Rapid antiretroviral therapy initiation following rollout of point-of-care early infant diagnosis testing, Uganda, 2018-2021.

BACKGROUND: Uganda Ministry of Health (MOH) recommends a first HIV DNA-PCR test at 4-6 weeks for early infant diagnosis (EID) of HIV-exposed infants (HEI) and immediate return of results. WHO recommends initiating antiretroviral therapy (ART) ≤ 7 days from HIV diagnosis. In 2019, MOH introduced point-of-care (POC) whole-blood EID testing in 33 health facilities and scaled up to 130 facilities in 2020. We assessed results turnaround time and ART linkage pre-POC and during POC testing. METHODS: We evaluated EID register data for HEI at 10 health facilities with POC and EID testing volume of ≥ 12 infants/month from 2018 to 2021. We abstracted data for 12 months before and after POC testing rollout and compared time to sample collection, results receipt, and ART initiation between periods using medians, Wilcoxon, and log-rank tests. RESULTS: Data for 4.004 HEI were abstracted, of which 1.685 (42%) were from the pre-POC period and 2.319 (58%) were from the period during POC; 3.773 (94%) had a first EID test (pre-POC: 1.649 [44%]; during POC: 2.124 [56%]). Median age at sample collection was 44 (IQR 38-51) days pre-POC and 42 (IQR 33-50) days during POC (p < 0.001). Among 3.773 HEI tested, 3.678 (97%) had test results. HIV-positive infants' (n = 69) median age at sample collection was 94 (IQR 43-124) days pre-POC and 125 (IQR 74-206) days during POC (p = 0.04). HIV positivity rate was 1.6% (27/1.617) pre-POC and 2.0% (42/2.061) during POC (p = 0.43). For all infants, median days from sample collection to results receipt by infants' caregivers was 28 (IQR 14-52) pre-POC and 1 (IQR 0-25) during POC (p < 0.001); among HIV-positive infants, median days were 23 (IQR 7-30) pre-POC and 0 (0-3) during POC (p < 0.001). Pre-POC, 4% (1/23) HIV-positive infants started ART on the sample collection day compared to 33% (12/37) during POC (p < 0.001); ART linkage ≤ 7 days from HIV diagnosis was 74% (17/23) pre-POC and 95% (35/37) during POC (p < 0.001). CONCLUSION: POC testing improved EID results turnaround time and ART initiation for HIV-positive infants. While POC testing expansion could further improve ART linkage and loss to follow-up, there is need to explore barriers around same-day ART initiation for infants receiving POC testing.

Time to care and factors influencing appropriate Sudan Virus Disease care among case patients in Uganda, September to November 2022.

BACKGROUND: Early isolation and care for Ebola Disease patients at Ebola Treatment Units (ETU) curb outbreak spread. We evaluated time to ETU entry and associated factors during the 2022 Sudan virus disease (SVD) outbreak in Uganda. METHODS: We included persons with RT-PCR-confirmed SVD with onset September 20-November 30, 2022. We categorized days from symptom onset to ETU entry ('delays') as short (≤2), moderate (3-5), and long (≥6); the latter two were 'delayed isolation'. We categorized symptom onset timing as 'earlier' or 'later,' using October 15 as a cut-off. We assessed demographics, symptom onset timing, and awareness of contact status as predictors for delayed isolation. We explored reasons for early vs late isolation using key informant interviews. RESULTS: Among 118 case-patients, 25 (21%) had short, 43 (36%) moderate, and 50 (43%) long delays. Seventy-five (64%) had symptom onset later in the outbreak. Earlier symptom onset increased risk of delayed isolation [cRR=1∙8, 95%CI (1∙2-2∙8)]. Awareness of contact status and SVD symptoms, and belief that early treatment-seeking was lifesaving facilitated early care-seeking. Patients with long delays reported fear of ETUs and lack of transport as contributors. CONCLUSION: Delayed isolation was common early in the outbreak. Strong contact tracing and community engagement could expedite presentation to ETUs.

Trends and geospatial distribution of stillbirths in Uganda, 2014-2020.

