Factors Associated with Virological Non-suppression among HIV-Positive Patients on Antiretroviral Therapy in Uganda, August 2014-July 2015.

BACKGROUND: Despite the growing number of people on antiretroviral therapy (ART), there is limited information about virological non-suppression and its determinants among HIV-positive (HIV+) individuals enrolled in HIV care in many resource-limited settings. We estimated the proportion of virologically non-suppressed patients, and identified the factors associated with virological non-suppression. METHODS: We conducted a descriptive cross-sectional study using routinely collected program data from viral load (VL) samples collected across the country for testing at the Central Public Health Laboratories (CPHL) in Uganda. Data were generated between August 2014 and July 2015. We extracted data on socio-demographic, clinical and VL testing results. We defined virological non-suppression as having ≥1000 copies of viral RNA/ml of blood for plasma or ≥5000 copies of viral RNA/ml of blood for dry blood spots. We used logistic regression to identify factors associated with virological non-suppression. RESULTS: The study was composed of 100,678 patients; of these, 94,766(94%) were for routine monitoring, 3492(4%) were suspected treatment failures while 1436(1%) were repeat testers after suspected failure. The overall proportion of non-suppression was 11%. Patients on routine monitoring registered the lowest (10%) proportion of non-suppressed patients. Virological non-suppression was higher among suspected treatment failures (29%) and repeat testers after suspected failure (50%). Repeat testers after suspected failure were six times more likely to have virological non-suppression (ORadj = 6.3, 95%CI = 5.5-7.2) when compared with suspected treatment failures (ORadj = 3.3, 95%CI = 3.0-3.6). The odds of virological non-suppression decreased with increasing age, with children aged 0-4 years (ORadj = 5.3, 95%CI = 4.6-6.1) and young adolescents (ORadj = 4.1, 95%CI = 3.7-4.6) registering the highest odds. Poor adherence (ORadj = 3.4, 95%CI = 2.9-3.9) and having active TB (ORadj = 1.9, 95%CI = 1.6-2.4) increased the odds of virological non-suppression. However, being on second/third line regimens (ORadj = 0.86, 95%CI = 0.78-0.95) protected patients against virological non-suppression. CONCLUSION: Young age, poor adherence and having active TB increased the odds of virological non-suppression while second/third line ART regimens were protective against non-suppression. We recommend close follow up and intensified targeted adherence support for repeat testers after suspected failure, children and adolescents

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

Marburg virus disease outbreak in Kween District Uganda, 2017: Epidemiological and laboratory findings.

INTRODUCTION: In October 2017, a blood sample from a resident of Kween District, Eastern Uganda, tested positive for Marburg virus. Within 24 hour of confirmation, a rapid outbreak response was initiated. Here, we present results of epidemiological and laboratory investigations. METHODS: A district task force was activated consisting of specialised teams to conduct case finding, case management and isolation, contact listing and follow up, sample collection and testing, and community engagement. An ecological investigation was also carried out to identify the potential source of infection. Virus isolation and Next Generation sequencing were performed to identify the strain of Marburg virus. RESULTS: Seventy individuals (34 MVD suspected cases and 36 close contacts of confirmed cases) were epidemiologically investigated, with blood samples tested for MVD. Only four cases met the MVD case definition; one was categorized as a probable case while the other three were confirmed cases. A total of 299 contacts were identified; during follow- up, two were confirmed as MVD. Of the four confirmed and probable MVD cases, three died, yielding a case fatality rate of 75%. All four cases belonged to a single family and 50% (2/4) of the MVD cases were female. All confirmed cases had clinical symptoms of fever, vomiting, abdominal pain and bleeding from body orifices. Viral sequences indicated that the Marburg virus strain responsible for this outbreak was closely related to virus strains previously shown to be circulating in Uganda. CONCLUSION: This outbreak of MVD occurred as a family cluster with no additional transmission outside of the four related cases. Rapid case detection, prompt laboratory testing at the Uganda National VHF Reference Laboratory and presence of pre-trained, well-prepared national and district rapid response teams facilitated the containment and control of this outbreak within one month, preventing nationwide and global transmission of the disease

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

Abstract Background In August 2017, the Uganda Ministry of Health was notified of increased cases of multidrug-resistant tuberculosis (MDR-TB) in Arua District, Uganda during 2017. We investigated to identify the scope of the increase and risk factors for infection, evaluate health facilities’ capacity to manage MDR-TB, and recommend evidence-based control measures. Methods We defined an MDR-TB case-patient as a TB patient attending Arua Regional Referral Hospital (ARRH) during 2013–2017 with a sputum sample yielding Mycobacterium tuberculosis resistant to at least rifampicin and isoniazid, confirmed by an approved drug susceptibility test. We reviewed clinical records from ARRH and compared the number of MDR-TB cases during January–August 2017 with the same months in 2013–2016. To identify risk factors specific for MDR-TB among cases with secondary infection, we conducted a case-control study using persons with drug-susceptible TB matched by sub-county of residence as controls. We observed infection prevention and control practices in health facilities and community, and assessed health facilities’ capacity to manage TB. Results We identified 33 patients with MDR-TB, of whom 30 were secondary TB infection cases. The number of cases during January–August 2017 was 10, compared with 3–4 cases in January–August from 2013 to 2016 (p = 0.02). Men were more affected than women (6.5 vs 1.6/100,000, p  15 months from symptom onset (aOR = 11, 95% CI: 1.5–87) were associated with MDR-TB. All ten facilities assessed reported stockouts of TB commodities. All 15 ambulatory MDR-TB patients we observed were not wearing masks given to them to minimize community infection. The MDR-TB ward at ARRH capacity was 4 patients but there were 11 patients. Conclusion The number of cases during January–August in 2017 was significantly higher than during the same months in 2013–2016. Poor adherence to TB drugs and delayed treatment initiation were associated with MDR-TB infection. We recommended strengthening directly-observed treatment strategy, increasing access to treatment services, and increasing the number of beds in the MDR-TB ward at ARRH

