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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Background

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

Methods

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

Results

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

Conclusion

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

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

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

Syndromic surveillance during 2022 Uganda Martyrs' commemoration

Mass gatherings frequently include close, prolonged interactions between people, which presents opportunities for infectious disease transmission. Over 20,000 pilgrims gathered at Namugongo Catholic and Protestant shrines to commemorate 2022 Uganda Martyr's Day. We described syndromes suggestive of key priority diseases particularly COVID-19 and viral hemorrhagic fever (VHF) among visiting pilgrims during May 25-June 5, 2022. We conducted a survey among pilgrims at the catholic and protestant shrines based on signs and symptoms for key priority diseases: COVID-19 and VHF. A suspected COVID-19 case was defined as acute respiratory illness (temperature greater 37.5°C and at least one sign/symptom of respiratory infection such as cough or shortness of breath) whereas a suspected VHF case was defined as fever >37.5°C and unexplained bleeding among pilgrims who visited Namugongo Catholic and Protestant shrines from May 25 to June 5, 2022. Pilgrims were sampled systematically at entrances and demarcated zonal areas to participate in the survey. Additionally, we extracted secondary data on pilgrims who sought emergency medical services from Health Management Information System registers. Descriptive analysis was conducted to identify syndromes suggestive of key priority diseases. Among 1,350 pilgrims interviewed, 767 (57%) were female. The mean age was 37.9 (±17.9) years. Nearly all pilgrims 1,331 (98.6%) were Ugandans. A total of 236 (18%) reported ≥1 case definition symptom and 42 (3%) reported ≥2 symptoms. Thirty-nine (2.9%) were suspected COVID-19 cases and three (0.2%) were suspected VHF cases from different regions of Uganda. Among 5,582 pilgrims who sought medical care from tents, 628 (11.3%) had suspected COVID-19 and one had suspected VHF. Almost one in fifty pilgrims at the 2022 Uganda Martyrs' commemoration had at least one symptom of COVID-19 or VHF. Intensified syndromic surveillance and planned laboratory testing capacity at mass gatherings is important for early detection of public health emergencies that could stem from such events.

Evaluation of malaria outbreak detection methods, Uganda, 2022

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Investigation of a bacterial meningitis cluster in a refugee settlement, Obongi District, Uganda, March 2023

On 6 March 2023, Neisseria meningitidis serogroup C was isolated from a cerebral spinal fluid sample from Obongi District, Uganda. This sample was one of many from patients who were presenting with fever, convulsions, and altered consciousness. We investigated to determine the scope of the meningitis cluster, identify risk factors of contracting meningitis, and inform control measures. We reviewed medical records, conducted active community case finding, and conducted key informant interviews in the affected communities to identify cases and factors associated with contracting meningitis. We analysed case data by person, place, and time. Between 22 December 2022 and 1 May 2023, 25 cases with 2 deaths of bacterial meningitis occurred in Palorinya Refugee Settlement, Obongi District. Of these, 4 were laboratory-confirmed with Neisseria meningitidis serogroup C, 6 were probable cases, and 15 were suspected cases. Most (76%) of case-patients were <18 years old with a median age of 12 years (range 1-66 years). None of the case-patients was vaccinated against Neisseria meningitidis serogroup C. Each case-patient was from a different household and there was no epidemiological link between any of the cases. This meningococcal meningitis cluster caused by Neisseria meningitidis serogroup C occurred among non-vaccinated persons mostly aged <18 years in Palorinya Refugee Settlement. We recommended vaccination of at-risk persons.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Introduction

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

Methods

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

Results

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

Conclusion

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

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

Introduction

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

Methods

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

Results

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

Conclusion

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

High blood pressure and associated factors among HIV-infected young persons aged 13 to 25 years at selected health facilities in Rwenzori region, western Uganda, September-October 2021

BACKGROUND

High blood pressure (HBP), including hypertension (HTN), is a predictor of cardiovascular events, and is an emerging challenge in young persons. The risk of cardiovascular events may be further amplified among people living with HIV (PLHIV). We determined the prevalence of HBP and associated factors among PLHIV aged 13 to 25 years in Rwenzori region, western Uganda.

