Implementing Joint External Evaluations of the International Health Regulations (2005) capacities in all countries in the WHO African region: process challenges, lessons learnt and perspectives for the future.

Following the West Africa Ebola virus disease outbreak (2013-2016), the Joint External Evaluation (JEE) is one of the three voluntary components recommended by the WHO for evaluating the International Health Regulations (2005) capacities in countries. Here, we share experience implementing JEEs in all 47 countries in the WHO African region. In February 2016, the United Republic of Tanzania (Mainland) was the first country globally to conduct a JEE. By April 2022, JEEs had been conducted in all 47 countries plus in the island of Zanzibar. A total of 360 subject matter experts (SMEs) from 88 organisations were deployed 607 times. Despite availability of guidelines, the process had to be contextualised while avoiding jeopardising the quality and integrity of the findings. Key challenges were: inadequate understanding of the process by in-country counterparts; competing country priorities; limited time for validating subnational capacities; insufficient availability of SMEs for biosafety and biosecurity, antimicrobial resistance, points of entry, chemical events and radio-nuclear emergencies; and inadequate financing to fill gaps identified. Key points learnt were: importance of country leadership and ownership; conducting orientation workshops before the self-assessment; availability of an external JEE expert to support the self-assessment; the skills, attitudes and leadership competencies of the team lead; identifying national experts as SMEs for future JEEs to promote capacity building and experience sharing; the centrality of involving One Health stakeholders from the beginning to the end of the process; and the need for dedicated staff for planning, coordination, implementation and timely report writing. Moving forward, it is essential to draw from this learning to plan future JEEs. Finally, predictable financing is needed immediately to fill gaps identified.

The road to a polio-free Uganda; contribution of the Expanded Program on Immunization Laboratory (EPI-LAB) at Uganda Virus Research Institute.

Background: The control of poliomyelitis in Uganda dates back as far as 1950 and acute flaccid paralysis (AFP) surveillance has since been used as a criterion for identifying wild polioviruses. Poliovirus isolation was initially pursued through collaborative research however, in 1993, the Expanded Program on Immunization Laboratory (EPI-LAB) was established as a member of the Global Poliovirus Laboratory Network (GPLN) and spearheaded this activity at Uganda Virus Research Institute. Objectives: The aim of this report is to document the progress and impact of the EPI-LAB on poliovirus eradication in Uganda. Methods: Poliovirus detection and identification were achieved fundamentally through tissue culture and intra-typic differentiation of the poliovirus based on the real-time reverse transcriptase polymerase chain reaction (rRT PCR). The data obtained was entered into the national AFP database and analysed using EpiInfoTM statistical software. Results: Quantitative and qualitative detection of wild and Sabin polioviruses corresponded with the polio campaigns. The WHO target indicators for AFP surveillance were achieved essentially throughout the study period. Conclusion: Virological tracking coupled with attaining standard AFP surveillance indicators has been pivotal in achieving and maintaining the national wild polio-free status. Laboratory surveillance remains key in informing the certification process of polio eradication.

Sustainable strategies for Ebola virus disease outbreak preparedness in Africa: a case study on lessons learnt in countries neighbouring the Democratic Republic of the Congo.

