Evaluation of the Ebola Virus Disease (EVD) preparedness and readiness program in Uganda: 2018 to 2019.

INTRODUCTION: the Democratic Republic of Congo (DRC) declared its 10thoutbreak of Ebola virus disease (EVD) in 42 years on August 1st 2018. The rapid rise and spread of the EVD outbreak threatened health security in neighboring countries and global health security. The United Nations developed an EVD preparedness and readiness (EVD-PR) plan to assist the nine neighboring countries to advance their critical preparedness measures. In Uganda, EVD-PR was implemented between 2018 and 2019. The World Health Organization commissioned an independent evaluation to assess the impact of the investment in EVD-PR in Uganda. Objectives: i) to document the program achievements; ii) to determine if the capacities developed represented good value for the funds and resources invested; iii) to assess if more cost-effective or sustainable alternative approaches were available; iv) to explore if the investments were aligned with country public health priorities; and v) to document the factors that contributed to the program success or failure. METHODS: during the EVD preparedness phase, Uganda's government conducted a risk assessment and divided the districts into three categories, based on the potential risk of EVD. Category I included districts that shared a border with the DRC provinces where EVD was ongoing or any other district with a direct transport route to the DRC. Category II were districts that shared a border with the DRC but not bordering the DRC provinces affected by the EVD outbreak. Category III was the remaining districts in Uganda. EVD-PR was implemented at the national level and in 22 category I districts. We interviewed key informants involved in program design, planning and implementation or monitoring at the national level and in five purposively selected category I districts. RESULTS: Ebola virus disease preparedness and readiness was a success and this was attributed mainly to donor support, the ministry of health's technical capacity, good coordination, government support and community involvement. The resources invested in EVD-PR represented good value for the funds and the activities were well aligned to the public health priorities for Uganda. CONCLUSION: Ebola virus disease preparedness and readiness program in Uganda developed capacities that played an essential role in preventing cross border spread of EVD from the affected provinces in the DRC and enabled rapid containment of the two importation events. These capacities are now being used to detect and respond to the COVID-19 pandemic.

Building a new platform to support public health emergency response in Africa: the AFENET Corps of Disease Detectives, 2018-2019.

Public health emergency (PHE) response in sub-Saharan Africa is constrained by inadequate skilled public health workforce and underfunding. Since 2005, the African Field Epidemiology Network (AFENET) has been supporting field epidemiology capacity development and innovative strategies are required to use this workforce. In 2018, AFENET launched a continental rapid response team: the AFENET Corps of Disease Detectives (ACoDD). ACoDD comprises field epidemiology graduates and residents and was established to support PHE response. Since 2018, AFENET has deployed the ACoDD to support response to several PHEs. The main challenges faced during ACoDD deployments were financing of operations, ACoDD safety and security, resistance to interventions and distrust of the responders by some communities. Our experience during these deployments showed that it was feasible to mobilise and deploy ACoDD within 48 hours. However, the sustainability of deployments will depend on establishing strong linkages with the employers of ACoDD members. PHEs are effectively controlled when there is a fast deployment and strong linkages between the stakeholders. There are ongoing efforts to strengthen PHE preparedness and response in sub-Saharan Africa. ACoDD members are a competent workforce that can effectively augment PHE response. ACoDD teams mentored front-line health workers and community health workers who are critical in PHE response. Public health emergence response in sub-Saharan Africa is constrained by inadequacies in a skilled workforce and underfunding. ACoDD can be utilised to overcome the challenges of accessing a skilled public health workforce. To improve health security in sub-Saharan Africa, more financing of PHE response is needed.

Factors Associated with Utilisation of Couple HIV Counselling and Testing Among HIV-Positive Adults in Kyoga Fishing Community Uganda, May 2017: Cross Sectional Study.