INTRODUCTION: Uganda with 17.8 stillbirths per 1,000 deliveries in 2021, is among the countries with a high burden of stillbirths globally. In 2014, Uganda adopted the World Health Organization Every New-born Action Plan (ENAP), which targets < 10 stillbirths per 1,000 deliveries by 2035. Little is known about the trends of stillbirth burden since ENAP was introduced. We assessed the temporal, and spatial distribution of stillbirths, in Uganda, 2014-2020, to inform programming for safe pregnancies and deliveries. METHODS: We obtained and analysed stillbirth surveillance data from the District Health Information System, 2014-2020. A stillbirth was defined as the death of a foetus > 28 weeks of pregnancy or weighing > 1000 g before or during birth and reported to a health facility. We calculated annual incidence rates of stillbirths per 1,000 deliveries at district, regional, and national levels. We used logistic regression to determine the significance of trends. RESULTS: The overall national annual incidence of stillbirths decreased from 24/1,000 deliveries in 2014 to 17/1,000 deliveries in 2020. During the same period, reporting rates declined from 71% in 2014 to 46% in 2020. The central region continuously had the highest incidence rate for the past 5 years despite the largest decline (OR = 0.79; CI = 0.77-0.83, P < 0.001) while the eastern region had the smallest decline (OR = 0.59; CI = 0.57-0.61, P < 0.001). Districts with persistently high annual incidence rates of stillbirths (> 30/1000) included Mubende, Kalangala, Hoima, and Nebbi. There was no difference in the reporting rates of the most- vs. least-affected districts. CONCLUSION: Even with suboptimal reporting, the incidence of stillbirths remained above the national target. Specific areas in the country appear to have particularly high stillbirth rates. We recommend continuous capacity building in managing pregnant women with an emphasis on the most affected districts, and investigation into the reasons for low reporting.

Factors associated with acute watery diarrhea among children aged 0-59 months in Obongi District, Uganda, April 2022: A case-control study.

Background: Diarrheal diseases, are major concerns for Ugandan children; persistent in Obongi District despite high rotavirus vaccination rates (2019-2021). The district recorded the country's highest annual acute watery diarrhea (AWD) incidence from 2017 to 2021. Our study, conducted in April 2022, assessed AWD risk factors among 0-59-month-old children in Obongi. Methods: We conducted a 1:2 (193:386) unmatched case-control study. A case was a child (0-59 months) with ≥ 3 loose/liquid stools/day, negative malaria/pneumonia tests, residing in Itula/Parolinya subcounty from 1 to 30 April 2022. Medical records from 10 facilities were reviewed. Simple random sampling identified cases, who were interviewed, and controls were randomly chosen from non-AWD neighboring households. Child health cards provided vaccination details. We used logistic regression to identify factors associated with AWD. Results: Among 193 cases and 386 controls, 104 (54 %) cases and 183 (47 %) controls were male, 58 (30 %) cases and 127 (33 %) controls were aged 12-23 months, 187 (97 %) cases and 369 (96 %) controls had received at least one dose of rotavirus vaccine, 58 (30 %) cases and 120 (34 %) controls treated drinking water. Comorbidity presence (undernutrition, diabetes, HIV) (AOR = 12; CI: 2.5-53), caregiver's unwashed hands post-toilet (AOR = 3.9; CI: 1.2-13), and borehole vs. piped water (AOR = 4.0; CI: 1.7-9.6) linked to AWD. Conclusion: Modifiable factors, including failure of caregivers to wash their hands with soap after visiting toilets and use of borehole water were associated with AWD, suggesting that community sensitization on handwashing at critical times, using clean water and soap, and expanded use of piped water could reduce AWD incidence in this area.

Investigation of COVID-19 outbreak at a refugee transit centre, Kisoro District, Uganda, June-July 2022.

Due to conflict in the Democratic Republic of Congo (DRC), approximately 34,000 persons arrived at Nyakabande Transit Centre (NTC) between March and June 2022. On June 12, 2022, Kisoro District reported >330 cases of COVID-19 among NTC residents. We investigated the outbreak to assess its magnitude, identify risk factors, and recommend control measures. We defined a confirmed case as a positive SARS-CoV-2 antigen test in an NTC resident during March 1-June 30, 2022. We generated a line list through medical record reviews and interviews with residents and health workers. We assessed the setting to understand possible infection mechanisms. In a case-control study, we compared exposures between cases (persons staying ≥5 days at NTC between June 26 and July 16, 2022, with a negative COVID-19 test at NTC entry and a positive test at exit) and unmatched controls (persons with a negative COVID-19 test at both entry and exit who stayed ≥5 days at NTC during the same period). We used multivariable logistic regression to identify factors associated with contracting COVID-19. Among 380 case-persons, 206 (54.2%) were male, with a mean age of 19.3 years (SD = 12.6); none died. The attack rate was higher among exiting persons (3.8%) than entering persons (0.6%) (p<0.01). Among 42 cases and 127 controls, close contact with symptomatic persons (aOR = 9.6; 95%CI = 3.1-30) increased the odds of infection; using a facemask (aOR = 0.06; 95% CI = 0.02-0.17) was protective. We observed overcrowding in shelters, poor ventilation, and most refugees not wearing face masks. The COVID-19 outbreak at NTC was facilitated by overcrowding and suboptimal use of facemasks. Enforcing facemask use and expanding shelter space could reduce the risk of future outbreaks. The collaborative efforts resulted in successful health sensitization and expanding the distribution of facemasks and shelter space. Promoting facemask use through refugee-led efforts is a viable strategy.

