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

Evaluation of Integrated Community Case Management in Eight Districts of Central Uganda

Objective Evidence is limited on whether Integrated Community Case Management (iCCM) improves treatment coverage of the top causes of childhood mortality (acute respiratory illnesses (ARI), diarrhoea and malaria). The coverage impact of iCCM in Central Uganda was evaluated. Methods Between July 2010 and December 2012 a pre-post quasi-experimental study in eight districts with iCCM was conducted; 3 districts without iCCM served as controls. A two-stage household cluster survey at baseline (n = 1036 and 1042) and end line (n = 3890 and 3844) was done in the intervention and comparison groups respectively. Changes in treatment coverage and timeliness were assessed using difference in differences analysis (DID). Mortality impact was modelled using the Lives Saved Tool. Findings 5,586 Village Health Team members delivered 1,907,746 treatments to children under age five. Use of oral rehydration solution (ORS) and zinc treatment of diarrhoea increased in the intervention area, while there was a decrease in the comparison area (DID = 22.9, p = 0.001). Due to national stock-outs of amoxicillin, there was a decrease in antibiotic treatment for ARI in both areas; however, the decrease was significantly greater in the comparison area (DID = 5.18; p<0.001). There was a greater increase in Artemisinin Combination Therapy treatment for fever in the intervention areas than in the comparison area but this was not significant (DID = 1.57, p = 0.105). In the intervention area, timeliness of treatments for fever and ARI increased significantly higher in the intervention area than in the comparison area (DID = 2.12, p = 0.029 and 7.95, p<0.001, respectively). An estimated 106 lives were saved in the intervention area while 611 lives were lost in the comparison area. Conclusion iCCM significantly increased treatment coverage for diarrhoea and fever, mitigated the effect of national stock outs of amoxicillin on ARI treatment, improved timeliness of treatments for fever and ARI and saved lives

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

Evaluation of HIV-1 rapid tests and identification of alternative testing algorithms for use in Uganda.

INTRODUCTION: The World Health Organization recommends that countries conduct two phase evaluations of HIV rapid tests (RTs) in order to come up with the best algorithms. In this report, we present the first ever such evaluation in Uganda, involving both blood and oral based RTs. The role of weak positive (WP) bands on the accuracy of the individual RT and on the algorithms was also investigated. METHODS: In total 11 blood based and 3 oral transudate kits were evaluated. All together 2746 participants from seven sites, covering the four different regions of Uganda participated. Two enzyme immunoassays (EIAs) run in parallel were used as the gold standard. The performance and cost of the different algorithms was calculated, with a pre-determined price cut-off of either cheaper or within 20% price of the current algorithm of Determine + Statpak + Unigold. In the second phase, the three best algorithms selected in phase I were used at the point of care for purposes of quality control using finger stick whole blood. RESULTS: We identified three algorithms; Determine + SD Bioline + Statpak; Determine + Statpak + SD Bioline, both with the same sensitivity and specificity of 99.2% and 99.1% respectively and Determine + Statpak + Insti, with sensitivity and specificity of 99.1% and 99% respectively as having performed better and met the cost requirements. There were 15 other algorithms that performed better than the current one but rated more than the 20% price. None of the 3 oral mucosal transudate kits were suitable for inclusion in an algorithm because of their low sensitivities. Band intensity affected the performance of individual RTs but not the final algorithms. CONCLUSION: We have come up with three algorithms we recommend for public or Government procurement based on accuracy and cost. In case one algorithm is preferred, we recommend to replace Unigold, the current tie breaker with SD Bioline. We further recommend that all the 18 algorithms that have shown better performance than the current one are made available to the private sector where cost may not be a limiting factor

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.

BackgroundAdolescence 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.ProtocolBiB 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