Couple HIV counseling and testing (CHCT) is key in preventing heterosexual HIV transmission and achievement of 90-90-90 UNAIDS treatment targets by 2020. We conducted secondary data analysis to assess utilization of CHCT and associated factors using logistic regression. 58/134 participants (49%) had ever utilized CHCT. Disclosure of individual HIV results to a partner [aOR = 16; 95% CI: (3.6-67)], residence for > 1 < 5 years [aOR = 0.04; 95% CI (0.005-0.33)], and none mobility [aOR = 3.6; 95% CI (1.1-12)] were significantly associated with CHCT. Age modified relationship between CHCT and disclosure (Likelihood-ratio test LR chi2 = 4.2 (p value = 0.041). Disclosure of individual HIV results with a partner and residence for more than 1 year improved utilization of CHCT; mobility reduced the odds of CHCT. Interventions should target prior discussion of individual HIV results among couples and mobile populations to increase CHCT.

Marburg virus disease outbreak in Kween District Uganda, 2017: Epidemiological and laboratory findings.

INTRODUCTION: In October 2017, a blood sample from a resident of Kween District, Eastern Uganda, tested positive for Marburg virus. Within 24 hour of confirmation, a rapid outbreak response was initiated. Here, we present results of epidemiological and laboratory investigations. METHODS: A district task force was activated consisting of specialised teams to conduct case finding, case management and isolation, contact listing and follow up, sample collection and testing, and community engagement. An ecological investigation was also carried out to identify the potential source of infection. Virus isolation and Next Generation sequencing were performed to identify the strain of Marburg virus. RESULTS: Seventy individuals (34 MVD suspected cases and 36 close contacts of confirmed cases) were epidemiologically investigated, with blood samples tested for MVD. Only four cases met the MVD case definition; one was categorized as a probable case while the other three were confirmed cases. A total of 299 contacts were identified; during follow- up, two were confirmed as MVD. Of the four confirmed and probable MVD cases, three died, yielding a case fatality rate of 75%. All four cases belonged to a single family and 50% (2/4) of the MVD cases were female. All confirmed cases had clinical symptoms of fever, vomiting, abdominal pain and bleeding from body orifices. Viral sequences indicated that the Marburg virus strain responsible for this outbreak was closely related to virus strains previously shown to be circulating in Uganda. CONCLUSION: This outbreak of MVD occurred as a family cluster with no additional transmission outside of the four related cases. Rapid case detection, prompt laboratory testing at the Uganda National VHF Reference Laboratory and presence of pre-trained, well-prepared national and district rapid response teams facilitated the containment and control of this outbreak within one month, preventing nationwide and global transmission of the disease.

Healthcare workers' experiences regarding scaling up of training on integrated disease surveillance and response (IDSR) in Uganda, 2016: cross sectional qualitative study.

BACKGROUND: The Integrated Disease Surveillance and Response (IDSR) strategy was adopted as the framework for implementation of International Health Regulation (2005) in the African region of World Health Organisation (WHO AFRO). While earlier studies documented gains in performance of core IDSR functions, Uganda still faces challenges due to infectious diseases. IDSR revitalisation programme aimed to improve prevention, early detection, and prompt response to disease outbreaks. However, little is known about health worker's perception of the revitalised IDSR training. METHODS: We conducted focus group discussions of health workers who were trained between 2015 and 2016. Discussions on benefits, challenges and possible solutions for improvement of IDSR training were recorded, transcribed, translated and coded using grounded theory. RESULTS: In total, 22/26 FGDs were conducted. Participants cited improved completeness and timeliness of reporting, case detection and data analysis and better response to disease outbreaks as key achievements after the training. Programme challenges included an inadequate number of trained staff, funding, irregular supervision, high turnover of trained health workers, and lack of key logistics. Suggestions to improve IDSR included pre-service and community training, mentorship, regular supervision and improving funding at the district level. CONCLUSION: Health workers perceived that scaling up revitalized IDSR training in Uganda improved public health surveillance. However, they acknowledge encountering challenges that hinder their performance after the training. Ministry of Health should have a mentorship plan, integrate IDSR training in pre-service curricula and advocate for funding IDSR activities to address some of the gaps highlighted in this study.

