Epidemiologic investigation of a cluster of deaths due to eating fried rice balls intentionally tainted with Quinalphos, Sironko District, Uganda, a case series, 2017

Background: Quinalphos is an organophosphate chemical chiefly used as a pesticide. On 13 November 2017, a cluster of unexplained deaths was reported in Village X, Sironko District, Eastern Uganda. We investigated to identify the scope and exposures for the cluster of deaths, and recommend control-measures. Case Presentation: We defined a suspected case as acute onset from 1-11 November 2017 of abdominal pain plus ≥1 of the following: vomiting, nasal bleeding, sweating, confusion, convulsion, loss of consciousness in a Village X resident. A confirmed case was a suspected case with a positive toxicological test of quinalphos by liquid chromatography. We reviewed clinical records and conducted active community case-finding. We investigated the exposure histories of case-patients, and inspected their homes for potential exposures. We identified 4 cases (including 1 confirmed) from a single household. The age range was six to fifty-two years; attack rate: 50%, 4/8, and case fatality rate: ¾ 75%. Symptoms included abdominal pain (100%), vomiting (75%), self-reported fever (50%), confusion (25%), convulsion (25%), loss of consciousness (25%), nasal bleeding (25%). Of the 4 case-patients, 3 had onset at 09:00hours and 1 at 19:00hours on 9 November 2017. The 4 case-patients shared 5 “bolingos” (fried rice balls) at 14:00hours, which had been given to case-patient A, a primary two level pupil (equivalent to the second grade in the US system) by an unknown person on her way home from school on 8 November. Case-patient A ate 1 bolingo and died within 35 hours, case-patient B ate 2 bolingos and died within 27 hours, case-patient D ate 1½ bolingo and died in 45 hours, case-patient C ate ½ bolingo, developed mild symptoms and survived. Additionally, 8 chickens also ate crumbs of the bolingo and died. A blood specimen of the lone survivor tested positive for quinalphos. After reading our report, police conducted a criminal investigation and found that the affected family had land disputes with a neighbour. One man was arrested and is awaiting trial. Conclusion: This fatal food-poisoning cluster of deaths was caused by eating bolingos (fried rice balls) intentionally tainted with quinalphos. We recommended strict control of pesticides, assessment of availability and use of pesticides in communities, and re-orientation of clinicians on case-presentation and management of organophosphate poisoning

The good, the bad, and the unknown: quality of clinical laboratories in Kampala, Uganda.

BACKGROUND: Clinical laboratories are crucial in addressing the high rates of communicable and non-communicable diseases seen in sub-Saharan Africa (SSA). However, the most basic information, such as the number and quality of clinical laboratories in SSA, is not available. The objective of this study was to create a practical method for obtaining this information in SSA towns and cities using an initial survey in Kampala, Uganda. METHODS: Kampala city was divided into 5 partially-overlapping regions. Each region was assigned to 2-3 surveyors who identified and surveyed laboratories in their respective regions; in person and on foot. A modified version of the World Health Organization - African Region (WHO/AFRO) Laboratory Strengthening Checklist was used to obtain baseline measures of quality for all clinical laboratories within Kampala city. The surveyors also measured other attributes of each laboratory, such as their affiliation (government, private etc), designation (national hospital, district hospital, standalone etc), staff numbers, and type of staff. RESULTS: The survey team identified and surveyed 954 laboratories in Kampala city. 96% of laboratories were private. Only 45 (5%) of the laboratories met or surpassed the lowest quality standards defined by the WHO/AFRO-derived laboratory strengthening tool (1-star). These 45 higher-quality laboratories were, on average, larger and had a higher number of laboratory-specific staff (technologists, phlebotomists etc) than the other 909 laboratories. 688 (72%) of the 954 laboratories were not registered with the Ministry of Health (MoH). CONCLUSIONS: This comprehensive evaluation of the number, scope, and quality of clinical laboratories in Kampala is the first published survey of its kind in sub-Saharan Africa. The survey findings demonstrated that laboratories in Kampala that had qualified personnel and those that had higher testing volumes, tended to be of higher-quality

Evaluation of the surveillance system in Kiryandongo Refugee Settlement, Kiryandongo District, Uganda, April 2017

