Visiting health centers as a risk factor for measles transmission: Kamwenge District, Uganda, April ­ July 2015

Introduction: Uganda has been implementing a one-dose measles vaccination at age 9 months in its national EPI schedule. On 27 April 2015, a measles outbreak, which was confirmed by serum positivity in several patients, occurred in Kamwenge District. Since then, the number of reported measles patients has increased despite the implementation of measures to control the outbreak by the local government. We investigated this outbreak to identify the risk factors for measles transmission, estimate vaccination coverage, determine vaccine effectiveness, and recommend control measures.Methods: we defined a probable case as onset in a Kamwenge District resident of fever and generalized rash from 16 April 2015 onward with ≥ 1 of the following: coryza, conjunctivitis, or cough. A confirmed case was a probable case with positive measles-specific IgM in patient serum. For case-finding we reviewed medical records and found patients in the community with the help of the village health team. We determined vaccination histories by vaccination cards or interviews. In a case-control study, we compared the exposure histories of 50 probable case-persons with 200 asymptomatic control-persons during case-persons' exposure period (i.e., between minimum and maximum incubation). We matched case- and control-persons by age and residence village. We estimated vaccination coverage for children aged ≤ 2 years based on the percent of control-children vaccinated. Results: we identified 213 probable/ confirmed cases from 3 affected sub-counties (attack rate = 5.1/10,000). The epidemic curve showed sustained community transmission. The case-control study showed that 42% (21/50) of case-persons and 12% (23/200) of control-persons visited health centers during case-persons' exposure period (AORM-H = 6.1; 95% CI = 2.7-14). Vaccination coverage among children aged ≤ 2 years was 58% (95% CI = 47-68%). The vaccine effectiveness was 80% (95% CI = 35-94%). We found that all health centers were crowded, with no triaging system to separate suspect measles patients from patients with other illnesses.Conclusion: exposures to measles patients at crowded health centers, low vaccination coverage, and suboptimal vaccine effectiveness facilitated measles transmission in this outbreak. We recommended an emergency immunization campaign targeting young children, triaging and isolating suspect measles patients at health centers, and introducing a second dose of measles vaccine in the immunization schedule

A community-wide cholera outbreak caused by drinking unsafe water: Kasese District, Western Uganda, February ­July 2015

Introduction: Kasese District is prone to cholera outbreaks and this was its third outbreak in 15 years. In May 2015, Kasese District reported a cholera outbreak that had lasted 3 months and caused >100 infections. A team from Ministry of Health set out to support the local response team in identifying the mode of transmission and informing control measures.Methods: we defined a suspected case as onset of acute watery diarrhoea from 1st February 2015 onward; a confirmed case was a suspect case with Vibrio cholerae cultured from a stool sample. We reviewed medical records for case finding and conducted a case-control study to compare the exposures of 49 confirmed cases with those of 201 asymptomatic controls, matched by village and age group. We conducted environmental assessments and tested water samples for faecal contamination.Results: we identified 183 suspected cases including 61 confirmed cases (serotype inaba) and 2 deaths from February to July. The outbreak occurred in 80 villages and affected all age groups; the highest attack rate occurred in persons aged 5-14 years (4.1/10,000). Stratified epidemic curves showed that the outbreak started in Bwera Sub-county bordering the Democratic Republic of Congo, and spread eastward. 94% (46/49) of cases compared with 75% (152/201) of controls drank water without boiling or treatment (ORM-H = 5.9; 95%CI = 1.6-22). The main water sources, public piped water (consumed by 39% of cases and 38% of controls) and stream water (consumed by 29% of cases and 24% controls), both had high levels of E. coli, a marker of faecal contamination. Environmental assessment revealed evidence of open defaecation along the streams. No food items were significantly associated with illness.Conclusion: drinking unsafe water contaminated by feces caused this outbreak. We recommended rigorous disposal of patients' feces, chlorination of piped water, and drinking boiled or treated water. The outbreak stopped 6 weeks after initiating implementation of these control measures

Malaria morbidity among children under 5 years of age: epidemic districts, Northern Uganda, July 2012 to June 2015

Introduction: a malaria epidemic has been confirmed in ten former IRS districts. Given the recent malaria control interventions, a sustained decline in the malaria cases would have been expected. Thus the need for a descriptive analysis on the trends in malaria morbidity in these districts among under 5yr olds for the past 3 financial years to help inform the Ministry of Health and predict future malaria epidemics. The objective of the analysis was to describe annual seasonal trends and peaks in prevalence in malaria morbidity among under 5yr olds over the past three financial years in former IRS districts. Describe the difference in incidence of malaria for the under 5yr olds among all the districts under study for the given period.Methods: a desk review of all under 5yr old malaria cases and malaria control interventions for the past three financial years in the given districts were conducted.Results: there are two malaria seasons each year from April to July and September to November which coincides with the rainy seasons. The peaks in prevalence for all the districts were in June 2015. For the past three financial years, 7/9 districts each had a higher malaria incidence than Lamwo district which has 100% coverage of iCCM (P < 0.001). Conclusion: the rainy seasons present an opportunity for malaria epidemics, iCCM seems to have an effect in reducing the incidence of malaria among under 5yr olds at health facilities. We recommended surveillance and monitoring of trends in malaria cases especially during the rainy season for early detection of epidemics; and assessment of the actual impact of iCCM on the reduction of malaria incidence

