Molecular characterization of the 2022 Sudan virus disease outbreak in Uganda

IMPORTANCE

Ebola disease (EBOD) is a public health threat with a high case fatality rate. Most EBOD outbreaks have occurred in remote locations, but the 2013-2016 Western Africa outbreak demonstrated how devastating EBOD can be when it reaches an urban population. Here, the 2022 Sudan virus disease (SVD) outbreak in Mubende District, Uganda, is summarized, and the genetic relatedness of the new variant is evaluated. The Mubende variant exhibited 96% amino acid similarity with historic SUDV sequences from the 1970s and a high degree of conservation throughout the outbreak, which was important for ongoing diagnostics and highly promising for future therapy development. Genetic differences between viruses identified during the Mubende SVD outbreak were linked with epidemiological data to better interpret viral spread and contact tracing chains. This methodology should be used to better integrate discrete epidemiological and sequence data for future viral outbreaks.

Development of a Scorecard to Monitor Progress toward National Cholera Elimination: Its Application in Uganda

In 2017, the Global Task Force for Cholera Control (GTFCC) set a goal to eliminate cholera from ≥ 20 countries and to reduce cholera deaths by 90% by 2030. Many countries have included oral cholera vaccine (OCV) in their cholera control plans. We felt that a simple, user-friendly monitoring tool would be useful to guide national progress toward cholera elimination. We reviewed cholera surveillance data of Uganda from 2015 to 2021 by date and district. We defined a district as having eliminated cholera if cholera was not reported in that district for at least 4 years. We prepared maps to show districts with cholera, districts that had eliminated it, and districts that had eliminated it but then "relapsed." These maps were compared with districts where OCV was used and the hotspot map recommended by the GTFCC. Between 2018 and 2021, OCV was administered in 16 districts previously identified as hotspots. In 2018, cholera was reported during at least one of the four previous years from 36 of the 146 districts of Uganda. This number decreased to 18 districts by 2021. Cholera was deemed "eliminated" from four of these 18 districts but then "relapsed." The cholera elimination scorecard effectively demonstrated national progress toward cholera elimination and identified districts where additional resources are needed to achieve elimination by 2030. Identification of the districts that have eliminated cholera and those that have relapsed will assist the national programs to focus on addressing the factors that result in elimination or relapse of cholera.

Factors Associated with COVID-19 Vaccine Hesitancy in Uganda: A Population-Based Cross-Sectional Survey

Purpose

Vaccination toward coronavirus disease (COVID-19) has been recommended and adopted as one of the measures of reducing the spread of this novel disease worldwide. Despite this, vaccine uptake among the Ugandan population has been low with reasons surrounding this being unknown. This study aimed to investigate the factors associated with COVID-19 vaccine hesitancy in Uganda.

Methods

A cross-sectional study was conducted on a total of 1042 adults in the districts of Mukono, Kiboga, Kumi, Soroti, Gulu, Amuru, Mbarara and Sheema from June to November 2021. Data were analyzed using STATA v.15. Barriers to vaccination were analyzed descriptively, while a binary logistic regression model was used to establish the factors associated with COVID-19 vaccine hesitancy.

Results

Overall, COVID-19 vaccine hesitancy was 58.6% (611). Respondents from urban areas and those in the eastern or northern region had increased odds of vaccine hesitancy. Further, higher education level and having knowledge on how COVID-19 is transmitted significantly reduced the odds of vaccine hesitancy. The study also noted individual perception such as COVID-19 kills only people with underlying medical conditions, as well as limited awareness on vaccine types or vaccination areas as the main reasons to vaccine hesitancy. Relatedly, other misconceptions like the ability of the vaccine to cause infertility, or spreading the virus into the body, and acknowledgment of alcohol as a possible cure were other reasons for vaccine hesitancy.

Conclusion

The proportion of COVID-19 vaccine hesitancy is still high among the population with this varying across regions. This is driven by low education level and limited awareness on the vaccination as well as perceived myths and misconceptions. The study recommends mass sensitization of the population on the benefits of vaccination using various channels as well as rolling out community-based outreach vaccination campaigns across the country.

