Accuracy of un-supervised versus provider-supervised self-administered HIV testing in Uganda: A randomized implementation trial.

Unsupervised HIV self-testing (HST) has potential to increase knowledge of HIV status; however, its accuracy is unknown. To estimate the accuracy of unsupervised HST in field settings in Uganda, we performed a non-blinded, randomized controlled, non-inferiority trial of unsupervised compared with supervised HST among selected high HIV risk fisherfolk (22.1 % HIV Prevalence) in three fishing villages in Uganda between July and September 2013. The study enrolled 246 participants and randomized them in a 1:1 ratio to unsupervised HST or provider-supervised HST. In an intent-to-treat analysis, the HST sensitivity was 90 % in the unsupervised arm and 100 % among the provider-supervised, yielding a difference 0f -10 % (90 % CI -21, 1 %); non-inferiority was not shown. In a per protocol analysis, the difference in sensitivity was -5.6 % (90 % CI -14.4, 3.3 %) and did show non-inferiority. We conclude that unsupervised HST is feasible in rural Africa and may be non-inferior to provider-supervised HST.

African swine fever among slaughter pigs in Mubende district, Uganda.

Owing to frequent reports of suspected outbreaks and the presence of reservoir hosts and vectors (warthogs, bushpigs and O. moubata ticks), African swine fever (ASF) is believed to be an endemic disease in Uganda. There have, however, been very few studies carried out to confirm its existence in Uganda. This study was carried out to describe the prevalence of ASF based on pathologic lesions and analysis of serum samples from slaughtered pigs during a suspected outbreak in the Mubende district of Uganda. The study was based on visits to 22 slaughterhouses where individual pigs were randomly selected for a detailed ante-mortem and post-mortem inspections. Sera were also collected for laboratory analysis. A total of 997 pigs (53.7% male and 46.3% female) were examined for lesions suggestive of ASF and sero-positivity of sera for ASF antibodies. The sera were tested using enzyme-linked immunosorbent assay (ELISA) and positive samples were further confirmed with an immunoblot assay. The results showed that 3.8% (38/997) of the pigs examined had clinical signs and post-mortem lesions suggestive of ASF. Two of 997 (0.2%) sera analysed were positive for ASF antibodies. Of the sub-counties investigated, Bagezza (12%) and Kiyuni (11%) had the highest prevalence of lesions suggestive of ASF based on ante- and post-mortem examination results, while Mubende town council (1.7%) had the lowest. This study found a low number of pigs (3.8%) with lesions suggestive of ASF at slaughter and an even lower number of pigs (0.2%) that were seropositive at slaughter, however a significantly higher number of pigs were slaughtered during the outbreak as a strategy for farmers to avoid losses associated with mortality.

Isolation of non-tuberculous mycobacteria from pastoral ecosystems of Uganda: public health significance.

BACKGROUND: The importance of non-tuberculous mycobacteria (NTM) infections in humans and animals in sub-Saharan Africa at the human-environment-livestock-wildlife interface has recently received increased attention. NTM are environmental opportunistic pathogens of humans and animals. Recent studies in pastoral ecosystems of Uganda detected NTM in humans with cervical lymphadenitis and cattle with lesions compatible with bovine tuberculosis. However, little is known about the source of these mycobacteria in Uganda. The aim of this study was to isolate and identify NTM in the environment of pastoral communities in Uganda, as well as assess the potential risk factors and the public health significance of NTM in these ecosystems. METHOD: A total of 310 samples (soil, water and faecal from cattle and pigs) were examined for mycobacteria. Isolates were identified by the INNO-Lipa test and by 16S rDNA sequencing. Additionally, a questionnaire survey involving 231 pastoralists was conducted during sample collection. Data were analysed using descriptive statistics followed by a multivariable logistic regression analysis. RESULTS: Forty-eight isolates of NTM were detected; 25.3% of soil samples, 11.8% of water and 9.1% from animal faecal samples contained mycobacteria. Soils around water sources were the most contaminated with NTM (29.8%). Of these samples, M. fortuitum-peregrinum complex, M. avium complex, M. gordonae, and M. nonchromogenicum were the most frequently detected mycobacteria. Drinking untreated compared to treated water (OR = 33), use of valley dam versus stream water for drinking and other domestic use (OR = 20), sharing of water sources with wild primates compared to antelopes (OR = 4.6), sharing of water sources with domestic animals (OR = 5.3), and close contact with cattle or other domestic animals (OR = 13.8) were the most plausible risk factors for humans to come in contact with NTM in the environment. CONCLUSIONS: The study detected a wide range of potentially pathogenic NTM from the environment around the pastoral communities in Uganda. Drinking untreated water and living in close contact with cattle or other domestic animals may be risk factors associated with the possibility of humans and animals acquiring NTM infections from these ecosystems.

