males were more affected than the females in the age groups less than 14 years, p-value of 0.0097. Conclusion this study showed that by implementing 3CS, it was possible to rapidly control cholera outbreaks in Kampala and Mbale cities and no cholera cases were reported amongst the listed household contacts. The findings on 3CS and specifically, selective antibiotic chemoprophylaxis for cholera prevention, could be used in similar manner to oral cholera vaccines to complement the core cholera control interventions (disease surveillance, treatment of cases and WaSH). However, studies are needed to guide such rollout and to understand the age-sex differences in Kampala city.
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Affiliation(s)
- Godfrey Bwire
- Department of Integrated Epidemiology, Surveillance and Public Health Emergencies, Ministry of Health, Kampala, Uganda
| | | | - Julius Simon Otim
- Directorate of Public Health, Kampala Capital City Authority, Kampala, Uganda
| | | | - Atek Kagirita
- Uganda National Health Laboratory Services/Central Public Health Laboratories, Ministry of Health, Kampala, Uganda
| | - Christopher Garimoi Orach
- Department of Community Health and Behavioral Sciences, Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda
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Kapiriri L, Essue B, Bwire G, Nouvet E, Kiwanuka S, Sengooba F, Reeleder D. A framework to support the integration of priority setting in the preparedness, alert, control and evaluation stages of a disease pandemic. Glob Public Health 2021; 17:1479-1491. [PMID: 34293263 DOI: 10.1080/17441692.2021.1931402] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The COVID-19 pandemic, where the need-resource gap has necessitated decision makers in some contexts to ration access to life-saving interventions, has demonstrated the critical need for systematic and fair priority setting and resource allocation mechanisms. Disease outbreaks are becoming increasingly common and priority setting lessons from previous disease outbreaks could be better harnessed to inform decision making and planning for future disease outbreaks. The purpose of this paper is to discuss how priority setting and resource allocation could, ideally, be integrated into the WHO pandemic planning and preparedness framework and used to inform the COVID-19 pandemic recovery plans and plans for future outbreaks. Priority setting and resource allocation during disease outbreaks tend to evoke a process similar to the 'rule of rescue'. This results in inefficient and unfair resource allocation, negative effects on health and non-health programs and increased health inequities. Integrating priority setting and resource allocation activities throughout the four phases of the WHO emergency preparedness framework could ensure that priority setting during health emergencies is systematic, evidence informed and fair.
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Affiliation(s)
- Lydia Kapiriri
- Department of Health, Aging and Society, McMaster University, Hamilton, Canada
| | | | - Godfrey Bwire
- Department of Integrated Epidemiology Surveillance and Public Health Emergencies, Ministry of Health, Kampala, Uganda
| | | | - Suzanne Kiwanuka
- Department of Health Policy Planning and Management, Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda
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Bwire G, Orach CG, Aceng FL, Arianitwe SE, Matseketse D, Tumusherure E, Makumbi I, Muruta A, Merrill RD, Debes A, Ali M, Sack DA. Refugee Settlements and Cholera Risks in Uganda, 2016-2019. Am J Trop Med Hyg 2021; 104:1225-1231. [PMID: 33556038 PMCID: PMC8045616 DOI: 10.4269/ajtmh.20-0741] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 08/28/2020] [Indexed: 11/07/2022] Open
Abstract
During 2016 to 2019, cholera outbreaks were reported commonly to the Ministry of Health from refugee settlements. To further understand the risks cholera posed to refugees, a review of surveillance data on cholera in Uganda for the period 2016-2019 was carried out. During this 4-year period, there were seven such outbreaks with 1,495 cases and 30 deaths in five refugee settlements and one refugee reception center. Most deaths occurred early in the outbreak, often in the settlements or before arrival at a treatment center rather than after arrival at a treatment center. During the different years, these outbreaks occurred during different times of the year but simultaneously in settlements that were geographically separated and affected all ages and genders. Some outbreaks spread to the local populations within Uganda. Cholera control prevention measures are currently being implemented; however, additional measures are needed to reduce the risk of cholera among refugees including oral cholera vaccination and a water, sanitation and hygiene package during the refugee registration process. A standardized protocol is needed to quickly conduct case-control studies to generate information to guide future cholera outbreak prevention in refugees and the host population.
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Affiliation(s)
- Godfrey Bwire
- Department of Integrated Epidemiology, Surveillance and Public Health Emergencies, Ministry of Health, Kampala Uganda
| | | | - Freda Loy Aceng
- Department of Integrated Epidemiology, Surveillance and Public Health Emergencies, Ministry of Health, Kampala Uganda
| | | | | | - Edson Tumusherure
- Department of Health, Isingiro District Local Government, Isingiro, Uganda
| | - Issa Makumbi
- Emergency Operational Centre, Ministry of Health, Kampala, Uganda
| | - Allan Muruta
- Department of Integrated Epidemiology, Surveillance and Public Health Emergencies, Ministry of Health, Kampala Uganda
| | - Rebecca D. Merrill
- Division of Global Migration and Quarantine, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Amanda Debes
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Mohammad Ali
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - David A. Sack
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Bwire G, Roskosky M, Ballard A, Brooks WA, Okello A, Rafael F, Ampeire I, Orach CG, Sack DA. Use of surveys to evaluate an integrated oral cholera vaccine campaign in response to a cholera outbreak in Hoima district, Uganda. BMJ Open 2020; 10:e038464. [PMID: 33303438 PMCID: PMC7733212 DOI: 10.1136/bmjopen-2020-038464] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 11/17/2020] [Accepted: 11/19/2020] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To evaluate the quality and coverage of the campaign to distribute oral cholera vaccine (OCV) during a cholera outbreak in Hoima, Uganda to guide future campaigns of cholera vaccine. DESIGN Survey of communities targeted for vaccination to determine vaccine coverage rates and perceptions of the vaccination campaign, and a separate survey of vaccine staff who carried out the campaign. SETTING Hoima district, Uganda. PARTICIPANTS Representative clusters of households residing in the communities targeted for vaccination and staff members who conducted the vaccine campaign. RESULTS Among 209 households (1274 individuals) included in the coverage survey, 1193 (94%; 95% CI 92% to 95%) reported receiving at least one OCV dose and 998 (78%; 95% CI 76% to 81%) reported receiving two doses. Among vaccinated individuals, minor complaints were reported by 71 persons (5.6%). Individuals with 'some' education (primary school or above) were more knowledgeable regarding the required OCV doses compared with non-educated (p=0.03). Factors negatively associated with campaign implementation included community sensitisation time, staff payment and problems with field transport. Although the campaign was carried out quickly, the outbreak was over before the campaign started. Most staff involved in the campaign (93%) were knowledgeable about cholera control; however, 29% did not clearly understand how to detect and manage adverse events following immunisation. CONCLUSION The campaign achieved high OCV coverage, but the surveys provided insights for improvement. To achieve high vaccine coverage, more effort is needed for community sensitisation, and additional resources for staff transportation and timely payment for campaign staff is required. Pretest and post-test assessment of staff training can identify and address knowledge and skill gaps.
