Miriam Nanyunja

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.

Epidemiological and laboratory characterization of a yellow fever outbreak in northern Uganda, October 2010-January 2011

BACKGROUND In November 2010, following reports of an outbreak of a fatal, febrile, hemorrhagic illness in northern Uganda, the Uganda Ministry of Health established multisector teams to respond to the outbreak. METHODS This was a case-series investigation in which the response teams conducted epidemiological and laboratory investigations on suspect cases. The cases identified were line-listed and a data analysis was undertaken regularly to guide the outbreak response. RESULTS Overall, 181 cases met the yellow fever (YF) suspected case definition; there were 45 deaths (case fatality rate 24.9%). Only 13 (7.5%) of the suspected YF cases were laboratory confirmed, and molecular sequencing revealed 92% homology to the YF virus strain Couma (Ethiopia), East African genotype. Suspected YF cases had fever (100%) and unexplained bleeding (97.8%), but jaundice was rare (11.6%). The overall attack rate was 13 cases/100000 population, and the attack rate was higher for males than females and increased with age. The index clusters were linked to economic activities undertaken by males around forests. CONCLUSIONS This was the largest YF outbreak ever reported in Uganda. The wide geographical case dispersion as well as the male and older age preponderance suggests transmission during the outbreak was largely sylvatic and related to occupational activities around forests.

Nodding syndrome—a new hypothesis and new direction for research

Nodding syndrome (NS) is an unexplained neurological illness that mainly affects children aged between 5 and 15 years. NS has so far been reported from South Sudan, northern Uganda, and Tanzania, but in spite of extensive investigations, the aetiology remains unknown. We hypothesize that blackflies (Diptera: Simuliidae) infected with Onchocerca volvulus microfilariae may also transmit another pathogen. This may be a novel neurotropic virus or an endosymbiont of the microfilariae, which causes not only NS, but also epilepsy without nodding. This hypothesis addresses many of the questions about NS that researchers have previously been unable to answer. An argument in favour of the hypothesis is the fact that in Uganda, the number of new NS cases decreased (with no new cases reported since 2013) after ivermectin coverage was increased and with the implementation of a programme of aerial spraying and larviciding of the large rivers where blackflies were breeding. If confirmed, our hypothesis will enable new strategies to control NS outbreaks.

New measles genotype, Uganda.

New measles virus genotype will increase epidemiologic and virologic surveillance in Africa.

Achieving measles control: lessons from the 2002–06 measles control strategy for Uganda

BACKGROUND The 2002-06 measles control strategy for Uganda was implemented to strengthen routine immunization, undertake large-scale catch-up and follow-up vaccination campaigns, and to initiate nationwide case-based, laboratory-backed measles surveillance. This study examines the impact of this strategy on the epidemiology of measles in Uganda, and the lessons learnt. METHODS Number of measles cases and routine measles vaccination coverage reported by each district were obtained from the National Health Management Information System reports of 1997 to 2007. The immunization coverage by district in a given year was calculated by dividing the number of children immunized by the projected population in the same age category. Annual measles incidence for each year was derived by dividing the number of cases in a year by the mid-year projected population. Commercial measles IgM enzyme-linked immunoassay kits were used to confirm measles cases. RESULTS Routine measles immunization coverage increased from 64% in 1997 to 90% in 2004, then stabilized around 87%. The 2003 national measles catch-up and 2006 follow-up campaigns reached 100% of children targeted with a measles supplemental dose. Over 80% coverage was also achieved with other child survival interventions. Case-based measles surveillance was rolled out nationwide to provide continuous epidemiological monitoring of measles occurrence. Following a 93% decline in measles incidence and no measles deaths, epidemic resurgence of measles occurred 3 years after a measles campaign targeting a wide age group, but no indigenous measles virus (D(10)) was isolated. Recurrence was delayed in regions where children were offered an early second opportunity for measles vaccination. CONCLUSION The integrated routine and campaign approach to providing a second opportunity for measles vaccination is effective in interrupting indigenous measles transmission and can be used to deliver other child survival interventions. Measles control can be sustained and the inter-epidemic interval lengthened by offering an early second opportunity for measles vaccination through other health delivery strategies.

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.

The design and implementation of the re-vitalised integrated disease surveillance and response (IDSR) in Uganda, 2013–2016

BackgroundUganda 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.MethodsThrough 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.ResultsThrough 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.ConclusionThe 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.