Barnabas Bakamutumaho

Assessment of core capacities for the international health regulations (IHR[2005]) - Uganda, 2009

BackgroundUganda is currently implementing the International Health Regulations (IHR[2005]) within the context of Integrated Disease Surveillance and Response (IDSR). The IHR(2005) require countries to assess the ability of their national structures, capacities, and resources to meet the minimum requirements for surveillance and response. This report describes the results of the assessment undertaken in Uganda.MethodsWe conducted a descriptive cross-sectional assessment using the protocol developed by the World Health Organisation (WHO). The data collection tools were adapted locally and administered to a convenience sample of HR(2005) stakeholders, and frequency analyses were performed.ResultsUgandan national laws relevant to the IHR(2005) existed, but they did not adequately support the full implementation of the IHR(2005). Correspondingly, there was a designated IHR National Focal Point (NFP), but surveillance activities and operational communications were limited to the health sector. All the districts (13/13) had designated disease surveillance offices, most had IDSR technical guidelines (92%, or 12/13), and all (13/13) had case definitions for infectious and zoonotic diseases surveillance. Surveillance guidelines were available at 57% (35/61) of the health facilities, while case definitions were available at 66% (40/61) of the health facilities. The priority diseases list, surveillance guidelines, case definitions and reporting tools were based on the IDSR strategy and hence lacked information on the IHR(2005). The rapid response teams at national and district levels lacked food safety, chemical and radio-nuclear experts. Similarly, there were no guidelines on the outbreak response to food, chemical and radio-nuclear hazards. Comprehensive preparedness plans incorporating IHR(2005) were lacking at national and district levels. A national laboratory policy existed and the strategic plan was being drafted. However, there were critical gaps hampering the efficient functioning of the national laboratory network. Finally, the points of entry for IHR(2005) implementation had not been designated.ConclusionsThe assessment highlighted critical gaps to guide the IHR(2005) planning process. The IHR(2005) action plan should therefore be developed to foster national and international public health security.

Hepatitis E Epidemic, Uganda

In October 2007, an epidemic of hepatitis E was suspected in Kitgum District of northern Uganda where no previous epidemics had been documented. This outbreak has progressed to become one of the largest hepatitis E outbreaks in the world. By June 2009, the epidemic had caused illness in >10,196 persons and 160 deaths.

Influenza Surveillance in 15 Countries in Africa, 2006-2010

BACKGROUND In response to the potential threat of an influenza pandemic, several international institutions and governments, in partnership with African countries, invested in the development of epidemiologic and laboratory influenza surveillance capacity in Africa and the African Network of Influenza Surveillance and Epidemiology (ANISE) was formed. METHODS We used a standardized form to collect information on influenza surveillance system characteristics, the number and percent of influenza-positive patients with influenza-like illness (ILI), or severe acute respiratory infection (SARI) and virologic data from countries participating in ANISE. RESULTS Between 2006 and 2010, the number of ILI and SARI sites in 15 African countries increased from 21 to 127 and from 2 to 98, respectively. Children 0-4 years accounted for 48% of all ILI and SARI cases of which 22% and 10%, respectively, were positive for influenza. Influenza peaks were generally discernible in North and South Africa. Substantial cocirculation of influenza A and B occurred most years. CONCLUSIONS Influenza is a major cause of respiratory illness in Africa, especially in children. Further strengthening influenza surveillance, along with conducting special studies on influenza burden, cost of illness, and role of other respiratory pathogens will help detect novel influenza viruses and inform and develop targeted influenza prevention policy decisions in the region.

Clinic- and hospital-based sentinel influenza surveillance, Uganda 2007-2010.