Risk factors associated with prevalence of tuberculosis-like lesions and associated mycobacteria in cattle slaughtered at public and export abattoirs in Ethiopia.

This study was aimed at investigating risk factors associated with prevalence of tuberculosis (TB)-like lesions and associated mycobacteria in Ethiopian cattle slaughtered. The study was carried out during 2006-2007 in five selected municipal and export abattoirs. Methods of investigation involved detailed necropsy examination of carcasses and isolation of mycobacteria from pathologic tissue specimens. Factors of animal and environment origin were recorded and examined as explanatory variables in relation to the presence or absence of TB-like lesions and the presence of viable mycobacteria. Multivariable logistic regression analysis was used to identify risk factors associated with prevalence of TB-like lesions and mycobacteria. Out of 3,322 carcasses inspected, 10.2% (95% confidence interval (CI) [9.2-11.3]) and 3.2% (95% CI [2.6-3.8]) were positive, respectively, based on necropsy and bacteriologic examinations. The highest and lowest lesion prevalence was recorded in Adama (24.7%) and Yabello (4.2%), respectively. Multivariable logistic regression analysis identified age, breed, abattoir location, geographic origin and management system as being risk factors for prevalence of TB-like lesions and occurrence of viable mycobacteria in Ethiopian cattle. The study demonstrated mycobacterial infection as important infectious disease of Ethiopian cattle. The reported confirmed cases of the disease in different management and geographic settings in Ethiopia disproved the earlier held opinion of its occurrence as a low sporadic profile. In view of a dietary proclivity of Ethiopian communities (milk and meat are predominantly consumed raw) and lifestyle (close contact of people with animals), the risk of bovine tuberculosis as a public health threat is eminent.

Seroprevalence of brucellosis and its associated risk factors in cattle from smallholder dairy farms in Zimbabwe.

A cross-sectional study was conducted to investigate seroprevalence of brucellosis and the associated risk factors in cattle from smallholder dairy farms in Gokwe, Marirangwe, Mushagashe, Nharira, Rusitu and Wedza areas of Zimbabwe. A total of 1,440 cattle from 203 herds were tested serially for Brucella antibodies using Rose Bengal test and the competitive ELISA. Weighted seroprevalence estimates were calculated and risk factors in individual cattle investigated using logistic regression analysis. The overall individual animal brucellosis seroprevalence was low, with mean of 5.6% (95% confidence interval (CI), 4.4%, 6.8%). Gokwe had the highest individual (12.6%; 95% CI, 3.9%, 21.4%) and herd-level (40.0%; 95% CI, 22.1%, 58.0%), while Wedza had the lowest individual (2.3%; 95% CI, 0%, 5.3%) and herd-level (8.0%; 95% CI, 0.0%, 18.9%) brucellosis seroprevalence, respectively. In individual cattle, the area of origin, age and history of abortion were independently associated with brucellosis seroprevalence. While the seroprevalence was independent of sex, it decreased with increasing age. Cattle 2-4 years old had higher odds (odds ratio (OR) = 3.2; 95% CI, 1.1%, 9.1%) of being seropositive compared to those >7 years. Cows with a history of abortion were more likely to be seropositive (OR = 7.9; 95% CI, 3.1, 20.1) than controls. In conclusion, the area-to-area variation of brucellosis may be linked to ecological factors and differences in management practices. The implementation of stamping out policy, bleeding and testing animals before movement and promoting the use self-contained units are likely to significantly reduce the public health risks associated with Brucella infections in cattle.

Molecular characterization of Mycobacterium bovis isolates from Ethiopian cattle.