Improving maternal and neonatal outcomes among pregnant women who are HIV-positive or HIV-negative through the Saving Mothers Giving Life initiative in Uganda: An analysis of population-based mortality surveillance data.

HIV infection is associated with poor maternal health outcomes. In 2016, the maternal mortality ratio (MMR) in Uganda was 336/100,000, and the neonatal mortality rate (NMR) was 19/1,000. Saving Mothers, Giving Life (SMGL) was a five-year maternal and neonatal health strengthening initiative launched in 2012 in Uganda. We extracted maternal and neonatal data for 2015-2016 from the initiative's population-based mortality surveillance system in 123 health facilities in Western Uganda. We collected data on the facilities, HIV status, antiretroviral drug (ARV) use, death, birth weight, delivery type, parity, Apgar scores, and complications. We compared mother and baby outcomes between HIV-positive or HIV-negative, computed risk ratios (RR) for adverse outcomes, and used the chi-square to test for significance in differences observed. Among 116,066 pregnant women who attended and gave birth at SMGL-implementing facilities during 2015-2016, 8,307 (7.7%) were HIV-positive, of whom 7,809 (94%) used antiretroviral drugs (ARVs) at the time of delivery. During birth, 23,993 (21%) women experienced ≥1 complications. Neonate Apgar scores <7 (8.8%) and maternal haemorrhage during birth (1.6%) were the most common outcomes. Overall facility MMR was 258/100,000 and NMR was 7.6/1,000. HIV infection increased risk of maternal death (RR = 3.6, 95% Confidence Interval (CI) = 2.4-5.5), maternal sepsis (RR = 2.1, 95% CI = 1.3-3.3), and infant birth weight <2,500g (RR = 1.2, 95% CI = 1.1-1.3), but was protective against maternal complications (RR = 0.92, 95% CI = 0.87-0.97) and perinatal death (RR = 0.78, 95% CI = 0.68-0.89). Among the HIV-positive, ARV non-use increased risk of maternal death (RR = 15, 95% CI = 7.1-31) and perinatal death (RR = 2.3, 95% CI = 1.6-3.4). SMGL reduced facility MMR and NMR below national rates. HIV-infection was associated with maternal sepsis and death. Failure to use ARVs among women living with HIV increased the risk of maternal and perinatal death. Use of the SMGL approach and complementary interventions that further strengthen HIV care, may continue to reduce MMR and NMR.

Performance and impact of contact tracing in the Sudan virus outbreak in Uganda, September 2022-January 2023.

BACKGROUND: Contact tracing (CT) is critical for ebolavirus outbreak response. Ideally, all new cases after the index case should be previously-known contacts (PKC) before their onset, and spend minimal time ill in the community. We assessed the impact of CT during the 2022 Sudan Virus Disease (SVD) outbreak in Uganda. METHODS: We collated anonymized data from the SVD case and contacts database to obtain and analyze data on CT performance indicators, comparing confirmed cases that were PKC and were not PKC (NPKC) before onset. We assessed the effect of being PKC on the number of people infected using Poisson regression. RESULTS: There were 3844 contacts of 142 confirmed cases (mean: 22 contacts/case). Forty-seven (33%) confirmed cases were PKC. PKCs had fewer median days from onset to isolation (4 vs 6; P<0.007) and laboratory confirmation (4 vs 7; P<0.001) than NPKC. Being a PKC vs NPKC reduced risk of transmitting infection by 84% (IRR=0.16, 95% CI 0.08-0.32). CONCLUSION: Contact identification was sub-optimal during the outbreak. However, CT reduced the time SVD cases spent in the community before isolation and the number of persons infected in Uganda. Approaches to improve contact tracing, especially contact listing, may improve control in future outbreaks.

Evaluation of malaria outbreak detection methods, Uganda, 2022.

