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

Risk factors for hematemesis in Hoima and Buliisa Districts, Western Uganda, September-October 2015

Introduction: On 17 September 2015, Buliisa District Health Office reported multiple deaths due to haemorrhage to the Uganda Ministry of Health. We conducted an investigation to verify the existence of an outbreak and to identify the disease nature, mode of transmission and risk factors.Methods: We defined a suspected case as onset of hematemesis between 1 June 2015 and 15 October 2015 in a resident of Hoima, Buliisa or neighbouring districts. We identified cases by reviewing medical records and actively searching in the community. We interviewed casepatients and health-care workers and performed descriptive epidemiology to generate hypotheses on possible exposures. In a case-control study we compared exposures between 21 cases and 81 controls, matched by age (± 10 years), sex and village of residence. We collected 22 biological specimens from 19 case-patients to test for Viral Haemorrhagic Fevers (VHF). We analysed the data using the Mantel-Haenszel method to account for the matched study design.Results: We identified 56 cases with onset from June to October (attack rate 15/100,000 in Buliisa District and 5.2/100,000 in Hoima District). The age-specific attack rate was highest in persons aged 31-60 years (15/100,000 in Hoima and 47/100,000 in Buliisa); no persons below 15 years of age had the illness. In the case-control study, 42% (5/12) of cases vs. 0.0% (0/77) of controls had liver disease (ORM-H = ∞; 95%CI = 3.7-∞); 71% (10/14) of cases vs. 35% (28/81) of controls had ulcer disease (ORM-H = 13; 95% CI = 1.6-98); 27% (3/11) of cases vs. 14% (11/81) of controls used indomethacin prior to disease onset (ORM-H = 6.0; 95% CI = 1.0-36). None of the blood samples were positive for any of the VHFs.Conclusion: This reported cluster of hematemesis illness was due to predisposing conditions and use of Non- Steroidal Anti-inflammatory Drugs (NSAID). Health education should be conducted on the danger of NSAIDs misuse, especially in persons with predisposing conditions.Keywords: Hematemesis, outbreak, case-control, Ugand

Prompt response to a cross-border plague outbreak in Zombo District, minimized spread, Uganda, March 2019

Introduction: Plague, which is caused by the bacterium Yersinia pestis, is a priority zoonotic disease targeted for elimination in Uganda. On 6 March 2019, the Uganda Ministry of Health was notified of a patient in Zombo District with clinical presentation similar to pneumonic plague, and a positive plague rapid diagnostic test (RDT). We determined the scope of the outbreak, determined the mode of transmission, and recommended evidence-based control and prevention measures. Methods: A suspected pneumonic plague case was one with two or more of the following signs and symptoms: cough (bloody or wet), chest pain, difficulty in breathing, or fever in a resident of Zombo District during February 1-March 31, 2019. A confirmed case was a suspected case testing positive for Yersinia pestis by rapid diagnostic test, culture or serology. We actively searched for case-patients, traced contacts and took samples as appropriate. We performed descriptive epidemiology of the outbreak. Results: We identified one suspected and one confirmed pneumonic plague case. On February 26, 2019, a 4-year-old boy was buried in DRC near the Uganda border after succumbing to bubonic plague. Case-patient A (35-year-old mother to the boy), fell ill with suspected pneumonic plague while attending to him. She was referred to a health facility in Uganda on February 28 but died on arrival. On March 4, Case-patient B (23-year-old sister to Case-patient A), presented with pneumonic plague symptoms to the same Uganda facility and tested plague-positive by RDT, culture, and serological tests. Contacts (n=114) were traced and given prophylaxis; no new cases were reported. Conclusion: This fatal plague outbreak started as bubonic and later manifested as pneumonic. There was cross-border spread from DRC to Uganda with no cross-border efforts at prevention and control. Person-to-person transmission appears to have occurred. The quick and effective response likely minimized spread

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

Factors associated with access to food and essential medicines among Ugandans during the COVID-19 lockdown: a cross-sectional study