BACKGROUND: Bovine Tuberculosis (BTB) is a widespread and endemic disease of cattle in Ethiopia. Information relating to genotypic characteristics of Mycobacterium bovis strains affecting the cattle population in Ethiopia is limited. We carried out molecular characterization of M. bovis strains isolated from BTB infected cattle using the spoligotyping technique. The relationship between distribution of spoligotypes and recorded variables was also investigated. A new approach that can numerically reflect the degree of genetic polymorphism in a M. bovis population was also developed. The study was conducted from July 2006 to January 2007 in cattle slaughtered at five representative abattoirs in Ethiopia. RESULTS: Forty-five M. bovis isolates were obtained from 406 pathologic tissue specimens collected from 337 carcasses with lesions compatible with BTB. Twelve spoligotypes were identified from 34 distinct strains; with SB1176 as a dominant spoligotype (41.2% of the isolates) followed by SB0133 (14.7%). Comparison of spoligotypes with an M. bovis global database http://www.mbovis.org revealed six new spoligotypes which were subsequently registered in the database with international identification codes of SB1517, SB1518, SB1519, SB1520, SB1521 and SB1522. The majority of strains were obtained from cattle slaughtered at Addis Ababa abattoir. On the basis of the Spoligotype Evolutionary Index, SEI (a numeric expression approach to make standardized comparison of spoligotype evolution), M. bovis isolates from Ethiopia were relatively more heterogeneous (SEI = 3.2) compared to isolates from other countries. This might be attributed to extensive livestock movement linked to trading or seasonal migration, high degree of livestock mingling, and also diversities of the country's agricultural and livestock ecosystems, in addition to lack of disease control measures that led to high infection prevalence. Multiple spoligotype infection was recorded in nine (50%) of infected carcasses and this may indicate the prevailing high degree of super infection. CONCLUSIONS: This study provided molecular evidence for the widespread distribution of M. bovis in the cattle population in Ethiopia. It also demonstrated a relatively high degree of genetic polymorphism of the isolates. Further molecular investigation of M. bovis strains in humans and other domestic animals is recommended in order to elucidate the zoonotic importance as well as reservoirs and pattern of transmission among various hosts.

Factors associated with pastoral community knowledge and occurrence of mycobacterial infections in human-animal interface areas of Nakasongola and Mubende districts, Uganda.

BACKGROUND: Nontuberculous mycobacteria (NTM) are emerging opportunistic pathogens whose role in human and animal disease is increasingly being recognized. Major concerns are their role as opportunistic pathogens in HIV/AIDS infections. The role of open natural water sources as source and livestock/wildlife as reservoirs of infections to man are well documented. This presents a health challenge to the pastoral systems in Africa that rely mostly on open natural water sources to meet livestock and human needs. Recent study in the pastoral areas of Uganda showed infections with same genotypes of NTM in pastoralists and their livestock. The aim of this study was to determine the environmental, animal husbandry and socio-demographic factors associated with occurrence and the pastoral community knowledge of mycobacterial infections at the human-environment-livestock/wildlife interface (HELI) areas in pastoral ecosystems of Uganda. METHODS: Two hundred and fifty three (253) individuals were subjected to a questionnaire survey across the study districts of Nakasongola and Mubende. Data were analyzed using descriptive statistics and multivariable logistic regression analysis. RESULTS: Humans sharing of the water sources with wild animals from the forest compared to savannah ecosystem (OR = 3.3), the tribe of herding pastoral community (OR = 7.9), number of rooms present in household (3-5 vs. 1-2 rooms) (OR = 3.3) were the socio-demographic factors that influenced the level of knowledge on mycobacterial infections among the pastoral communities. Tribe (OR = 6.4), use of spring vs. stream water for domestic use (OR = 4.5), presence of sediments in household water receptacle (OR = 2.32), non separation of water containers for drinking and domestic use (OR = 2.46), sharing of drinking water sources with wild animals (OR = 2.1), duration of involvement of >5 yrs in cattle keeping (OR = 3.7) and distance of household to animal night shelters (>20 meters) (OR = 3.8) were significant socio-demographic factors associated with the risk of occurrence of mycobacterioses among the pastoral communities in Uganda. CONCLUSION: The socio-demographic, environmental and household related factors influence the risk of occurrence as well as pastoralists' knowledge of mycobacterial infections in the pastoral households at the human-environment-livestock/wildlife pastoral interface areas of Uganda.

Distribution and intensity of Echinococcus granulosus infections in dogs in Moroto District, Uganda.