BACKGROUND To assess the epidemiology and seasonality of influenza in Uganda, we established a sentinel surveillance system for influenza in 5 hospitals and 5 outpatient clinics in 4 geographically distinct regions, using standard case definitions for influenzalike illness (ILI) and severe acute respiratory illness (SARI). METHODS Nasopharyngeal and oropharyngeal specimens were collected from April 2007 through September 2010 from patients with ILI and SARI aged ≥ 2 months, tested for influenza A and B with real-time reverse-transcription polymerase chain reaction, and subtyped for seasonal A/H1, A/H3, A/H5, and 2009 pandemic influenza A (pH1N1). RESULTS Among the 2758 patients sampled, 2656 (96%) enrolled with ILI and 101 (4%) with SARI. Specimens from 359 (13.0%) were positive for influenza; 267 (74.4%) were influenza A, and 92 (25.6%) were influenza B. The median age of both patients with ILI and patients with SARI was 4 years (range, 2 months to 67 years); patients aged 5-14 years had the highest influenza-positive percentage (19.6%), and patients aged 0-4 years had the lowest percentage (9.1%). Influenza circulated throughout the year, but the percentage of influenza-positive specimens peaked during June-November, coinciding with the second rainy season. CONCLUSIONS Continued and increased surveillance is needed to better understand the morbidity and mortality of influenza in Uganda.

Hepatitis E as a Cause of Acute Jaundice Syndrome in Northern Uganda, 2010–2012

Hepatitis E virus (HEV) is a common cause of acute viral hepatitis in developing countries; however, its contribution to acute jaundice syndrome is not well-described. A large outbreak of hepatitis E occurred in northern Uganda from 2007 to 2009. In response to this outbreak, acute jaundice syndrome surveillance was established in 10 district healthcare facilities to determine the proportion of cases attributable to hepatitis E. Of 347 acute jaundice syndrome cases reported, the majority (42%) had hepatitis E followed by hepatitis B (14%), malaria (10%), hepatitis C (5%), and other/unknown (29%). Of hepatitis E cases, 72% occurred in Kaboong district, and 68% of these cases occurred between May and August of 2011. Residence in Kaabong district was independently associated with hepatitis E (adjusted odds ratio = 13; 95% confidence interval = 7-24). The findings from this surveillance show that an outbreak and sporadic transmission of hepatitis E occur in northern Uganda.

Phylogenetic analysis of rubella viruses identified in Uganda, 2003-2012.

Molecular data on rubella viruses are limited in Uganda despite the importance of congenital rubella syndrome (CRS). Routine rubella vaccination, while not administered currently in Uganda, is expected to begin by 2015. The World Health Organization recommends that countries without rubella vaccination programs assess the burden of rubella and CRS before starting a routine vaccination program. Uganda is already involved in integrated case‐based surveillance, including laboratory testing to confirm measles and rubella, but molecular epidemiologic aspects of rubella circulation have so far not been documented in Uganda. Twenty throat swab or oral fluid samples collected from 12 districts during routine rash and fever surveillance between 2003 and 2012 were identified as rubella virus RNA positive and PCR products encompassing the region used for genotyping were sequenced. Phylogenetic analysis of the 20 sequences identified 19 genotype 1G viruses and 1 genotype 1E virus. Genotype‐specific trees showed that the Uganda viruses belonged to specific clusters for both genotypes 1G and 1E and grouped with similar sequences from neighboring countries. Genotype 1G was predominant in Uganda. More epidemiological and molecular epidemiological data are required to determine if genotype 1E is also endemic in Uganda. The information obtained in this study will assist the immunization program in monitoring changes in circulating genotypes. J. Med. Virol. 86:2107–2113, 2014.

Hepatitis E in Karamoja, Uganda, 2009-2012: epidemiology and challenges to control in a setting of semi-nomadic pastoralism.

BACKGROUND A prolonged hepatitis E outbreak occurred between 2009 and 2012 among a semi-nomadic pastoralist population in the Karamoja region of Uganda. As data on the public health problems of nomadic pastoralists in sub-Saharan Africa is limited, we sought to characterize the epidemiology and challenges to control of hepatitis E in such a setting. METHODS A retrospective case-series investigation was undertaken. Surveillance line-lists of suspected hepatitis E cases maintained during the outbreak were analyzed. Standardized interviews and focus group discussions were conducted with key informants involved in outbreak control activities. RESULTS Between August 2009 and September 2012, 987 hepatitis E cases with individual case-based data were identified. Of 22 total deaths, almost half occurred during the first 4 months of the outbreak. Infection attack rates were higher among males and young adults. The average time between onset of jaundice and presentation was approximately 1 week. Challenges to control were related to persistent consumption of untreated water, poor sanitation infrastructure, remote geography, nomadic movement and civil insecurity. CONCLUSIONS The hepatitis E outbreak in Karamoja highlights the emergence of sanitation and hygiene-related disease among semi-nomadic pastoralist populations. Improving sanitation and safe water access and extending health education programs to remote pastoralist communities is crucial to prevent such diseases from becoming endemic.

