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

Comparing static and outreach immunization strategies and associated factors in Uganda, Nov-Dec 2016

Introduction: the government of Uganda aims at reducing childhood morbidity through provision of immunization services. We compared the proportion of children 12-33 months reached using either static or outreach immunization strategies and factors affecting utilization of routine vaccination services in order to inform policy updates. Methods: we adopted the 2015 vaccination coverage cluster survey technique. The sample selection was based on a stratified three-stage sample design. Using the Fleiss formula, a sample of 50 enumeration areas was sufficient to generate immunization coverages at each region. A total of 200 enumeration areas were selected for the survey. Thirty households were selected per enumeration area. Epi-Info software was used to calculate weighted coverage estimates. Results: among the 2231 vaccinated children aged 12-23 months who participated in the survey, 68.1% received immunization services from a health unit and 10.6% from outreaches. The factors that affected utilization of routine vaccination services were; accessibility, where 78.2% resided within 5km from a health facility. 29.7% missed vaccination due to lack of vaccines at the health facility. Other reasons were lack of supplies at 39.2% and because the caretaker had other things to do, 26.4%. The survey showed 1.8% (40/2271) respondents had not vaccinated their children. Among these, 70% said they had not vaccinated their child because they were busy doing other things and 27.5% had not done so because of lack of motivation. Conclusion: almost 7 in 10 children aged 12-23 months access vaccination at health facilities. There is evidence of parental apathy as well as misconceptions about vaccination

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

An outbreak of monkeypox in Doedain District, Rivercess County, Liberia, June, 2017

Introduction: Monkeypox is a zoonotic virus disease with symptoms similar to smallpox, although less severe. The last confirmed monkeypox case in Liberia was recorded in 1970 from Grand Gedeh County. On June 23, 2017, Rivercess County Health Team received information from Dodain District, Rivercess County about a suspected monkeypox that reported at the clinic on June 19. We investigated to verify the report, confirm the diagnosis, determine the source and magnitude of the disease, and recommend evidence-based control and prevention measures. Methods: We defined a suspected case as any person who presented with generalized rash with fever, headache, lymphadenopathy, back pain, myalgia, and weakness in Dodain District from June 1 to July 1, 2017. We defined the probable case as a suspected case in whom the clinician suspected monkeypox. A confirmed case was a suspected or probable case with laboratory confirmed monkeypox. We reviewed patient records, and using the case definitions, we conducted active case search and contact tracing in the affected community to identify cases. We interviewed family and community members to identify cases and contacts. We performed laboratory tests on identified cases to confirm the diagnosis. We monitored and followed up contacts for 21 days to see if any developed signs and symptoms. Results: We identified two cases, one confirmed, and one suspected. The confirmed case was an 8-year old male with onset of symptoms on 17 June 2017. He presented with rashes, fever, and headache. His mother (a suspected case/primary case) was a farmer married to a hunter. She had similar symptoms (onset date, 19th April 2017) but recovered two weeks before her son's onset. Although the suspected case's husband was a hunter, there was no clear information that the primary case had been exposed to bush meat. Both the mother and her child had not traveled outside their area of residence. Both cases responded well to symptomatic treatment. None of the 15 contacts developed signs and symptoms in the 21-day follow-up. Conclusion: This was a confirmed outbreak of monkeypox in Dodain District, Rivercess County whose source was not identified. The outbreak was most likely spread through person-to-person transmission. The outbreak was controlled through effective case management, awareness in the community and early reporting

Monkeypox outbreak, Harper District, Maryland County, Liberia, December 2017

Introduction: Monkeypox is a viral zoonotic disease caused by orthopoxyvirus. In Liberia, one confirmed case of monkeypox constitutes an outbreak. A District Surveillance Officer (DSO) of Harper District, Maryland County reported a suspected case of monkeypox on December 5, 2017. We investigated to verify the diagnosis, identify the source of the disease, assess the magnitude of the outbreak, and implement evidence-based control measures. Methods: We interviewed family and community members, and health workers to identify additional cases and contacts, and to obtain information on the source of the illness. We collected samples (whole blood and lesion swabs) for confirmation of the disease. We monitored the contacts for 21 days for signs and symptoms of monkeypox signs. We also conducted environmental assessment on source of the infection. Results: We identified one confirmed case of monkeypox in a 5-year old male from Tenken Community Maryland County in Liberia, who tested positive for West African strain of monkeypox virus. The case-patient had no history of direct contact with wild animals nor consumption of bush, and no travel history or contact with a sick person. The patient was isolated and recovered after three weeks of treatment on analgesics and antibiotics. We identified 35 contacts, none of whom developed signs and symptoms during 21 days of follow up. Conclusion: This was a confirmed monkeypox outbreak in Maryland County. Laboratory confirmation was delayed, and the source of infection remained unknown