METHODS

We conducted a cross-sectional study among PLHIV aged 13 to 25 years at nine health facilities in Kabarole and Kasese districts during September 16 to October 15, 2021. We reviewed medical records to obtain clinical and demographic data. At a single clinic visit, we measured and classified BP as normal (< 120/ < 80 mmHg), elevated (120/ < 80 to 129/ < 80), stage 1 HTN (130/80 to 139/89), and stage 2 HTN (≥ 140/90). We categorized participants as having HBP if they had elevated BP or HTN. We performed multivariable analysis using modified Poisson regression to identify factors associated with HBP.

RESULTS

Of the 1,045 PLHIV, most (68%) were female and the mean age was 20 (3.8) years. The prevalence of HBP was 49% (n = 515; 95% confidence interval [CI], 46%-52%), the prevalence of elevated BP was 22% (n = 229; 95% CI, 26%-31%), and the prevalence of HTN was 27% (n = 286; 95% CI, 25%-30%), including 220 (21%) with stage 1 HTN and 66 (6%) with stage 2 HTN. Older age (adjusted prevalence ratio [aPR], 1.21; 95% CI, 1.01-1.44 for age group of 18-25 years vs. 13-17 years), history of tobacco smoking (aPR, 1.41; 95% CI, 1.08-1.83), and higher resting heart rate (aPR, 1.15; 95% CI, 1.01-1.32 for > 76 beats/min vs. ≤ 76 beats/min) were associated with HBP.

CONCLUSIONS

Nearly half of the PLHIV evaluated had HBP, and one-quarter had HTN. These findings highlight a previously unknown high burden of HBP in this setting's young populations. HBP was associated with older age, elevated resting heart rate, and ever smoking; all of which are known traditional risk factors for HBP in HIV-negative persons. To prevent future cardiovascular disease epidemics among PLHIV, there is a need to integrate HBP/HIV management.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Uganda's experience in establishing an electronic compendium for public health emergencies

Uganda has implemented several interventions that have contributed to prevention, early detection, and effective response to Public Health Emergencies (PHEs). However, there are gaps in collecting and documenting data on the overall response to these PHEs. We set out to establish a comprehensive electronic database of PHEs that occurred in Uganda since 2000. We constituted a core development team, developed a data dictionary, and worked with Health Information Systems Program (HISP)-Uganda to develop and customize a compendium of PHEs using the electronic Integrated Disease Surveillance and Response (eIDSR) module on the District Health Information Software version 2 (DHIS2) platform. We reviewed literature for retrospective data on PHEs for the compendium. Working with the Uganda Public Health Emergency Operations Center (PHEOC), we prospectively updated the compendium with real-time data on reported PHEs. We developed a user's guide to support future data entry teams. An operational compendium was developed within the eIDSR module of the DHIS2 platform. The variables for PHEs data collection include those that identify the type, location, nature and time to response of each PHE. The compendium has been updated with retrospective PHE data and real-time prospective data collection is ongoing. Data within this compendium is being used to generate information that can guide future outbreak response and management. The compendium development highlights the importance of documenting outbreak detection and response data in a central location for future reference. This data provides an opportunity to evaluate and inform improvements in PHEs response.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The potential distribution of Bacillus anthracis suitability across Uganda using INLA

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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

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

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

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

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

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

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

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

Background

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

Methods

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

Results

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

Conclusion

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

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

Background

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

Methods

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

Results

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

Conclusion

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

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

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

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

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

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

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

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

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

Investigation of a COVID-19 Outbreak at a Regional Prison, Northern Uganda, September 2020