Cholera risk in cities in Uganda: understanding cases and contacts centered strategy (3CS) for rapid cholera outbreak control

Introduction

in the recent past, cities in sub-Saharan Africa have reported serious cholera outbreaks that last for several months. Uganda is one of the African countries where cities are prone to cholera outbreaks. Studies on cholera in Bangladesh show increased risk of cholera for the immediate household members (contacts) yet the control interventions mainly target cases with little or no focus on contacts. This study aimed to describe the rapid control of cholera outbreaks in Kampala and Mbale cities, Uganda, using, “Cases and Contacts Centered Strategy (3CS)” that consisted of identification and treatment of cases, promotion of safe water, sanitation, hygiene (WaSH) and selective chemoprophylaxis for the contacts.

Methods

a cross-sectional study was conducted in 2015-2016 in the Kampala and Mbale cities during cholera outbreaks. Cholera cases were treated and 816 contacts from 188 households were listed and given cholera preventive packages. Data were collected, cleaned, analysed and stored in spreadsheet. Comparison of categories was done using Chi-Square test.

Results

a total of 58 and 41 confirmed cholera cases out of 318 and 153 suspected cases were recorded in Kampala and Mbale cities respectively. The outbreaks lasted for 41 days in both cities. Case fatality rates were high; 12.1% (5/41) for Mbale city and 1.7% (1/58) for Kampala city. Fifty-five percent (210/379) of stool samples were tested by culture to confirm V. choleraeO1. No contacts listed and given cholera preventive package developed cholera. Both sexes and all age groups were affected. In Kampala city, the males were more affected than the females in the age groups less than 14 years, p-value of 0.0097.

Conclusion

this study showed that by implementing 3CS, it was possible to rapidly control cholera outbreaks in Kampala and Mbale cities and no cholera cases were reported amongst the listed household contacts. The findings on 3CS and specifically, selective antibiotic chemoprophylaxis for cholera prevention, could be used in similar manner to oral cholera vaccines to complement the core cholera control interventions (disease surveillance, treatment of cases and WaSH). However, studies are needed to guide such rollout and to understand the age-sex differences in Kampala city.

Effectiveness of thermal screening in detection of COVID-19 among truck drivers at Mutukula Land Point of Entry, Uganda

Introduction

Despite the limited evidence for its effectiveness, thermal screening at points of entry has increasingly become a standard protocol in numerous parts of the globe in response to the COVID-19 pandemic. We sought to determine the effectiveness of thermal screening as a key step in diagnosing COVID-19 in a resource-limited setting.

Materials and methods

This was a retrospective cross-sectional study based on a review of body temperature and Xpert Xpress SARS CoV-2 test results records for truck drivers entering Uganda through Mutukula between 15^th May and 30^th July 2020. All records missing information for body temperature, age, gender, and Xpert Xpress SARS CoV-2 status were excluded from the data set. A data set of 7,181 entries was used to compare thermal screening and Xpert Xpress SARS CoV-2 assay test results using the diagnostic statistical test in STATAv15 software. The prevalence of COVID-19 amongst the truck drivers based on Xpert Xpress SARS CoV-2 assay results was determined. The sensitivity, specificity, positive predictive value, negative predictive value, positive and negative Likelihood ratios were obtained using Xpert Xpress SARS CoV-2 assay as the gold standard.

Results

Based on our gold standard test, the proportion of persons that tested positive for COVID-19 was 6.7% (95% CI: 6.1–7.3). Of the 7,181 persons that were thermally screened, 6,844 (95.3%) were male. The sample median age was 38 years (interquartile range, IQR: 31–45 years). The median body temperature was 36.5°C (IQR: 36.3–36.7) and only n (1.2%) had a body temperature above 37.5°C. The sensitivity and specificity of thermal screening were 9.9% (95% CI: 7.4–13.0) and 99.5% (95% CI: 99.3–99.6) respectively. The positive and negative predictive values were 57.8 (95% CI: 46.5–68.6) and 93.9 (95% CI: 93.3–94.4) respectively. The positive and negative Likelihood Ratios (LRs) were 19 (95% CI: 12.4–29.1) and 0.9 (95% CI: 0.88–0.93) respectively.

