Outbreak of Cyanide Poisoning Caused by Consumption of Cassava Flour - Kasese District, Uganda, September 2017.

Cassava (Manihot esculenta), an edible tuberous root that is resistant to drought, diseases, and pests, is a major source of carbohydrates in tropical areas, the second most widely grown and consumed food in Uganda after bananas, and a staple in the diet for approximately 57% of the Uganda population (Figure 1) (1). On September 5, 2017, a funeral was held in Kasese District in western Uganda. Following the funeral, 33 persons with symptoms that included diarrhea, vomiting, and abdominal pains were admitted to Bwera Hospital in Kasese District. On September 8, the Uganda Ministry of Health received notification from the Kasese District health team regarding this outbreak of suspected food poisoning. An investigation to determine the cause of the outbreak and recommend control measures revealed that the outbreak resulted from consumption of a cassava dish made by combining hot water with cassava flour. The implicated batch of cassava flour was traced back to a single wholesaler and found to contain high cyanogenic content. Informed by the investigation findings, police confiscated all cassava flour from retailers identified as the patients' source of the flour. Health education about cyanide poisoning from cassava and the need to adequately process cassava to reduce cyanogenic content was conducted by public health officials.

Analyzing fast and slow: Combining traditional and rapid qualitative analysis to meet multiple objectives of a complex transnational study.

Much of the methodological literature on rapid qualitative analysis describes processes used by a relatively small number of researchers focusing on one study site and using rapid analysis to replace a traditional analytical approach. In this paper, we describe the experiences of a transnational research consortium integrating both rapid and traditional qualitative analysis approaches to develop social theory while also informing program design. Research was conducted by the Innovations for Choice and Autonomy (ICAN) consortium, which seeks to understand how self-injection of the contraceptive subcutaneous depot medroxyprogesterone acetate (DMPA-SC) can be implemented in a way that best meets women's needs, as defined by women themselves. Consortium members are based in Kenya, Uganda, Malawi, Nigeria, and the United States. Data for the ICAN study was collected in all four countries in sub-Saharan Africa. In order to both illuminate social phenomena across study sites and inform the program design component of the study, researchers developed tools meant to gather both in-depth information about women's contraceptive decision-making and data targeted specifically to program design during the formative qualitative phase of the study. Using these two bodies of data, researchers then simultaneously conducted both a traditional qualitative and rapid analysis to meet multiple study objectives. To complete the traditional analysis, researchers coded interview transcripts and kept analytical memos, while also drawing on data collected by tools developed for the rapid analysis. Rapid analysis consisted of simultaneously collecting data and reviewing notes developed specifically for this analysis. We conclude that integrating traditional and rapid qualitative analysis enabled us to meet the needs of a complex transnational study with the added benefit of grounding our program design work in more robust primary data than normally is available for studies using a human-centered design approach to intervention development. However, the realities of conducting a multi-faceted study across multiple countries and contexts made truly "rapid" analysis challenging.

Many Cooks in the Kitchen: Iterating a Qualitative Analysis Process Across Multiple Countries, Sites, and Teams.

Establishing and proving methodological rigor has long been a challenge for qualitative researchers where quantitative methods prevail, but much published literature on qualitative analysis assumes a relatively small number of researchers working in relative proximity. This is particularly true for research conducted with a grounded theory approach. Different versions of grounded theory are commonly used, but this methodology was originally developed for a single researcher collecting and analyzing data in isolation. Although grounded theory has evolved since its development, little has been done to reconcile this approach with the changing nature and composition of international research teams. Advances in technology and an increased emphasis on transnational collaboration have facilitated a shift wherein qualitative datasets have been getting larger and the teams collecting and analyzing them more diverse and diffuse. New processes and systems are therefore required to respond to these conditions. Data for this article are drawn from the experiences of the Innovations for Choice and Autonomy (ICAN) Research Consortium. ICAN aims to understand how self-injectable contraceptives can be implemented in ways that best meet women's needs in Kenya, Uganda, Malawi, and Nigeria. We found that taking a structured approach to analysis was important for maintaining consistency and making the process more manageable across countries. However, it was equally important to allow for flexibility within this structured approach so that teams could adapt more easily to local conditions, making data collection and accompanying analysis more feasible. Meaningfully including all interested researchers in the analysis process and providing support for learning also increased rigor. However, competing priorities in a complex study made it difficult to adhere to planned timelines. We conclude with recommendations for both funders and study teams to design and conduct global health studies that ensure more equitable contributions to analysis while remaining logistically feasible and methodologically sound.