Despite implementing measures to prevent introduction of COVID-19 in prisons, a COVID-19 outbreak occurred at Moroto Prison, northern Uganda in September 2020. We investigated factors associated with the introduction and spread of COVID-19 in the prison. A case was PCR-confirmed SARS-CoV-2 infection in a prisoner/staff at Moroto Prison during August-September 2020. We reviewed prison medical records to identify case-patients and interviewed prison and hospital staff to understand possible infection mechanisms for the index case-patient and opportunities for spread. In a retrospective cohort study, we interviewed all prisoners and available staff to identify risk factors. Data were analyzed using log-binomial regression. On September 1, 2020, a recently-hospitalized prisoner with unrecognized SARS-CoV-2 infection was admitted to Moroto Prison quarantine. He had become infected while sharing a hospital ward with a subsequently-diagnosed COVID-19 patient. A sample taken from the hospitalized prisoner on August 20 tested positive on September 3. Mass reactive testing at the prison on September 6, 14, and 15 revealed infection among 202/692 prisoners and 8/90 staff (overall attack rate=27%). One prison staff and one prisoner who cared for the sick prisoner while at the hospital re-entered the main prison without quarantining. Both tested positive on September 6. Food and cleaning service providers also regularly transited between quarantine and unrestricted prison areas. Using facemasks >50% of the time (adjusted risk ratio [aRR]=0.26; 95%CI: 0.13-0.54), or in combination with handwashing after touching surfaces (aRR=0.25; 95%CI: 0.14-0.46) were protective. Prisoners recently transferred from other facilities to Moroto Prison had an increased risk of infection (aRR=1.50; 95%CI: 1.02-2.22). COVID-19 was likely introduced into Moroto Prison quarantine by a prisoner with hospital-acquired infection and delayed test results, and/or by caretakers who were not quarantined after hospital exposures. The outbreak may have amplified via shared food/cleaning service providers who transited between quarantined and non-quarantined prisoners. Facemasks and handwashing were protective. Reduced test turnaround time for the hospitalized prisoner could have averted this outbreak. Testing incoming prisoners for SARS-CoV-2 before quarantine, providing unrestricted soap/water for handwashing, and universal facemask use in prisons could mitigate risk of future outbreaks.

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

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

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

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

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

Background

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

Methods

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

Results

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

Conclusions

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

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

Background

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

Methods

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

Results

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

Conclusions

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Cutaneous anthrax associated with handling carcasses of animals that died suddenly of unknown cause: Arua District, Uganda, January 2015-August 2017

BACKGROUND

Anthrax is a zoonotic disease that can be transmitted to humans from infected animals. During May-June 2017, three persons with probable cutaneous anthrax were reported in Arua District, Uganda; one died. All had recently handled carcasses of livestock that died suddenly and a skin lesion from a deceased person tested positive by PCR for Bacillus anthracis. During July, a bull in the same community died suddenly and the blood sample tested positive by PCR for Bacillus anthracis. The aim of this investigation was to establish the scope of the problem, identify exposures associated with illness, and recommend evidence-based control measures.

METHODS

A probable case was defined as acute onset of a papulo-vesicular skin lesion subsequently forming an eschar in a resident of Arua District during January 2015-August 2017. A confirmed case was a probable case with a skin sample testing positive by polymerase chain reaction (PCR) for B. anthracis. Cases were identified by medical record review and active community search. In a case-control study, exposures between case-patients and frequency- and village-matched asymptomatic controls were compared. Key animal health staff were interviewed to learn about livestock deaths.

RESULTS

There were 68 case-patients (67 probable, 1 confirmed), and 2 deaths identified. Cases occurred throughout the three-year period, peaking during dry seasons. All cases occurred following sudden livestock deaths in the villages. Case-patients came from two neighboring sub-counties: Rigbo (attack rate (AR) = 21.9/10,000 population) and Rhino Camp (AR = 1.9/10,000). Males (AR = 24.9/10,000) were more affected than females (AR = 0.7/10,000). Persons aged 30-39 years (AR = 40.1/10,000 population) were most affected. Among all cases and 136 controls, skinning (ORM-H = 5.0, 95%CI: 2.3-11), butchering (ORM-H = 22, 95%CI: 5.5-89), and carrying the carcass of livestock that died suddenly (ORM-H = 6.9, 95%CI: 3.0-16) were associated with illness.