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

Abstract 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

Malaria Outbreak Facilitated by Appearance of Vector-Breeding Sites after Heavy Rainfall and Inadequate Preventive Measures: Nwoya District, Northern Uganda, February–May 2018

Background. Malaria is a leading cause of morbidity and mortality in Uganda. In April 2018, malaria cases surged in Nwoya District, Northern Uganda, exceeding expected limits and thereby requiring epidemic response. We investigated this outbreak to estimate its magnitude, identify exposure factors for transmission, and recommend evidence-based control measures. Methods. We defined a malaria case as onset of fever in a resident of Anaka subcounty, Koch Goma subcounty, and Nwoya Town Council, Nwoya District, with a positive rapid diagnostic test or microscopy for malaria from 1 February to 25 May 2018. We reviewed medical records in all health facilities of affected subcounties to find cases. In a case-control study, we compared exposure factors between case-persons and asymptomatic controls matched by age and village. We also conducted entomological assessments on vector density and behavior. Results. We identified 3,879 case-persons (attack rate [AR] = 6.5%) and two deaths (case-fatality rate = 5.2/10,000). Females (AR = 8.1%) were more affected than males (AR = 4.7%) (p<0.0001). Of all age groups, 5–18 years (AR = 8.4%) were most affected. Heavy rain started in early March 2018, and a propagated outbreak followed in the first week of April 2018. In the case-control study, 55% (59/107) of case-persons and 18% (19/107) of controls had stagnant water around households for several days following rainfall (ORM-H = 5.6, 95% CI = 3.0–11); 25% (27/107) of case-persons and 51% (55/107) of controls wore full extremity covering clothes during evening hours (ORM-H = 0.30, 95% CI = 0.20–0.60); 71% (76/107) of case-persons and 85% (91/107) of controls slept under a long-lasting insecticide-treated net (LLIN) 14 days before symptom onset (ORM-H = 0.43, 95% CI = 0.22–0.85); 37% (40/107) of case-persons and 52% (56/107) of controls had access to at least one LLIN per 2 household members (ORM-H = 0.54, 95% CI = 0.30–0.97). Entomological assessment indicated active breeding sites in the entire study area; Anopheles gambiae sensu lato species were the predominant vector. Conclusion. Increased vector-breeding sites after heavy rainfall and inadequate malaria preventive measures were found to have contributed to this outbreak. We recommended increasing coverage for LLINs and larviciding breeding sites in the area

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

Malaria incidence among children less than 5 years during and after cessation of indoor residual spraying in Northern Uganda

This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Background: In June 2015, a malaria epidemic was confirmed in ten districts of Northern Uganda; after cessation of indoor residual spraying (IRS). Epidemic was defined as an increase in incidence per month beyond one standard deviation above mean incidence of previous 5 years. Trends in malaria incidence among children-under-5-years were analysed so as to describe the extent of change in incidence prior to and after cessation of IRS. Methods: Secondary data on out-patient malaria case numbers for children-under-5-years July 2012 to June 2015 was electronically extracted from the district health management information software2 (DHIS2) for ten districts that had IRS and ten control districts that didn’t have IRS. Data was adjusted by reporting rates, cleaned by smoothing and interpolation and incidence of malaria per 1000 population derived. Population data obtained from 2002 and 2014 census reports. Data on interventions obtained from malaria programme reports, rainfall data obtained from Uganda National Meteorological Authority. Three groups of districts were created; two based on when IRS ended, the third not having IRS. Line graphs were plotted showing malaria incidence vis-à-vis implementation of IRS, mass net distribution and rainfall. Changes in incidence after withdrawal of IRS were obtained using incidence rate ratios (IRR). IRR was calculated as incidence for each month after the last IRS divided by incidence of the IRS month. Poisson regression was used to test statistical significance. Results: Incidence of malaria declined between spray activities in districts that had IRS. Decline in IRR for 4 months after last IRS month was greater in the sprayed than control districts. On the seventh month following cessation of IRS, incidence in sprayed districts rose above that of the last spray month [1.74: 95% CI (1.40–2.15); and 1.26: 95% CI (1.05–1.51)]. Rise in IRR continued from 1.26 to 2.62 (95% CI 2.21–3.12) in June 2015 for districts that ended IRS in April 2014. Peak in rainfall occurred in May 2015. Conclusion: There was sustained control of malaria incidence during IRS implementation. Following withdrawal and peak in rainfall, incidence rose to epidemic proportions. This suggests a plausible link between the malaria epidemic, peak in rainfall and cessation of IRS