Introduction: Integrated Disease Surveillance and Response (IDSR) involves surveillance of priority diseases and conditions, and is implemented in many African countries, including Uganda. During humanitarian emergencies, public health surveillance systems such as IDSR may face challenges. We assessed the capacity of health facilities (HF) in Kiryandongo District, a district with a large and recent refugee influx, to perform IDSR core functions. Methods: We visited five HF serving refugee settlements and one serving the host community. We interviewed HF in-charges, surveillance Focal Persons, and District Health Team (DHT) members about their capacity to perform IDSR. We reviewed paper-based forms in IDSR to evaluate system attributes during April 2016-March 2017. We determined the average weekly health Management Information System (HMIS) reporting rate for weeks 1-13 of 2017. Results: All HFs were well-staffed. However, half of the 12 suspected disease outbreaks reported in the past year were not investigated. The average weekly reporting rate was 79% (target: 80%). Barriers to IDSR included absence of standard case definition booklets (50%) and updated paper forms (67%), incomplete filling of registers, and inadequate data analysis (33%). The District Epidemic Preparedness and Response Committee (DEPRC) was non-functional. Conclusion: There was low capacity of the district to conduct IDSR, which could have slowed detection of and response to outbreaks. We recommended IDSR refresher trainings in two-year cycles and supplying guidelines to all HFs. The DEPRC and DHT should be strengthened through funding, regular meetings, and supplies of essential commodities

Men at risk; a qualitative study on HIV risk, gender identity and violence among men who have sex with men who report high risk behavior in Kampala, Uganda.

In Uganda, men who have sex with men (MSM) are at high risk for HIV. Between May 2008 and February 2009 in Kampala, Uganda, we used respondent driven sampling (RDS) to recruit 295 MSM≥18 years who reported having had sex with another man in the preceding three months. The parent study conducted HIV and STI testing and collected demographic and HIV-related behavioral data through audio computer-assisted self-administered interviews. We conducted a nested qualitative sub-study with 16 men purposively sampled from among the survey participants based on responses to behavioral variables indicating higher risk for HIV infection. Sub-study participants were interviewed face-to-face. Domains of inquiry included sexual orientation, gender identity, condom use, stigma, discrimination, violence and health seeking behavior. Emergent themes included a description of sexual orientation/gender identity categories. All groups of men described conflicting feelings related to their sexual orientation and contextual issues that do not accept same-sex identities or behaviors and non-normative gender presentation. The emerging domains for facilitating condom use included: lack of trust in partner and fear of HIV infection. We discuss themes in the context of social and policy issues surrounding homosexuality and HIV prevention in Uganda that directly affect men\u27s lives, risk and health-promoting behaviors

Ebola Hemorrhagic Fever Associated with Novel Virus Strain, Uganda, 2007–2008

Case-fatality rate is lower for this strain than for the other 3 Ebola species known to be pathogenic to humans

HIV Infection among Men Who Have Sex with Men in Kampala, Uganda–A Respondent Driven Sampling Survey

Uganda's generalized HIV epidemic is well described, including an estimated adult male HIV prevalence in Kampala of 4.5%, but no data are available on the prevalence of and risk factors for HIV infection among men who have sex with men (MSM).From May 2008 to February 2009, we used respondent-driven sampling to recruit MSM ≥18 years old in Kampala who reported anal sex with another man in the previous three months. We collected demographic and HIV-related behavioral data through audio computer-assisted self-administered interviews. Laboratory testing included biomarkers for HIV and other sexually transmitted infections. We obtained population estimates adjusted for the non-random sampling frame using RDSAT and STATA. 300 MSM were surveyed over 11 waves; median age was 25 years (interquartile range, 21-29 years). Overall HIV prevalence was 13.7% (95% confidence interval [CI] 7.9%-20.1%), and was higher among MSM ≥25 years (22.4%) than among MSM aged 18-24 years (3.9%, odds ratio [OR] 5.69, 95% CI 2.02-16.02). In multivariate analysis, MSM ≥25 years (adjusted OR [aOR] 4.32, 95% CI 1.33-13.98) and those reporting ever having been exposed to homophobic abuse (verbal, moral, sexual, or physical abuse; aOR 5.38, 95% CI 1.95-14.79) were significantly more likely to be HIV infected.MSM in Kampala are at substantially higher risk for HIV than the general adult male population. MSM reporting a lifetime history of homophobic abuse are at increased risk of being HIV infected. Legal challenges and stigma must be overcome to provide access to tailored HIV prevention and care services

