Epidemiology of extended-spectrum beta-lactamase-producing Escherichia coli at the human-animal-environment interface in a farming community of central Uganda.

BACKGROUND: Extended-spectrum beta-lactamase-producing Escherichia coli (ESBL-Ec) represents a significant global public health concern. The epidemiology of ESBL-Ec in Uganda is not well understood although it is harbored by humans, animals, and the environment. This study explains the epidemiology of ESBL-Ec using a one health approach in selected farming households in Wakiso district, Uganda. METHODOLOGY: Environmental, human, and animal samples were collected from 104 households. Additional data were obtained using observation checklists and through interviews with household members using a semi-structured questionnaire. Surface swabs, soil, water, human and animal fecal samples were introduced onto ESBL chromogenic agar. The isolates were identified using biochemical tests and double-disk synergy tests. To assess associations, prevalence ratios (PRs) were computed using a generalized linear model (GLM) analysis with modified Poisson and a log link with robust standard errors in R software. RESULTS: Approximately 83% (86/104) households had at least one positive ESBL-Ec isolate. The overall prevalence of ESBL-Ec at the human-animal-environment interface was approximately 25.0% (95% CI: 22.7-28.3). Specifically, humans, animals and the environment had an ESBL-Ec prevalence of 35.4%, 55.4%, and 9.2% respectively. Having visitors (adj PR = 1.19, 95% CI: 1.04-1.36), utilizing veterinary services (adj PR = 1.39, 95% CI: 1.20-1.61) and using animal waste for gardening (adj PR = 1.29, 95% CI: 1.05-1.60) were positively associated with household ESBL-Ec contamination. Covering the drinking water container with a lid (adj PR = 0.84 95% CI: 0.73-0.96) was associated with absence of ESBL-Ec in a household. CONCLUSION: There is wider dissemination of ESBL-Ec in the environment, humans, and animals, indicating poor infection prevention and control (IPC) measures in the area. Improved collaborative one health mitigation strategies such as safe water chain, farm biosecurity, household and facility-based IPC measures are recommended to reduce the burden of antimicrobial resistance at community level.

Antimicrobial resistance among farming communities in Wakiso District, Central Uganda: A knowledge, awareness and practice study.

BACKGROUND: Antibiotics are increasingly becoming ineffective as antimicrobial resistance (AMR) continues to develop and spread globally-leading to more difficult to treat infections. Countries such as Uganda are still challenged with implementation of AMR related strategies due to data paucity. This includes a lack of data on the prevailing knowledge and awareness of antimicrobial resistance and antibiotic use among farming communities, both commercial and subsistence, which are instrumental in the implementation of targeted interventions. The aim of our study was to assess the knowledge, attitudes and practices on AMR among subsistence and commercial farmers in Wakiso district, central Uganda. METHODS: A cross-sectional study was conducted using a semi-structured questionnaire in Wakiso district, Central Uganda in between June and September 2021. Polytomous latent class analyses were performed to group participants based on their responses. Multivariable regression and conditional inference trees were used to determine the association between demographic factors and knowledge on antibiotics and AMR. RESULTS: A total of 652 respondents participated in the study among whom 84% were able to correctly describe what antibiotics are. Subsistence farmers (OR = 6.89, 95% CI [3.20; 14.83]), and to a lesser extent, farming community members which obtained their main income by another business (OR = 2.25, 95% CI [1.345; 3.75]) were more likely to be able to describe antibiotics correctly than individuals involved in commercial farming. Based on the latent class analysis, three latent classes indicating different levels of knowledge on AMR, were found. Subsistence farming, higher educational level and younger age were found to be associated with belonging to a class of better knowledge. CONCLUSION: The majority of participants were able to correctly describe antibiotics and aware of AMR, however there was some degree of misunderstanding of several AMR concepts. Targeted AMR interventions should improve awareness and also ensure that not only subsistence farmers, but commercial farmers, are included.

Phenotypic Characterization and Antibiograms of Extended-Spectrum Beta-Lactamase-Producing Escherichia coli Isolated at the Human-Animal-Environment Interface Using a One Health Approach Among Households in Wakiso District, Uganda.