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Affiliation(s)
- Godfrey Bwire
- Department of Community Health, Ministry of Health, Kampala, Uganda
| | - Mellisa Roskosky
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Anne Ballard
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - W Abdullah Brooks
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Alfred Okello
- Makerere University, College of Health Sciences, Kampala, Uganda
| | - Florentina Rafael
- Department of Infectious Hazard Management, World Health Organization, Geneva, Switzerland
| | - Immaculate Ampeire
- Ministry of Health, Uganda National Expanded Program on Immunization, Kampala, Uganda
| | | | - David A Sack
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Monje F, Ario AR, Musewa A, Bainomugisha K, Mirembe BB, Aliddeki DM, Eurien D, Nsereko G, Nanziri C, Kisaakye E, Ntono V, Kwesiga B, Kadobera D, Bulage L, Bwire G, Tusiime P, Harris J, Zhu BP. A prolonged cholera outbreak caused by drinking contaminated stream water, Kyangwali refugee settlement, Hoima District, Western Uganda: 2018. Infect Dis Poverty 2020; 9:154. [PMID: 33148338 PMCID: PMC7640409 DOI: 10.1186/s40249-020-00761-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 09/30/2020] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Fred Monje
- Uganda Public Health Fellowship Program, Kampala, Uganda.
| | - Alex Riolexus Ario
- Uganda Public Health Fellowship Program, Kampala, Uganda.,Ministry of Health, Kampala, Uganda
| | - Angella Musewa
- Uganda Public Health Fellowship Program, Kampala, Uganda
| | | | | | | | - Daniel Eurien
- Uganda Public Health Fellowship Program, Kampala, Uganda
| | | | - Carol Nanziri
- Uganda Public Health Fellowship Program, Kampala, Uganda
| | | | - Vivian Ntono
- Uganda Public Health Fellowship Program, Kampala, Uganda
| | - Benon Kwesiga
- Uganda Public Health Fellowship Program, Kampala, Uganda
| | | | - Lilian Bulage
- Uganda Public Health Fellowship Program, Kampala, Uganda
| | | | | | - Julie Harris
- Division of Global Health Protection, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, USA
| | - Bao-Ping Zhu
- Uganda Public Health Fellowship Program, Kampala, Uganda.,US Centers for Disease Control and Prevention, Kampala, Uganda
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Bwire G, Sack DA, Kagirita A, Obala T, Debes AK, Ram M, Komakech H, George CM, Orach CG. The quality of drinking and domestic water from the surface water sources (lakes, rivers, irrigation canals and ponds) and springs in cholera prone communities of Uganda: an analysis of vital physicochemical parameters. BMC Public Health 2020; 20:1128. [PMID: 32680495 PMCID: PMC7368733 DOI: 10.1186/s12889-020-09186-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 07/01/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Water is the most abundant resource on earth, however water scarcity affects more than 40% of people worldwide. Access to safe drinking water is a basic human right and is a United Nations Sustainable Development Goal (SDG) 6. Globally, waterborne diseases such as cholera are responsible for over two million deaths annually. Cholera is a major cause of ill-health in Africa and Uganda. This study aimed to determine the physicochemical characteristics of the surface and spring water in cholera endemic communities of Uganda in order to promote access to safe drinking water. METHODS A longitudinal study was carried out between February 2015 and January 2016 in cholera prone communities of Uganda. Surface and spring water used for domestic purposes including drinking from 27 sites (lakes, rivers, irrigation canal, springs and ponds) were tested monthly to determine the vital physicochemical parameters, namely pH, temperature, dissolved oxygen, conductivity and turbidity. RESULTS Overall, 318 water samples were tested. Twenty-six percent (36/135) of the tested samples had mean test results that were outside the World Health Organization (WHO) recommended drinking water range. All sites (100%, 27/27) had mean water turbidity values greater than the WHO drinking water recommended standards and the temperature of above 17 °C. In addition, 27% (3/11) of the lake sites and 2/5 of the ponds had pH and dissolved oxygen respectively outside the WHO recommended range of 6.5-8.5 for pH and less than 5 mg/L for dissolved oxygen. These physicochemical conditions were ideal for survival of Vibrio. cholerae. CONCLUSIONS This study showed that surface water and springs in the study area were unsafe for drinking and had favourable physicochemical parameters for propagation of waterborne diseases including cholera. Therefore, for Uganda to attain the SDG 6 targets and to eliminate cholera by 2030, more efforts are needed to promote access to safe drinking water. Also, since this study only established the vital water physicochemical parameters, further studies are recommended to determine the other water physicochemical parameters such as the nitrates and copper. Studies are also needed to establish the causal-effect relationship between V. cholerae and the physicochemical parameters.
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Affiliation(s)
- Godfrey Bwire
- Department of Community and Behavioral Sciences, Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda.
| | - David A Sack
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Dove Project, Baltimore, MD, USA
| | - Atek Kagirita
- Uganda National Health Laboratory Services (UNHS/CPHL), Ministry of Health, Kampala, Uganda
| | - Tonny Obala
- Department of Quality Control, Uganda National Drug Authority, Kampala, Uganda
| | - Amanda K Debes
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Dove Project, Baltimore, MD, USA
| | - Malathi Ram
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Dove Project, Baltimore, MD, USA
| | - Henry Komakech
- Department of Community and Behavioral Sciences, Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda
| | - Christine Marie George
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Dove Project, Baltimore, MD, USA
| | - Christopher Garimoi Orach
- Department of Community and Behavioral Sciences, Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda
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Ambroise J, Irenge LM, Durant JF, Bearzatto B, Bwire G, Stine OC, Gala JL. Backward compatibility of whole genome sequencing data with MLVA typing using a new MLVAtype shiny application for Vibrio cholerae. PLoS One 2019; 14:e0225848. [PMID: 31825986 PMCID: PMC6905556 DOI: 10.1371/journal.pone.0225848] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 11/13/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Multiple-Locus Variable Number of Tandem Repeats (VNTR) Analysis (MLVA) is widely used by laboratory-based surveillance networks for subtyping pathogens causing foodborne and water-borne disease outbreaks. However, Whole Genome Sequencing (WGS) has recently emerged as the new more powerful reference for pathogen subtyping, making a data conversion method necessary which enables the users to compare the MLVA identified by either method. The MLVAType shiny application was designed to extract MLVA profiles of Vibrio cholerae isolates from WGS data while ensuring backward compatibility with traditional MLVA typing methods. METHODS To test and validate the MLVAType algorithm, WGS-derived MLVA profiles of nineteen Vibrio cholerae isolates from Democratic Republic of the Congo (n = 9) and Uganda (n = 10) were compared to MLVA profiles generated by an in silico PCR approach and Sanger sequencing, the latter being used as the reference method. RESULTS Results obtained by Sanger sequencing and MLVAType were totally concordant. However, the latter were affected by censored estimations whose percentage was inversely proportional to the k-mer parameter used during genome assembly. With a k-mer of 127, less than 15% estimation of V. cholerae VNTR was censored. Preventing censored estimation was only achievable when using a longer k-mer size (i.e. 175), which is not proposed in the SPAdes v.3.13.0 software. CONCLUSION As NGS read lengths and qualities tend to increase with time, one may expect the increase of k-mer size in a near future. Using MLVAType application with a longer k-mer size will then efficiently retrieve MLVA profiles from WGS data while avoiding censored estimation.
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Affiliation(s)
- Jérôme Ambroise
- Center for Applied Molecular Technologies, Institute of Clinical and Experimental Research, Université catholique de Louvain, Brussels, Belgium
| | - Léonid M. Irenge
- Center for Applied Molecular Technologies, Institute of Clinical and Experimental Research, Université catholique de Louvain, Brussels, Belgium
| | - Jean-François Durant
- Center for Applied Molecular Technologies, Institute of Clinical and Experimental Research, Université catholique de Louvain, Brussels, Belgium
| | - Bertrand Bearzatto
- Center for Applied Molecular Technologies, Institute of Clinical and Experimental Research, Université catholique de Louvain, Brussels, Belgium
| | - Godfrey Bwire
- Ministry of Health Uganda, Department of Community Health, Kampala, Uganda
| | - O. Colin Stine
- University of Maryland School of Medicine, Department of Epidemiology and Public Health, Baltimore, Maryland, United States of America
| | - Jean-Luc Gala
- Center for Applied Molecular Technologies, Institute of Clinical and Experimental Research, Université catholique de Louvain, Brussels, Belgium
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Nantima N, Ilukor J, Kaboyo W, Ademun ARO, Muwanguzi D, Sekamatte M, Sentumbwe J, Monje F, Bwire G. The importance of a One Health approach for prioritising zoonotic diseases to focus on capacity-building efforts in Uganda. REV SCI TECH OIE 2019; 38:315-325. [PMID: 31564725 DOI: 10.20506/rst.38.1.2963] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Zoonotic diseases constitute a significant threat to the health of humans, livestock and wildlife, as well as to livestock production, and can also have a negative impact on our shared environment and on livelihoods. Uganda is a hotspot for emerging and re-emerging zoonotic disease threats, with the main drivers of this phenomenon being identified as agricultural intensification, proximity to wildlife reservoirs and climate change. The threat of zoonotic disease outbreaks affects not only human healthcare systems but also livestock production, food security, human capital development, wildlife health, environmental health and privatesector growth. Firstly, to prevent, control and mitigate the threat from zoonotic diseases, in March 2017, Uganda prioritised zoonotic diseases using a One Health approach that focuses the limited resources available on those diseases that have the greatest impact at the national level. The prioritised zoonotic diseases in question are anthrax, zoonotic influenza viruses, viral haemorrhagic fevers, brucellosis, trypanosomiosis (African sleeping sickness), plague and rabies. Secondly, in January 2018, Uganda published a National One Health Strategic Plan, which was developed after these zoonotic diseases had been prioritised. In addition, the Ugandan Government and its partners are currently collaboratively addressing several of these previously neglected, endemic zoonotic diseases, such as anthrax, brucellosis and rabies. As a result of these One Health efforts, capacity has increased for early detection of, reporting on and response to zoonotic diseases at all levels. To consolidate the achievements of the One Health approach, the Ugandan Government and its partners should continue to support capacity building for the prevention and control of zoonotic diseases.