HIV-1 prevalence and factors associated with infection in the conflict-affected region of North Uganda

BACKGROUND: Since 1986, northern Uganda has been severely affected by civil strife with most of its population currently living internally displaced in protected camps. This study aims at estimating the HIV-1 prevalence among this population and the factors associated with infection. METHODS: In June-December 2005, a total of 3051 antenatal clinics attendees in Gulu, Kitgum and Pader districts were anonymously tested for HIV-1 infection as part of routine sentinel surveillance. Factors associated with the infection were evaluated using logistic regression models. RESULTS: The age-standardised HIV-1 prevalence was 10.3%, 9.1% and 4.3% in the Gulu, Kitgum and Pader district, respectively. The overall prevalence in the area comprised of these districts was 8.2% when data was weighted according to the districts' population size. Data from all sites combined show that, besides older women [20–24 years: adjusted odds ratio (AOR) = 1.96, 95% confidence interval (CI): 1.29–2.97; 25–29 years: AOR = 2.01, 95% CI: 1.30–3.11; ≥ 30 years: AOR = 1.91, 95% CI: 1.23–2.97], unmarried women (AOR = 1.47, 95% CI: 1.06–2.04), and those with a partner with a non-traditional occupation (AOR = 1.62, 95% CI: 1.18–2.21), women living outside of protected camps for internally displaced persons have a higher risk of being HIV-1 infected than internally displaced women (AOR = 1.55, 95% CI: 1.15–2.08). CONCLUSION: Although published data from Gulu district show a declining HIV-1 prevalence trend that is consistent with that observed at the national level since 1993, the prevalence in North Uganda is still high. Internally displaced women have a lower risk of being infected probably because of their reduced mobility and accessibility, and increased access to health prevention services

Born in Bradford’s Age of Wonder cohort : protocol for adolescent data collection

Background Adolescence and transition into adulthood are periods shaping life-long mental health, cardiometabolic risk, and inequalities. However, they are poorly studied and understood. By extending and expanding the Born in Bradford (BiB) cohort study through this period using innovative, co-produced approaches to collect and analyse data, we aim to understand better the interplay of factors that influence health and wellbeing, and inform/evaluate interventions to improve them and reduce inequalities. Protocol BiB Age of Wonder (AoW) is a large, whole city cohort that will capture the contemporary lived experience amongst multi-ethnic adolescents progressing into young adulthood. We will collect repeated data from existing BiB participants and their peers (N~30,000 adolescents). The protocol for the first phase of the quantitative methods, involving survey measurements and health assessments in mainstream secondary schools is described here. We describe the co-production behind these methods, and lessons learned from the first year of data collection

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

BACKGROUND: Since the declaration of the 10th Ebola Virus Disease (EVD) outbreak in DRC on 1st Aug 2018, several neighboring countries have been developing and implementing preparedness efforts to prevent EVD cross-border transmission to enable timely detection, investigation, and response in the event of a confirmed EVD outbreak in the country. We describe Uganda's experience in EVD preparedness. RESULTS: On 4 August 2018, the Uganda Ministry of Health (MoH) activated the Public Health Emergency Operations Centre (PHEOC) and the National Task Force (NTF) for public health emergencies to plan, guide, and coordinate EVD preparedness in the country. The NTF selected an Incident Management Team (IMT), constituting a National Rapid Response Team (NRRT) that supported activation of the District Task Forces (DTFs) and District Rapid Response Teams (DRRTs) that jointly assessed levels of preparedness in 30 designated high-risk districts representing category 1 (20 districts) and category 2 (10 districts). The MoH, with technical guidance from the World Health Organisation (WHO), led EVD preparedness activities and worked together with other ministries and partner organisations to enhance community-based surveillance systems, develop and disseminate risk communication messages, engage communities, reinforce EVD screening and infection prevention measures at Points of Entry (PoEs) and in high-risk health facilities, construct and equip EVD isolation and treatment units, and establish coordination and procurement mechanisms. CONCLUSION: As of 31 May 2019, there was no confirmed case of EVD as Uganda has continued to make significant and verifiable progress in EVD preparedness. There is a need to sustain these efforts, not only in EVD preparedness but also across the entire spectrum of a multi-hazard framework. These efforts strengthen country capacity and compel the country to avail resources for preparedness and management of incidents at the source while effectively cutting costs of using a "fire-fighting" approach during public health emergencies

Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: A systematic analysis for the Global Burden of Disease Study 2017

Background: The Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017) includes a comprehensive assessment of incidence, prevalence, and years lived with disability (YLDs) for 354 causes in 195 countries and territories from 1990 to 2017. Previous GBD studies have shown how the decline of mortality rates from 1990 to 2016 has led to an increase in life expectancy, an ageing global population, and an expansion of the non-fatal burden of disease and injury. These studies have also shown how a substantial portion of the world's population experiences non-fatal health loss with considerable heterogeneity among different causes, locations, ages, and sexes. Ongoing objectives of the GBD study include increasing the level of estimation detail, improving analytical strategies, and increasing the amount of high-quality data. Methods: We estimated incidence and prevalence for 354 diseases and injuries and 3484 sequelae. We used an updated and extensive body of literature studies, survey data, surveillance data, inpatient admission records, outpatient visit records, and health insurance claims, and additionally used results from cause of death models to inform estimates using a total of 68 781 data sources. Newly available clinical data from India, Iran, Japan, Jordan, Nepal, China, Brazil, Norway, and Italy were incorporated, as well as updated claims data from the USA and new claims data from Taiwan (province of China) and Singapore. We used DisMod-MR 2.1, a Bayesian meta-regression tool, as the main method of estimation, ensuring consistency between rates of incidence, prevalence, remission, and cause of death for each condition. YLDs were estimated as the product of a prevalence estimate and a disability weight for health states of each mutually exclusive sequela, adjusted for comorbidity. We updated the Socio-demographic Index (SDI), a summary development indicator of income per capita, years of schooling, and total fertility rate. Additionally, we calculated differences between male and female YLDs to identify divergent trends across sexes. GBD 2017 complies with the Guidelines for Accurate and Transparent Health Estimates Reporting. Findings: Globally, for females, the causes with the greatest age-standardised prevalence were oral disorders, headache disorders, and haemoglobinopathies and haemolytic anaemias in both 1990 and 2017. For males, the causes with the greatest age-standardised prevalence were oral disorders, headache disorders, and tuberculosis including latent tuberculosis infection in both 1990 and 2017. In terms of YLDs, low back pain, headache disorders, and dietary iron deficiency were the leading Level 3 causes of YLD counts in 1990, whereas low back pain, headache disorders, and depressive disorders were the leading causes in 2017 for both sexes combined. All-cause age-standardised YLD rates decreased by 3·9% (95% uncertainty interval [UI] 3·1-4·6) from 1990 to 2017; however, the all-age YLD rate increased by 7·2% (6·0-8·4) while the total sum of global YLDs increased from 562 million (421-723) to 853 million (642-1100). The increases for males and females were similar, with increases in all-age YLD rates of 7·9% (6·6-9·2) for males and 6·5% (5·4-7·7) for females. We found significant differences between males and females in terms of age-standardised prevalence estimates for multiple causes. The causes with the greatest relative differences between sexes in 2017 included substance use disorders (3018 cases [95% UI 2782-3252] per 100 000 in males vs 1400 [1279-1524] per 100 000 in females), transport injuries (3322 [3082-3583] vs 2336 [2154-2535]), and self-harm and interpersonal violence (3265 [2943-3630] vs 5643 [5057-6302]). Interpretation: Global all-cause age-standardised YLD rates have improved only slightly over a period spanning nearly three decades. However, the magnitude of the non-fatal disease burden has expanded globally, with increasing numbers of people who have a wide spectrum of conditions. A subset of conditions has remained globally pervasive since 1990, whereas other conditions have displayed more dynamic trends, with different ages, sexes, and geographies across the globe experiencing varying burdens and trends of health loss. This study emphasises how global improvements in premature mortality for select conditions have led to older populations with complex and potentially expensive diseases, yet also highlights global achievements in certain domains of disease and injury