Background: The occurrence of extended spectrum beta-lactamase (ESBL) producing bacteria such as Escherichia coli has increasingly become recognized beyond hospital settings. Resistance to other types of antibiotics limits treatment options while the existence of such bacteria among humans, animals, and the environment is suggestive of potential zoonotic and reverse-zoonotic transmission. This study aimed to establish the antibiotic susceptibility profiles of the ESBL-producing Escherichia coli (ESBL-EC) from human, animal, and environmental isolates obtained among farming households within Wakiso district using a One Health approach. Methods: A total of 100 ESBL-EC isolates from humans 35/100 (35%), animals 56/100 (56%), and the environment 9/100 (9%) were tested for susceptibility to 11 antibiotics. This was done using the Kirby-Bauer disk diffusion method according to Clinical and Laboratory Standards Institute (CLSI) guidelines. Data were analyzed in STATA ver. 16 and graphs were drawn in Microsoft excel ver. 10. Results: Most of the ESBL-EC isolates (98%) were resistant to more than two antibiotics. ESBL-EC isolates were most susceptible to meropenem (MEM) (88.0%), and imipenem (82.0%) followed by gentamicin (72%). ESBL-EC isolates from humans were most susceptible to meropenem (MEM) followed by imipenem (IPM)> gentamicin (CN)> ciprofloxacin (CIP). Animal samples were more susceptible to MEM, IPM, and CN but were highly resistant to cefotaxime (CTX)> cefepime (FEP)>other antibiotics. Multidrug resistance (MDR) was mostly reported among households keeping goats under intensive husbandry practices. Seven percent of the isolates exhibited carbapenem resistance while 22% showed aminoglycoside resistance. Similar resistance patterns among humans, animals, and environmental samples were also reported. Conclusion: Our study provides baseline information on non-hospital-based MDR caused by ESBL-EC using a One Health approach. ESBL-EC isolates were prevalent among apparently healthy community members, animals, and their environment. It is important to conduct more One Health approach studies to generate evidence on the drivers, resistance patterns, and transmission of ESBL-producing organisms at the human-animal-environmental interface.

Utilization of health belief model in comprehending diarrheal disease dynamics: a case of cryptosporidiosis in Uganda.

BACKGROUND: Diarrheal diseases contribute greatly to the reported global childhood mortality and morbidity with related social, economic consequences. This study was conducted to analyze the utilization of the Health Belief Model (HBM) theory to comprehend diarrheal disease dynamics in Uganda. METHODS: Our study utilized a qualitative cross-sectional design among adult livestock farmers in selected farming communities. A total of 80 individuals were recruited and interviewed through Focus Discussion Groups (FDGs) (n = 6) and Key Informant Interviews (KIIs) (n = 8) to evaluate diarrheal disease dynamics. The scope of dynamics included but not limited to exposure risks, knowledge, and attitudes. Our results were presented using the five (5) constructs of the HBM. RESULTS: Perceived susceptibility; communities believed that both humans and their animals are at high risk of different kinds of diarrheal infections. The farmers believed that majority of these diarrhea infections are hard to treat especially among animals. Perceived severity; farmers believed that diarrheal diseases are characterized by loss of weight, fever, emaciation, dry eyes, severe prolonged diarrhea and sudden death. Perceived barriers; limited knowledge and misconceptions about the diarrheal infections were great inhibitors to successful disease prevention and control. Self-efficacy; farmers had fear of laxity that interventions being suggested and put in place to curb diarrheal diseases such as cryptosporidiosis would wither away with time thus endemicity of the problem in the community. Modifying factors and cues to action; most of the farmers treat animals by themselves based on; probability, traditional knowledge and previous experience. CONCLUSION: Sustained public health interventional activities should therefore be undertaken by both human and animal health sectors with maximum community involvement. Communities suggested the need to increase preventive measures and promote household hygiene efforts to always wash hands with soap and running water in order to reduce the burden of diarrhea diseases such as cryptosporidiosis.

Awareness of hepatitis B post-exposure prophylaxis among healthcare providers in Wakiso district, Central Uganda.