The impact of poverty on dog ownership and access to canine rabies vaccination: results from a knowledge, attitudes and practices survey, Uganda 2013

BackgroundRabies is a neglected disease despite being responsible for more human deaths than any other zoonosis. A lack of adequate human and dog surveillance, resulting in low prioritization, is often blamed for this paradox. Estimation methods are often employed to describe the rabies burden when surveillance data are not available, however these figures are rarely based on country-specific data.MethodsIn 2013 a knowledge, attitudes, and practices survey was conducted in Uganda to understand dog population, rabies vaccination, and human rabies risk factors and improve in-country and regional rabies burden estimates. Poisson and multi-level logistic regression techniques were conducted to estimate the total dog population and vaccination coverage.ResultsTwenty-four villages were selected, of which 798 households completed the survey, representing 4 375 people. Dog owning households represented 12.9% of the population, for which 175 dogs were owned (25 people per dog). A history of vaccination was reported in 55.6% of owned dogs. Poverty and human population density highly correlated with dog ownership, and when accounted for in multi-level regression models, the human to dog ratio fell to 47:1 and the estimated national canine-rabies vaccination coverage fell to 36.1%. This study estimates there are 729 486 owned dogs in Uganda (95% CI: 719 919 – 739 053). Ten percent of survey respondents provided care to dogs they did not own, however unowned dog populations were not enumerated in this estimate. 89.8% of Uganda’s human population was estimated to reside in a community that can support enzootic canine rabies transmission.ConclusionsThis study is the first to comprehensively evaluate the effect of poverty on dog ownership in Africa. These results indicate that describing a dog population may not be as simple as applying a human: dog ratio, and factors such as poverty are likely to heavily influence dog ownership and vaccination coverage. These modelled estimates should be confirmed through further field studies, however, if validated, canine rabies elimination through mass vaccination may not be as difficult as previously considered in Uganda. Data derived from this study should be considered to improve models for estimating the in-country and regional rabies burden.

The viral aetiology of influenza-like illnesses in Kampala and Entebbe, Uganda, 2008

Background As the threat of zoonoses and the emergence of pandemic-prone respiratory viruses increases, there is a need to establish baseline information on the incidence of endemic pathogens in countries worldwide. Objectives To investigate the presence of viruses associated with influenza-like illnesses (ILI) in Uganda. Methods A cross-sectional study was conducted in which nasopharyngeal swab specimens were collected from patients diagnosed with ILI in Kampala and Entebbe between 14 August 2008 – 15 December 2008. A multiplex polymerase chain reaction assay for detecting 12 respiratory viruses was used. Results A total of 369 patients (52.3% females) was enrolled; the median age was 6 years (range 1–70). One or more respiratory viruses were detected in 172 (46.6%) cases and their prevalence were influenza A virus (19.2%), adenovirus (8.7%), human rhinovirus A (7.9%), coronavirus OC43 (4.3%), parainfluenza virus 1 (2.7%), parainfluenza virus 3 (2.7%), influenza B virus (2.2%), respiratory syncytial virus B (2.2%), human metapneumovirus (1.4%), respiratory syncytial virus A (1.1%), parainfluenza virus 2 (0.5%) and coronavirus 229E (0.5%). There were 24 (14.0%) mixed infections. Conclusions This study identified some of the respiratory viruses associated with ILI in Uganda. The circulation of some of the viruses was previously unknown in the study population. These results are useful in order to guide future surveillance and case management strategies involving respiratory illnesses in Uganda.

Dynamics of influenza in tropical Africa: Temperature, humidity, and co-circulating (sub)types

The association of influenza with meteorological variables in tropical climates remains controversial. Here, we investigate the impact of weather conditions on influenza in the tropics and factors that may contribute to this uncertainty.