Conclusion

In this study population, the use of Thermal screening alone is ineffective in the detection of potential COVID-19 cases at point of entry. We recommend a combination of screening tests or additional testing using highly sensitive molecular diagnostics such as Polymerase Chain Reaction.

The quality of drinking and domestic water from the surface water sources (lakes, rivers, irrigation canals and ponds) and springs in cholera prone communities of Uganda: an analysis of vital physicochemical parameters

BACKGROUND

Water is the most abundant resource on earth, however water scarcity affects more than 40% of people worldwide. Access to safe drinking water is a basic human right and is a United Nations Sustainable Development Goal (SDG) 6. Globally, waterborne diseases such as cholera are responsible for over two million deaths annually. Cholera is a major cause of ill-health in Africa and Uganda. This study aimed to determine the physicochemical characteristics of the surface and spring water in cholera endemic communities of Uganda in order to promote access to safe drinking water.

METHODS

A longitudinal study was carried out between February 2015 and January 2016 in cholera prone communities of Uganda. Surface and spring water used for domestic purposes including drinking from 27 sites (lakes, rivers, irrigation canal, springs and ponds) were tested monthly to determine the vital physicochemical parameters, namely pH, temperature, dissolved oxygen, conductivity and turbidity.

RESULTS

Overall, 318 water samples were tested. Twenty-six percent (36/135) of the tested samples had mean test results that were outside the World Health Organization (WHO) recommended drinking water range. All sites (100%, 27/27) had mean water turbidity values greater than the WHO drinking water recommended standards and the temperature of above 17 °C. In addition, 27% (3/11) of the lake sites and 2/5 of the ponds had pH and dissolved oxygen respectively outside the WHO recommended range of 6.5-8.5 for pH and less than 5 mg/L for dissolved oxygen. These physicochemical conditions were ideal for survival of Vibrio. cholerae.

CONCLUSIONS

This study showed that surface water and springs in the study area were unsafe for drinking and had favourable physicochemical parameters for propagation of waterborne diseases including cholera. Therefore, for Uganda to attain the SDG 6 targets and to eliminate cholera by 2030, more efforts are needed to promote access to safe drinking water. Also, since this study only established the vital water physicochemical parameters, further studies are recommended to determine the other water physicochemical parameters such as the nitrates and copper. Studies are also needed to establish the causal-effect relationship between V. cholerae and the physicochemical parameters.

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.

Conducting the Joint External Evaluation in Uganda: The Process and Lessons Learned

Uganda is currently implementing the Global Health Security Agenda (GHSA), aiming at accelerating compliance to the International Health Regulations (IHR) (2005). To assess progress toward compliance, a Joint External Evaluation (JEE) was conducted by the World Health Organization (WHO). Based on this evaluation, we present the process and lessons learned. Uganda's methodological approach to the JEE followed the WHO recommendations, including conducting a whole-of-government in-country self-assessment prior to the final assessment, using the same tool at both assessments, and generating consensus scores during the final assessment. The in-country self-assessment process began on March 24, 2017, with a multisectoral representation of 203 subject matter experts from 81 institutions. The final assessment was conducted between June 26 and 30, 2017, by 15 external evaluators. Discrepancies between the in-country and final scores occurred in 27 of 50 indicators. Prioritized gaps from the JEE formed the basis of the National Action Plan for Health Security. We learned 4 major lessons from this process: subject matter experts should be adequately oriented on the scoring requirements of the JEE tool; whole-of-government representation should be ensured during the entire JEE process; equitable multisectoral implementation of IHR activities must be ensured; and over-reliance on external support is a threat to sustainability of GHSA gains.