BACKGROUND: Healthcare providers (HCPs) are at an elevated occupational health risk of hepatitis B virus infections. Post-exposure prophylaxis (PEP) is one of the measures recommended to avert this risk. However, there is limited evidence of HCPs' awareness of hepatitis B PEP. Therefore, this study aimed to establish awareness of hepatitis B PEP among HCPs in Wakiso, a peri-urban district that surrounds Uganda's capital, Kampala. METHODS: A total of 306 HCPs, selected from 55 healthcare facilities (HCFs) were interviewed using a validated structured questionnaire. The data were collected and entered using the Kobo Collect mobile application. Multivariable binary logistic regression was used to establish the factors associated with awareness of hepatitis B PEP. RESULTS: Of the 306 HCPs, 93 (30.4%) had ever heard about hepatitis B PEP and 16 (5.2%) had ever attended training where they were taught about hepatitis B PEP. Only 10.8% were aware of any hepatitis B PEP options, with 19 (6.2%) and 14 (4.6%) mentioning hepatitis B immunoglobulin (HBIG) and hepatitis B vaccine, respectively as PEP options. Individuals working in the maternity department were less likely to be aware of hepatitis B PEP (AOR = 0.10, 95% CI = 0.02-0.53). There was a positive association between working in a healthcare facility in an urban setting and awareness of hepatitis B PEP (AOR = 5.48, 95% CI = 1.42-21.20). Hepatitis B screening and vaccination were not associated with awareness of PEP. CONCLUSIONS: Only one-tenth of the HCPs were aware of any hepatitis B PEP option. Awareness of hepatitis B PEP is associated with the main department of work and working in a healthcare facility in an urban setting. This study suggests a need to sensitise HCPs, especially those in rural HCFs and maternity wards on hepatitis B PEP. The use of innovative strategies such as e-communication channels, including mobile text messaging might be paramount in bridging the awareness gap.

Awareness, Knowledge, and Perceptions Regarding Rabies Prevention Among Rural Communities in Masaka District, Central Uganda: A Qualitative Study.

Rabies is a zoonotic disease that is mainly transmitted to humans through dog bites. It remains a major public health threat in many Asian and African countries, including Uganda. The main objective of this study was to investigate awareness, knowledge, and perceptions of communities toward human and dog health related to rabies prevention, as well as dog management practices within Masaka district, central Uganda. Data collection involved nine key informant interviews (KIIs) and six focus group discussions (FGDs). Methods used during focus group discussions included qualitative interviews (using open-ended questions), simple ranking, and proportional piling. Data from KIIs and FGDs were analyzed using content analysis in NVivo (version 12.0). This study reveals that community members in the rural settings uses herbal concoctions in replacement or as an alternative to dog vaccination. Furthermore, the study reveals that dogs play the vital roles in the households like as they offer protection to people and household properties, despite being ranked second least among the household animals. The commonest livelihood activity was a small-scale mixed farming. Most of the households kept dogs, but they are ranked at second lowest in terms of economic value among all domestic animals. Free roaming and tethering were the common dog-keeping systems, and home-based feed (food leftovers, bones) was provided mainly to the tethered dogs. Rabies, also locally known as "Eddalu Lyembwa" (that can be translated as "madness of the dogs"), was ranked as the disease of most important among dogs, besides other common diseases such as skin diseases, venereal diseases, worm infestations, and tick infestations. Inadequate vaccination services for both humans and dogs were reported, and dog bite victims traveled a long distance to seek for post-exposure prophylaxis after dog bites. It can be concluded that there is a clear request for periodic mass vaccination campaigns against rabies among dogs, and access to vaccines within reasonable distances by humans after a rabies exposure, but also pre-emptive vaccination for those at high risk, such as veterinarians, needs to be improved.

Prevalence of leptospirosis among patients attending renal and general outpatient clinics in Mulago Hospital, Kampala, Uganda.

In this study, we sought to establish the prevalence of leptospirosis among renal patients and general outpatients attending Mulago National Referral Hospital, Uganda. A total of 254 patients were recruited, their blood samples collected and interviewer-administered semi-structured questionnaires provided between July and October 2018. These questionnaires captured data on sociodemographic characteristics and symptoms of leptospirosis disease. An individual with an average body temperature of 37.3 ± 1.1 °C was considered to be having fever. The blood samples were analyzed using the standard Microscopic Agglutination Test (MAT) with a panel of 14 Leptospira-serovars belonging to 11 serogroups. Prevalence was reported with confidence intervals while questionnaire data was analyzed using logistic regression analysis. We present an overall prevalence of leptospirosis at 4.70% (95% CI = 2.60-8.30) after analysis of samples from recruited patients. This seropositivity (12/254) was classified into 7 serovars, among which, Canicola and Djasiman presented with titers between ≥ 200 and ≥ 400 in samples of both renal patients and outpatients, indicative of the active disease. Djasiman was the highest contributor to the reported prevalence. Overall, most examined participants presented with common symptoms of abdominal pain (AOR = 24.4, 95% CI (2.42-267.89), p = 0.02) and dehydration (AOR = 0.1, 95% CI (0.01-0.69), p = 0.05). Our study suggests that these symptoms and previous history of abdominal pain may be caused by Leptospira infections among the studied participants. We therefore recommend inclusion of leptospirosis in the differential diagnosis for renal and febrile illnesses. Indeed, abdominal pain and dehydration should be further studied with a bigger sample size and for other related febrile illnesses.