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Abubakar A, Bwire G, Azman AS, Bouhenia M, Deng LL, Wamala JF, Rumunu J, Kagirita A, Rauzier J, Grout L, Martin S, Orach CG, Luquero FJ, Quilici ML. Cholera Epidemic in South Sudan and Uganda and Need for International Collaboration in Cholera Control. Emerg Infect Dis 2019; 24:883-887. [PMID: 29664387 PMCID: PMC5938777 DOI: 10.3201/eid2405.171651] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Combining the official cholera line list data and outbreak investigation reports from the ministries of health in Uganda and South Sudan with molecular analysis of Vibrio cholerae strains revealed the interrelatedness of the epidemics in both countries in 2014. These results highlight the need for collaboration to control cross-border outbreaks.
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Bwire G, Debes AK, Orach CG, Kagirita A, Ram M, Komakech H, Voeglein JB, Buyinza AW, Obala T, Brooks WA, Sack DA. Environmental Surveillance of Vibrio cholerae O1/O139 in the Five African Great Lakes and Other Major Surface Water Sources in Uganda. Front Microbiol 2018; 9:1560. [PMID: 30123189 PMCID: PMC6085420 DOI: 10.3389/fmicb.2018.01560] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 06/25/2018] [Indexed: 12/21/2022] Open
Abstract
Cholera is a major public health problem in the African Great Lakes basin. Two hypotheses might explain this observation, namely the lakes are reservoirs of toxigenic Vibrio cholerae O1 and O139 bacteria, or cholera outbreaks are a result of repeated pathogen introduction from the neighboring communities/countries but the lakes facilitate the introductions. A prospective study was conducted in Uganda between February 2015 and January 2016 in which 28 selected surface water sources were tested for the presence of V. cholerae species using cholera rapid test and multiplex polymerase chain reaction. Of 322 water samples tested, 35 (10.8%) were positive for V. cholerae non O1/non O139 and two samples tested positive for non-toxigenic atypical V. cholerae O139. None of the samples tested had toxigenic V. cholerae O1 or O139 that are responsible for cholera epidemics. The Lake Albert region registered the highest number of positive tests for V. cholerae non O1/non O139 at 47% (9/19). The peak period for V. cholerae non O1/non O139 positive tests was in March–July 2015 which coincided with the first rainy season in Uganda. This study showed that the surface water sources, including the African Great Lakes in Uganda, are less likely to be reservoirs for the observed V. cholerae O1 or O139 epidemics, though they are natural habitats for V. cholerae non O1/non O139 and atypical non-toxigenic V. cholerae O139. Further studies by WGS tests of non-toxigenic atypical V. cholerae O139 and physicochemical tests of surface water sources that supports V. cholerae should be done to provide more information. Since V. cholerae non O1/non O139 may cause other human infections, their continued surveillance is needed to understand their potential pathogenicity.
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Affiliation(s)
- Godfrey Bwire
- Department of Community Health, Ministry of Health, Kampala, Uganda.,Department of Quality Control, National Drug Authority, Ministry of Health, Kampala, Uganda
| | - Amanda K Debes
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Christopher G Orach
- Community and Behavioral Sciences, College of Health Sciences, Makerere University School of Public Health, Kampala, Uganda
| | - Atek Kagirita
- Department of Quality Control, National Drug Authority, Ministry of Health, Kampala, Uganda.,Uganda National Health Laboratory Services - Central Public Health Laboratory, Ministry of Health, Kampala, Uganda
| | - Malathi Ram
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Henry Komakech
- Community and Behavioral Sciences, College of Health Sciences, Makerere University School of Public Health, Kampala, Uganda
| | - Joseph B Voeglein
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | | | - Tonny Obala
- Department of Quality Control, National Drug Authority, Ministry of Health, Kampala, Uganda
| | - W Abdullah Brooks
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - David A Sack
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
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Pande G, Kwesiga B, Bwire G, Kalyebi P, Riolexus A, Matovu JKB, Makumbi F, Mugerwa S, Musinguzi J, Wanyenze RK, Zhu BP. Cholera outbreak caused by drinking contaminated water from a lakeshore water-collection site, Kasese District, south-western Uganda, June-July 2015. PLoS One 2018; 13:e0198431. [PMID: 29949592 PMCID: PMC6021037 DOI: 10.1371/journal.pone.0198431] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 05/18/2018] [Indexed: 11/19/2022] Open
Abstract
On 20 June 2015, a cholera outbreak affecting more than 30 people was reported in a fishing village, Katwe, in Kasese District, south-western Uganda. We investigated this outbreak to identify the mode of transmission and to recommend control measures. We defined a suspected case as onset of acute watery diarrhoea between 1 June and 15 July 2015 in a resident of Katwe village; a confirmed case was a suspected case with Vibrio cholerae cultured from stool. For case finding, we reviewed medical records and actively searched for cases in the community. In a case-control investigation we compared exposure histories of 32 suspected case-persons and 128 age-matched controls. We also conducted an environmental assessment on how the exposures had occurred. We found 61 suspected cases (attack rate = 4.9/1000) during this outbreak, of which eight were confirmed. The primary case-person had onset on 16 June; afterwards cases sharply increased, peaked on 19 June, and rapidly declined afterwards. After 22 June, eight scattered cases occurred. The case-control investigation showed that 97% (31/32) of cases and 62% (79/128) of controls usually collected water from inside a water-collection site "X" (ORM-H = 16; 95% CI = 2.4-107). The primary case-person who developed symptoms while fishing, reportedly came ashore in the early morning hours on 17 June, and defecated "near" water-collection site X. We concluded that this cholera outbreak was caused by drinking lake water collected from inside the lakeshore water-collection site X. At our recommendations, the village administration provided water chlorination tablets to the villagers, issued water boiling advisory to the villagers, rigorously disinfected all patients' faeces and, three weeks later, fixed the tap-water system.