Establishment of a National Inventory of Dangerous Pathogens in the Republic of Uganda

One of the challenges of global biosecurity is to protect and control dangerous pathogens from unauthorized access and intentional release. A practical and feasible option to protect life science institutes against theft and sabotage, and secure their biological materials against misuse, is to establish a national electronic database with a comprehensive overview of the locations of all controlled dangerous pathogens in a country. This national database could be used as an instrument to secure and account for dangerous pathogens in a country, but it could also assist in establishing a biosecurity assessing and monitoring system for laboratories that work with these controlled biological agents. The Republic of Uganda is one of the first countries, prompted by the World Health Organization's (WHO's) Joint External Evaluation (JEE), to implement a national electronic database that assembles information collected from relevant Ugandan laboratories. This Ugandan Inventory of Dangerous Pathogens is different from an institute-specific pathogen inventory system, as it is intended to store the information collected from laboratories in the country working with dangerous pathogens in 1 centralized secure location. The Uganda National Council for Science and Technology (UNCST) has coordinated the implementation of the Ugandan national inventory. The inventory was recognized by the WHO JEE as contributing to Uganda's developed capacities regarding biosafety and biosecurity. This article describes the steps in implementing Uganda's National Inventory of Dangerous Pathogens. In addition, it presents a straightforward approach that can be adapted by other countries that aim to enhance their biosecurity capacities.

The Republic of Uganda is one of the first countries to implement a national electronic database that assembles information collected from relevant Ugandan laboratories. This Ugandan Inventory of Dangerous Pathogens is different from an institute-specific pathogen inventory system, as it is intended to store the information collected from laboratories in the country working with dangerous pathogens in a centralized secure location.

Cholera Epidemic in South Sudan and Uganda and Need for International Collaboration in Cholera Control

Combining the official cholera line list data and outbreak investigation reports from the ministries of health in Uganda and South Sudan with molecular analysis of Vibrio cholerae strains revealed the interrelatedness of the epidemics in both countries in 2014. These results highlight the need for collaboration to control cross-border outbreaks.

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 (OR_adj = 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 (OR_adj = 3.1, 95%CI = 1.1-8.6); and 20 case-patients (63%) and 35 control-persons (27%) farmed in forest areas (OR_adj = 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.

Environmental Surveillance of Vibrio cholerae O1/O139 in the Five African Great Lakes and Other Major Surface Water Sources in Uganda

Cholera is a major public health problem in the African Great Lakes basin. Two hypotheses might explain this observation, namely the lakes are reservoirs of toxigenic Vibrio cholerae O1 and O139 bacteria, or cholera outbreaks are a result of repeated pathogen introduction from the neighboring communities/countries but the lakes facilitate the introductions. A prospective study was conducted in Uganda between February 2015 and January 2016 in which 28 selected surface water sources were tested for the presence of V. cholerae species using cholera rapid test and multiplex polymerase chain reaction. Of 322 water samples tested, 35 (10.8%) were positive for V. cholerae non O1/non O139 and two samples tested positive for non-toxigenic atypical V. cholerae O139. None of the samples tested had toxigenic V. cholerae O1 or O139 that are responsible for cholera epidemics. The Lake Albert region registered the highest number of positive tests for V. cholerae non O1/non O139 at 47% (9/19). The peak period for V. cholerae non O1/non O139 positive tests was in March–July 2015 which coincided with the first rainy season in Uganda. This study showed that the surface water sources, including the African Great Lakes in Uganda, are less likely to be reservoirs for the observed V. cholerae O1 or O139 epidemics, though they are natural habitats for V. cholerae non O1/non O139 and atypical non-toxigenic V. cholerae O139. Further studies by WGS tests of non-toxigenic atypical V. cholerae O139 and physicochemical tests of surface water sources that supports V. cholerae should be done to provide more information. Since V. cholerae non O1/non O139 may cause other human infections, their continued surveillance is needed to understand their potential pathogenicity.

Molecular characterization of Vibrio cholerae responsible for cholera epidemics in Uganda by PCR, MLVA and WGS

Background

For almost 50 years sub-Saharan Africa, including Uganda, has experienced several outbreaks due to Vibrio cholerae. Our aim was to determine the genetic relatedness and spread of strains responsible for cholera outbreaks in Uganda.