BACKGROUND: Malaria outbreaks are detected by applying the World Health Organization (WHO)-recommended thresholds (the less sensitive 75th percentile or mean + 2 standard deviations [2SD] for medium-to high-transmission areas, and the more sensitive cumulative sum [C-SUM] method for low and very low-transmission areas). During 2022, > 50% of districts in Uganda were in an epidemic mode according to the 75th percentile method used, resulting in a need to restrict national response to districts with the highest rates of complicated malaria. The three threshold approaches were evaluated to compare their outbreak-signaling outputs and help identify prioritization approaches and method appropriateness across Uganda. METHODS: The three methods were applied as well as adjusted approaches (85th percentile and C-SUM + 2SD) for all weeks in 2022 for 16 districts with good reporting rates ( ≥ 80%). Districts were selected from regions originally categorized as very low, low, medium, and high transmission; district thresholds were calculated based on 2017-2021 data and re-categorized them for this analysis. RESULTS: Using district-level data to categorize transmission levels resulted in re-categorization of 8/16 districts from their original transmission level categories. In all districts, more outbreak weeks were detected by the 75th percentile than the mean + 2SD method (p < 0.001). For all 9 very low or low-transmission districts, the number of outbreak weeks detected by C-SUM were similar to those detected by the 75th percentile. On adjustment of the 75th percentile method to the 85th percentile, there was no significant difference in the number of outbreak weeks detected for medium and low transmission districts. The number of outbreak weeks detected by C-SUM + 2SD was similar to those detected by the mean + 2SD method for all districts across all transmission intensities. CONCLUSION: District data may be more appropriate than regional data to categorize malaria transmission and choose epidemic threshold approaches. The 75th percentile method, meant for medium- to high-transmission areas, was as sensitive as C-SUM for low- and very low-transmission areas. For medium and high-transmission areas, more outbreak weeks were detected with the 75th percentile than the mean + 2SD method. Using the 75th percentile method for outbreak detection in all areas and the mean + 2SD for prioritization of medium- and high-transmission areas in response may be helpful.

Trends and spatial distribution of neonatal sepsis, Uganda, 2016-2020.

BACKGROUND: In Uganda, sepsis is the third-leading cause of neonatal deaths. Neonatal sepsis can be early-onset sepsis (EOS), which occurs ≤ 7 days postpartum and is usually vertically transmitted from the mother to newborn during the intrapartum period, or late-onset sepsis (LOS), occurring 8-28 days postpartum and largely acquired from the hospital environment or community. We described trends and spatial distribution of neonatal sepsis in Uganda, 2016-2020. METHODS: We conducted a descriptive incidence study using routinely-reported surveillance data on in-patient neonatal sepsis from the District Health Information System version 2 (DHIS2) during 2016-2020. We calculated incidence of EOS, LOS, and total sepsis as cases per 1,000 live births (LB) at district (n = 136), regional (n = 4), and national levels, as well as total sepsis incidence by health facility level. We used logistic regression to evaluate national and regional trends and illustrated spatial distribution using choropleth maps. RESULTS: During 2016-2020, 95,983 neonatal sepsis cases were reported, of which 71,262 (74%) were EOS. Overall neonatal sepsis incidence was 17.4/1,000 LB. EOS increased from 11.7 to 13.4 cases/1,000 LB with an average yearly increase of 3% (p < 0.001); LOS declined from 5.7 to 4.3 cases/1,000 LB with an average yearly decrease of 7% (p < 0.001). Incidence was highest at referral hospitals (68/1,000 LB) and lowest at Health Center IIs (1.3/1,000 LB). Regionally, total sepsis increased in Central (15.5 to 23.0/1,000 LB, p < 0.001) and Northern regions (15.3 to 22.2/1,000 LB, p < 0.001) but decreased in Western (23.7 to 17.0/ 1,000 LB, p < 0.001) and Eastern (15.0 to 8.9/1,000, p < 0.001) regions. CONCLUSION: The high and increasing incidence of EOS in Uganda suggests a major gap in sepsis prevention and quality of care for pregnant women. The heterogenous distribution of neonatal sepsis incidence requires root cause analysis by health authorities in regions with consistently high incidence. Strengthening prevention and treatment interventions in Central and Northern regions, and in the most affected districts, could reduce neonatal sepsis. Employment of strategies which increase uptake of safe newborn care practices and prevent neonatal sepsis, such as community health worker (CHW) home visits for mothers and newborns, could reduce incidence.

Timeliness and completeness of monthly disease surveillance data reporting, Uganda, 2020-2021.

Introduction: timely and complete reporting of routine public health information about diseases and public health events are important aspects of a robust surveillance system. Although data on the completeness and timeliness of monthly surveillance data are collected in the District Health Information System-2 (DHIS2), they have not been routinely analyzed. We assessed completeness and timeliness of monthly outpatient department (OPD) data, January 2020-December 2021. Methods: we analyzed secondary data from all the 15 regions and 146 districts of Uganda. Completeness was defined as the number of submitted reports divided by the number of expected reports. Timeliness was defined as the number of reports submitted by the deadline (15th day of the following month) divided by reports received. Completeness or timeliness score of <80% was regarded incomplete or untimely. Results: overall, there was good general performance with the median completeness being high in 2020 (99.5%; IQR 97.8-100%) and 2021 (100%; IQR 98.7-100%), as was the median timeliness (2020; 82.8%, IQR 74.6-91.8%; 2021, 94.9%, IQR 86.5-99.1%). Kampala Region was the only region that consistently failed to reach ≥ 80% OPD timeliness (2020: 44%; 2021: 65%). Nakasongola was the only district that consistently performed poorly in the submission of timely reports in both years (2020: 54.4%, 2021: 58.3%). Conclusion: there was an overall good performance in the submission of complete and timely monthly OPD reports in most districts and regions in Uganda. There is a need to strengthen the good reporting practices exhibited and offer support to regions, districts, and health facilities with timeliness challenges.