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Affiliation(s)
- Gerald Pande
- Uganda Public Health Fellowship Program – Field Epidemiology Track, Kampala, Uganda
- Ministry of Health Uganda, Kampala, Uganda
| | - Benon Kwesiga
- Uganda Public Health Fellowship Program – Field Epidemiology Track, Kampala, Uganda
- Makerere University School of Public Health, Kampala, Uganda
| | - Godfrey Bwire
- Uganda Public Health Fellowship Program – Field Epidemiology Track, Kampala, Uganda
| | | | - AlexArio Riolexus
- Uganda Public Health Fellowship Program – Field Epidemiology Track, Kampala, Uganda
- Makerere University School of Public Health, Kampala, Uganda
| | - Joseph K. B. Matovu
- Uganda Public Health Fellowship Program – Field Epidemiology Track, Kampala, Uganda
- Makerere University School of Public Health, Kampala, Uganda
| | | | | | | | - Rhoda K. Wanyenze
- Uganda Public Health Fellowship Program – Field Epidemiology Track, Kampala, Uganda
- Makerere University School of Public Health, Kampala, Uganda
| | - Bao-Ping Zhu
- United States Centers for Disease Control and Prevention, Kampala, Uganda
- Divison of Global Health Protection, Center for Global Health, United States Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
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Bwire G, Sack DA, Almeida M, Li S, Voeglein JB, Debes AK, Kagirita A, Buyinza AW, Orach CG, Stine OC. Molecular characterization of Vibrio cholerae responsible for cholera epidemics in Uganda by PCR, MLVA and WGS. PLoS Negl Trop Dis 2018; 12:e0006492. [PMID: 29864113 PMCID: PMC6002109 DOI: 10.1371/journal.pntd.0006492] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 06/14/2018] [Accepted: 05/03/2018] [Indexed: 12/23/2022] Open
Abstract
Background For almost 50 years sub-Saharan Africa, including Uganda, has experienced several outbreaks due to Vibrio cholerae. Our aim was to determine the genetic relatedness and spread of strains responsible for cholera outbreaks in Uganda. Methodology/Principal findings Sixty-three V. cholerae isolates collected from outbreaks in Uganda between 2014 and 2016 were tested using multiplex polymerase chain reaction (PCR), multi-locus variable number of tandem repeat analysis (MLVA) and whole genome sequencing (WGS). Three closely related MLVA clonal complexes (CC) were identified: CC1, 32% (20/63); CC2, 40% (25/63) and CC3, 28% (18/63). Each CC contained isolates from a different WGS clade. These clades were contained in the third wave of the 7th cholera pandemic strain, two clades were contained in the transmission event (T)10 lineage and other in T13. Analysing the dates and genetic relatedness revealed that V. cholerae genetic lineages spread between districts within Uganda and across national borders. Conclusion The V. cholerae strains showed local and regional transmission within Uganda and the East African region. To prevent, control and eliminate cholera, these countries should implement strong cross-border collaboration and regional coordination of preventive activities. Cholera, an acute diarrheal disease, essentially was eliminated in the western world many decades ago, but has continued to cause many deaths in sub-Saharan Africa, South America and Asia. Cholera diagnosis in most countries in sub-Saharan Africa, including Uganda, is by stool culture, serology and biochemical methods. These testing methods are unable to establish the relatedness, virulence and spread of Vibrio cholerae in region. To determine the spread, relatedness and virulence of V. cholerae responsible for the various cholera outbreaks in Uganda, we used DNA-based testing methods. We tested 63 V. cholerae isolates from samples collected in Uganda from 2014–2016. Our results showed three distinct lineages of genetically related cholera-causing bacteria. These organisms showed internal spread in Uganda and cross-border spread to neighboring countries in East Africa. These findings provide a valuable baseline and help define the context for directing control measures and technologies for cholera prevention in East Africa.
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Affiliation(s)
- Godfrey Bwire
- Ministry of Health Uganda, Department of Community Health, Kampala, Uganda
- * E-mail:
| | - David A. Sack
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, DOVE Project, Baltimore, Maryland United States of America
| | - Mathieu Almeida
- University of Maryland School of Medicine, Department of Epidemiology and Public Health, Baltimore, Maryland, United States of America
| | - Shan Li
- University of Maryland School of Medicine, Department of Epidemiology and Public Health, Baltimore, Maryland, United States of America
| | - Joseph B. Voeglein
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, DOVE Project, Baltimore, Maryland United States of America
| | - Amanda Kay Debes
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, DOVE Project, Baltimore, Maryland United States of America
| | - Atek Kagirita
- Uganda National Health Laboratory Services (UNHS/CPHL), Kampala, Uganda
| | | | | | - O. Colin Stine
- University of Maryland School of Medicine, Department of Epidemiology and Public Health, Baltimore, Maryland, United States of America
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Nadri J, Sauvageot D, Njanpop-Lafourcade BM, Baltazar CS, Banla Kere A, Bwire G, Coulibaly D, Kacou N’Douba A, Kagirita A, Keita S, Koivogui L, Landoh DE, Langa JP, Miwanda BN, Mutombo Ndongala G, Mwakapeje ER, Mwambeta JL, Mengel MA, Gessner BD. Sensitivity, Specificity, and Public-Health Utility of Clinical Case Definitions Based on the Signs and Symptoms of Cholera in Africa. Am J Trop Med Hyg 2018; 98:1021-1030. [PMID: 29488455 PMCID: PMC5928804 DOI: 10.4269/ajtmh.16-0523] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 12/20/2017] [Indexed: 11/07/2022] Open
Abstract
During 2014, Africa reported more than half of the global suspected cholera cases. Based on the data collected from seven countries in the African Cholera Surveillance Network (Africhol), we assessed the sensitivity, specificity, and positive and negative predictive values of clinical cholera case definitions, including that recommended by the World Health Organization (WHO) using culture confirmation as the gold standard. The study was designed to assess results in real-world field situations in settings with recent cholera outbreaks or endemicity. From June 2011 to July 2015, a total of 5,084 persons with suspected cholera were tested for Vibrio cholerae in seven different countries of which 35.7% had culture confirmation. For all countries combined, the WHO case definition had a sensitivity = 92.7%, specificity = 8.1%, positive predictive value = 36.1%, and negative predictive value = 66.6%. Adding dehydration, vomiting, or rice water stools to the case definition could increase the specificity without a substantial decrease in sensitivity. Future studies could further refine our findings primarily by using more sensitive methods for cholera confirmation.
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Affiliation(s)
| | | | | | | | - Abiba Banla Kere
- Institut National d’Hygiène, Lomé, Togo
- Ministry of Health, Lomé, Togo
| | - Godfrey Bwire
- Control of Diarrheal Diseases, Community Health Department, Ministry of Health, Kampala, Uganda
| | | | | | - Atek Kagirita
- Central Public Health Laboratory, Ministry of Health, Kampala, Uganda
| | - Sakoba Keita
- Division Prévention et Lutte contre la Maladie, Ministry of Health, Conakry, Guinea
| | | | | | - Jose P. Langa
- Instituto Nacional de Saúde, Ministry of Health, Maputo, Mozambique
| | - Berthe N. Miwanda
- Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of Congo
| | - Guy Mutombo Ndongala
- Division Provinciale de la Santé du Nord Kivu, Goma, Democratic Republic of Congo
| | - Elibariki R. Mwakapeje
- Epidemiology and Diseases Control Section, Preventive Department, Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania
| | - Jacob L. Mwambeta
- Curative Department, National Health Laboratory Quality Assurance and Training Center, Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania
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Bwire G, Ali M, Sack DA, Nakinsige A, Naigaga M, Debes AK, Ngwa MC, Brooks WA, Garimoi Orach C. Identifying cholera "hotspots" in Uganda: An analysis of cholera surveillance data from 2011 to 2016. PLoS Negl Trop Dis 2017; 11:e0006118. [PMID: 29284003 PMCID: PMC5746206 DOI: 10.1371/journal.pntd.0006118] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 11/17/2017] [Indexed: 11/19/2022] Open
Abstract
Background Despite advance in science and technology for prevention, detection and treatment of cholera, this infectious disease remains a major public health problem in many countries in sub-Saharan Africa, Uganda inclusive. The aim of this study was to identify cholera hotspots in Uganda to guide the development of a roadmap for prevention, control and elimination of cholera in the country. Methodology/Principle findings We obtained district level confirmed cholera outbreak data from 2011 to 2016 from the Ministry of Health, Uganda. Population and rainfall data were obtained from the Uganda Bureau of Statistics, and water, sanitation and hygiene data from the Ministry of Water and Environment. A spatial scan test was performed to identify the significantly high risk clusters. Cholera hotspots were defined as districts whose center fell within a significantly high risk cluster or where a significantly high risk cluster was completely superimposed onto a district. A zero-inflated negative binomial regression model was employed to identify the district level risk factors for cholera. In total 11,030 cases of cholera were reported during the 6-year period. 37(33%) of 112 districts reported cholera outbreaks in one of the six years, and 20 (18%) districts experienced cholera at least twice in those years. We identified 22 districts as high risk for cholera, of which 13 were near a border of Democratic Republic of Congo (DRC), while 9 districts were near a border of Kenya. The relative risk of having cholera inside the high-risk districts (hotspots) were 2 to 22 times higher than elsewhere in the country. In total, 7 million people were within cholera hotspots. The negative binomial component of the ZINB model shows people living near a lake or the Nile river were at increased risk for cholera (incidence rate ratio, IRR = 0.98, 95% CI: 0.97 to 0.99, p < .01); people living near the border of DRC/Kenya or higher incidence rate in the neighboring districts were increased risk for cholera in a district (IRR = 0.99, 95% CI: 0.98 to 1.00, p = .02 and IRR = 1.02, 95% CI: 1.01 to 1.03, p < .01, respectively). The zero inflated component of the ZINB model yielded shorter distance to Kenya or DRC border, higher incidence rate in the neighboring districts, and higher annual rainfall in the district were associated with the risk of having cholera in the district. Conclusions/significance The study identified cholera hotspots during the period 2011–2016. The people located near the international borders, internationally shared lakes and river Nile were at higher risk for cholera outbreaks than elsewhere in the country. Targeting cholera interventions to these locations could prevent and ultimately eliminate cholera in Uganda. Uganda has regularly reported cholera since its first appearance in 1971. Although the Government of Uganda implements cholera prevention and control interventions such as provision of safe water, promotion of sanitation and hygiene, health education and healthcare, the disease continues to threaten many districts in the country. The population with access to improved water supply in the urban and rural areas were 71% and 67% respectively, and with access to improved sanitation was 86% in urban areas and 79% in rural areas. Identifying the districts with increased risk is an important step in defining areas where additional preventive interventions are needed. We used district level confirmed cholera outbreak data for a six year period (2011–2016), and identified cholera “hotspot” districts. Rates of cholera in these districts, with a population of about 7 million, are 2 to 22 times higher than elsewhere in the country. These “hotspots” located along the international borders with Democratic Republic of Congo (DRC) and Kenya and the internationally shared lakes and river Nile. Targeted cholera prevention and control interventions to the hotspots in Uganda could lead to reduction in cholera cases and deaths. The hotspots identified herein provide an affordable way of implementation of the comprehensive cholera prevention and control mechanism as recommended by WHO. Since the hotspots are along the international borders, collaboration with the neighboring countries is the key to eliminate cholera in Uganda and the region as a whole.