This study was carried out during August 2007-March 2008 in pastoral areas of Moroto District, Uganda. It investigated the distribution and infection intensity of Echinococcus granulosus in the dog population and involved the postmortem examination of 327 dogs (106 domesticated; 80 semi-domesticated, and 141 strays; comprised of 163 females and 164 males). The overall prevalence of E. granulosus was 66.3% (95% CI=60.8-71.4) with parasite burdens of 6-5,213 among the infected dogs. The prevalence of E. granulosus was primarily associated with the season. While the dogs were more likely to have high parasite burdens during the rainy as opposed to the dry season, the parasite burden of E. granulosus infection was also highly associated with age and husbandry. Young dogs were at greater risk of carrying a heavy burden of E. granulosus infection than adults. Likewise, stray dogs were more likely to have a heavy parasite burden. As the study documented a high prevalence and intensity of E. granulosus infection in the dog population in Moroto District of Uganda, further studies need to be carried out in human and intermediate hosts to elucidate the cycle of transmission that could help to design appropriate controlling measures.

African 1, an epidemiologically important clonal complex of Mycobacterium bovis dominant in Mali, Nigeria, Cameroon, and Chad.

We have identified a clonal complex of Mycobacterium bovis present at high frequency in cattle in population samples from several sub-Saharan west-central African countries. This closely related group of bacteria is defined by a specific chromosomal deletion (RDAf1) and can be identified by the absence of spacer 30 in the standard spoligotype typing scheme. We have named this group of strains the African 1 (Af1) clonal complex and have defined the spoligotype signature of this clonal complex as being the same as the M. bovis BCG vaccine strain but with the deletion of spacer 30. Strains of the Af1 clonal complex were found at high frequency in population samples of M. bovis from cattle in Mali, Cameroon, Nigeria, and Chad, and using a combination of variable-number tandem repeat typing and spoligotyping, we show that the population of M. bovis in each of these countries is distinct, suggesting that the recent mixing of strains between countries is not common in this area of Africa. Strains with the Af1-specific deletion (RDAf1) were not identified in M. bovis isolates from Algeria, Burundi, Ethiopia, Madagascar, Mozambique, South Africa, Tanzania, and Uganda. Furthermore, the spoligotype signature of the Af1 clonal complex has not been identified in population samples of bovine tuberculosis from Europe, Iran, and South America. These observations suggest that the Af1 clonal complex is geographically localized, albeit to several African countries, and we suggest that the dominance of the clonal complex in this region is the result of an original introduction into cows naïve to bovine tuberculosis.

Comparative effect of direct-fed microbials on fecal shedding of Escherichia coli O157:H7 and Salmonella in naturally infected feedlot cattle.

The effect of direct-fed microbials (DFM) on fecal shedding of Escherichia coli O157:H7 and Salmonella in naturally infected feedlot cattle was evaluated in a clinical trial involving 138 feedlot steers. Following standard laboratory methods, fecal samples collected from steers were evaluated for change in the detectable levels of E. coli O157:H7 and Salmonella shed in feces after DFM treatment. Sampling of steers was carried out every 3 weeks for 84 days. A significant reduction (32%) in fecal shedding of E. coli O157:H7 (P < 0.001), but not Salmonella (P = 0.24), was observed among the treatment steers compared with the control group during finishing. The probability of recovery of E. coli O157:H7 from the feces of treated and control steers was 34.0 and 66.0%, respectively. Steers placed on DFM supplement were almost three times less likely to shed E. coli O157:H7 (odds ratio, 0.36; 95% confidence interval, 0.25 to 0.53; P < 0.001) in their feces as opposed to their control counterparts. The probability of recovery of Salmonella from the feces of the control (14.0%) and the treated (11.3%) steers was similar. However, the DFM significantly reduced probability of new infections with Salmonella among DFM-treated cattle compared with controls (nontreated ones). It appears that DFM as applied in our study are capable of significantly reducing fecal shedding of E. coli O157:H7 in naturally infected cattle but not Salmonella. The factors responsible for the observed difference in the effects of DFM on E. coli O157:H7 and Salmonella warrants further investigation.

Household Socioeconomic and Demographic Correlates of Cryptosporidium Seropositivity in the United States.