Evaluation of integrated disease surveillance and response (IDSR) core and support functions after the revitalisation of IDSR in Uganda from 2012 to 2016.

BACKGROUND: Uganda is a low income country that continues to experience disease outbreaks caused by emerging and re-emerging diseases such as cholera, meningococcal meningitis, typhoid and viral haemorrhagic fevers. The Integrated Disease Surveillance and Response (IDSR) strategy was adopted by WHO-AFRO in 1998 as a comprehensive strategy to improve disease surveillance and response in WHO Member States in Africa and was adopted in Uganda in 2000. To address persistent inconsistencies and inadequacies in the core and support functions of IDSR, Uganda initiated an IDSR revitalisation programme in 2012. The objective of this evaluation was to assess IDSR core and support functions after implementation of the revitalised IDSR programme. METHODS: The evaluation was a cross-sectional survey that employed mixed quantitative and qualitative methods. We assessed IDSR performance indicators, knowledge acquisition, knowledge retention and level of confidence in performing IDSR tasks among health workers who underwent IDSR training. Qualitative data was collected to guide the interpretation of quantitative findings and to establish a range of views related to IDSR implementation. RESULTS: Between 2012 and 2016, there was an improvement in completeness of monthly reporting (69 to 100%) and weekly reporting (56 to 78%) and an improvement in timeliness of monthly reporting (59 to 93%) and weekly reporting (40 to 68%) at the national level. The annualised non-polio AFP rate increased from 2.8 in 2012 to 3.7 cases per 100,000 population < 15 years in 2016. The case fatality rate for cholera decreased from 3.2% in 2012 to 2.1% in 2016. All districts received IDSR feedback from the national level. Key IDSR programme challenges included inadequate numbers of trained staff, inadequate funding, irregular supervision and high turnover of trained staff. Recommendations to improve IDSR performance included: improving funding, incorporating IDSR training into pre-service curricula for health workers and strengthening support supervision. CONCLUSION: The revitalised IDSR programme in Uganda was associated with improvements in performance. However in 2016, the programme still faced significant challenges and some performance indicators were still below the target. It is important that the documented gains are consolidated and challenges are continuously identified and addressed as they emerge.

Outbreak of yellow fever in central and southwestern Uganda, February-may 2016.

BACKGROUND: On 28 March, 2016, the Ministry of Health received a report on three deaths from an unknown disease characterized by fever, jaundice, and hemorrhage which occurred within a one-month period in the same family in central Uganda. We started an investigation to determine its nature and scope, identify risk factors, and to recommend eventually control measures for future prevention. METHODS: We defined a probable case as onset of unexplained fever plus ≥1 of the following unexplained symptoms: jaundice, unexplained bleeding, or liver function abnormalities. A confirmed case was a probable case with IgM or PCR positivity for yellow fever. We reviewed medical records and conducted active community case-finding. In a case-control study, we compared risk factors between case-patients and asymptomatic control-persons, frequency-matched by age, sex, and village. We used multivariate conditional logistic regression to evaluate risk factors. We also conducted entomological studies and environmental assessments. RESULTS: From February to May, we identified 42 case-persons (35 probable and seven confirmed), of whom 14 (33%) died. The attack rate (AR) was 2.6/100,000 for all affected districts, and highest in Masaka District (AR = 6.0/100,000). Men (AR = 4.0/100,000) were more affected than women (AR = 1.1/100,000) (p = 0.00016). Persons aged 30-39 years (AR = 14/100,000) were the most affected. Only 32 case-patients and 128 controls were used in the case control study. Twenty three case-persons (72%) and 32 control-persons (25%) farmed in swampy areas (ORadj = 7.5; 95%CI = 2.3-24); 20 case-patients (63%) and 32 control-persons (25%) who farmed reported presence of monkeys in agriculture fields (ORadj = 3.1, 95%CI = 1.1-8.6); and 20 case-patients (63%) and 35 control-persons (27%) farmed in forest areas (ORadj = 3.2; 95%CI = 0.93-11). No study participants reported yellow fever vaccination. Sylvatic monkeys and Aedes mosquitoes were identified in the nearby forest areas. CONCLUSION: This yellow fever outbreak was likely sylvatic and transmitted to a susceptible population probably by mosquito bites during farming in forest and swampy areas. A reactive vaccination campaign was conducted in the affected districts after the outbreak. We recommended introduction of yellow fever vaccine into the routine Uganda National Expanded Program on Immunization and enhanced yellow fever surveillance.