Risk factors for measles death during an outbreak: Kyegegwa District, Uganda

Introduction: on 18 August 2015, Kyegegwa District reported 8 deaths during a suspected measles outbreak. We investigated this cluster of deaths to verify the cause, identify risk factors, and inform public health interventions. Methods: we conducted active community case-finding to identify probable measles patients, defined as a Kyegegwa District resident with fever (> 39°C) and generalized rash during 1 February - 15 September, plus ≥ one of the following: coryza, conjunctivitis, and cough. A deceased measles case was defined as death to a probable measles patient. In a case-control study, we compared risk factors between 16 deceased measles cases and 48 probable measles patients who survived (i.e., controls), matched by age (± 4 years) and village of residence. Blood specimens from probable measles patients were tested for measles-specific IgM.Results: we identified 94 probable measles patients. Children aged < 5 years accounted for 68% (64/94) of probable measles patients and all 16 deaths (case fatality ratio = 25%, 16/64). In the case-control study, 63% (10/16) of deceased measles cases and 33% (16/48) of controls received no vitamin A supplementation during illness (ORM-H = 7.1; 95% CI = 1.3-37); 31% (5/16) of deceased measles cases and 2.1% (1/48) of controls were not treated according to guidelines (adjORML = 8; 95% CI = 80-8); 6.3% (1/16) of deceased measles cases and 46% (22/48) of controls were vaccinated against measles (adjORML = 0.0; 95% CI = 0.0-0.33). Of blood specimens collected from probable measles patients, 71% (10/14) were positive for measles-specific IgM.Conclusion: no vaccination, lack of vitamin A supplementation and inappropriate treatment increased risk for measles deaths. The one-dose measles vaccination currently in the national EPI schedule, although providing inadequate protection against infection, did protect against measles death. We recommended enhancing measles vaccination, providing universal vitamin A supplementation, and enforcing treatment guidelines

Factors affecting virological non-suppression amongst HIV-positive patients on antiretroviral therapy: Uganda, August 2014 - July 2015

Introduction: virological suppression is a critical indicator for HIV treatment success and reduction in HIV transmission risk. However, despite the increasing number of people on antiretroviral therapy (ART), there is limited information about non-suppression and its determinants among HIV-positive (HIV+) individuals enrolled in care in many resource-limited settings. This study estimated the virological non-suppression rates amongst HIV+ patients who had been on ART for at least 6 months and the factors associated with non-suppression. Methods: a descriptive cross-sectional study was conducted using routinely collected data from viral load testing samples from 100,678 HIV+ patients enrolled in HIV care across the country between August 2014 and July 2015. Viral load testing was conducted at the Central Public Health Laboratories in Kampala, Uganda. We extracted data on socio-demographic, clinical and viral load testing results. We defined virological non-suppression as having ≥ 1000 copies of viral RNA/ml of blood for plasma or ≥ 5000 copies of viral RNA/ml of blood for dry blood spots. We used logistic regression to identify factors associated with virological non-suppression. Results: majority of the patients (68%) were females. The overall non-suppression rate was 11%. Second-time testers had a higher non-suppression rate than first-time testers (50% vs. 10%, OR = 7.0, 95%CI = 6.2-7.9); and children aged < 5 years (29%, OR = 5.3, 95%CI = 4.8-6.0) and adolescents aged 15-19 (27%, OR = 4.1, 95%CI = 3.7-4.5) had higher non-suppression rates than persons of other age groups. Non-suppression rates were also higher among suspected treatment failures (29%, OR = 4.0, 95%CI = 3.7-4.4), patients with reported adherence levels < 85% (35%, OR = 3.4, 95%CI = 3.0-3.9), and patients with active TB (20%, OR = 2.0, 95%CI = 1.5-2.3) than those without these conditions. Breastfeeding (6%, OR = 0.61, 95%CI = 0.54-0.69) and pregnant women (8%, OR = 0.77, 95%CI = 0.65-0.91) had lower non-suppression rates than non-breastfeeding and non-pregnant women (10%). Conclusion: virological non-suppression was associated with second time testers, young age, poor adherence, and TB co-infection. To maximize the benefits of the expanded ART, we recommend close follow-up and intensified targeted adherence support for second time testers, children and adolescents. Adherence to standard guidelines for managing TB/HIV co-infections should be emphasized by all ART clinics