BACKGROUND: From May 2018 to September 2022, the Democratic Republic of Congo (DRC) experienced seven Ebola virus disease (EVD) outbreaks within its borders. During the 10th EVD outbreak (2018-2020), the largest experienced in the DRC and the second largest and most prolonged EVD outbreak recorded globally, a WHO risk assessment identified nine countries bordering the DRC as moderate to high risk from cross border importation. These countries implemented varying levels of Ebola virus disease preparedness interventions. This case study highlights the gains and shortfalls with the Ebola virus disease preparedness interventions within the various contexts of these countries against the background of a renewed and growing commitment for global epidemic preparedness highlighted during recent World Health Assembly events. MAIN TEXT: Several positive impacts from preparedness support to countries bordering the affected provinces in the DRC were identified, including development of sustained capacities which were leveraged upon to respond to the subsequent coronavirus disease 2019 (COVID-19) pandemic. Shortfalls such as lost opportunities for operationalizing cross-border regional preparedness collaboration and better integration of multidisciplinary perspectives, vertical approaches to response pillars such as surveillance, over dependence on external support and duplication of efforts especially in areas of capacity building were also identified. A recurrent theme that emerged from this case study is the propensity towards implementing short-term interventions during active Ebola virus disease outbreaks for preparedness rather than sustainable investment into strengthening systems for improved health security in alignment with IHR obligations, the Sustainable Development Goals and advocating global policy for addressing the larger structural determinants underscoring these outbreaks. CONCLUSIONS: Despite several international frameworks established at the global level for emergency preparedness, a shortfall exists between global policy and practice in countries at high risk of cross border transmission from persistent Ebola virus disease outbreaks in the Democratic Republic of Congo. With renewed global health commitment for country emergency preparedness resulting from the COVID-19 pandemic and cumulating in a resolution for a pandemic preparedness treaty, the time to review and address these gaps and provide recommendations for more sustainable and integrative approaches to emergency preparedness towards achieving global health security is now.

Framing the future of the COVID-19 response operations in 2022 in the WHO African region.

BACKGROUND: With the evolving epidemiological parameters of COVID-19 in Africa, the response actions and lessons learnt during the pandemic's past two years, SARS-COV 2 will certainly continue to circulate in African countries in 2022 and beyond. As countries in the African continent need to be more prepared and plan to 'live with the virus' for the upcoming two years and after and at the same time mitigate risks by protecting the future most vulnerable and those responsible for maintaining essential services, WHO AFRO is anticipating four interim scenarios of the evolution of the pandemic in 2022 and beyond in the region. OBJECTIVE: In preparation for the rollout of response actions given the predicted scenarios, WHO AFRO has identified ten strategic orientations and areas of focus for supporting member states and partners in responding to the COVID-19 pandemic in Africa in 2022 and beyond. METHODS: WHO analysed trends of the transmissions since the first case in the African continent and reviewed lessons learnt over the past months. RESULTS: Establishing a core and agile team solely dedicated to the COVID-19 response at the WHO AFRO, the emergency hubs, and WCOs will improve the effectiveness of the response and address identified challenges. The team will collaborate with the various clusters of the regional office, and other units and subunits in the WCOs supported with good epidemics intelligence. COVID-19 pandemic has afflicted global humanity at unprecedented levels. CONCLUSION: Two years later and while starting the third year of the COVID-19 response, we now need to change and adapt our strategies, tools and approaches in responding timely and effectively to the pandemic in Africa and save more lives.

Continuity of essential health services in the context of COVID-19: the Eastern and Southern Africa Regional continuity of essential services sub-working group.

COVID-19 cases have continued to increase globally putting intense pressure on health systems, including in the East and Southern African (ESA) region, which bears the brunt of the continent´s cases, and where many health systems are already weak or overstretched. Evidence from the West Africa Ebola disease outbreak and early estimates for COVID-19 show that indirect impacts due to disruptions in access to essential health services can result in even higher mortality than that directly related to the outbreak. In March 2020, World Health Organisation (WHO) established a coordination mechanism to support ESA countries to enhance their response to COVID-19. Technical working groups were established, including a subgroup addressing continuity of essential health services. In this article, the development, activities and achievements of the subgroup over the past six months are reviewed and presented as a model for collaborative action for optimal service delivery in the context of COVID-19 and potentially, during other infectious disease outbreak responses.

Coordination mechanisms for COVID-19 in the WHO Regional office for Africa.