CONCLUSIONS

Exposure to carcasses of animals that died suddenly was a likely risk factor for cutaneous anthrax in Arua District during 2015-2017. The recommendations are investigation of anthrax burden in livestock, prevention of animal infections through vaccinations, safe disposal of the carcasses, public education on risk factors for infection and prompt treatment of illness following exposure to animals that died suddenly.

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

Background

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

Methods

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

Results

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

Conclusion

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

Outbreak of Anthrax Associated with Handling and Eating Meat from a Cow, Uganda, 2018

On April 20, 2018, the Kween District Health Office in Kween District, Uganda reported 7 suspected cases of human anthrax. A team from the Uganda Ministry of Health and partners investigated and identified 49 cases, 3 confirmed and 46 suspected; no deaths were reported. Multiple exposures from handling the carcass of a cow that had died suddenly were significantly associated with cutaneous anthrax, whereas eating meat from that cow was associated with gastrointestinal anthrax. Eating undercooked meat was significantly associated with gastrointestinal anthrax, but boiling the meat for >60 minutes was protective. We recommended providing postexposure antimicrobial prophylaxis for all exposed persons, vaccinating healthy livestock in the area, educating farmers to safely dispose of animal carcasses, and avoiding handling or eating meat from livestock that died of unknown causes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Cutaneous anthrax outbreak associated with handling dead animals, Rhino Camp sub-county: Arua District, Uganda, January-May 2018

BACKGROUND

On 18 January 2018 a 40 year old man presented with skin lesions at Rhino Camp Health Centre. A skin lesion swab was collected on 20 January 2018 and was confirmed by PCR at Uganda Virus Research Institute on 21 January 2018. Subsequently, about 9 persons were reported to have fallen ill after reporting contact with livestock that died suddenly. On 9 February 2018, Arua District notified Uganda Ministry of Health of a confirmed anthrax outbreak among humans in Rhino Camp sub-county. We investigated to determine the scope and mode of transmission and exposures associated with identified anthrax to guide control and prevention measures.

METHODS

We defined a suspected cutaneous anthrax case as onset of skin lesions (e.g., papule, vesicle, or eschar) in a person residing in Rhino Camp sub-county, Arua District from 25 December 2017 to 31 May 2018. A confirmed case was a suspected case with PCR-positivity for Bacillus anthracis from a clinical sample. We identified cases by reviewing medical records at Rhino Camp Health Centre. We also conducted additional case searches in the affected community with support from Community Health Workers. In a retrospective cohort study, we interviewed all members of households in which at least one person had contact with the carcasses of or meat from animals suspected to have died of anthrax. We collected and tested hides of implicated animals using an anthrax rapid diagnostic test.

RESULTS

We identified 14 case-patients (1 confirmed, 13 suspected); none died. Only males were affected (affected proportion: 12/10,000). Mean age of case-persons was 33 years (SD: 22). The outbreak lasted for 5 months, from January 2018-May 2018, peaking in February. Skinning (risk ratio = 2.7, 95% CI = 1.1-6.7), dissecting (RR = 3.0, 95% CI = 1.2-7.6), and carrying dead animals (RR = 2.7, 95% CI = 1.1-6.7) were associated with increased risk of illness, as were carrying dissected parts of animals (RR = 2.9, 95% CI 1.3-6.5) and preparing and cooking the meat (RR = 2.3, 95% CI 0.9-5.9). We found evidence of animal remains on pastureland.

CONCLUSION

Multiple exposures to the hides and meat of animals that died suddenly were associated with this cutaneous anthrax outbreak in Arua District. We recommended public education about safe disposal of carcasses of livestock that die suddenly.