Community dialogue meetings among district leaders improved their willingness to receive COVID-19 vaccines in Western Uganda, May 2021.

BACKGROUND: Widespread COVID-19 vaccine uptake can facilitate epidemic control. A February 2021 study in Uganda suggested that public vaccine uptake would follow uptake among leaders. In May 2021, Baylor Uganda led community dialogue meetings with district leaders from Western Uganda to promote vaccine uptake. We assessed the effect of these meetings on the leaders' COVID-19 risk perception, vaccine concerns, perception of vaccine benefits and access, and willingness to receive COVID-19 vaccine. METHODS: All departmental district leaders in the 17 districts in Western Uganda, were invited to the meetings, which lasted approximately four hours. Printed reference materials about COVID-19 and COVID-19 vaccines were provided to attendees at the start of the meetings. The same topics were discussed in all meetings. Before and after the meetings, leaders completed self-administered questionnaires with questions on a five-point Likert Scale about risk perception, vaccine concerns, perceived vaccine benefits, vaccine access, and willingness to receive the vaccine. We analyzed the findings using Wilcoxon's signed-rank test. RESULTS: Among 268 attendees, 164 (61%) completed the pre- and post-meeting questionnaires, 56 (21%) declined to complete the questionnaires due to time constraints and 48 (18%) were already vaccinated. Among the 164, the median COVID-19 risk perception scores changed from 3 (neutral) pre-meeting to 5 (strong agreement with being at high risk) post-meeting (p < 0.001). Vaccine concern scores reduced, with medians changing from 4 (worried about vaccine side effects) pre-meeting to 2 (not worried) post-meeting (p < 0.001). Median scores regarding perceived COVID-19 vaccine benefits changed from 3 (neutral) pre-meeting to 5 (very beneficial) post-meeting (p < 0.001). The median scores for perceived vaccine access increased from 3 (neutral) pre-meeting to 5 (very accessible) post-meeting (p < 0.001). The median scores for willingness to receive the vaccine changed from 3 (neutral) pre-meeting to 5 (strong willingness) post-meeting (p < 0.001). CONCLUSION: COVID-19 dialogue meetings led to district leaders' increased risk perception, reduced concerns, and improvement in perceived vaccine benefits, vaccine access, and willingness to receive the COVID-19 vaccine. These could potentially influence public vaccine uptake if leaders are vaccinated publicly as a result. Broader use of such meetings with leaders could increase vaccine uptake among themselves and the community.

Readiness of health facilities to manage individuals infected with COVID-19, Uganda, June 2021.

BACKGROUND: The COVID-19 pandemic overwhelmed the capacity of health facilities globally, emphasizing the need for readiness to respond to rapid increases in cases. The first wave of COVID-19 in Uganda peaked in late 2020 and demonstrated challenges with facility readiness to manage cases. The second wave began in May 2021. In June 2021, we assessed the readiness of health facilities in Uganda to manage the second wave of COVID-19. METHODS: Referral hospitals managed severe COVID-19 patients, while lower-level health facilities screened, isolated, and managed mild cases. We assessed 17 of 20 referral hospitals in Uganda and 71 of 3,107 lower-level health facilities, selected using multistage sampling. We interviewed health facility heads in person about case management, coordination and communication and reporting, and preparation for the surge of COVID-19 during first and the start of the second waves of COVID-19, inspected COVID-19 treatment units (CTUs) and other service delivery points. We used an observational checklist to evaluate capacity in infection prevention, medicines, personal protective equipment (PPE), and CTU surge capacity. We used the "ReadyScore" criteria to classify readiness levels as > 80% ('ready'), 40-80% ('work to do'), and < 40% ('not ready') and tailored the assessments to the health facility level. Scores for the lower-level health facilities were weighted to approximate representativeness for their health facility type in Uganda. RESULTS: The median (interquartile range (IQR)) readiness scores were: 39% (IQR: 30, 51%) for all health facilities, 63% (IQR: 56, 75%) for referral hospitals, and 32% (IQR: 24, 37%) for lower-level facilities. Of 17 referral facilities, two (12%) were 'ready' and 15 (88%) were in the "work to do" category. Fourteen (82%) had an inadequate supply of medicines, 12 (71%) lacked adequate supply of oxygen, and 11 (65%) lacked space to expand their CTU. Fifty-five (77%) lower-level health facilities were "not ready," and 16 (23%) were in the "work to do" category. Seventy (99%) lower-level health facilities lacked medicines, 65 (92%) lacked PPE, and 53 (73%) lacked an emergency plan for COVID-19. CONCLUSION: Few health facilities were ready to manage the second wave of COVID-19 in Uganda during June 2021. Significant gaps existed for essential medicines, PPE, oxygen, and space to expand CTUs. The Uganda Ministry of Health utilized our findings to set up additional COVID-19 wards in hospitals and deliver medicines and PPE to referral hospitals. Adequate readiness for future waves of COVID-19 requires additional support and action in Uganda.