Cutaneous anthrax associated with handling carcasses of animals that died suddenly of unknown cause: Arua District, Uganda, January 2015-August 2017.

BACKGROUND: Anthrax is a zoonotic disease that can be transmitted to humans from infected animals. During May-June 2017, three persons with probable cutaneous anthrax were reported in Arua District, Uganda; one died. All had recently handled carcasses of livestock that died suddenly and a skin lesion from a deceased person tested positive by PCR for Bacillus anthracis. During July, a bull in the same community died suddenly and the blood sample tested positive by PCR for Bacillus anthracis. The aim of this investigation was to establish the scope of the problem, identify exposures associated with illness, and recommend evidence-based control measures. METHODS: A probable case was defined as acute onset of a papulo-vesicular skin lesion subsequently forming an eschar in a resident of Arua District during January 2015-August 2017. A confirmed case was a probable case with a skin sample testing positive by polymerase chain reaction (PCR) for B. anthracis. Cases were identified by medical record review and active community search. In a case-control study, exposures between case-patients and frequency- and village-matched asymptomatic controls were compared. Key animal health staff were interviewed to learn about livestock deaths. RESULTS: There were 68 case-patients (67 probable, 1 confirmed), and 2 deaths identified. Cases occurred throughout the three-year period, peaking during dry seasons. All cases occurred following sudden livestock deaths in the villages. Case-patients came from two neighboring sub-counties: Rigbo (attack rate (AR) = 21.9/10,000 population) and Rhino Camp (AR = 1.9/10,000). Males (AR = 24.9/10,000) were more affected than females (AR = 0.7/10,000). Persons aged 30-39 years (AR = 40.1/10,000 population) were most affected. Among all cases and 136 controls, skinning (ORM-H = 5.0, 95%CI: 2.3-11), butchering (ORM-H = 22, 95%CI: 5.5-89), and carrying the carcass of livestock that died suddenly (ORM-H = 6.9, 95%CI: 3.0-16) were associated with illness. CONCLUSIONS: Exposure to carcasses of animals that died suddenly was a likely risk factor for cutaneous anthrax in Arua District during 2015-2017. The recommendations are investigation of anthrax burden in livestock, prevention of animal infections through vaccinations, safe disposal of the carcasses, public education on risk factors for infection and prompt treatment of illness following exposure to animals that died suddenly.

Fatal Methanol Poisoning Caused by Drinking Adulterated Locally Distilled Alcohol: Wakiso District, Uganda, June 2017.

Background: Methanol, an industrial solvent, can cause illness and death if ingested. In June 2017, the Uganda Ministry of Health was notified of a cluster of deaths which occurred after drinking alcohol. We investigated to determine the cause of outbreak, identify risk factors, and recommend evidence-based control measures. Methods: We defined a probable case as acute loss of eyesight and ≥1 of the following symptoms: profuse sweating, vomiting, dizziness, or loss of consciousness in a resident of either Nabweru or Nangabo Subcounty from 1 to 30 June 2017. In a case-control study, we compared exposures of case-patients and controls selected among asymptomatic neighbors who drank alcohol and matched by age and sex. We collected alcohol samples from implicated bars and wholesaler X for testing. Results: We identified 15 cases; 12 (80%) died. Among case-patients, 12 (80%) were men; the median age was 43 (range: 23-66) years. Thirteen (87%) of 15 case-patients and 15 (25%) of 60 controls last drank a locally distilled alcohol at one of the three bars supplied by wholesaler X (ORM-H = 15; 95% CI: 2.3-106). We found that alcohol sellers sometimes added methanol to drinking alcohol to increase their profit margin. Among the 10 alcohol samples from wholesaler X, the mean methanol content (1200 mg/L, range: 77-2711 mg/L) was 24 times higher than the safe level. Conclusion: This outbreak was caused by drinking a locally distilled alcohol adulterated with methanol from wholesaler X. We recommended enforcing existing laws governing alcohol manufacture and sale. We recommended timely intravenous administration of ethanol to methanol poisoning victims.