Methodology/Principal findings

Sixty-three V. cholerae isolates collected from outbreaks in Uganda between 2014 and 2016 were tested using multiplex polymerase chain reaction (PCR), multi-locus variable number of tandem repeat analysis (MLVA) and whole genome sequencing (WGS). Three closely related MLVA clonal complexes (CC) were identified: CC1, 32% (20/63); CC2, 40% (25/63) and CC3, 28% (18/63). Each CC contained isolates from a different WGS clade. These clades were contained in the third wave of the 7^th cholera pandemic strain, two clades were contained in the transmission event (T)10 lineage and other in T13. Analysing the dates and genetic relatedness revealed that V. cholerae genetic lineages spread between districts within Uganda and across national borders.

Conclusion

The V. cholerae strains showed local and regional transmission within Uganda and the East African region. To prevent, control and eliminate cholera, these countries should implement strong cross-border collaboration and regional coordination of preventive activities.

Cholera, an acute diarrheal disease, essentially was eliminated in the western world many decades ago, but has continued to cause many deaths in sub-Saharan Africa, South America and Asia. Cholera diagnosis in most countries in sub-Saharan Africa, including Uganda, is by stool culture, serology and biochemical methods. These testing methods are unable to establish the relatedness, virulence and spread of Vibrio cholerae in region. To determine the spread, relatedness and virulence of V. cholerae responsible for the various cholera outbreaks in Uganda, we used DNA-based testing methods. We tested 63 V. cholerae isolates from samples collected in Uganda from 2014–2016. Our results showed three distinct lineages of genetically related cholera-causing bacteria. These organisms showed internal spread in Uganda and cross-border spread to neighboring countries in East Africa. These findings provide a valuable baseline and help define the context for directing control measures and technologies for cholera prevention in East Africa.

Sensitivity, Specificity, and Public-Health Utility of Clinical Case Definitions Based on the Signs and Symptoms of Cholera in Africa

During 2014, Africa reported more than half of the global suspected cholera cases. Based on the data collected from seven countries in the African Cholera Surveillance Network (Africhol), we assessed the sensitivity, specificity, and positive and negative predictive values of clinical cholera case definitions, including that recommended by the World Health Organization (WHO) using culture confirmation as the gold standard. The study was designed to assess results in real-world field situations in settings with recent cholera outbreaks or endemicity. From June 2011 to July 2015, a total of 5,084 persons with suspected cholera were tested for Vibrio cholerae in seven different countries of which 35.7% had culture confirmation. For all countries combined, the WHO case definition had a sensitivity = 92.7%, specificity = 8.1%, positive predictive value = 36.1%, and negative predictive value = 66.6%. Adding dehydration, vomiting, or rice water stools to the case definition could increase the specificity without a substantial decrease in sensitivity. Future studies could further refine our findings primarily by using more sensitive methods for cholera confirmation.

Risk factors for hematemesis in Hoima and Buliisa Districts, Western Uganda, September-October 2015

Introduction

On 17 September 2015, Buliisa District Health Office reported multiple deaths due to haemorrhage to the Uganda Ministry of Health. We conducted an investigation to verify the existence of an outbreak and to identify the disease nature, mode of transmission and risk factors.

Methods

We defined a suspected case as onset of hematemesis between 1 June 2015 and 15 October 2015 in a resident of Hoima, Buliisa or neighbouring districts. We identified cases by reviewing medical records and actively searching in the community. We interviewed case-patients and health-care workers and performed descriptive epidemiology to generate hypotheses on possible exposures. In a case-control study we compared exposures between 21 cases and 81 controls, matched by age (± 10 years), sex and village of residence. We collected 22 biological specimens from 19 case-patients to test for Viral Haemorrhagic Fevers (VHF). We analysed the data using the Mantel-Haenszel method to account for the matched study design.