Virological failure on first-line antiretroviral therapy; associated factors and a pragmatic approach for switching to second line therapy-evidence from a prospective cohort study in rural South-Western Uganda, 2004-2011.

INTRODUCTION: We investigated factors affecting Virological failure (VF) on first line Antiretroviral Therapy (ART) and evaluated a pragmatic approach to switching to second line ART. METHODS: Between 2004 and 2011, we assessed adults taking ART. After 6 months or more on ART, participants with VL >1000 copies/ml or two successive VL > 400 copies/ml (Conventional VF) received intensified adherence counselling and continued on first-line ART for 6 more months, after which participants who still had VL > 1000 copies/ml (Pragmatic VF) were switched to second line ART. VF rates were calculated and predictors of failure were found by fitting logistic regression and Cox proportional hazards models. RESULTS: The 316 participants accrued 1036 person years at risk (pyar), 84 (26.6%) had conventional VF (rate 8.6 per 100 pyar) of whom 28 (33.3%) had pragmatic VF (rate 2.7 per 100 pyar). Independent predictors of conventional VF were; alcohol consumption, (adjusted Hazard Ratio; aHR = 1.71, 95% CI 1.05-2.79, P = 0.03) and ART adherence: per 10% decrease in proportion of adherent visits, (aHR = 1.83, 95% CI 1.50-2.23; P < 0.001). Using reference age group < 30 years, among conventional failures, the adjusted odds ratio (aOR) of pragmatic failure for age group 30-39 years were 0.12, 95% CI 0.03-0.57, P = 0.02 and for age group > 40 years were 0.14, 95%CI 0.03-0.71, P = 0.02. Alcohol consumers had a threefold odds of pragmatic failure than non-alcohol consumers (aOR = 3.14, 95%CI 0.95-10.34, P = 0.06). CONCLUSION: A pragmatic VF approach is essential to guide switching to second line ART. Patient tailored ART adherence counselling among young patients and alcohol users is recommended.

Long term trends and spatial distribution of animal bite injuries and deaths due to human rabies infection in Uganda, 2001-2015.

BACKGROUND: In the absence of accurate data on trends and the burden of human rabies infection in developing countries, animal bite injuries provide useful information to bridge that gap. Rabies is one of the most deadly infectious diseases, with a case fatality rate approaching 100%. Despite availability of effective prevention and control strategies, rabies still kills 50,000 to 60,000 people worldwide annually, the majority of whom are in the developing world. We describe trends and geographical distribution of animal bite injuries (a proxy of potential exposure to rabies) and deaths due to suspected human rabies in Uganda from 2001 to 2015. METHODS: We used 2001-2015 surveillance data on suspected animal bite injuries, collected from health facilities in Uganda. To describe annual trends, line graphs were used and linear regression tested significance of observed trends at P<0.05. We used maps to describe geographical distribution of animal bites by district. RESULTS: A total of 208,720 cases of animal bite injuries were reported. Of these, 27% were in Central, 22% in Eastern, 27% in Northern and 23% in Western regions. Out of 48,720 animal bites between 2013 and 2015, 59% were suffered by males and 81% were persons aged above 5 years. Between 2001 and 2015, the overall incidence (per 100,000 population) of animal bites was 58 in Uganda, 76 in Northern, 58 in Central, 53 in Western and 50 in Eastern region. From 2001 to 2015, the annual incidence (per 100,000 population) increased from 21 to 47 (P = 0.02) in Central, 27 to 34 (P = 0.04) in Eastern, 23 to 70 (P = 0.01) in Northern and 16 to 46 (P = 0.001) in Western region. A total of 486 suspected human rabies deaths were reported, of which 29% were reported from Eastern, 28% from Central, 27% from Northern and 17% from Western region. CONCLUSION: Animal bite injuries, a potential exposure to rabies infection, and mortality attributed to rabies infection are public health challenges affecting all regions of Uganda. Eliminating rabies requires strengthening of rabies prevention and control strategies at all levels of the health sector. These strategies should utilize the "One Health" approach with strategic focus on strengthening rabies surveillance, controlling rabies in dogs and ensuring availability of post exposure prophylaxis at lower health facilities.