Determinants of hygiene practices among mothers seeking delivery services from healthcare facilities in the Kampala metropolitan area, Uganda.

Our study aimed at assessing the determinants of hand hygiene and utilisation of bathing facilities in healthcare facilities (HCFs) in the greater Kampala metropolitan area, Uganda. Results indicate that 19.9% of the respondents wished to wash hands and failed while 39.3% faced challenges related to bathing. Failure to wash hands was associated with received information on hand washing (APR = 1.14, 95% CI: 1.06-1.24), using piped water (APR = 0.88, 95%CI: 0.78-0.98) or a well as the main water source at the HCF (APR = 1.21,95% CI: 1.03-1.42). Experiencing challenges of bathing was associated with accessing healthcare services at a hospital (APR = 0.89, 95% CI 0.81-0.97) and using public HCF (APR = 1.10, 95% CI: 1.01-1.120). There is urgent need to improve hand hygiene and bathing facilities though providing reliable water and soap.

The Epidemiology of Zoonotic Brucellosis in Bahr el Ghazal Region of South Sudan.

Background: In this study, we focused on three zoonotic brucellosis risk groups; abattoir workers, febrile cases at Wau hospital and cattle herders, in Bahr el Ghazal region, South Sudan. Competitive c-ELISA was used to detect anti-Brucella antibodies in 725 individuals between December 2015 and May 2016. In addition, questionnaire metadata, focus group discussions and key informant interviews were used to characterize the epidemiology of zoonotic brucellosis in this region. Results: Overall, we estimate 27.2 % (95% CI = 23.9-30.6) brucellosis sero-prevalence; 32.1% (95% CI = 26.2-38.4), 23.0% (95% CI = 19.1-27.4) and 34.6% (95% CI = 24.4-46.3) among abattoir workers, febrile cases, and herders, respectively. Marital status (Single, OR = 0.58, 95%CI: 0.36-0.91, P = 0.02) and ethnicity (Kerash OR = 6.01, 95%CI: 1.97-21.10, P = 0.003 and Balanda, OR = 3.78, 95%CI: 1.42-12.02, P = 0.01) were associated with brucellosis. While gender and ethnicity were important factors for general awareness of zoonotic diseases. Highly ranked occupations at risk included veterinarian, butchers and milk handlers. We also identified covariate patterns for clinical diagnostics and public health interventions. Conclusion: We report the highest sero-prevalence of zoonotic brucellosis in three risk groups in the East African region. All this is not only occurring in a population with limited awareness that brucellosis is a zoonotic disease but also where one in nine health workers tested was sero-positive. We identified social demographic associations with brucellosis, however, the qualitative analysis suggests these are more complex and nuanced. Therefore, future studies could benefit from the use of the mixed methods approach to add extensiveness and depth to our understanding of zoonotic disease drivers, in order to implement mitigating measures such as cattle vaccination.

The sero-prevalence of brucellosis in cattle and their herders in Bahr el Ghazal region, South Sudan.