Results

We identified 56 cases with onset from June to October (attack rate 15/100,000 in Buliisa District and 5.2/100,000 in Hoima District). The age-specific attack rate was highest in persons aged 31-60 years (15/100,000 in Hoima and 47/100,000 in Buliisa); no persons below 15 years of age had the illness. In the case-control study, 42% (5/12) of cases vs. 0.0% (0/77) of controls had liver disease (OR_M-H = ∞; 95%CI = 3.7-∞); 71% (10/14) of cases vs. 35% (28/81) of controls had ulcer disease (OR_M-H = 13; 95% CI = 1.6-98); 27% (3/11) of cases vs. 14% (11/81) of controls used indomethacin prior to disease onset (OR_M-H = 6.0; 95% CI = 1.0-36). None of the blood samples were positive for any of the VHFs.

Conclusion

This reported cluster of hematemesis illness was due to predisposing conditions and use of Non-Steroidal Anti-inflammatory Drugs (NSAID). Health education should be conducted on the danger of NSAIDs misuse, especially in persons with pre-disposing conditions.

Epidemiology of cholera outbreaks and socio-economic characteristics of the communities in the fishing villages of Uganda: 2011-2015

Background

The communities in fishing villages in the Great Lakes Region of Africa and particularly in Uganda experience recurrent cholera outbreaks that lead to considerable mortality and morbidity. We evaluated cholera epidemiology and population characteristics in the fishing villages of Uganda to better target prevention and control interventions of cholera and contribute to its elimination from those communities.

Methodology/Principal findings

We conducted a prospective study between 2011–15 in fishing villages in Uganda. We collected, reviewed and documented epidemiological and socioeconomic data for 10 cholera outbreaks that occurred in fishing communities located along the African Great Lakes and River Nile in Uganda. These outbreaks caused 1,827 suspected cholera cases and 43 deaths, with a Case-Fatality Ratio (CFR) of 2.4%. Though the communities in the fishing villages make up only 5–10% of the Ugandan population, they bear the biggest burden of cholera contributing 58% and 55% of all reported cases and deaths in Uganda during the study period. The CFR was significantly higher among males than females (3.2% vs. 1.3%, p = 0.02). The outbreaks were seasonal with most cases occurring during the months of April-May. Male children under age of 5 years, and 5–9 years had increased risk. Cholera was endemic in some villages with well-defined “hotspots”. Practices predisposing communities to cholera outbreaks included: the use of contaminated lake water, poor sanitation and hygiene. Additional factors were: ignorance, illiteracy, and poverty.

Conclusions/Significance

Cholera outbreaks were a major cause of morbidity and mortality among the fishing communities in Uganda. In addition to improvements in water, sanitation, and hygiene, oral cholera vaccines could play an important role in the prevention and control of these outbreaks, particularly when targeted to high-risk areas and populations. Promotion and facilitation of access to social services including education and reduction in poverty should contribute to cholera prevention, control and elimination in these communities.

Cholera, though a preventable and treatable disease, remains a major cause of morbidity and mortality in the Great Lakes Region of Africa, including Uganda. The communities in the fishing villages constitute 5–10% of the total Ugandan population. Most fishing villages are located along Lakes Victoria, Albert and Edward and the River Nile. During the study period, 2011–2015 these villages were responsible for over 50% of the reported annual cholera cases and deaths in Uganda. The CFR was significantly higher among males than females (3.2% vs. 1.3%, p = 0.02). Our study is the first to systematically describe the epidemiology of these outbreaks and socioeconomic characteristics of communities in the fishing villages in Uganda. Our study found that persons in the fishing villages were at increased risk of cholera outbreaks due to poor access to safe water, sanitation, and hygiene. Furthermore, the villages had similar population characteristics such as illiteracy, ignorance regarding cholera transmission, poverty and constant population migration. In addition to improvements in water, sanitation, and hygiene, complementary use of oral cholera vaccines could play an important role, particularly when targeted to high-risk areas and populations. As a long term strategy, improvements in education and reduction in poverty should contribute to cholera prevention, control and elimination in the fishing villages and Uganda as whole.