The design and implementation of the re-vitalised integrated disease surveillance and response (IDSR) in Uganda, 2013-2016.

BACKGROUND: Uganda adopted and has been implementing the Integrated Disease Surveillance (IDSR) strategy since 2000. The goal was to build the country's capacity to detect, report promptly, and effectively respond to public health emergencies and priorities. The considerable investment into the program startup realised significant IDSR core performance. However, due to un-sustained funding from the mid-2000s onwards, these achievements were undermined. Following the adoption of the revised World Health Organization guidelines on IDSR, the Uganda Ministry of Health (MoH) in collaboration with key partners decided to revitalise IDSR and operationalise the updated IDSR guidelines in 2012. METHODS: Through the review of both published and unpublished national guidelines, reports and other IDSR program records in addition to an interview of key informants, we describe the design and process of IDSR revitalisation in Uganda, 2013-2016. The program aimed to enhance the districts' capacity to promptly detect, assess and effectively respond to public health emergencies. RESULTS: Through a cascaded, targeted skill-development training model, 7785 participants were trained in IDSR between 2015 and 2016. Of these, 5489(71%) were facility-based multi-disciplinary health workers, 1107 (14%) comprised the district rapid response teams and 1188 (15%) constituted the district task forces. This training was complemented by other courses for regional teams in addition to the provision of logistics to support IDSR activities. Centrally, IDSR implementation was coordinated and monitored by the MoH's national task force (NTF) on epidemics and emergencies. The NTF and in close collaboration with the WHO Country Office, mobilised resources from various partners and development initiatives. At regional and district levels, the technical and political leadership were mobilised and engaged in monitoring and overseeing program implementation. CONCLUSION: The IDSR re-vitalization in Uganda highlights unique features that can be considered by other countries that would wish to strengthen their IDSR programs. Through a coordinated partner response, the program harnessed resources which primarily were not earmarked for IDSR to strengthen the program nation-wide. Engagement of the local district leadership helped promote ownership, foster accountability and sustainability of the program.

The contribution of the polio eradication initiative on the operations and outcomes of non-polio public health programs: a survey of programs in the African region.