Violence and discrimination among Ugandan residents during the COVID-19 lockdown

Background

In March 2020, the World Health Organization (WHO) declared COVID-19 a pandemic. Many countries in Sub-Saharan Africa, Uganda inclusive, implemented lockdowns, curfew, banning of both private and public transport systems, and mass gatherings to minimize spread. Social control measures for COVID-19 are reported to increase violence and discrimination globally, including in Uganda as some may be difficult to implement resulting in the heavy deployment of law enforcement. Media reports indicated that cases of violence and discrimination had increased in Uganda’s communities following the lockdown. We estimated the incidence and factors associated with experiencing violence and discrimination among Ugandans during the COVID-19 lockdown to inform control and prevention measures.

Methods

In April 2020, we conducted a secondary analysis of cross-sectional data under the International Citizen Project (ICP) to assess adherence to public health measures and their impact on the COVID-19 outbreak in Uganda. We analyzed data on violence and discrimination from the ICP study. We performed descriptive statistics for all the participants’ characteristics and created a binary outcome variable called experiencing violence and/or discrimination. We performed logistic regression analysis to identify the factors associated with experiencing violence and discrimination.

Results

Of the 1726 ICP study participants, 1051 (58.8%) were males, 841 (48.7%) were currently living with a spouse or partner, and 376 (21.8%) had physically attended work for more than 3 days in the past week. Overall, 145 (8.4%) experienced any form of violence and/or discrimination by any perpetrator, and 46 (31.7%) of the 145 reported that it was perpetrated by a law enforcement officer. Factors associated with experiencing violence or discrimination were: being male (AOR = 1.60 CI:1.10–2.33), having attended work physically for more than 3 days in the past week (AOR = 1.52 CI:1.03–2.23), and inability to access social or essential health services since the epidemic started (AOR = 3.10 CI:2.14–4.50).

Conclusion

A substantial proportion of Ugandan residents experienced violence and/or discrimination during the COVID-19 lockdown, mostly perpetrated by law enforcement officers. We recommend mitigation of the collateral impact of lockdowns with interventions that focus on improving policing quality, ensuring continuity of essential services, and strengthening support systems for vulnerable groups including males.

Timing of onset of symptom for COVID-19 from publicly reported confirmed cases in Uganda

INTRODUCTION

incubation period for COVID-19, 2-14 (average 5-6) days. Timing of onset of COVID-19 signs and symptoms amongst cases in Uganda is however not known.

METHODS

we utilized data on real-time reverse transcription polymerase chain reaction (RT-PCR) confirmed cases to investigate symptom onset timing, from 21st March to 4th September 2020. Since timing of COVID-19 symptom onset is highly likely to be an interval rather than a point estimate, we generated 3-tertile categories: 1st, 2nd and 3rd tertile denoting symptom presentation within 3, 4 to 6 and at least 7 days. We considered all signs and symptoms in the database and analysed using Chi-square test and multinomial logistic regression, controlling for age and sex.

RESULTS

we analysed a total of 420 symptomatic case-patients; 72.0% were males, median age of 33 years. Common symptoms were cough (47.6%), running nose (46.2%), fever (27.4%), headache (26.4%) and sore throat (20.5%). We utilized 293 cases with clinical symptom onset date recorded. Most of the patients, 37.5%, presented symptom within 3 days, 31.4% had symptoms in the 2nd and 31.4% in 3rd tertile, denoting 4 to 6 days and at least 7 days after exposure. Running nose (RRR=0.45, 95%CI: 0.24-0.84) and chest pain (RRR=0.64, 95%CI: 0.09-0.72) were more likely to occur in 3rd tertile than 1st or 2nd tertile. Cases aged ≥20 years were less likely to have symptoms in the 1st and 2nd tertile compared to ≤20 years (p<0.05).

CONCLUSION

our study provides empirical evidence for epidemiological characterization of cases by signs and symptoms which complements current proposals for the length of active monitoring of persons exposed to SARS-CoV-2.