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Affiliation(s)
- Godfrey Bwire
- Department of Community Health, Uganda Ministry of Health, Kampala, Uganda
| | - Mohammad Ali
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- * E-mail:
| | - David A. Sack
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Anne Nakinsige
- Department of National Disease Control, Uganda Ministry of Health, Kampala, Uganda
| | - Martha Naigaga
- Department of Environmental Health, Uganda Ministry of Water and Environment, Kampala, Uganda
| | - Amanda K. Debes
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Moise C. Ngwa
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - W. Abdullah Brooks
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Christopher Garimoi Orach
- Department of Community and Behavioural Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
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Oguttu DW, Okullo A, Bwire G, Nsubuga P, Ario AR. Cholera outbreak caused by drinking lake water contaminated with human faeces in Kaiso Village, Hoima District, Western Uganda, October 2015. Infect Dis Poverty 2017; 6:146. [PMID: 28992811 PMCID: PMC5634859 DOI: 10.1186/s40249-017-0359-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Accepted: 09/04/2017] [Indexed: 11/10/2022] Open
Abstract
Background On 12 October 2015, a cholera outbreak involving 65 cases and two deaths was reported in a fishing village in Hoima District, Western Uganda. Despite initial response by the local health department, the outbreak persisted. We conducted an investigation to identify the source and mode of transmission, and recommend evidence-led interventions to control and prevent cholera outbreaks in this area. Methods We defined a suspected case as the onset of acute watery diarrhoea from 1 October to 2 November 2015 in a resident of Kaiso Village. A confirmed case was a suspected case who had Vibrio cholerae isolated from stool. We found cases by record review and active community case finding. We performed descriptive epidemiologic analysis for hypothesis generation. In an unmatched case-control study, we compared exposure histories of 61 cases and 126 controls randomly selected among asymptomatic village residents. We also conducted an environmental assessment and obtained meteorological data from a weather station. Results We identified 122 suspected cases, of which six were culture-confirmed, 47 were confirmed positive with a rapid diagnostic test and two died. The two deceased cases had onset of the disease on 2 October and 10 October, respectively. Heavy rainfall occurred on 7–11 October; a point-source outbreak occurred on 12–15 October, followed by continuous community transmission for two weeks. Village residents usually collected drinking water from three lakeshore points – A, B and C: 9.8% (6/61) of case-persons and 31% (39/126) of control-persons were found to usually use point A, 21% (13/61) of case-persons and 37% (46/126) of control-persons were found to usually use point B (OR = 1.8, 95% CI: 0.64–5.3), and 69% (42/61) of case-persons and 33% (41/126) of control-persons were found to usually use point C (OR = 6.7; 95% CI: 2.5–17) for water collection. All case-persons (61/61) and 93% (117/126) of control-persons reportedly never treated/boiled drinking water (OR = ∞, 95% CIFisher: 1.0 – ∞). The village’s piped water system had been vandalised and open defecation was common due to a lack of latrines. The lake water was found to be contiminated due to a gully channel that washed the faeces into the lake at point C. Conclusions This outbreak was likely caused by drinking lake water contaminated by faeces from a gully channel. We recommend treatment of drinking water, fixing the vandalised piped-water system and constructing latrines. Electronic supplementary material The online version of this article (10.1186/s40249-017-0359-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- David W Oguttu
- Uganda Public Health Fellowship Program - Field Epidemiology Track, P.O. Box 7272, Kampala, Uganda.
| | - A Okullo
- Uganda Public Health Fellowship Program - Field Epidemiology Track, P.O. Box 7272, Kampala, Uganda
| | - G Bwire
- Ministry of Health, Kampala, Uganda
| | - P Nsubuga
- African Field Epidemiology Network, Kampala, Uganda
| | - A R Ario
- Uganda Public Health Fellowship Program - Field Epidemiology Track, P.O. Box 7272, Kampala, Uganda
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Bwire G, Munier A, Ouedraogo I, Heyerdahl L, Komakech H, Kagirita A, Wood R, Mhlanga R, Njanpop-Lafourcade B, Malimbo M, Makumbi I, Wandawa J, Gessner BD, Orach CG, Mengel MA. Epidemiology of cholera outbreaks and socio-economic characteristics of the communities in the fishing villages of Uganda: 2011-2015. PLoS Negl Trop Dis 2017; 11:e0005407. [PMID: 28288154 PMCID: PMC5370135 DOI: 10.1371/journal.pntd.0005407] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 03/28/2017] [Accepted: 02/13/2017] [Indexed: 11/18/2022] Open
Abstract
Background The communities in fishing villages in the Great Lakes Region of Africa and particularly in Uganda experience recurrent cholera outbreaks that lead to considerable mortality and morbidity. We evaluated cholera epidemiology and population characteristics in the fishing villages of Uganda to better target prevention and control interventions of cholera and contribute to its elimination from those communities. Methodology/Principal findings We conducted a prospective study between 2011–15 in fishing villages in Uganda. We collected, reviewed and documented epidemiological and socioeconomic data for 10 cholera outbreaks that occurred in fishing communities located along the African Great Lakes and River Nile in Uganda. These outbreaks caused 1,827 suspected cholera cases and 43 deaths, with a Case-Fatality Ratio (CFR) of 2.4%. Though the communities in the fishing villages make up only 5–10% of the Ugandan population, they bear the biggest burden of cholera contributing 58% and 55% of all reported cases and deaths in Uganda during the study period. The CFR was significantly higher among males than females (3.2% vs. 1.3%, p = 0.02). The outbreaks were seasonal with most cases occurring during the months of April-May. Male children under age of 5 years, and 5–9 years had increased risk. Cholera was endemic in some villages with well-defined “hotspots”. Practices predisposing communities to cholera outbreaks included: the use of contaminated lake water, poor sanitation and hygiene. Additional factors were: ignorance, illiteracy, and poverty. Conclusions/Significance Cholera outbreaks were a major cause of morbidity and mortality among the fishing communities in Uganda. In addition to improvements in water, sanitation, and hygiene, oral cholera vaccines could play an important role in the prevention and control of these outbreaks, particularly when targeted to high-risk areas and populations. Promotion and facilitation of access to social services including education and reduction in poverty should contribute to cholera prevention, control and elimination in these communities. Cholera, though a preventable and treatable disease, remains a major cause of morbidity and mortality in the Great Lakes Region of Africa, including Uganda. The communities in the fishing villages constitute 5–10% of the total Ugandan population. Most fishing villages are located along Lakes Victoria, Albert and Edward and the River Nile. During the study period, 2011–2015 these villages were responsible for over 50% of the reported annual cholera cases and deaths in Uganda. The CFR was significantly higher among males than females (3.2% vs. 1.3%, p = 0.02). Our study is the first to systematically describe the epidemiology of these outbreaks and socioeconomic characteristics of communities in the fishing villages in Uganda. Our study found that persons in the fishing villages were at increased risk of cholera outbreaks due to poor access to safe water, sanitation, and hygiene. Furthermore, the villages had similar population characteristics such as illiteracy, ignorance regarding cholera transmission, poverty and constant population migration. In addition to improvements in water, sanitation, and hygiene, complementary use of oral cholera vaccines could play an important role, particularly when targeted to high-risk areas and populations. As a long term strategy, improvements in education and reduction in poverty should contribute to cholera prevention, control and elimination in the fishing villages and Uganda as whole.