INTRODUCTION: The effect of the Global polio eradication initiative (PEI) on public health programs beyond polio is widely debated. PEI contribution to other health programs has been assessed from the perspective of polio-funded personnel, which may introduce bias as PEI staff are probably more likely to show that they have benefited of other programs. We set out to identify and document how public health programs have benefited from the public health capacity that was provided at the country level as part of the PEI program in a systematic and standardized manner. METHODS: Between July and November 2017, we conducted a mixed-methods cross-sectional study, which combined two methods: a multi-country quantitative survey and a qualitative study. We created a self-administered electronic multi-lingual questionnaire in English, French and Portuguese. The qualitative study, which followed an interim analysis of the quantitative survey, comprised interviews with national and subnational level staff in a few countries. RESULTS: A total of 127 public health workers from 43 of the 47 countries in the African WHO Region responded online. Most of the respondents 56/127 (42.7%) belonged to the immunization sector and 51/127 (38.9%) belonged to the emergencies and outbreaks sector. Respondents who identified themselves with the immunization (50/64 (78%)) and maternal health program (64/82 (78%)) reported the highest level of greatly benefiting from PEI resources. A total of 78/103 (76%) respondents rated PEI's contribution data management system to their program very high and high. Of the 127 respondents, the majority 91 (71.6%) reported that the withdrawal of PEI resources would result in a weakening of surveillance for other diseases; 88 (62.9%) reported that there would be inadequate resources to carry out planned activities and 80 (62.9%) reported that there would be poor logistics and transport for implementation of activities. Cameroon, DRC, Nigeria and Uganda participated in the qualitative study. Each country had between 7-8 key informants from the national and sub-national level for a total of 31 key informants. Polio funds and other PEI resources have supported various activities in the ministries of health of the four countries especially IDSR, data management, laboratories and development of the public health workforce. Respondents believed that the infrastructure and processes that PEI has created need to be maintained, along with the workforce and they believed that this was an essential role of their governments with support from the partners. CONCLUSION: There is a high awareness of the PEI program in all the countries and at all levels which should be leveraged into improving other child survival activities for example routine immunizations. Future large-scale programs of this nature should be designed to benefit other public health programs beyond the specific program. The public health workforce, surveillance development, data management and laboratory strengthening that have been developed by PEI need to be maintained.

Modifiable risk factors for typhoid intestinal perforations during a large outbreak of typhoid fever, Kampala Uganda, 2015.

BACKGROUND: Between January and June, 2015, a large typhoid fever outbreak occurred in Kampala, Uganda, with 10,230 suspected cases. During the outbreak, area surgeons reported a surge in cases of typhoid intestinal perforation (TIP), a complication of typhoid fever. We conducted an investigation to characterize TIP cases and identify modifiable risk factors for TIP. METHODS: We defined a TIP case as a physician-diagnosed typhoid patient with non-traumatic terminal ileum perforation. We identified cases by reviewing medical records at all five major hospitals in Kampala from 2013 to 2015. In a matched case-control study, we compared potential risk factors among TIP cases and controls; controls were typhoid patients diagnosed by TUBEX TF, culture, or physician but without TIP, identified from the outbreak line-list and matched to cases by age, sex and residence. Cases and controls were interviewed using a standard questionnaire from 1st -23rd December 2015. We used conditional logistic regression to assess risk factors for TIP and control for confounding. RESULTS: Of the 88 TIP cases identified during 2013-2015, 77% (68/88) occurred between January and June, 2015; TIPs sharply increased in January and peaked in March, coincident with the typhoid outbreak. The estimated risk of TIP was 6.6 per 1000 suspected typhoid infections (68/10,230). The case-fatality rate was 10% (7/68). Cases sought care later than controls; Compared with 29% (13/45) of TIP cases and 63% (86/137) of controls who sought treatment within 3 days of onset, 42% (19/45) of cases and 32% (44/137) of controls sought treatment 4-9 days after illness onset (ORadj = 2.2, 95%CI = 0.83-5.8), while 29% (13/45) of cases and 5.1% (7/137) of controls sought treatment ≥10 days after onset (ORadj = 11, 95%CI = 1.9-61). 68% (96/141) of cases and 23% (23/100) of controls had got treatment before being treated at the treatment centre (ORadj = 9.0, 95%CI = 1.1-78). CONCLUSION: Delay in seeking treatment increased the risk of TIPs. For future outbreaks, we recommended aggressive community case-finding, and informational campaigns in affected communities and among local healthcare providers to increase awareness of the need for early and appropriate treatment.

Risk Factors for Podoconiosis: Kamwenge District, Western Uganda, September 2015.