Cholera Incidence and Mortality in Sub-Saharan African Sites during Multi-country Surveillance

BACKGROUND

Cholera burden in Africa remains unknown, often because of weak national surveillance systems. We analyzed data from the African Cholera Surveillance Network (www.africhol.org).

METHODS/ PRINCIPAL FINDINGS

During June 2011-December 2013, we conducted enhanced surveillance in seven zones and four outbreak sites in Togo, the Democratic Republic of Congo (DRC), Guinea, Uganda, Mozambique and Cote d'Ivoire. All health facilities treating cholera cases were included. Cholera incidences were calculated using culture-confirmed cholera cases and culture-confirmed cholera cases corrected for lack of culture testing usually due to overwhelmed health systems and imperfect test sensitivity. Of 13,377 reported suspected cases, 34% occurred in Conakry, Guinea, 47% in Goma, DRC, and 19% in the remaining sites. From 0-40% of suspected cases were aged under five years and from 0.3-86% had rice water stools. Within surveillance zones, 0-37% of suspected cases had confirmed cholera compared to 27-38% during outbreaks. Annual confirmed incidence per 10,000 population was <0.5 in surveillance zones, except Goma where it was 4.6. Goma and Conakry had corrected incidences of 20.2 and 5.8 respectively, while the other zones a median of 0.3. During outbreaks, corrected incidence varied from 2.6 to 13.0. Case fatality ratios ranged from 0-10% (median, 1%) by country.

CONCLUSIONS/SIGNIFICANCE

Across different African epidemiological contexts, substantial variation occurred in cholera incidence, age distribution, clinical presentation, culture confirmation, and testing frequency. These results can help guide preventive activities, including vaccine use.

Nosocomial Cholera Outbreak in a Mental Hospital: Challenges and Lessons Learnt from Butabika National Referral Mental Hospital, Uganda

During the last four decades, Uganda has experienced repeated cholera outbreaks in communities; no cholera outbreaks have been reported in Ugandan health facilities. In October 2008, a unique cholera outbreak was confirmed in Butabika National Mental Referral Hospital (BNMRH), Uganda. This article describes actions taken to control the outbreak, challenges, and lessons learnt. We reviewed patient and hospital reports for clinical symptoms and signs, treatment and outcome, patient mental diagnosis, and challenges noted during management of patients and contacts. Out of 114 BNMRH patients on two affected wards, 18 cholera cases and five deaths were documented for an attack rate of 15.8% and a case fatality rate of 28%. Wards and surroundings were intensively disinfected and 96 contacts (psychiatric patients) in the affected wards received chemoprophylaxis with oral ciprofloxacin 500 mg twice daily until November 5, 2008. We documented a nosocomial cholera outbreak in BNMRH with a high case fatality of 28% compared with the national average of 2.4% for cholera outbreaks in communities. To avoid cholera outbreaks and potentially high mortality among patients in mental institutions, procedures for prompt diagnosis, treatment, disinfection, and prophylaxis are needed and preemptive use of oral cholera vaccines should be considered.

Shifts in geographic distribution and antimicrobial resistance during a prolonged typhoid fever outbreak--Bundibugyo and Kasese Districts, Uganda, 2009-2011

Background

Salmonella enterica serovar Typhi is transmitted by fecally contaminated food and water and causes approximately 22 million typhoid fever infections worldwide each year. Most cases occur in developing countries, where approximately 4% of patients develop intestinal perforation (IP). In Kasese District, Uganda, a typhoid fever outbreak notable for a high IP rate began in 2008. We report that this outbreak continued through 2011, when it spread to the neighboring district of Bundibugyo.