BACKGROUND: Cryptosporidium are parasitic protozoa that infect humans, domestic animals, and wildlife globally. In the United States, cryptosporidiosis occurs in an estimated 750,000 persons annually, and is primarily caused by either of the Cryptosporidium parvum genotypes 1 and 2, exposure to which occurs through ingestion of food or water contaminated with oocytes shed from infected hosts. Although most cryptosporidiosis cases are caused by genotype 1 and are of human origin, the zoonotic sources of genotype 2, such as livestock, are increasingly recognized as important for understanding human disease patterns. Social inequality could mediate patterns of human exposure and infection by placing individuals in environments where food or water contamination and livestock contact is high or through reducing the availability of educational and sanitary resources required to avoid exposure. METHODOLOGY/PRINCIPAL FINDINGS: We here analyzed data from the National Health and Nutritional Examination Survey (NHANES) between 1999 and 2000, and related seropositivity to Cryptosporidium parvum to correlates of social inequality at the household and individual scale. After accounting for the complex sampling design of NHANES and confounding by individual demographics and household conditions, we found impaired household food adequacy was associated with greater odds of Cryptosporidium seropositivity. Additionally, we identified individuals of non-white race and ethnicity and those born outside the United States as having significantly greater risk than white, domestic-born counterparts. Furthermore, we provide suggestive evidence for direct effects of family wealth on Cryptosporidium seropositivity, in that persons from low-income households and from families close to the poverty threshold had elevated odds of seropositivity relative to those in high-income families and in households far above the poverty line. CONCLUSIONS/SIGNIFICANCE: These results refute assertions that cryptosporidiosis in the United States is independent of social marginalization and poverty, and carry implications for targeted public health interventions for Cryptosporidium infection in resource-poor groups. Future longitudinal and multilevel studies are necessary to elucidate the complex interactions between ecological factors, social inequality, and Cryptosporidium dynamics.

Cost-effectiveness analysis of community active case finding and household contact investigation for tuberculosis case detection in urban Africa.

INTRODUCTION: Case detection by passive case finding (PCF) strategy alone is inadequate for detecting all tuberculosis (TB) cases in high burden settings especially Sub-Saharan Africa. Alternative case detection strategies such as community Active Case Finding (ACF) and Household Contact Investigations (HCI) are effective but empirical evidence of their cost-effectiveness is sparse. The objective of this study was to determine whether adding ACF or HCI compared with standard PCF alone represent cost-effective alternative TB case detection strategies in urban Africa. METHODS: A static decision modeling framework was used to examine the costs and effectiveness of three TB case detection strategies: PCF alone, PCF+ACF, and PCF+HCI. Probability and cost estimates were obtained from National TB program data, primary studies conducted in Uganda, published literature and expert opinions. The analysis was performed from the societal and provider perspectives over a 1.5 year time-frame. The main effectiveness measure was the number of true TB cases detected and the outcome was incremental cost-effectiveness ratios (ICERs) expressed as cost in 2013 US$ per additional true TB case detected. RESULTS: Compared to PCF alone, the PCF+HCI strategy was cost-effective at US$443.62 per additional TB case detected. However, PCF+ACF was not cost-effective at US$1492.95 per additional TB case detected. Sensitivity analyses showed that PCF+ACF would be cost-effective if the prevalence of chronic cough in the population screened by ACF increased 10-fold from 4% to 40% and if the program costs for ACF were reduced by 50%. CONCLUSIONS: Under our baseline assumptions, the addition of HCI to an existing PCF program presented a more cost-effective strategy than the addition of ACF in the context of an African city. Therefore, implementation of household contact investigations as a part of the recommended TB control strategy should be prioritized.

Age, sex, and nutritional status modify the CD4+ T-cell recovery rate in HIV-tuberculosis co-infected patients on combination antiretroviral therapy.