AbstractPodoconiosis, a noninfectious elephantiasis, is a disabling neglected tropical disease. In August 2015, an elephantiasis case-cluster was reported in Kamwenge District, western Uganda. We investigated to identify the disease's nature and risk factors. We defined a suspected podoconiosis case as onset in a Kamwenge resident of bilateral asymmetrical lower limb swelling lasting ≥ 1 month, plus ≥ 1 of the following associated symptoms: skin itching, burning sensation, plantar edema, lymph ooze, prominent skin markings, rigid toes, or mossy papillomata. A probable case was a suspected case with negative microfilaria antigen immunochromatographic card test (ruling out filarial elephantiasis). We conducted active case-finding. In a case-control investigation, we tested the hypothesis that the disease was caused by prolonged foot skin exposure to irritant soils, using 40 probable case-persons and 80 asymptomatic village control-persons, individually matched by age and sex. We collected soil samples to characterize irritants. We identified 52 suspected (including 40 probable) cases with onset from 1980 to 2015. Prevalence rates increased with age; annual incidence (by reported onset of disease) was stable over time at 2.9/100,000. We found that 93% (37/40) of cases and 68% (54/80) of controls never wore shoes at work (Mantel-Haenszel odds ratio [ORMH] = 7.7; 95% [confidence interval] CI = 2.0-30); 80% (32/40) of cases and 49% (39/80) of controls never wore shoes at home (ORMH = 5.2; 95% CI = 1.8-15); and 70% (27/39) of cases and 44% (35/79) of controls washed feet at day end (versus immediately after work) (OR = 11; 95% CI = 2.1-56). Soil samples were characterized as rich black-red volcanic clays. In conclusion, this reported elephantiasis is podoconiosis associated with prolonged foot exposure to volcanic soil. We recommended foot hygiene and universal use of protective shoes.

A large and persistent outbreak of typhoid fever caused by consuming contaminated water and street-vended beverages: Kampala, Uganda, January - June 2015.

BACKGROUND: On 6 February 2015, Kampala city authorities alerted the Ugandan Ministry of Health of a "strange disease" that killed one person and sickened dozens. We conducted an epidemiologic investigation to identify the nature of the disease, mode of transmission, and risk factors to inform timely and effective control measures. METHODS: We defined a suspected case as onset of fever (≥37.5 °C) for more than 3 days with abdominal pain, headache, negative malaria test or failed anti-malaria treatment, and at least 2 of the following: diarrhea, nausea or vomiting, constipation, fatigue. A probable case was defined as a suspected case with a positive TUBEX® TF test. A confirmed case had blood culture yielding Salmonella Typhi. We conducted a case-control study to compare exposures of 33 suspected case-patients and 78 controls, and tested water and juice samples. RESULTS: From 17 February-12 June, we identified 10,230 suspected, 1038 probable, and 51 confirmed cases. Approximately 22.58% (7/31) of case-patients and 2.56% (2/78) of controls drank water sold in small plastic bags (ORM-H = 8.90; 95%CI = 1.60-49.00); 54.54% (18/33) of case-patients and 19.23% (15/78) of controls consumed locally-made drinks (ORM-H = 4.60; 95%CI: 1.90-11.00). All isolates were susceptible to ciprofloxacin and ceftriaxone. Water and juice samples exhibited evidence of fecal contamination. CONCLUSION: Contaminated water and street-vended beverages were likely vehicles of this outbreak. At our recommendation authorities closed unsafe water sources and supplied safe water to affected areas.