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Affiliation(s)
- Godfrey Bwire
- Department of Community Health, Ministry of Health (MOH), Kampala, Uganda
- * E-mail:
| | - Aline Munier
- Agence de Médecine Préventive (AMP), Paris, France
| | | | | | - Henry Komakech
- Department of Community and Behavioral Sciences, Makerere University School of Public Health (MUSPH), Kampala, Uganda
| | - Atek Kagirita
- National Health Laboratory Services, Ministry of Health, Kampala, Uganda
| | - Richard Wood
- Agence de Médecine Préventive (AMP), Ferney-Voltaire, France
| | | | | | - Mugagga Malimbo
- National Disease Control Department, Ministry of Health, Kampala, Uganda
| | - Issa Makumbi
- Health Emergency Operation Centre (EOC), Ministry of Health, Kampala, Uganda
| | - Jennifer Wandawa
- Department of Health, Mbale District Local Government, Mbale, Uganda
| | | | - Christopher Garimoi Orach
- Department of Community and Behavioral Sciences, Makerere University School of Public Health (MUSPH), Kampala, Uganda
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Bwire G, Mwesawina M, Baluku Y, Kanyanda SSE, Orach CG. Cross-Border Cholera Outbreaks in Sub-Saharan Africa, the Mystery behind the Silent Illness: What Needs to Be Done? PLoS One 2016; 11:e0156674. [PMID: 27258124 PMCID: PMC4892562 DOI: 10.1371/journal.pone.0156674] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 05/18/2016] [Indexed: 11/22/2022] Open
Abstract
Introduction Cross-border cholera outbreaks are a major public health problem in Sub-Saharan Africa contributing to the high annual reported cholera cases and deaths. These outbreaks affect all categories of people and are challenging to prevent and control. This article describes lessons learnt during the cross-border cholera outbreak control in Eastern and Southern Africa sub-regions using the case of Uganda-DRC and Malawi-Mozambique borders and makes recommendations for future outbreak prevention and control. Materials and Methods We reviewed weekly surveillance data, outbreak response reports and documented experiences on the management of the most recent cross-border cholera outbreaks in Eastern and Southern Africa sub-regions, namely in Uganda and Malawi respectively. Uganda-Democratic Republic of Congo and Malawi-Mozambique borders were selected because the countries sharing these borders reported high cholera disease burden to WHO. Results A total of 603 cross-border cholera cases with 5 deaths were recorded in Malawi and Uganda in 2015. Uganda recorded 118 cases with 2 deaths and CFR of 1.7%. The under-fives and school going children were the most affected age groups contributing 24.2% and 36.4% of all patients seen along Malawi-Mozambique and Uganda-DRC borders, respectively. These outbreaks lasted for over 3 months and spread to new areas leading to 60 cases with 3 deaths, CRF of 5%, and 102 cases 0 deaths in Malawi and Uganda, respectively. Factors contributing to these outbreaks were: poor sanitation and hygiene, use of contaminated water, floods and rampant cross-border movements. The outbreak control efforts mainly involved unilateral measures implemented by only one of the affected countries. Conclusions Cross-border cholera outbreaks contribute to the high annual reported cholera burden in Sub-Saharan Africa yet they remain silent, marginalized and poorly identified by cholera actors (governments and international agencies). The under-fives and the school going children were the most affected age groups. To successfully prevent and control these outbreaks, guidelines and strategies should be reviewed to assign clear roles and responsibilities to cholera actors on collaboration, prevention, detection, monitoring and control of these epidemics.
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Affiliation(s)
- Godfrey Bwire
- Ministry of Health Uganda, Control of Diarrheal Diseases Unit, Kampala, Uganda
- * E-mail:
| | | | - Yosia Baluku
- Ministry of Health Uganda, Bwera Hospital, Kasese, Uganda
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Sauvageot D, Njanpop-Lafourcade BM, Akilimali L, Anne JC, Bidjada P, Bompangue D, Bwire G, Coulibaly D, Dengo-Baloi L, Dosso M, Orach CG, Inguane D, Kagirita A, Kacou-N’Douba A, Keita S, Kere Banla A, Kouame YJP, Landoh DE, Langa JP, Makumbi I, Miwanda B, Malimbo M, Mutombo G, Mutombo A, NGuetta EN, Saliou M, Sarr V, Senga RK, Sory F, Sema C, Tante OV, Gessner BD, Mengel MA. Cholera Incidence and Mortality in Sub-Saharan African Sites during Multi-country Surveillance. PLoS Negl Trop Dis 2016; 10:e0004679. [PMID: 27186885 PMCID: PMC4871502 DOI: 10.1371/journal.pntd.0004679] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 04/09/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Cholera burden in Africa remains unknown, often because of weak national surveillance systems. We analyzed data from the African Cholera Surveillance Network (www.africhol.org). METHODS/ PRINCIPAL FINDINGS During June 2011-December 2013, we conducted enhanced surveillance in seven zones and four outbreak sites in Togo, the Democratic Republic of Congo (DRC), Guinea, Uganda, Mozambique and Cote d'Ivoire. All health facilities treating cholera cases were included. Cholera incidences were calculated using culture-confirmed cholera cases and culture-confirmed cholera cases corrected for lack of culture testing usually due to overwhelmed health systems and imperfect test sensitivity. Of 13,377 reported suspected cases, 34% occurred in Conakry, Guinea, 47% in Goma, DRC, and 19% in the remaining sites. From 0-40% of suspected cases were aged under five years and from 0.3-86% had rice water stools. Within surveillance zones, 0-37% of suspected cases had confirmed cholera compared to 27-38% during outbreaks. Annual confirmed incidence per 10,000 population was <0.5 in surveillance zones, except Goma where it was 4.6. Goma and Conakry had corrected incidences of 20.2 and 5.8 respectively, while the other zones a median of 0.3. During outbreaks, corrected incidence varied from 2.6 to 13.0. Case fatality ratios ranged from 0-10% (median, 1%) by country. CONCLUSIONS/SIGNIFICANCE Across different African epidemiological contexts, substantial variation occurred in cholera incidence, age distribution, clinical presentation, culture confirmation, and testing frequency. These results can help guide preventive activities, including vaccine use.
