Strengthening anthrax outbreak response and preparedness: simulation and stakeholder education in Namisindwa district, Uganda.

BACKGROUND: Anthrax is a zoonotic disease caused by Bacillus anthracis that poses a significant threat to both human health and livestock. Effective preparedness and response to anthrax outbreak at the district level is essential to mitigate the devastating impact of the disease to humans and animals. The current diseaae surveillance in animals and humans uses two different infrastructure systems with online platform supported by established diagnostic facilities. The differences in surveillance systems affect timely outbreak response especially for zoonotic diseases like anthrax. We therefore aimed to assess the feasibility of implementing a simulation exercise for a potential anthrax outbreak in a local government setting and to raise the suspicion index of different district stakeholders for a potential anthrax outbreak in Namisindwa District, Uganda. METHODS: We conducted a field-based simulation exercise and a health education intervention using quantitative data collection methods. The study participants mainly members of the District Taskforce (DTF) were purposively selected given their role(s) in disease surveillance and response at the sub-national level. We combined 26 variables (all dichotomized) assessing knowledge on anthrax and knowledge on appropriate outbreak response measures into an additive composite index. We then dichotomized overall score based on the 80% blooms cutoff i.e. we considered those scoring at least 80% to have high knowledge, otherwise low. We then assessed the factors associated with knowledge using binary logistic regression with time as a proxy for the intervention effect. Odds ratios (ORs) and 95% Confidence intervals (95%CI) have been reported. RESULTS: The overall district readiness score was 35.0% (24/69) and was deficient in the following domains: coordination and resource mobilization (5/16), surveillance (5/11), laboratory capacity (3/10), case management (4/7), risk communications (4/12), and control measures (4/13). The overall community readiness score was 7 out of 32 (22.0%). We noted poor scores of readiness in all domains except for case management (2/2). The knowledge training did not have an effect on the overall readiness score, but improved specific domains such as control measures. Instead tertiary education was the only independent predictor of higher knowledge on anthrax and how to respond to it (OR = 1.57, 95% CI = 1.07-2.31). Training did not have a significant association with overall knowledge improvement but had an effect on several individual knowledge aspects. CONCLUSION: We found that the district's preparedness to respond to a potential anthrax outbreak was inadequate, especially in coordination and mobilisation, surveillance, case management, risk communication and control measures. The health education training intervention showed increased knowledge levels compared to the pre-test and post-test an indicator that the health education sessions could increase the index of suspicion. The low preparedness underscores the urgency to strengthen anthrax preparedness in the district and could have implications for other districts. We deduce that trainings of a similar nature conducted regularly and extensively would have better effects. This study's insights are valuable for improving anthrax readiness and safeguarding public and animal health in similar settings.

Changes in Access to Alcohol-Based Hand Rub and Hand Hygiene Adherence among Healthcare Workers after a Hand Rub Production and Distribution Program in Rural Uganda before and during the COVID-19 Pandemic.

During the COVID-19 pandemic, the use of alcohol-based hand rubs (ABHRs) was critical for improving hand hygiene (HH) among healthcare workers (HCWs). Before and during the pandemic, we supported district-led production and district-wide distribution of ABHRs and one-time provision of portable handwashing stations to select healthcare facilities (HCFs) in five rural districts in Uganda. Comparison between baseline and follow-up assessments showed an overall increase in access to HH materials and HH adherence (HHA; handwashing with soap and water or use of ABHR) among HCWs. However, large differences in the changes in HH material coverage and HHA across districts may have been heavily influenced by the COVID-19 disease burden and its risk perception when the assessments were conducted. Using data collected at multiple time points before and during the pandemic across districts and estimating and controlling for pandemic effects in an exploratory multivariate analysis, the adjusted odds ratio of HHA in district HCFs was 4.6 (95% CI: 1.8-11.8) after (versus before) the ABHR intervention. This increase appeared to be primarily in larger HCFs, where the perceived need for ABHRs may have been greater. Additional strategies are needed to further increase HHA, especially in the smallest HCFs, among laboratory technicians and nurses and before patient contact. However, district-scale ABHR interventions seemed successful in ensuring the continued availability of HH materials.

Access to and Use of Hand Hygiene Resources during the COVID-19 Pandemic in Two Districts in Uganda, January-April 2021.

To understand access to and use of hand hygiene in healthcare facilities (HCFs) and community locations during the COVID-19 pandemic, we evaluated factors associated with hand hygiene in 60 priority HCFs and community locations in two border districts in Uganda. We assessed water and hand hygiene resource availability and observed hand hygiene practice by staff or patrons. Regression modeling estimated factors associated with the availability or use of hand hygiene. In HCFs, most inpatient (61%), outpatient (71%), and laboratory or staff (90%) rooms contained hand hygiene materials. Only 38% of community locations had hand hygiene materials at all entrances and exits, 35% of congregation areas had hand hygiene materials. Overall, 38% of healthcare staff, 48% of patrons post-latrine use, and 21% of patrons entering or exiting community locations practiced hand hygiene. HCF hand hygiene access was lower in inpatient rooms (odds ratio [OR] = 0.17, 95% CI: 0.06-0.45) and outpatient rooms (OR = 0.23, 95% CI: 0.07-0.70) compared with laboratory/staff rooms. HCF hand hygiene practice was higher for doctors than nurses (OR = 3.58, 95% CI: 1.15-11.14) and with new versus existing patient encounters (OR = 2.27, 95% CI: 1.20-4.27); it was lower before versus after patient contact for both invasive (OR = 0.03, 95% CI: 0.00-0.20) and noninvasive (OR = 0.66, 95% CI: 0.45-0.95) procedures. In community settings, hand hygiene practice after using the latrine was higher than at an entrances/exits (OR = 3.39, 95% CI: 2.08-5.52). Hand hygiene rates were relatively low in healthcare and community settings. Greater emphasis on hand hygiene before patient interactions (at HCFs) and at community entrances/exits for patrons is also needed.

Establishment of District-Led Production of WHO-Recommended Alcohol-based Hand Rub (ABHR) during the COVID-19 Pandemic: A Model for Improving Access to ABHR during Health Emergencies.

In response to the COVID-19 pandemic, we established and sustained local production of alcohol-based handrub (ABHR) at district scale for healthcare facilities and community, public locations in four districts in Uganda. District officials provided space and staff for production units. The project renovated space for production, trained staff on ABHR production, and transported ABHR to key locations. The production officer conducted internal ABHR quality assessments while trained district health inspectors conducted external quality assessments prior to distribution. Information, education, and communication materials accompanied ABHR distribution. Onsite ABHR consumption was monitored by site staff using stock cards. On average, it took 11 days (range: 8-14) and 5,760 USD (range: 4,400-7,710) to set up a production unit. From March-December 2021, 21,600L of quality-controlled ABHR were produced for 111 healthcare facilities and community locations at an average cost of 4.30 USD/L (range: 3.50-5.76). All ABHR passed both internal and external quality control (average ethanol concentration of 80%, range: 78-81%). This case study demonstrated that establishing centralized, local production of quality-controlled, affordable ABHR at a district-wide scale is feasible and strengthens the ability of healthcare workers and community locations to access and use ABHR during infectious disease outbreaks in low-resource countries.