Risk factors for Podoconiosis: Kamwenge District, Western Uganda, 2015

Introduction: Podoconiosis, a form of non-infectious elephantiasis, is a disabling Neglected Tropical Disease. In August 2015, a non-government organization reported an increase in elephantiasis cases in Kamwenge District. We conducted an investigation to confirm the diagnosis, identify causes and risk factors, and guide control efforts. Methods: we defined a suspect case-person as a Kamwenge resident with bilateral asymmetrical swelling of lower limbs lasting ≥ 1month, plus ≥ 1 of the following: skin itching; burning sensation; plantar oedema; lymph-ooze; prominent skin markings; rigid toes; mossy papillomata. A probable case was a suspect case with negative microfilaria antigen immunological-card test results. We conducted active case-finding in affected communities. In a case-control study we compared shoe-use and feet-washing practices before disease onset among 40 probable case-persons and 75 asymptomatic village control-persons, matched by age (± 5y) and sex. We collected soil samples to characterize soil-irritant composition. Results: our active case-finding identified 52 suspect cases in two affected sub-counties during 1980-2015 (incidence = 2.9/100,000/year), including 40 probable cases (mean age = 47y; range: 13-80y). The annual case counts did not increase significantly over time. All case-persons had negative immunological-card test. In the case-control study, 93% (37/40) of probable case-persons and 31% (23/75) of controls-persons never wore shoes at work (ORM-H = 6.7; 95%CI = 1.7-26); 80% (32/40) of probable case-persons and 55% (39/75) of control-persons never wore shoes at home (ORM-H = 4.4, 95%CI = 1.5-13); 70% (27/39) of probable case-persons and 47% (34/72) of control-persons washed feet at day-end rather than immediately after work (OR = 11, 95%CI = 2.1-57). Soils samples were characterized as being rich black-red volcanic clay. Conclusion: the reported elephantiasis was podoconiosis, which was associated with prolonged foot exposure to volcanic soil. We recommended health education on foot protection and washing, and universal use of protective shoes

Mortality and its predictors among antiretroviral therapy naïve HIV-infected individuals with CD4 cell count ≥350 cells/mm(3) compared to the general population: data from a population-based prospective HIV cohort in Uganda.

BACKGROUND: Evidence exists that even at high CD4 counts, mortality among HIV-infected antiretroviral therapy (ART) naïve individuals is higher than that in the general population. However, many developing countries still initiate ART at CD4 ≤350 cells/mm(3). OBJECTIVE: To compare mortality among HIV-infected ART naïve individuals with CD4 counts ≥350 cells/mm(3) with mortality in the general Ugandan population and to investigate risk factors for death. DESIGN: Population-based prospective HIV cohort. METHODS: The study population consisted of HIV-infected people in rural southwest Uganda. Patients were reviewed at the study clinic every 3 months. CD4 cell count was measured every 6 months. Rate ratios were estimated using Poisson regression. Indirect methods were used to calculate standardised mortality ratios (SMRs). RESULTS: A total of 374 participants with CD4 ≥350 cells/mm(3) were followed for 1,328 person-years (PY) over which 27 deaths occurred. Mortality rates (MRs) (per 1,000 PY) were 20.34 (95% CI: 13.95-29.66) among all participants and 16.43 (10.48-25.75) among participants aged 15-49 years. Mortality was higher in periods during which participants had CD4 350-499 cells/mm(3) than during periods of CD4 ≥500 cells/mm(3) although the difference was not statistically significant [adjusted rate ratio (aRR)=1.52; 95% CI: 0.71-3.25]. Compared to the general Ugandan population aged 15-49 years, MRs were 123% higher among participants with CD4 ≥500 cells/mm(3) (SMR: 223%, 95% CI: 127-393%) and 146% higher among participants with CD4 350-499 cells/mm(3) (246%, 117%-516). After adjusting for current age, mortality was associated with increasing WHO clinical stage (aRR comparing stage 3 or 4 and stage 1: 10.18, 95% CI: 3.82-27.15) and decreasing body mass index (BMI) (aRR comparing categories ≤17.4 Kg/m(2) and ≥18.5 Kg/m(2): 6.11, 2.30-16.20). CONCLUSION: HIV-infected ART naïve individuals with CD4 count ≥350 cells/mm(3) had a higher mortality than the general population. After adjusting for age, the main predictors of mortality were WHO clinical stage and BMI.