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Affiliation(s)
| | | | | | | | | | - Didier Bompangue
- Universite de Kinshasa, Kinshasa, Republique Democratique du Congo
| | | | | | | | | | | | | | - Atek Kagirita
- Central Public Health Laboratory, Ministry of Health, Kampala, Uganda
| | | | - Sakoba Keita
- Ministere de la sante publique et de l’hygiene publique, Conakry, Guinea
| | | | | | | | | | | | - Berthe Miwanda
- Institut National de Recherche Biomedicale, Kinshasa, Republique Democratique du Congo
| | | | - Guy Mutombo
- Ministere de la santé, Division Provinciale de la santé, Goma, Republique Democratique du Congo
| | - Annie Mutombo
- Ministère de la santé, Kinshasa, Republique Democratique du Congo
| | | | | | - Veronique Sarr
- Ministere de la sante publique et de l’hygiene publique, Conakry, Guinea
| | | | - Fode Sory
- Ministere de la sante publique et de l’hygiene publique, Conakry, Guinea
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Awor P, Wamani H, Bwire G, Jagoe G, Peterson S. Private sector drug shops in integrated community case management of malaria, pneumonia, and diarrhea in children in Uganda. Am J Trop Med Hyg 2015; 87:92-96. [PMID: 23136283 PMCID: PMC3748528 DOI: 10.4269/ajtmh.2012.11-0791] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
We conducted a survey involving 1,604 households to determine community care-seeking patterns and 163 exit interviews to determine appropriateness of treatment of common childhood illnesses at private sector drug shops in two rural districts of Uganda. Of children sick within the last 2 weeks, 496 (53.1%) children first sought treatment in the private sector versus 154 (16.5%) children first sought treatment in a government health facility. Only 15 (10.3%) febrile children treated at drug shops received appropriate treatment for malaria. Five (15.6%) children with both cough and fast breathing received amoxicillin, although no children received treatment for 5–7 days. Similarly, only 8 (14.3%) children with diarrhea received oral rehydration salts, but none received zinc tablets. Management of common childhood illness at private sector drug shops in rural Uganda is largely inappropriate. There is urgent need to improve the standard of care at drug shops for common childhood illness through public–private partnerships.
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Affiliation(s)
- Phyllis Awor
- *Address correspondence to Phyllis Awor, Department of Community Health and Behavioral Sciences, School of Public Health, Makerere University College of Health Sciences, 7072 Kampala, Uganda. E-mail:
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Bwire G, Malimbo M, Kagirita A, Makumbi I, Mintz E, Mengel MA, Orach CG. Nosocomial Cholera Outbreak in a Mental Hospital: Challenges and Lessons Learnt from Butabika National Referral Mental Hospital, Uganda. Am J Trop Med Hyg 2015; 93:534-8. [PMID: 26195468 PMCID: PMC4559692 DOI: 10.4269/ajtmh.14-0730] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 05/12/2015] [Indexed: 11/07/2022] Open
Abstract
During the last four decades, Uganda has experienced repeated cholera outbreaks in communities; no cholera outbreaks have been reported in Ugandan health facilities. In October 2008, a unique cholera outbreak was confirmed in Butabika National Mental Referral Hospital (BNMRH), Uganda. This article describes actions taken to control the outbreak, challenges, and lessons learnt. We reviewed patient and hospital reports for clinical symptoms and signs, treatment and outcome, patient mental diagnosis, and challenges noted during management of patients and contacts. Out of 114 BNMRH patients on two affected wards, 18 cholera cases and five deaths were documented for an attack rate of 15.8% and a case fatality rate of 28%. Wards and surroundings were intensively disinfected and 96 contacts (psychiatric patients) in the affected wards received chemoprophylaxis with oral ciprofloxacin 500 mg twice daily until November 5, 2008. We documented a nosocomial cholera outbreak in BNMRH with a high case fatality of 28% compared with the national average of 2.4% for cholera outbreaks in communities. To avoid cholera outbreaks and potentially high mortality among patients in mental institutions, procedures for prompt diagnosis, treatment, disinfection, and prophylaxis are needed and preemptive use of oral cholera vaccines should be considered.
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Affiliation(s)
- Godfrey Bwire
- Control of Diarrheal Diseases Section, Ministry of Health, Kampala, Uganda; Epidemiological Surveillance Division, Ministry of Health, Kampala, Uganda; U.S. Centers for Disease Control and Prevention, Atlanta, Georgia; Central Public Health Laboratory, Kampala, Uganda; Agence de Médicine Préventive, Paris, France; Makerere University School of Public Health, Kampala, Uganda
| | - Mugagga Malimbo
- Control of Diarrheal Diseases Section, Ministry of Health, Kampala, Uganda; Epidemiological Surveillance Division, Ministry of Health, Kampala, Uganda; U.S. Centers for Disease Control and Prevention, Atlanta, Georgia; Central Public Health Laboratory, Kampala, Uganda; Agence de Médicine Préventive, Paris, France; Makerere University School of Public Health, Kampala, Uganda
| | - Atek Kagirita
- Control of Diarrheal Diseases Section, Ministry of Health, Kampala, Uganda; Epidemiological Surveillance Division, Ministry of Health, Kampala, Uganda; U.S. Centers for Disease Control and Prevention, Atlanta, Georgia; Central Public Health Laboratory, Kampala, Uganda; Agence de Médicine Préventive, Paris, France; Makerere University School of Public Health, Kampala, Uganda
| | - Issa Makumbi
- Control of Diarrheal Diseases Section, Ministry of Health, Kampala, Uganda; Epidemiological Surveillance Division, Ministry of Health, Kampala, Uganda; U.S. Centers for Disease Control and Prevention, Atlanta, Georgia; Central Public Health Laboratory, Kampala, Uganda; Agence de Médicine Préventive, Paris, France; Makerere University School of Public Health, Kampala, Uganda
| | - Eric Mintz
- Control of Diarrheal Diseases Section, Ministry of Health, Kampala, Uganda; Epidemiological Surveillance Division, Ministry of Health, Kampala, Uganda; U.S. Centers for Disease Control and Prevention, Atlanta, Georgia; Central Public Health Laboratory, Kampala, Uganda; Agence de Médicine Préventive, Paris, France; Makerere University School of Public Health, Kampala, Uganda
| | - Martin A Mengel
- Control of Diarrheal Diseases Section, Ministry of Health, Kampala, Uganda; Epidemiological Surveillance Division, Ministry of Health, Kampala, Uganda; U.S. Centers for Disease Control and Prevention, Atlanta, Georgia; Central Public Health Laboratory, Kampala, Uganda; Agence de Médicine Préventive, Paris, France; Makerere University School of Public Health, Kampala, Uganda
| | - Christopher Garimoi Orach
- Control of Diarrheal Diseases Section, Ministry of Health, Kampala, Uganda; Epidemiological Surveillance Division, Ministry of Health, Kampala, Uganda; U.S. Centers for Disease Control and Prevention, Atlanta, Georgia; Central Public Health Laboratory, Kampala, Uganda; Agence de Médicine Préventive, Paris, France; Makerere University School of Public Health, Kampala, Uganda
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Bwire G, Malimbo M, Makumbi I, Kagirita A, Wamala JF, Kalyebi P, Bingi A, Gitta S, Mukanga D, Mengel M, Dahlke M. Cholera surveillance in Uganda: an analysis of notifications for the years 2007-2011. J Infect Dis 2013; 208 Suppl 1:S78-85. [PMID: 24101649 DOI: 10.1093/infdis/jit203] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Cholera outbreaks have occurred periodically in Uganda since 1971. The country has experienced intervals of sporadic cases and localized outbreaks, occasionally resulting in prolonged widespread epidemics. METHODS Cholera surveillance data reported to the Uganda Ministry of Health from 2007 through 2011 were reviewed to determine trends in annual incidence and case fatality rate. Demographic characteristics of cholera cases were analyzed from the national line list for 2011. Cases were analyzed by district and month of report to understand the geographic distribution and identify any seasonal patterns of disease occurrence. RESULTS From 2007 through 2011, Uganda registered a total of 7615 cholera cases with 181 deaths (case fatality rate = 2.4%). The absolute number of cases and incidence per 100 000 varied from year to year with the highest incidence occurring in 2008 following heavy rainfall and flooding in eastern Uganda. For 2011, cholera cases occurred in 1.6 times more males than females. The geographical areas affected by the outbreaks shifted each year, with the exception of a few endemic districts. No clear seasonal trends in cholera occurrence were identified for this time period. CONCLUSIONS We observed an overall decline in cases reported during the 5 years under review. During this period, concerted efforts were made by the Ugandan government and development partners to educate communities on proper sanitation and hygiene and provide safe water and timely treatment. Mechanisms to ensure timely and complete cholera surveillance data are reported to the national level should continue to be strengthened.