Methodology/Principal Findings

A suspected typhoid fever case was defined as IP or symptoms of fever, abdominal pain, and ≥1 of the following: gastrointestinal disruptions, body weakness, joint pain, headache, clinically suspected IP, or non-responsiveness to antimalarial medications. Cases were identified retrospectively via medical record reviews and prospectively through laboratory-enhanced case finding. Among Kasese residents, 709 cases were identified from August 1, 2009–December 31, 2011; of these, 149 were identified during the prospective period beginning November 1, 2011. Among Bundibugyo residents, 333 cases were identified from January 1–December 31, 2011, including 128 cases identified during the prospective period beginning October 28, 2011. IP was reported for 507 (82%) and 59 (20%) of Kasese and Bundibugyo cases, respectively. Blood and stool cultures performed for 154 patients during the prospective period yielded isolates from 24 (16%) patients. Three pulsed-field gel electrophoresis pattern combinations, including one observed in a Kasese isolate in 2009, were shared among Kasese and Bundibugyo isolates. Antimicrobial susceptibility was assessed for 18 isolates; among these 15 (83%) were multidrug-resistant (MDR), compared to 5% of 2009 isolates.

Conclusions/Significance

Molecular and epidemiological evidence suggest that during a prolonged outbreak, typhoid spread from Kasese to Bundibugyo. MDR strains became prevalent. Lasting interventions, such as typhoid vaccination and improvements in drinking water infrastructure, should be considered to minimize the risk of prolonged outbreaks in the future.

Typhoid fever is an acute febrile illness caused by the bacteria Salmonella Typhi and transmitted through food and water contaminated with the feces of typhoid fever patients or carriers. We investigated typhoid fever outbreaks in two neighboring Ugandan districts, Kasese and Bundibugyo, where typhoid fever outbreaks began in 2008 and 2011, respectively. In Kasese from August 2009–December 2011, we documented 709 cases of typhoid fever. In Bundibugyo from January–December 2011, we documented 333 cases. Salmonella Typhi from Bundibugyo and Kasese had indistinguishable molecular fingerprints; laboratory and epidemiological evidence indicate that the outbreak spread from Kasese to Bundibugyo. Salmonella Typhi isolated during our investigation were resistant to more antibiotics than isolates obtained from Kasese in 2009. Drinking water in both districts was fecally contaminated and the likely vehicle for the outbreaks. Our investigation highlights that in unchecked typhoid fever outbreaks, illness can become geographically dispersed and outbreak strains can become increasingly resistant to antibiotics. Lasting interventions, including investments in drinking water infrastructure and typhoid vaccination, are needed to control these outbreaks and prevent future outbreaks.

Cholera surveillance in Uganda: an analysis of notifications for the years 2007-2011

INTRODUCTION

Cholera outbreaks have occurred periodically in Uganda since 1971. The country has experienced intervals of sporadic cases and localized outbreaks, occasionally resulting in prolonged widespread epidemics.

METHODS

Cholera surveillance data reported to the Uganda Ministry of Health from 2007 through 2011 were reviewed to determine trends in annual incidence and case fatality rate. Demographic characteristics of cholera cases were analyzed from the national line list for 2011. Cases were analyzed by district and month of report to understand the geographic distribution and identify any seasonal patterns of disease occurrence.

RESULTS

From 2007 through 2011, Uganda registered a total of 7615 cholera cases with 181 deaths (case fatality rate = 2.4%). The absolute number of cases and incidence per 100 000 varied from year to year with the highest incidence occurring in 2008 following heavy rainfall and flooding in eastern Uganda. For 2011, cholera cases occurred in 1.6 times more males than females. The geographical areas affected by the outbreaks shifted each year, with the exception of a few endemic districts. No clear seasonal trends in cholera occurrence were identified for this time period.

CONCLUSIONS

We observed an overall decline in cases reported during the 5 years under review. During this period, concerted efforts were made by the Ugandan government and development partners to educate communities on proper sanitation and hygiene and provide safe water and timely treatment. Mechanisms to ensure timely and complete cholera surveillance data are reported to the national level should continue to be strengthened.

Outbreak of Marburg hemorrhagic fever among miners in Kamwenge and Ibanda Districts, Uganda, 2007

Marburg hemorrhagic fever was detected among 4 miners in Ibanda District, Uganda, from June through September, 2007. Infection was likely acquired through exposure to bats or bat secretions in a mine in Kamwenge District, Uganda, and possibly human-to-human transmission between some patients. We describe the epidemiologic investigation and the health education response.