AIM: This study describes the coordination mechanisms that have been used for management of the COVID 19 pandemic in the WHO AFRO region; relate the patterns of the disease (length of time between onset of coordination and first case; length of the wave of the disease and peak attack rate) to coordination mechanisms established at the national level, and document best practices and lessons learned. METHOD: We did a retrospective policy tracing of the COVID-19 coordination mechanisms from March 2020 (when first cases of COVID-19 in the AFRO region were reported) to the end of the third wave in September 2021. Data sources were from document and Literature review of COVID-19 response strategies, plans, regulations, press releases, government websites, grey and peer-reviewed literature. The data was extracted to Excel file database and coded then analysed using Stata (version 15). Analysis was done through descriptive statistical analysis (using measures of central tendencies (mean, SD, and median) and measures of central dispersion (range)), multiple linear regression, and thematic analysis of qualitative data. RESULTS: There are three distinct layered coordination mechanisms (strategic, operational, and tactical) that were either implemented singularly or in tandem with another coordination mechanism. 87.23% (n = 41) of the countries initiated strategic coordination, and 59.57% (n = 28) initiated some form of operational coordination. Some of countries (n = 26,55.32%) provided operational coordination using functional Public Health Emergency Operation Centres (PHEOCs) which were activated for the response. 31.91% (n = 15) of the countries initiated some form of tactical coordination which involved the decentralisation of the operations at the local/grassroot level/district/ county levels. Decentralisation strategies played a key role in coordination, as was the innovative strategies by the countries; some coordination mechanisms built on already existing coordination systems and the heads of states were effective in the success of the coordination process. Financing posed challenge to majority of the countries in initiating coordination. CONCLUSION: Coordinating an emergency is a multidimensional process that includes having decision-makers and institutional agents define and prioritise policies and norms that contain the spread of the disease, regulate activities and behaviour and citizens, and respond to personnel who coordinate prevention.

Intention to vaccinate against COVID-19 and adherence to non-pharmaceutical interventions against COVID-19 prior to the second wave of the pandemic in Uganda: a cross-sectional study.

OBJECTIVES: The resurgence in cases and deaths due to COVID-19 in many countries suggests complacency in adhering to COVID-19 preventive guidelines. Vaccination, therefore, remains a key intervention in mitigating the impact of the COVID-19 pandemic. This study investigated the level of adherence to COVID-19 preventive measures and intention to receive the COVID-19 vaccine among Ugandans. DESIGN, SETTING AND PARTICIPANTS: A nationwide cross-sectional survey of 1053 Ugandan adults was conducted in March 2021 using telephone interviews. MAIN OUTCOME MEASURES: Participants reported on adherence to COVID-19 preventive measures and intention to be vaccinated with COVID-19 vaccines. RESULTS: Overall, 10.2% of the respondents adhered to the COVID-19 preventive guidelines and 57.8% stated definite intention to receive a SARS-CoV-2 vaccine. Compared with women, men were less likely to adhere to COVID-19 guidelines (Odds Ratio (OR)=0.64, 95% CI 0.41 to 0.99). Participants from the northern (4.0%, OR=0.28, 95% CI 0.12 to 0.92), western (5.1%, OR=0.30, 95% CI 0.14 to 0.65) and eastern regions (6.5%, OR=0.47, 95% CI 0.24 to 0.92), respectively, had lower odds of adhering to the COVID-19 guidelines than those from the central region (14.7%). A higher monthly income of ≥US$137 (OR=2.31, 95% CI 1.14 to 4.58) and a history of chronic disease (OR=1.81, 95% CI 1.14 to 2.86) were predictors of adherence. Concerns about the chances of getting COVID-19 in the future (Prevalence Ratio (PR)=1.26, 95% CI 1.06 to 1.48) and fear of severe COVID-19 infection (PR=1.20, 95% CI 1.04 to 1.38) were the strongest predictors for a definite intention, while concerns for side effects were negatively associated with vaccination intent (PR=0.75, 95% CI 0.68 to 0.83). CONCLUSION: Behaviour change programmes need to be strengthened to promote adherence to COVID-19 preventive guidelines as vaccination is rolled out as another preventive measure. Dissemination of accurate, safe and efficacious information about the vaccines is necessary to enhance vaccine uptake.

