Sudan virus disease super-spreading, Uganda, 2022.

BACKGROUND: On 20 September 2022, Uganda declared its fifth Sudan virus disease (SVD) outbreak, culminating in 142 confirmed and 22 probable cases. The reproductive rate (R) of this outbreak was 1.25. We described persons who were exposed to the virus, became infected, and they led to the infection of an unusually high number of cases during the outbreak. METHODS: In this descriptive cross-sectional study, we defined a super-spreader person (SSP) as any person with real-time polymerase chain reaction (RT-PCR) confirmed SVD linked to the infection of ≥ 13 other persons (10-fold the outbreak R). We reviewed illness narratives for SSPs collected through interviews. Whole-genome sequencing was used to support epidemiologic linkages between cases. RESULTS: Two SSPs (Patient A, a 33-year-old male, and Patient B, a 26-year-old male) were identified, and linked to the infection of one probable and 50 confirmed secondary cases. Both SSPs lived in the same parish and were likely infected by a single ill healthcare worker in early October while receiving healthcare. Both sought treatment at multiple health facilities, but neither was ever isolated at an Ebola Treatment Unit (ETU). In total, 18 secondary cases (17 confirmed, one probable), including three deaths (17%), were linked to Patient A; 33 secondary cases (all confirmed), including 14 (42%) deaths, were linked to Patient B. Secondary cases linked to Patient A included family members, neighbours, and contacts at health facilities, including healthcare workers. Those linked to Patient B included healthcare workers, friends, and family members who interacted with him throughout his illness, prayed over him while he was nearing death, or exhumed his body. Intensive community engagement and awareness-building were initiated based on narratives collected about patients A and B; 49 (96%) of the secondary cases were isolated in an ETU, a median of three days after onset. Only nine tertiary cases were linked to the 51 secondary cases. Sequencing suggested plausible direct transmission from the SSPs to 37 of 39 secondary cases with sequence data. CONCLUSION: Extended time in the community while ill, social interactions, cross-district travel for treatment, and religious practices contributed to SVD super-spreading. Intensive community engagement and awareness may have reduced the number of tertiary infections. Intensive follow-up of contacts of case-patients may help reduce the impact of super-spreading events.

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

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

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

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

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

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