Lassa fever outbreak in Newaken Community, Grand Kru County, Liberia, September-October 2017

Introduction: Lassa fever (LF) is an acute viral hemorrhagic febrile disease spread by infected multi-mammate rats and from person-to-person by direct contact with infected body fluids. On 4th October 2017, the surveillance focal person of Newaken clinic reported to the surveillance focal person of Grand Kru County a suspected case of Lf, who had presented with fever, headache, vomiting blood, and weakness. We investigated to confirm the outbreak, determine its scope, establish its source, and implement evidence-based control and prevention measures. Methods: We defined a suspected case as any person with an acute onset of fever (≥ 38° Celsius) and two or more of the following symptoms: bleeding, headache, vomiting, diarrhea, muscle weakness, and chest pain, who lived in Newaken Community from September 14, 2017 to October 25, 2017. A probable case as anyone who was epidemiological linked to a confirmed case, within 21 days of onset of symptoms while a confirmed case was either a suspected or probable case who was laboratory confirmed (positive IgM antibody, PCR or virus isolation). A contact was defined as anyone who associated with the confirmed case either by providing therapeutic care or living in the same household. We reviewed medical records, interviewed family, and community members to identify cases and contacts. We conducted active case search in the affected community to identify cases and contacts. We followed and monitored the contacts for 21 days. Results: We identified one confirmed case of LF, an 11-year old boy, whose onset of illness started with fever, cough, vomiting blood, and body weakness three days after he returned from Cote d'Ivoire where he had been residing for the past two years. He was isolated at hospital A. He was managed using anti-pyretic drugs and anti-viral drug (Ribavirin). Patient recovered after 30 days of intensive management. No other case was identified among the 21 contacts. The case-patient's resident community in Liberia was fond of storing food without covering it and also consuming bush meat. There was no documented LF outbreak in the Cote d'Ivoire community where the case-patient was residing before coming back to Liberia. Conclusion: This was LF outbreak whose source could not be established and no spread occurred among the human population beyond the index case. It was controlled by effective management and public education about infection prevention and the outbreak was declared over on the 25th of October 2017

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

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 large and persistent outbreak of typhoid fever caused by consuming contaminated water and street-vended beverages: Kampala, Uganda, January - June 2015.

BACKGROUND: On 6 February 2015, Kampala city authorities alerted the Ugandan Ministry of Health of a "strange disease" that killed one person and sickened dozens. We conducted an epidemiologic investigation to identify the nature of the disease, mode of transmission, and risk factors to inform timely and effective control measures. METHODS: We defined a suspected case as onset of fever (≥37.5 °C) for more than 3 days with abdominal pain, headache, negative malaria test or failed anti-malaria treatment, and at least 2 of the following: diarrhea, nausea or vomiting, constipation, fatigue. A probable case was defined as a suspected case with a positive TUBEX® TF test. A confirmed case had blood culture yielding Salmonella Typhi. We conducted a case-control study to compare exposures of 33 suspected case-patients and 78 controls, and tested water and juice samples. RESULTS: From 17 February-12 June, we identified 10,230 suspected, 1038 probable, and 51 confirmed cases. Approximately 22.58% (7/31) of case-patients and 2.56% (2/78) of controls drank water sold in small plastic bags (ORM-H = 8.90; 95%CI = 1.60-49.00); 54.54% (18/33) of case-patients and 19.23% (15/78) of controls consumed locally-made drinks (ORM-H = 4.60; 95%CI: 1.90-11.00). All isolates were susceptible to ciprofloxacin and ceftriaxone. Water and juice samples exhibited evidence of fecal contamination. CONCLUSION: Contaminated water and street-vended beverages were likely vehicles of this outbreak. At our recommendation authorities closed unsafe water sources and supplied safe water to affected areas