Introduction: Many sub-Saharan African countries implemented lockdowns, curfew, and restricted movements among other strategies to control and prevent the spread of COVID-19. These measures caused problems of access to food and essential medicines. We evaluated the importance of this problem in Uganda. Methods: In April 2020, we organized an online survey using a questionnaire to investigate the adherence to COVID-19 preventive measures and the impact of COVID-19. We used a modified Poisson regression analysis to identify factors associated with difficulties to access food or essential medicines. Results: Of the 1,726 study participants, 1,015 (58.8%) were males, 1,660 (92.6%) had at least tertiary level of education, 734 (42.5%) reported difficulties to obtain food. Of the 300 with a chronic illness, 107 (35.7%) experienced difficulties in accessing medication and 40 (13.3%) completely discontinued medication in the past week. Experiencing violence (Adjusted POR=1.61 CI:1.31 -1.99) was associated with difficulties accessing food or essential medicines while increasing age was associated with lower odds of experiencing difficulties (Adjusted POR= 0.97 CI: 0.96 – 0.98). Conclusion: This study confirms the reports that the strict lockdown measures implemented in Uganda made it difficult for Ugandan citizens to access food and essential medicines. Lockdown measures should be accompanied by interventions that ensure the continuity of access to food and essential medicines

Severe morbidity and hospital-based mortality from Rift Valley fever disease between November 2017 and March 2020 among humans in Uganda

Background: Rift Valley fever (RVF) is a zoonotic viral disease of increasing intensity among humans in Africa and the Arabian Peninsula. In Uganda, cases reported prior to 2016 were mild or not fully documented. We report in this paper on the severe morbidity and hospital-based mortality of human cases in Uganda. Methods: Between November 2017 and March 2020 human cases reported to the Uganda Virus Research Institute (UVRI) were confirmed by polymerase chain reaction (PCR). Ethical and regulatory approvals were obtained to enrol survivors into a one-year follow-up study. Data were collected on socio-demographics, medical history, laboratory tests, potential risk factors, and analysed using Stata software. Results: Overall, 40 cases were confirmed with acute RVF during this period. Cases were not geographically clustered and nearly all were male (39/40; 98%), median age 32 (range 11–63). The median definitive diagnosis time was 7 days and a delay of three days between presumptive and definitive diagnosis. Most patients (31/40; 78%) presented with fever and bleeding at case detection. Twenty-eight (70%) cases were hospitalised, out of whom 18 (64%) died. Mortality was highest among admissions in regional referral (11/16; 69%) and district (4/5; 80%) hospitals, hospitalized patients with bleeding at case detection (17/27; 63%), and patients older than 44 years (9/9; 100%). Survivors mostly manifested a mild gastro-intestinal syndrome with nausea (83%), anorexia (75%), vomiting (75%), abdominal pain (50%), and diarrhoea (42%), and prolonged symptoms of severe disease including jaundice (67%), visual difficulties (67%), epistaxis (50%), haemoptysis (42%), and dysentery (25%). Symptom duration varied between two to 120 days. Conclusion: RVF is associated with high hospital-based mortality, severe and prolonged morbidity among humans that present to the health care system and are confirmed by PCR. One-health composite interventions should be developed to improve environmental and livestock surveillance, prevent infections, promptly detect outbreaks, and improve patient outcomes

Estimating the costs of responding to a measles outbreak: Buvuma Islands, Lake Victoria, Uganda, February-May 2017

Introduction: Despite the strong prevention efforts by the Uganda Ministry of Health (MOH), measles outbreaks continue to occur. The MOH responded to a measles outbreak in the hard to reach areas of Buvuma Islands, identifying 54 case-patients, 4 of whom developed complications and were hospitalized. We defined a measles case as; Any suspected case with a positive measles IgM antibodies or detection of measles viral RNA by PCR in a suspected case. We estimated the provider cost of responding to this outbreak, cost of prevention, and the cost the government would have saved with effective prevention. Methods: We interviewed health facility in charges, record clerks, and measles cases to collect information on patient management and days of illness. Using an itemized form, we systematically collected data on quantities and unit costs of all the resource inputs for both direct and indirect costs at national, district, and facility levels. Medical costs referred to hospital and clinic costs for medications, supplies, utilities, transport, and personnel; non-medical costs included those associated with person-hours spent on the outbreak investigation and control effort. Results: The overall cost of investigating and controlling this outbreak was $16,459.50 (including$5,526.30) of medical costs, $10,733.20 of non-medical costs) and the cost per capita of number of children 6months-5years was$117.80 (16,259.5/138 (number of children 6months-5years. This is the target for measles intensified immunization following an outbreak). Conclusion: The total cost incurred in this outbreak is four fold the amount needed to vaccinate all children in Buvuma which would have averted the outbreak. We recommended strengthening vaccination services in the entire country, especially hard-to-reach areas, to enable the government forego the extra cost and morbidity associated with outbreak control

The COVID-19 pandemic in the African continent.