BACKGROUND: Brucellosis is a worldwide recognized bacterial zoonotic disease. There is currently no information on bovine brucellosis sero-prevalence in South Sudan regardless of the economic, social and public health impact on populations. Therefore, for the first time in 33 years, we report the sero-prevalence of brucellosis in cattle and their herders. Furthermore, we characterize the drivers associated with the disease at the human-animal interface in Bahr el Ghazal region, South Sudan. METHODS: A total of 893 and 87 animal and human sera respectively were examined between December 2015 and May 2016. Rose Bengal Plate Test (RBPT) and Competitive Enzyme Linked Immuno Sorbent Assay (c-ELISA) were used in parallel to detect anti-Brucella antibodies. Questionnaires were administered to collect relevant metadata used for the association analysis in R version 3.2.3. Odds Ratio (OR) and Confidence Intervals (CI) were determined. RESULTS: Overall bovine brucellosis prevalence was 31% (95%CI = 28.0-34.2), with the highest 63% (95%CI = 53-70) and lowest 10% (95%CI = 4.5-20.1) prevalence estimates in Wau and Gogrial states respectively. The bovine sero-prevalence was approximately equally distributed among the male 30.4% (26.9-34.2) and the females 32.5% (26.8-38.7). Poor body condition (OR = 0.22; 95%CI = 0.07-0.54) and larger herd sizes (OR = 0.05; 95%CI = 0.008-0.173) were protective factors for brucellosis, while the opposite was true for the second (OR = 1.70; 95%CI = 1.08-2.67) and third (OR = 2.5; 95%CI = 1.46-4.47) lactation stage. The overall brucellosis sero-prevalence in herders was estimated at 33.3% (23.9-44.3). CONCLUSION: We report a high prevalence of anti-Brucella antibodies in cattle and their herders in Bahr el Ghazal, indicating an enzootic status in the cattle population being an important source of infection for humans. This represents a genuine public health challenge. Therefore, there is need to raise awareness and build capacity and infrastructure in this fragile state to underwrite future public health strategies for brucellosis.

A Framework for Integrating Qualitative and Quantitative Data in Knowledge, Attitude, and Practice Studies: A Case Study of Pesticide Usage in Eastern Uganda.

Knowledge, attitude, and practice (KAP) studies guide the implementation of public health interventions (PHIs), and they are important tools for political persuasion. The design and implementation of PHIs assumes a linear KAP relationship, i.e., an awareness campaign results in the desirable societal behavioral change. However, there is no robust framework for testing this relationship before and after PHIs. Here, we use qualitative and quantitative data on pesticide usage to test this linear relationship, identify associated context specific factors as well as assemble a framework that could be used to guide and evaluate PHIs. We used data from a cross-sectional mixed methods study on pesticide usage. Quantitative data were collected using a structured questionnaire from 167 households representing 1,002 individuals. Qualitative data were collected from key informants and focus group discussions. Quantitative and qualitative data analysis was done in R 3.2.0 as well as qualitative thematic analysis, respectively. Our framework shows that a KAP linear relationship only existed for households with a low knowledge score, suggesting that an awareness campaign would only be effective for ~37% of the households. Context specific socioeconomic factors explain why this relationship does not hold for households with high knowledge scores. These findings are essential for developing targeted cost-effective and sustainable interventions on pesticide usage and other PHIs with context specific modifications.

Participatory evaluation of delivery of animal health care services by community animal health workers in Karamoja region of Uganda.

AIM: An evaluation exercise was carried out to assess the performance of Community Animal Health Workers (CAHWs) in the delivery of animal health care services in Karamoja region, identify capacity gaps and recommend remedial measures. MATERIALS & METHODS: Participatory methods were used to design data collection tools. Questionnaires were administered to 204 CAHWs, 215 farmers and 7 District Veterinary Officers (DVOs) to collect quantitative data. Seven DVOs and 1 Non Government Organization (NGO) representative were interviewed as key informants and one focus group discussion was conducted with a farmer group in Nakapiripirit to collect qualitative data. Questionnaire data was analyzed using SPSS version 19. Key messages from interviews and the focus group discussion were recorded in a notebook and reported verbatim. RESULTS: 70% of the farmers revealed that CAHWs are the most readily available animal health care service providers in their respective villages. CAHWs were instrumental in treatment of sick animals, disease surveillance, control of external parasites, animal production, vaccination, reporting, animal identification, and performing minor surgeries. Regarding their overall performance 88.8%(191/215) of the farmers said they were impressed. The main challenges faced by the CAHWs were inadequate facilitation, lack of tools and equipments, unwillingness of government to integrate them into the formal extension system, poor information flow, limited technical capacity to diagnose diseases, unwillingness of farmers to pay for services and sustainability issues. CONCLUSIONS AND RECOMMENDATIONS: CAHWs remain the main source of animal health care services in Karamoja region and their services are largely satisfactory. The technical deficits identified require continuous capacity building programs, close supervision and technical backstopping. For sustainability of animal health care services in the region continuous training and strategic deployment of paraprofessionals that are formally recognised by the traditional civil service to gradually replace CAHWs is recommended.