Timeliness and completeness of weekly surveillance data reporting on epidemic prone diseases in Uganda, 2020-2021.

INTRODUCTION: Disease surveillance provides vital data for disease prevention and control programs. Incomplete and untimely data are common challenges in planning, monitoring, and evaluation of health sector performance, and health service delivery. Weekly surveillance data are sent from health facilities using mobile tracking (mTRAC) program, and synchronized into the District Health Information Software version 2 (DHIS2). The data are then merged into district, regional, and national level datasets. We described the completeness and timeliness of weekly surveillance data reporting on epidemic prone diseases in Uganda, 2020-2021. METHODS: We abstracted data on completeness and timeliness of weekly reporting of epidemic-prone diseases from 146 districts of Uganda from the DHIS2.Timeliness is the proportion of all expected weekly reports that were submitted to DHIS2 by 12:00pm Monday of the following week. Completeness is the proportion of all expected weekly reports that were completely filled and submitted to DHIS2 by 12:00pm Wednesday of the following week. We determined the proportions and trends of completeness and timeliness of reporting at national level by year, health region, district, health facility level, and facility ownership. RESULTS: National average reporting timeliness and completeness was 44% and 70% in 2020, and 49% and 75% in 2021. Eight of the 15 health regions achieved the target for completeness of ≥ 80%; Lango attained the highest (93%) in 2020, and Karamoja attained 96% in 2021. None of the regions achieved the timeliness target of ≥ 80% in either 2020 or 2021. Kampala District had the lowest completeness (38% and 32% in 2020 and 2021, respectively) and the lowest timeliness (19% in both 2020 and 2021). Referral hospitals and private owned health facilities did not attain any of the targets, and had the poorest reporting rates throughout 2020 and 2021. CONCLUSION: Weekly surveillance reporting on epidemic prone diseases improved modestly over time, but timeliness of reporting was poor. Further investigations to identify barriers to reporting timeliness for surveillance data are needed to address the variations in reporting.

Investigation of human tungiasis cases, Sheema District, Uganda, November 2021-February 2022.

Introduction: no formal surveillance system exists in Uganda for jiggers (tungiasis); however, outbreaks are frequently reported in the media. On 27th January 2022, a news alert reported a jiggers' outbreak in Sheema District, Southwestern Uganda. We investigated to establish the magnitude of the problem and identify possible exposures associated with infestation to inform control measures. Methods: we defined a confirmed case as visible Tunga penetrans (T. penetrans) in the skin of a resident of any of 6 villages in Bwayegamba Parish, Sheema District, in February 2022. A suspected case was self-reported T. penetrans infestation during the three months preceding the interview. We visited all households in the 3 most affected villages in Bwayegamba Parish to identify cases and conducted interviews to identify possible exposures. We described cases by person, place, and time. We assessed socioeconomic status, household construction, mitigation measures against jiggers, and observed participants and their environments for hygiene. We conducted 2 case-control studies. One compared case-households (with ≥1 case) with control-households (without any cases). The second compared individual cases (suspected and confirmed) to neighbourhood controls. Results: among 278 households, we identified 60 case-patients, among whom 34 (57%) were male. Kiyungu West was the most affected village (attack rate=31/1,000). Cases had higher odds of being male (ORMH=2.3, 95% CI=1.3-4.0), <20 years of age (ORMH=2.0, 95%CI=1.1-3.6), unmarried (ORMH=2.97, 95% CI=1.7-5.2), unemployed (ORMH=3.28, 95% CI=1.8-5.8), and having poor personal hygiene (ORMH=3.73, 95% CI=2.0-7.4) than controls. In the household case-control study, case-households had higher odds of having dirty or littered compounds (ORMH=2.3, 95% CI=1.2-4.6) and lower odds of practicing mitigation measures against jiggers (ORMH=0.33, 95% CI=0.1-0.8) than control-households. Conclusion: males, unemployed persons, and those with poor personal or household hygiene had increased odds of tungiasis in this outbreak. Multi-sectoral, tailored interventions that improve standards of living could reduce risk of tungiasis in this area. Adding tungiasis to national surveillance reporting tools could facilitate early identification of future outbreaks.

Improving the effectiveness of Field Epidemiology Training Programs: characteristics that facilitated effective response to the COVID-19 pandemic in Uganda.