Assessment of COVID-19 pandemic responses in African countries: thematic synthesis of WHO intra-action review reports.

OBJECTIVES: We conducted a review of intra-action review (IAR) reports of the national response to the COVID-19 pandemic in Africa. We highlight best practices and challenges and offer perspectives for the future. DESIGN: A thematic analysis across 10 preparedness and response domains, namely, governance, leadership, and coordination; planning and monitoring; risk communication and community engagement; surveillance, rapid response, and case investigation; infection prevention and control; case management; screening and monitoring at points of entry; national laboratory system; logistics and supply chain management; and maintaining essential health services during the COVID-19 pandemic. SETTING: All countries in the WHO African Region were eligible for inclusion in the study. National IAR reports submitted by March 2021 were analysed. RESULTS: We retrieved IAR reports from 18 African countries. The COVID-19 pandemic response in African countries has relied on many existing response systems such as laboratory systems, surveillance systems for previous outbreaks of highly infectious diseases and a logistics management information system. These best practices were backed by strong political will. The key challenges included low public confidence in governments, inadequate adherence to infection prevention and control measures, shortages of personal protective equipment, inadequate laboratory capacity, inadequate contact tracing, poor supply chain and logistics management systems, and lack of training of key personnel at national and subnational levels. CONCLUSION: These findings suggest that African countries' response to the COVID-19 pandemic was prompt and may have contributed to the lower cases and deaths in the region compared with countries in other regions. The IARs demonstrate that many technical areas still require immediate improvement to guide decisions in subsequent waves or future outbreaks.

Predictors of COVID-19 epidemics in countries of the World Health Organization African Region.

Countries of the World Health Organization (WHO) African Region have experienced a wide range of coronavirus disease 2019 (COVID-19) epidemics. This study aimed to identify predictors of the timing of the first COVID-19 case and the per capita mortality in WHO African Region countries during the first and second pandemic waves and to test for associations with the preparedness of health systems and government pandemic responses. Using a region-wide, country-based observational study, we found that the first case was detected earlier in countries with more urban populations, higher international connectivity and greater COVID-19 test capacity but later in island nations. Predictors of a high first wave per capita mortality rate included a more urban population, higher pre-pandemic international connectivity and a higher prevalence of HIV. Countries rated as better prepared and having more resilient health systems were worst affected by the disease, the imposition of restrictions or both, making any benefit of more stringent countermeasures difficult to detect. Predictors for the second wave were similar to the first. Second wave per capita mortality could be predicted from that of the first wave. The COVID-19 pandemic highlights unanticipated vulnerabilities to infectious disease in Africa that should be taken into account in future pandemic preparedness planning.

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.

Uganda's experience in Ebola virus disease outbreak preparedness, 2018-2019.

BACKGROUND: Since the declaration of the 10th Ebola Virus Disease (EVD) outbreak in DRC on 1st Aug 2018, several neighboring countries have been developing and implementing preparedness efforts to prevent EVD cross-border transmission to enable timely detection, investigation, and response in the event of a confirmed EVD outbreak in the country. We describe Uganda's experience in EVD preparedness. RESULTS: On 4 August 2018, the Uganda Ministry of Health (MoH) activated the Public Health Emergency Operations Centre (PHEOC) and the National Task Force (NTF) for public health emergencies to plan, guide, and coordinate EVD preparedness in the country. The NTF selected an Incident Management Team (IMT), constituting a National Rapid Response Team (NRRT) that supported activation of the District Task Forces (DTFs) and District Rapid Response Teams (DRRTs) that jointly assessed levels of preparedness in 30 designated high-risk districts representing category 1 (20 districts) and category 2 (10 districts). The MoH, with technical guidance from the World Health Organisation (WHO), led EVD preparedness activities and worked together with other ministries and partner organisations to enhance community-based surveillance systems, develop and disseminate risk communication messages, engage communities, reinforce EVD screening and infection prevention measures at Points of Entry (PoEs) and in high-risk health facilities, construct and equip EVD isolation and treatment units, and establish coordination and procurement mechanisms. CONCLUSION: As of 31 May 2019, there was no confirmed case of EVD as Uganda has continued to make significant and verifiable progress in EVD preparedness. There is a need to sustain these efforts, not only in EVD preparedness but also across the entire spectrum of a multi-hazard framework. These efforts strengthen country capacity and compel the country to avail resources for preparedness and management of incidents at the source while effectively cutting costs of using a "fire-fighting" approach during public health emergencies.