Malaria morbidity among under 5 children years of age: Epidemic Districts, Northern Uganda, July 2012 to June 2015

Introduction: a malaria epidemic has been confirmed in ten former IRS districts. Given the recent malaria control interventions, a sustained decline in the malaria cases would have been expected. Thus the need for a descriptive analysis on the trends in malaria morbidity in these districts among under 5yr olds for the past 3 financial years to help inform the Ministry of Health and predict future malaria epidemics. The objective of the analysis was to describe annual seasonal trends and peaks in prevalence in malaria morbidity among under 5yr olds over the past three financial years in former IRS districts. Describe the difference in incidence of malaria for the under 5yr olds among all the districts under study for the given period.Methods: a desk review of all under 5yr old malaria cases and malaria control interventions for the past three financial years in the given districts were conducted.Results: there are two malaria seasons each year from April to July and September to November which coincides with the rainy seasons. The peaks in prevalence for all the districts were in June 2015. For the past three financial years, 7/9 districts each had a higher malaria incidence than Lamwo district which has 100% coverage of iCCM (P < 0.001). Conclusion: the rainy seasons present an opportunity for malaria epidemics, iCCM seems to have an effect in reducing the incidence of malaria among under 5yr olds at health facilities. We recommended surveillance and monitoring of trends in malaria cases especially during the rainy season for early detection of epidemics; and assessment of the actual impact of iCCM on the reduction of malaria incidence

The burden of HIV/AIDS and uptake of services among adolescents/youths in Kasensero fishing community, Rakai District

Introduction: there is limited data on HIV burden and access to services among adolescents/youths in fishing communities in Uganda.Kasensero fishing community has an HIV prevalence of 41.0% and incidence of 3.9 per 100 person years. We assessed the burden of HIV and uptake of services among adolescents in Kasensero.Methods: we analyzed data collected between 2013-2014 among youths aged 15-24 in the Rakai Community Cohort Study. Social demographic, behavioral and risk characteristics were collected and blood taken for HIV diagnosis using rapid and enzyme-immunoassay (EIA) tests. Adolescents' characteristics in Kasensero were compared with those in two neighboring communities 4 and 12 kilometers apart. HIV prevalence and uptake of services was compared between communities using Chi square. Data was analyzed using Stata version 12.Results: of the 789 youth interviewed 155 (19.7%) were HIV positive. HIV prevalence was higher among females than males 112/431(26.0%) vs 43/358(12.0%)) and was highest in Kasensero fishing community (25.1%) than neighboring communities (11.0% an -d 3.9%). HIV prevalence among females in Kasensero was 34.7% compared to 8.7% and 4.7% in the neighboring communities (P < 0.001). Youths in Kasensero were more likely to be married or separated, 81.5% compared to 75.2% and 52.0% for females, and 42.0% compared to 25.9% and 11.4% for males. HIV prevalence was highest among youths who were bar-workers (64.3%), do housework in own home (36.9%), and trading and vending (43.0%). Consistent condom use was practiced by only 3.4% of the youths (6.4% Male; 1.3% Female). Only 27.7% of HIV positive females and 7.0% of males were on ART, and 44.8% of non-Muslim males were circumcised.Conclusion: HIV burden among youths in fishing communities is high especially among females yet uptake of prevention and care services is poor despite availability. There is need to provide youth friendly services in these MARPs

Trends of alcohol abuse using surveillance data from the Health Management Information System (HMIS) of Uganda

Introduction: Uganda has the highest alcohol per capita consumption in Africa. Surveillance data was analysed to describe trends in alcohol abuse by gender, identify districts with most cases and describe trends of annual rates by region.Methods: data was from HMIS 108 (inpatient), HMIS 105 (outpatient) forms. Total number of cases was acquired by summing age-aggregated cases by gender in both reports. Rates of alcohol abuse were acquired by dividing annual total cases by annual regional projected population.Results: 57897 cases were reported between 2010 and 2014. Most were males 72% (1963). There is a steady increase in reported cases. All regions show increases in cases reported, the highest being central, western, northern then eastern. Kampala, Kabale, Arua, Gulu, Wakiso reported most cases. Higher numbers among males might be because of a higher genetic risk for disorders. Men are more likely to exhibit risk factors of disorders such as impulsivity making diagnosis simpler. Additionally, biological and social consequences among women may be deterrents to alcohol use. Increasing numbers of cases might be because of social acceptability of alcohol and aggressive advertising. Current legislation limiting alcohol use covers only manufacture and sale, is weak and poorly enforced. High numbers in central region might be due to higher numbers of health centers and population density. Actual numbers are likely to be higher as people with alcohol abuse rarely seek for help. Findings are subject to epidemiological weaknesses: healthcare access bias, referral filter bias, mis classification bias.Conclusion: there is urgent need to address the increasing problem of alcohol abuse especially in central region. The national alcohol control policy should be completed and passed to address issues such as alcohol advertising, taxation and sale of alcohol to minors to limit access. Interventions to address alcohol abuse should be gender specific