Level and Determinants of Adherence to COVID-19 Preventive Measures in the First Stage of the Outbreak in Uganda

We conducted an online survey in the first two months of the Coronavirus Disease 2019 (COVID-19) epidemic in Uganda to assess the level and determinants of adherence to and satisfaction with the COVID-19 preventive measures recommended by the government. We generated Likert scales for adherence and satisfaction outcome variables and measured them with four preventive measures, including handwashing, wearing face masks, physical distancing, and coughing/sneezing hygiene. Of 1726 respondents (mean age: 36 years; range: 12–72), 59% were males, 495 (29%) were adherent to, and 545 (32%) were extremely satisfied with all four preventive measures. Adherence to all four measures was associated with living in Kampala City Centre (AOR: 1.7, 95% CI: 1.1–2.6) and receiving COVID-19 information from health workers (AOR: 1.2, 95% CI: 1.01–1.5) or village leaders (AOR: 1.4, 95% CI: 1.02–1.9). Persons who lived with younger siblings had reduced odds of adherence to all four measures (AOR: 0.75, 95% CI: 0.61–0.93). Extreme satisfaction with all four measures was associated with being female (AOR: 1.3, 95% CI: 1.1–1.6) and health worker (AOR: 1.2, 95% CI: 1.0–1.5). Experiencing violence at home (AOR: 0.25, 95% CI: 0.09–0.67) was associated with lower satisfaction. Following reported poor adherence and satisfaction with preventive measures, behavior change programs using health workers should be expanded throughout, with emphasis on men.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Background

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

Methods

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

Results

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

Conclusions

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

Ebola Virus Disease Preparedness Assessment and Risk Mapping in Uganda, August-September 2018

Uganda's proximity to the tenth Ebola virus disease (EVD) outbreak in the Democratic Republic of the Congo (DRC) presents a high risk of cross-border EVD transmission. Uganda conducted preparedness and risk-mapping activities to strengthen capacity to prevent EVD importation and spread from cross-border transmission. We adapted the World Health Organization (WHO) EVD Consolidated Preparedness Checklist to assess preparedness in 11 International Health Regulations domains at the district level, health facilities, and points of entry; the US Centers for Disease Control and Prevention (CDC) Border Health Capacity Discussion Guide to describe public health capacity; and the CDC Population Connectivity Across Borders tool kit to characterize movement and connectivity patterns. We identified 40 ground crossings (13 official, 27 unofficial), 80 health facilities, and more than 500 locations in 12 high-risk districts along the DRC border with increased connectivity to the EVD epicenter. The team also identified routes and congregation hubs, including origins and destinations for cross-border travelers to specified locations. Ten of the 12 districts scored less than 50% on the preparedness assessment. Using these results, Uganda developed a national EVD preparedness and response plan, including tailored interventions to enhance EVD surveillance, laboratory capacity, healthcare professional capacity, provision of supplies to priority locations, building treatment units in strategic locations, and enhancing EVD risk communication. We identified priority interventions to address risk of EVD importation and spread into Uganda. Lessons learned from this process will inform strategies to strengthen public health emergency systems in their response to public health events in similar settings.

Factors Associated with Utilisation of Couple HIV Counselling and Testing Among HIV-Positive Adults in Kyoga Fishing Community Uganda, May 2017: Cross Sectional Study

Couple HIV counseling and testing (CHCT) is key in preventing heterosexual HIV transmission and achievement of 90-90-90 UNAIDS treatment targets by 2020. We conducted secondary data analysis to assess utilization of CHCT and associated factors using logistic regression. 58/134 participants (49%) had ever utilized CHCT. Disclosure of individual HIV results to a partner [aOR = 16; 95% CI: (3.6-67)], residence for > 1 < 5 years [aOR = 0.04; 95% CI (0.005-0.33)], and none mobility [aOR = 3.6; 95% CI (1.1-12)] were significantly associated with CHCT. Age modified relationship between CHCT and disclosure (Likelihood-ratio test LR chi2 = 4.2 (p value = 0.041). Disclosure of individual HIV results with a partner and residence for more than 1 year improved utilization of CHCT; mobility reduced the odds of CHCT. Interventions should target prior discussion of individual HIV results among couples and mobile populations to increase CHCT.

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

Background

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

Methods

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

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

Results

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

Conclusion

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

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

Background

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

Methods

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

Results

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

Conclusions

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

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

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