Integrated Disease Surveillance and Response (IDSR) strategy: current status, challenges and perspectives for the future in Africa.

In 1998, the WHO African region adopted a strategy called Integrated Disease Surveillance and Response (IDSR). Here, we present the current status of IDSR implementation; and provide some future perspectives for enhancing the IDSR strategy in Africa. In 2017, we used two data sources to compile information on the status of IDSR implementation: a pretested rapid assessment questionnaire sent out biannually to all countries and quarterly compilation of data for two IDSR key performance indicators (KPI). The first KPI measures country IDSR performance and the second KPI tracks the number of countries that the WHO secretariat supports to scale up IDSR. The KPI data for 2017 were compared with a retrospective baseline for 2014. By December 2017, 44 of 47 African countries (94%) were implementing IDSR. Of the 44 countries implementing IDSR, 40 (85%) had initiated IDSR training at subnational level; 32 (68%) had commenced community-based surveillance; 35 (74%) had event-based surveillance; 33 (70%) had electronic IDSR; and 32 (68%) had a weekly/monthly bulletin for sharing IDSR data. Thirty-two countries (68%) had achieved the timeliness and completeness threshold of at least 80% of the reporting units. However, only 12 countries (26%) had the desired target of at least 90% IDSR implementation coverage at the peripheral level. After 20 years of implementing IDSR, there are major achievements in the indicator-based surveillance systems. However, major gaps were identified in event-based surveillance. All African countries should enhance IDSR everywhere.

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.

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.

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.

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

Contact Tracing during an Outbreak of Ebola Virus Disease in the Western Area Districts of Sierra Leone: Lessons for Future Ebola Outbreak Response.

INTRODUCTION: Contact tracing is a critical strategy required for timely prevention and control of Ebola virus disease (EVD) outbreaks. Available evidence suggests that poor contact tracing was a driver of the EVD outbreak in West Africa, including Sierra Leone. In this article, we answered the question as to whether EVD contact tracing, as practiced in Western Area (WA) districts of Sierra Leone from 2014 to 2015, was effective. The goal is to describe contact tracing and identify obstacles to its effective implementation. METHODS: Mixed methods comprising secondary data analysis of the EVD case and contact tracing data sets collected from WA during the period from 2014 to 2015, key informant interviews of contact tracers and their supervisors, and a review of available reports on contact tracing were implemented to obtain data for this study. RESULTS: During the study period, 3,838 confirmed cases and 32,706 contacts were listed in the viral hemorrhagic fever and contact databases for the district (mean 8.5 contacts per case). Only 22.1% (852) of the confirmed cases in the study area were listed as contacts at the onset of their illness, which indicates incomplete identification and tracing of contacts. Challenges associated with effective contact tracing included lack of community trust, concealing of exposure information, political interference with recruitment of tracers, inadequate training of contact tracers, and incomplete EVD case and contact database. While the tracers noted the usefulness of community quarantine in facilitating their work, they also reported delayed or irregular supply of basic needs, such as food and water, which created resistance from the communities. CONCLUSION: Multiple gaps in contact tracing attributed to a variety of factors associated with implementers, and communities were identified as obstacles that impeded timely control of the EVD outbreak in the WA of Sierra Leone. In future outbreaks, early community engagement and participation in contact tracing, establishment of appropriate mechanisms for selection, adequate training and supervision of qualified contact tracers, establishment of a well-managed and complete contact tracing database, and provision of basic needs to quarantined contacts are recommended as measures to enhance effective contact tracing.