Cholera outbreak caused by drinking lakeshore water contaminated by feces washed down from a hill-side residential area: Kaiso Village, Uganda

Introduction: cholera is a bacterial diarrheal disease caused by Vibrio cholerae. On 15 October 2015, a cholera outbreak involving dozens of cases and 2 deaths was reported in Kaiso, a lakeshore fishing village. The district health department responded by setting up a treatment center and sensitizing the community. Despite initial response, the outbreak persisted, prompting a detailed epidemiological investigation to identify the source and mode of transmission and recommend evidence-based interventions to stop the epidemic.Methods: we defined a suspected case as onset of acute watery diarrhoea in a Kaiso Village resident from 1st October 2015 onward; a confirmed case was a suspected case with Vibrio cholerae isolated from stool. We performed descriptive epidemiology to generate a hypothesis, and conducted a case-control study to compare exposure histories of 61 cases and 126 controls randomly selected among village residents (age ≥ 4 years in both groups). We conducted environmental assessment and obtained meteorological data from a local weather station.Results: 123 suspected cases (2 deaths) were line-listed at the village's cholera clinic. The initial 2 deceased cases had onset on 2nd and 10th October. Heavy rainfall occurred during 7­11th October, setting in a point-source outbreak which started on 12th and peaked on 13th October. Three water collection points (WCP) A, B and C were associated with the outbreak. 9.8% (6/61) of case-persons and 31% (39/126) of control-persons usually collected water from WCP A. In comparison, 21% (13/61) of case-persons and 37% (46/126) of control-persons usually collected water from WCP B (OR = 1.8, 95%CI: 0.64-5.3) and 69% (42/61) of case-persons and 33% (41/126) of control-persons from WCP C (OR = 6.7; 95%CI = 2.5-17). 100% (61/61) of case-persons and 93% (117/126) of control-persons never treated/boiled drinking water (OR = ∞, 95%CIFisher = 1.0-∞). A gully channel from a hillside open defecation area washed down feces to the lakeshore at WCP C.Conclusion: this outbreak was caused by drinking lakeshore water contaminated by feces washed down a gully from the village. We recommended water boiling and treatment, fixing the broken piped-water system, and constructing latrines. The outbreak was stopped by implementing treatment and boiling of drinking water at household level

Risk factors for Podoconiosis: Kamwenge District, Western Uganda, 2015

Introduction: Podoconiosis, a form of non-infectious elephantiasis, is a disabling Neglected Tropical Disease. In August 2015, a non-government organization reported an increase in elephantiasis cases in Kamwenge District. We conducted an investigation to confirm the diagnosis, identify causes and risk factors, and guide control efforts. Methods: we defined a suspect case-person as a Kamwenge resident with bilateral asymmetrical swelling of lower limbs lasting ≥ 1month, plus ≥ 1 of the following: skin itching; burning sensation; plantar oedema; lymph-ooze; prominent skin markings; rigid toes; mossy papillomata. A probable case was a suspect case with negative microfilaria antigen immunological-card test results. We conducted active case-finding in affected communities. In a case-control study we compared shoe-use and feet-washing practices before disease onset among 40 probable case-persons and 75 asymptomatic village control-persons, matched by age (± 5y) and sex. We collected soil samples to characterize soil-irritant composition. Results: our active case-finding identified 52 suspect cases in two affected sub-counties during 1980-2015 (incidence = 2.9/100,000/year), including 40 probable cases (mean age = 47y; range: 13-80y). The annual case counts did not increase significantly over time. All case-persons had negative immunological-card test. In the case-control study, 93% (37/40) of probable case-persons and 31% (23/75) of controls-persons never wore shoes at work (ORM-H = 6.7; 95%CI = 1.7-26); 80% (32/40) of probable case-persons and 55% (39/75) of control-persons never wore shoes at home (ORM-H = 4.4, 95%CI = 1.5-13); 70% (27/39) of probable case-persons and 47% (34/72) of control-persons washed feet at day-end rather than immediately after work (OR = 11, 95%CI = 2.1-57). Soils samples were characterized as being rich black-red volcanic clay. Conclusion: the reported elephantiasis was podoconiosis, which was associated with prolonged foot exposure to volcanic soil. We recommended health education on foot protection and washing, and universal use of protective shoes