BACKGROUND: Baseline age and combination antiretroviral therapy (cART) were examined as determinants of CD4+ T-cell recovery during 6 months of tuberculosis (TB) therapy with/without cART. It was determined whether this association was modified by patient sex and nutritional status. METHODS: This longitudinal analysis included 208 immune-competent, non-pregnant, ART-naive HIV-positive patients from Uganda with a first episode of pulmonary TB. CD4+ T-cell counts were measured using flow cytometry. Age was defined as ≤24, 25-29, 30-34, and 35-39 vs. ≥40 years. Nutritional status was defined as normal (>18.5kg/m(2)) vs. underweight (≤18.5kg/m(2)) using the body mass index (BMI). Multivariate random effects linear mixed models were fitted to estimate differences in CD4+ T-cell recovery in relation to specified determinants. RESULTS: cART was associated with a monthly rise of 15.7 cells/µl (p<0.001). Overall, age was not associated with CD4+ T-cell recovery during TB therapy (p = 0.655). However, among patients on cART, the age-associated CD4+ T-cell recovery rate varied by sex and nutritional status, such that age <40 vs. ≥40 years predicted superior absolute CD4+ T-cell recovery among females (p=0.006) and among patients with a BMI ≥18.5kg/m(2) (p<0.001). CONCLUSIONS: TB-infected HIV-positive patients aged ≥40 years have a slower rate of immune restoration given cART, particularly if BMI is >18.5kg/m(2) or they are female. These patients may benefit from increased monitoring and nutritional support during cART.

Molecular characterization of Mycobacterium avium subspecies hominissuis isolated from humans, cattle and pigs in the Uganda cattle corridor using VNTR analysis.

BACKGROUND: Members of the Mycobacterium avium complex (MAC) cause disease in both human and animals. Their ubiquitous nature makes them both successful microbes and difficult to source track. The precise characterization of MAC species is a fundamental step in epidemiological studies and evaluating of possible reservoirs. This study aimed at identifying and characterizing Mycobacterium avium subsp. hominissuis isolated from human, slaughter cattle and pigs in various parts of the Uganda cattle corridor (UCC) at two temporal points using variable number of tandem repeat (VNTR) analysis. METHODS: A total of 46 M. avium isolates; 31 from 997 pigs, 12 from 43 humans biopsies and three from 61 cattle lesions were identified to subspecies level using IS1245 and IS901 PCR, thereafter characterized using VNTR. Twelve loci from two previously described VNTR methods were used and molecular results were analyzed and interpreted using Bionumerics 6.1. PRINCIPAL FINDINGS: 37 of the isolates were identified as M. avium subsp. hominissuis and four as M. avium subsp. avium, while five could not be differentiated, possibly due to mixed infection. There was distinct clustering that coincides with the temporal and spatial differences of the isolates. The isolates from humans and cattle in the North Eastern parts of the UCC shared identical VNTR genotypes. The panel of loci gave an overall discriminatory power of 0.88. Some loci were absent in several isolates, probably reflecting differences in isolates from Uganda/Africa compared to isolates previously analyzed by these methods in Europe and Asia. CONCLUSIONS: The findings indicate a molecular difference between M. avium subsp. hominissuis isolates from pigs in Mubende and cattle and human in the rest of the UCC. Although human and cattle shared VNTR genotypes in the North Eastern parts of the UCC, it is most likely a reflection of a shared environmental source.

European 1: a globally important clonal complex of Mycobacterium bovis.

We have identified a globally important clonal complex of Mycobacterium bovis by deletion analysis of over one thousand strains from over 30 countries. We initially show that over 99% of the strains of M. bovis, the cause of bovine tuberculosis, isolated from cattle in the Republic of Ireland and the UK are closely related and are members of a single clonal complex marked by the deletion of chromosomal region RDEu1 and we named this clonal complex European 1 (Eu1). Eu1 strains were present at less than 14% of French, Portuguese and Spanish isolates of M. bovis but are rare in other mainland European countries and Iran. However, strains of the Eu1 clonal complex were found at high frequency in former trading partners of the UK (USA, South Africa, New Zealand, Australia and Canada). The Americas, with the exception of Brazil, are dominated by the Eu1 clonal complex which was at high frequency in Argentina, Chile, Ecuador and Mexico as well as North America. Eu1 was rare or absent in the African countries surveyed except South Africa. A small sample of strains from Taiwan were non-Eu1 but, surprisingly, isolates from Korea and Kazakhstan were members of the Eu1 clonal complex. The simplest explanation for much of the current distribution of the Eu1 clonal complex is that it was spread in infected cattle, such as Herefords, from the UK to former trading partners, although there is evidence of secondary dispersion since. This is the first identification of a globally dispersed clonal complex M. bovis and indicates that much of the current global distribution of this important veterinary pathogen has resulted from relatively recent International trade in cattle.