In December 2019, a new coronavirus, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and associated disease, coronavirus disease 2019 (COVID-19), was identified in China. This virus spread quickly and in March, 2020, it was declared a pandemic. Scientists predicted the worst scenario to occur in Africa since it was the least developed of the continents in terms of human development index, lagged behind others in achievement of the United Nations sustainable development goals (SDGs), has inadequate resources for provision of social services, and has many fragile states. In addition, there were relatively few research reporting findings on COVID-19 in Africa. On the contrary, the more developed countries reported higher disease incidences and mortality rates. However, for Africa, the earlier predictions and modelling into COVID-19 incidence and mortality did not fit into the reality. Therefore, the main objective of this forum is to bring together infectious diseases and public health experts to give an overview of COVID-19 in Africa and share their thoughts and opinions on why Africa behaved the way it did. Furthermore, the experts highlight what needs to be done to support Africa to consolidate the status quo and overcome the negative effects of COVID-19 so as to accelerate attainment of the SDGs

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

BACKGROUND: A cholera outbreak started on 29 February in Bwikhonge Sub-county, Bulambuli District in Eastern Uganda. Local public health authorities implemented initial control measures. However, in late March, cases sharply increased in Bwikhonge Sub-county. We investigated the outbreak to determine its scope and mode of transmission, and to inform control measures. METHODS: We defined a suspected case as sudden onset of watery diarrhea from 1 March 2016 onwards in a resident of Bulambuli District. A confirmed case was a suspected case with positive stool culture for V. cholerae. We conducted descriptive epidemiologic analysis of the cases to inform the hypothesis on mode of transmission. To test the hypothesis, we conducted a case-control study involving 100 suspected case-patients and 100 asymptomatic controls, individually-matched by residence village and age. We collected seven water samples for laboratory testing. RESULTS: We identified 108 suspected cases (attack rate: 1.3%, 108/8404), including 7 confirmed cases. The case-control study revealed that 78% (78/100) of case-patients compared with 51% (51/100) of control-persons usually collected drinking water from the nearby Cheptui River (ORMH = 7.8, 95% CI = 2.7-22); conversely, 35% (35/100) of case-patients compared with 54% (54/100) of control-persons usually collected drinking water from borehole pumps (ORMH = 0.31, 95% CI = 0.13-0.65). The index case in Bwikhonge Sub-county had onset on 29 February but the outbreak had been on-going in the neighbouring sub-counties in the previous 3 months. V. cholera was isolated in 2 of the 7 river water samples collected from different locations. CONCLUSIONS: We concluded that this cholera outbreak was caused by drinking contaminated water from Cheptui River. We recommended boiling and/or treating drinking water, improved sanitation, distribution of chlorine tablets to the affected villages, and as a long-term solution, construction of more borehole pumps. After implementing preventive measures, the number of cases declined and completely stopped after 6th April

A comparative analysis of national HIV policies in six African countries with generalized epidemics.

OBJECTIVE: To compare national human immunodeficiency virus (HIV) policies influencing access to HIV testing and treatment services in six sub-Saharan African countries. METHODS: We reviewed HIV policies as part of a multi-country study on adult mortality in sub-Saharan Africa. A policy extraction tool was developed and used to review national HIV policy documents and guidelines published in Kenya, Malawi, South Africa, Uganda, the United Republic of Tanzania and Zimbabwe between 2003 and 2013. Key informant interviews helped to fill gaps in findings. National policies were categorized according to whether they explicitly or implicitly adhered to 54 policy indicators, identified through literature and expert reviews. We also compared the national policies with World Health Organization (WHO) guidance. FINDINGS: There was wide variation in policies between countries; each country was progressive in some areas and not in others. Malawi was particularly advanced in promoting rapid initiation of antiretroviral therapy. However, no country had a consistently enabling policy context expected to increase access to care and prevent attrition. Countries went beyond WHO guidance in certain areas and key informants reported that practice often surpassed policy. CONCLUSION: Evaluating the impact of policy differences on access to care and health outcomes among people living with HIV is challenging. Certain policies will exert more influence than others and official policies are not always implemented. Future research should assess the extent of policy implementation and link these findings with HIV outcomes