BACKGROUND: The global need for well-trained field epidemiologists has been underscored in the last decade in multiple pandemics, the most recent being COVID-19. Field Epidemiology Training Programs (FETPs) are in-service training programs that improve country capacities to respond to public health emergencies across different levels of the health system. Best practices for FETP implementation have been described previously. The Uganda Public Health Fellowship Program (PHFP), or Advanced-FETP in Uganda, is a two-year fellowship in field epidemiology funded by the U.S. Centers for Disease Control and situated in the Uganda National Institute of Public Health (UNIPH). We describe how specific attributes of the Uganda PHFP that are aligned with best practices enabled substantial contributions to the COVID-19 response in Uganda. METHODS: We describe the PHFP in Uganda and review examples of how specific program characteristics facilitate integration with Ministry of Health needs and foster a strong response, using COVID-19 pandemic response activities as examples. We describe PHFP activities and outputs before and during the COVID-19 response and offer expert opinions about the impact of the program set-up on these outputs. RESULTS: Unlike nearly all other Advanced FETPs in Africa, PHFP is delinked from an academic degree-granting program and enrolls only post-Master's-degree fellows. This enables full-time, uninterrupted commitment of academically-trained fellows to public health response. Uganda's PHFP has strong partner support in country, sufficient technical support from program staff, Ministry of Health (MoH), CDC, and partners, and full-time dedicated directorship from a well-respected MoH staff member. The PHFP is physically co-located inside the UNIPH with the emergency operations center (EOC), which provides a direct path for health alerts to be investigated by fellows. It has recognized value within the MoH, which integrates graduates into key MoH and partner positions. During February 2020-September 2021, PHFP fellows and graduates completed 67 major COVID-related projects. PHFP activities during the COVID-19 response were specifically requested by the MoH or by partners, or generated de novo by the program, and were supervised by all partners. CONCLUSION: Specific attributes of the PHFP enable effective service to the Ministry of Health in Uganda. Among the most important is the enrollment of post-graduate fellows, which leads to a high level of utilization of the program fellows by the Ministry of Health to fulfill real-time needs. Strong leadership and sufficient technical support permitted meaningful program outputs during COVID-19 pandemic response. Ensuring the inclusion of similar characteristics when implementing FETPs elsewhere may allow them to achieve a high level of impact.

Ownership and use of long-lasting insecticidal nets three months after a mass distribution campaign in Uganda, 2021.

BACKGROUND: Uganda conducted its third mass long-lasting insecticidal net (LLIN) distribution campaign in 2021. The target of the campaign was to ensure that 100% of households own at least one LLIN per two persons and to achieve 85% use of distributed LLINs. LLIN ownership, use and associated factors were assessed 3 months after the campaign. METHODS: A cross-sectional household survey was conducted in 14 districts from 13 to 30 April, 2021. Households were selected using multistage sampling. Each was asked about LLIN ownership, use, duration since received to the time of interview, and the presence of LLINs was visually verified. Outcomes were having at least one LLIN per two household members, and individual LLIN use. Modified Poisson regression was used to assess associations between exposures and outcomes. RESULTS: In total, 5529 households with 27,585 residents and 15,426 LLINs were included in the analysis. Overall, 95% of households owned ≥ 1 LLIN, 92% of the households owned ≥ 1 LLIN < 3 months old, 64% of households owned ≥ 1 LLIN per two persons in the household. Eighty-seven per cent could sleep under an LLIN if every LLIN in the household were used by two people, but only 69% slept under an LLIN the night before the survey. Factors associated with LLIN ownership included believing that LLINs are protective against malaria (aPR = 1.13; 95% CI 1.04-1.24). Reported use of mosquito repellents was negatively associated with ownership of LLINs (aPR = 0.96; 95% CI 0.95-0.98). The prevalence of LLIN use was 9% higher among persons who had LLINs 3-12 months old (aPR = 1.09; 95% CI 1.06-1.11) and 10% higher among those who had LLINs 13-24 months old (aPR = 1.10; 95% CI 1.06-1.14) than those who had LLINs < 3 months old. Of 3,859 LLINs identified in the households but not used for sleeping the previous night, 3250 (84%) were < 3 months old. Among these 3250, 41% were not used because owners were using old LLINs; 16% were not used because of lack of space for hanging them; 11% were not used because of fear of chemicals in the net; 5% were not used because of dislike of the smell of the nets; and, 27% were not used for other reasons. CONCLUSION: The substantial difference between the population that had access to LLINs and the population that slept under LLINs indicates that the National Malaria Control Programme (NMCP) may need to focus on addressing the main drivers or barriers to LLIN use. NMCP and/or other stakeholders could consider designing and conducting targeted behaviour change communication during subsequent mass distribution of LLINs after the mass distribution campaign to counter misconceptions about new LLINs.

Malaria outbreak facilitated by increased mosquito breeding sites near houses and cessation of indoor residual spraying, Kole district, Uganda, January-June 2019.