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Affiliation(s)
- Godfrey Bwire
- Ministry of Health Uganda, Control of Diarrheal Diseases Unit
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Abstract
INTRODUCTION In 2010, the World Health Organization released a new cholera vaccine position paper, which recommended the use of cholera vaccines in high-risk endemic areas. However, there is a paucity of data on the burden of cholera in endemic countries. This article reviewed available cholera surveillance data from Uganda and assessed the sufficiency of these data to inform country-specific strategies for cholera vaccination. METHODS The Uganda Ministry of Health conducts cholera surveillance to guide cholera outbreak control activities. This includes reporting the number of cases based on a standardized clinical definition plus systematic laboratory testing of stool samples from suspected cases at the outset and conclusion of outbreaks. This retrospective study analyzes available data by district and by age to estimate incidence rates. Since surveillance activities focus on more severe hospitalized cases and deaths, a sensitivity analysis was conducted to estimate the number of non-severe cases and unrecognized deaths that may not have been captured. RESULTS Cholera affected all ages, but the geographic distribution of the disease was very heterogeneous in Uganda. We estimated that an average of about 11,000 cholera cases occurred in Uganda each year, which led to approximately 61-182 deaths. The majority of these cases (81%) occurred in a relatively small number of districts comprising just 24% of Uganda's total population. These districts included rural areas bordering the Democratic Republic of Congo, South Sudan, and Kenya as well as the slums of Kampala city. When outbreaks occurred, the average duration was about 15 weeks with a range of 4-44 weeks. DISCUSSION There is a clear subdivision between high-risk and low-risk districts in Uganda. Vaccination efforts should be focused on the high-risk population. However, enhanced or sentinel surveillance activities should be undertaken to better quantify the endemic disease burden and high-risk populations prior to introducing the vaccine.
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Affiliation(s)
- Godfrey Bwire
- Control of Diarrheal Diseases Section, Ministry of Health, Kampala, Uganda
| | - Mugagga Malimbo
- Epidemiological Surveillance Division, Ministry of Health, Kampala, Uganda
| | | | | | | | - Ann Levin
- Independent Consultant, Bethesda, Maryland, United States of America
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Talisuna AO, Daumerie PG, Balyeku A, Egan T, Piot B, Coghlan R, Lugand M, Bwire G, Rwakimari JB, Ndyomugyenyi R, Kato F, Byangire M, Kagwa P, Sebisubi F, Nahamya D, Bonabana A, Mpanga-Mukasa S, Buyungo P, Lukwago J, Batte A, Nakanwagi G, Tibenderana J, Nayer K, Reddy K, Dokwal N, Rugumambaju S, Kidde S, Banerji J, Jagoe G. Closing the access barrier for effective anti-malarials in the private sector in rural Uganda: consortium for ACT private sector subsidy (CAPSS) pilot study. Malar J 2012; 11:356. [PMID: 23107021 PMCID: PMC3523984 DOI: 10.1186/1475-2875-11-356] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Accepted: 10/25/2012] [Indexed: 11/27/2022] Open
Abstract
Background Artemisinin-based combination therapy (ACT), the treatment of choice for uncomplicated falciparum malaria, is unaffordable and generally inaccessible in the private sector, the first port of call for most malaria treatment across rural Africa. Between August 2007 and May 2010, the Uganda Ministry of Health and the Medicines for Malaria Venture conducted the Consortium for ACT Private Sector Subsidy (CAPSS) pilot study to test whether access to ACT in the private sector could be improved through the provision of a high level supply chain subsidy. Methods Four intervention districts were purposefully selected to receive branded subsidized medicines - “ACT with a leaf”, while the fifth district acted as the control. Baseline and evaluation outlet exit surveys and retail audits were conducted at licensed and unlicensed drug outlets in the intervention and control districts. A survey-adjusted, multivariate logistic regression model was used to analyse the intervention’s impact on: ACT uptake and price; purchase of ACT within 24 hours of symptom onset; ACT availability and displacement of sub-optimal anti-malarial. Results At baseline, ACT accounted for less than 1% of anti-malarials purchased from licensed drug shops for children less than five years old. However, at evaluation, “ACT with a leaf” accounted for 69% of anti-malarial purchased in the interventions districts. Purchase of ACT within 24 hours of symptom onset for children under five years rose from 0.8% at baseline to 26.2% (95% CI: 23.2-29.2%) at evaluation in the intervention districts. In the control district, it rose modestly from 1.8% to 5.6% (95% CI: 4.0-7.3%). The odds of purchasing ACT within 24 hours in the intervention districts compared to the control was 0.46 (95% CI: 0.08-2.68, p=0.4) at baseline and significant increased to 6.11 (95% CI: 4.32-8.62, p<0.0001) at evaluation. Children less than five years of age had “ACT with a leaf” purchased for them more often than those aged above five years. There was no evidence of price gouging. Conclusions These data demonstrate that a supply-side subsidy and an intensive communications campaign significantly increased the uptake and use of ACT in the private sector in Uganda.
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Affiliation(s)
- Ambrose O Talisuna
- Medicines for Malaria Venture-MMV, PO Box 1826 20, rte de Pré-Bois, Geneva 15, 1215, Switzerland.
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Talisuna AO, Grevval P, Balyeku A, Egan T, Bwire G, Piot B, Coghlan R, Lugand M, Rwakimari JB, Ndyomugyenyi R, Kato F, Byangire M, Kagwa P, Sebisubi F, Nahamya D, Bonabana A, Mpanga-Mukasa S, Buyungo P, Lukwago J, Batte A, Nakanwagi G, Tibenderana J, Nayer K, Reddy K, Dokvval N, Rugumambaju S, Kidde S, Banerji J, Jagoe G. Overcoming the affordability barrier for effective and high quality life saving malaria medicines in the private sector in rural Uganda: the Consortium for ACT Private Sector Subsidy (CAPSS) pilot study. Malar J 2012. [PMCID: PMC3472303 DOI: 10.1186/1475-2875-11-s1-o16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Watson JT, El Bushra H, Lebo EJ, Bwire G, Kiyengo J, Emukule G, Omballa V, Tole J, Zuberi M, Breiman RF, Katz MA. Outbreak of beriberi among African Union troops in Mogadishu, Somalia. PLoS One 2011; 6:e28345. [PMID: 22205947 PMCID: PMC3244391 DOI: 10.1371/journal.pone.0028345] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Accepted: 11/07/2011] [Indexed: 11/21/2022] Open
Abstract
Context and Objectives In July 2009, WHO and partners were notified of a large outbreak of unknown illness, including deaths, among African Union (AU) soldiers in Mogadishu. Illnesses were characterized by peripheral edema, dyspnea, palpitations, and fever. Our objectives were to determine the cause of the outbreak, and to design and recommend control strategies. Design, Setting, and Participants The illness was defined as acute onset of lower limb edema, with dyspnea, chest pain, palpitations, nausea, vomiting, abdominal pain, or headache. Investigations in Nairobi and Mogadishu included clinical, epidemiologic, environmental, and laboratory studies. A case-control study was performed to identify risk factors for illness. Results From April 26, 2009 to May 1, 2010, 241 AU soldiers had lower limb edema and at least one additional symptom; four patients died. At least 52 soldiers were airlifted to hospitals in Kenya and Uganda. Four of 31 hospitalized patients in Kenya had right-sided heart failure with pulmonary hypertension. Initial laboratory investigations did not reveal hematologic, metabolic, infectious or toxicological abnormalities. Illness was associated with exclusive consumption of food provided to troops (not eating locally acquired foods) and a high level of insecurity (e.g., being exposed to enemy fire on a daily basis). Because the syndrome was clinically compatible with wet beriberi, thiamine was administered to ill soldiers, resulting in rapid and dramatic resolution. Blood samples taken from 16 cases prior to treatment showed increased levels of erythrocyte transketolase activation coefficient, consistent with thiamine deficiency. With mass thiamine supplementation for healthy troops, the number of subsequent beriberi cases decreased with no further deaths reported. Conclusions An outbreak of wet beriberi caused by thiamine deficiency due to restricted diet occurred among soldiers in a modern, well-equipped army. Vigilance to ensure adequate micronutrient intake must be a priority in populations completely dependent upon nutritional support from external sources.
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