BACKGROUND: In June 2019, surveillance data from the Uganda's District Health Information System revealed an outbreak of malaria in Kole District. Analysis revealed that cases had exceeded the outbreak threshold from January 2019. The Ministry of Health deployed our team to investigate the areas and people affected, identify risk factors for disease transmission, and recommend control and prevention measures. METHODS: We conducted an outbreak investigation involving a matched case-control study. We defined a confirmed case as a positive malaria test in a resident of Aboke, Akalo, Alito, and Bala sub-counties of Kole District January-June 2019. We identified cases by reviewing outpatient health records. Exposures were assessed in a 1:1 matched case-control study (n = 282) in Aboke sub-county. We selected cases systematically from 10 villages using probability proportionate to size and identified age- and village-matched controls. We conducted entomological and environmental assessments to identify mosquito breeding sites. We plotted epidemic curves and overlaid rainfall, and indoor residual spraying (IRS). Case-control exposures were combined into: breeding site near house, proximity to swamp and breeding site, and proximity to swamp; these were compared to no exposure in a logistic regression analysis. RESULTS: Of 18,737 confirmed case-patients (AR = 68/1,000), Aboke sub-county residents (AR = 180/1,000), children < 5 years (AR = 94/1,000), and females (AR = 90/1,000) were most affected. Longitudinal analysis of surveillance data showed decline in cases after an IRS campaign in 2017 but an increase after IRS cessation in 2018-2019. Overlay of rainfall and case data showed two malaria upsurges during 2019, occurring 35-42 days after rainfall increases. Among 141 case-patients and 141 controls, the combination of having mosquito breeding sites near the house and proximity to swamps increased the odds of malaria 6-fold (OR = 6.6, 95% CI = 2.24-19.7) compared to no exposures. Among 84 abandoned containers found near case-patients' and controls' houses, 14 (17%) had mosquito larvae. Adult Anopheles mosquitoes, larvae, pupae, and pupal exuviae were identified near affected houses. CONCLUSION: Stagnant water formed by increased rainfall likely provided increased breeding sites that drove this outbreak. Cessation of IRS preceded the malaria upsurges. We recommend re-introduction of IRS and removal of mosquito breeding sites in Kole District.

Measles outbreak in Semuto Subcounty, Nakaseke District, Uganda, June-August 2021.

Background: Semuto Subcounty reported rubella/measles outbreaks in January 2020 and June-August 2021. This study investigated the outbreak in 2021 to determine the scope, and the factors associated with transmission. Methods: A probable case was defined as a resident of Semuto Subcounty with acute onset of fever and a generalized maculopapular rash with either cough/cold or red eyes from 1 June to 31 August 2021. A confirmed case was defined as a probable case with a blood sample positive for measles-specific IgM. A village-matched case-control study was conducted with 30 cases and 122 controls (1:4 ratio). A control was defined as an individual aged 6 months-9 years, sampled at random, with no signs or symptoms of measles from 1 June to 31 August 2021, residing in the same village as the matched case. Adjusted Mantel-Haenszel odds ratios (ORMH) and confidence intervals (CIs) were calculated. Results: Of the 30 cases (27 probable and three confirmed), 16 (53%) were male. The subcounty attack rate (AR) was 3.2/1000. Children aged 5-9 years were the most affected (AR 5.0/1000). Twenty-two (79%) cases and 116 (97%) controls had ever received measles vaccine (ORMH 0.13, 95% CI 0.03-0.52). Interaction with symptomatic persons at water collection points (ORMH 4.4, 95% CI 1.6-12) and playing at community playgrounds (ORMH 4.2, 95% CI 1.7-11) increased the odds of infection. Conclusions: Socializing/congregating at water collection points and community playgrounds facilitated the transmission of measles in this outbreak.

Delayed outbreak detection: a wake-up call to evaluate a surveillance system.

During May, 83 of the 120 districts in Uganda had reported malaria cases above the upper limit of the normal channel. Across all districts, cases had exceeded malaria normal channel upper limits for an average of six months. Yet no alarms had been raised! Starting in 2000, Uganda adopted the World Health Organization (WHO) Integrated Disease Surveillance and Response (IDSR) strategy for disease reporting, including for malaria. Even early on, however, it was unclear how effectively IDSR and DHIS2 were being used in Uganda. Outbreaks were consistently detected late, but the underlying cause of the late detection was unclear. Suspecting there might be gaps in the surveillance system that were not immediately obvious, the Uganda FETP was asked to evaluate the malaria surveillance system in Uganda. This case study teaches trainees in Field Epidemiology and Laboratory Training Programs, public health students, public health workers who may participate in evaluation of public health surveillance systems, and others who are interested in this topic on reasons, steps, and attributes and uses the surveillance evaluation approach to identify gaps and facilitates discussion of practical solutions for improving a public health surveillance system.