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.

Time to care and factors influencing appropriate Sudan virus disease care among case patients in Uganda, September to November 2022.

OBJECTIVES: Early isolation and care for Ebola disease patients at Ebola Treatment Units (ETU) curb outbreak spread. We evaluated time to ETU entry and associated factors during the 2022 Sudan virus disease (SVD) outbreak in Uganda. METHODS: We included persons with RT-PCR-confirmed SVD with onset September 20-November 30, 2022. We categorized days from symptom onset to ETU entry ("delays") as short (≤2), moderate (3-5), and long (≥6); the latter two were "delayed isolation." We categorized symptom onset timing as "earlier" or "later," using October 15 as a cut-off. We assessed demographics, symptom onset timing, and awareness of contact status as predictors for delayed isolation. We explored reasons for early vs late isolation using key informant interviews. RESULTS: Among 118 case-patients, 25 (21%) had short, 43 (36%) moderate, and 50 (43%) long delays. Seventy-five (64%) had symptom onset later in the outbreak. Earlier symptom onset increased risk of delayed isolation (crude risk ratio = 1.8, 95% confidence interval (1.2-2.8]). Awareness of contact status and SVD symptoms, and belief that early treatment-seeking was lifesaving facilitated early care-seeking. Patients with long delays reported fear of ETUs and lack of transport as contributors. CONCLUSION: Delayed isolation was common early in the outbreak. Strong contact tracing and community engagement could expedite presentation to ETUs.

Investigation of COVID-19 outbreak at a refugee transit centre, Kisoro District, Uganda, June-July 2022.

Due to conflict in the Democratic Republic of Congo (DRC), approximately 34,000 persons arrived at Nyakabande Transit Centre (NTC) between March and June 2022. On June 12, 2022, Kisoro District reported >330 cases of COVID-19 among NTC residents. We investigated the outbreak to assess its magnitude, identify risk factors, and recommend control measures. We defined a confirmed case as a positive SARS-CoV-2 antigen test in an NTC resident during March 1-June 30, 2022. We generated a line list through medical record reviews and interviews with residents and health workers. We assessed the setting to understand possible infection mechanisms. In a case-control study, we compared exposures between cases (persons staying ≥5 days at NTC between June 26 and July 16, 2022, with a negative COVID-19 test at NTC entry and a positive test at exit) and unmatched controls (persons with a negative COVID-19 test at both entry and exit who stayed ≥5 days at NTC during the same period). We used multivariable logistic regression to identify factors associated with contracting COVID-19. Among 380 case-persons, 206 (54.2%) were male, with a mean age of 19.3 years (SD = 12.6); none died. The attack rate was higher among exiting persons (3.8%) than entering persons (0.6%) (p<0.01). Among 42 cases and 127 controls, close contact with symptomatic persons (aOR = 9.6; 95%CI = 3.1-30) increased the odds of infection; using a facemask (aOR = 0.06; 95% CI = 0.02-0.17) was protective. We observed overcrowding in shelters, poor ventilation, and most refugees not wearing face masks. The COVID-19 outbreak at NTC was facilitated by overcrowding and suboptimal use of facemasks. Enforcing facemask use and expanding shelter space could reduce the risk of future outbreaks. The collaborative efforts resulted in successful health sensitization and expanding the distribution of facemasks and shelter space. Promoting facemask use through refugee-led efforts is a viable strategy.

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.

Measles outbreak in Semuto Subcounty, Nakaseke District, Uganda, June-August 2021.

Background: Semuto Subcounty reported rubella/measles outbreaks in January 2020 and June-August 2021. This study investigated the outbreak in 2021 to determine the scope, and the factors associated with transmission. Methods: A probable case was defined as a resident of Semuto Subcounty with acute onset of fever and a generalized maculopapular rash with either cough/cold or red eyes from 1 June to 31 August 2021. A confirmed case was defined as a probable case with a blood sample positive for measles-specific IgM. A village-matched case-control study was conducted with 30 cases and 122 controls (1:4 ratio). A control was defined as an individual aged 6 months-9 years, sampled at random, with no signs or symptoms of measles from 1 June to 31 August 2021, residing in the same village as the matched case. Adjusted Mantel-Haenszel odds ratios (ORMH) and confidence intervals (CIs) were calculated. Results: Of the 30 cases (27 probable and three confirmed), 16 (53%) were male. The subcounty attack rate (AR) was 3.2/1000. Children aged 5-9 years were the most affected (AR 5.0/1000). Twenty-two (79%) cases and 116 (97%) controls had ever received measles vaccine (ORMH 0.13, 95% CI 0.03-0.52). Interaction with symptomatic persons at water collection points (ORMH 4.4, 95% CI 1.6-12) and playing at community playgrounds (ORMH 4.2, 95% CI 1.7-11) increased the odds of infection. Conclusions: Socializing/congregating at water collection points and community playgrounds facilitated the transmission of measles in this outbreak.

Large outbreak of Jimsonweed (Datura stramonium) poisoning due to consumption of contaminated humanitarian relief food: Uganda, March-April 2019.

BACKGROUND: Jimsonweed (Datura stramonium) contains toxic alkaloids that cause gastrointestinal and central nervous system symptoms when ingested. This can be lethal at high doses. The plant may grow together with leguminous crops, mixing with them during harvesting. On 13 March 2019, more than 200 case-patients were admitted to multiple health centres for acute gastrointestinal and neurologic symptoms. We investigated to determine the cause and magnitude of the outbreak and recommended evidence-based control and prevention measures. METHODS: We defined a suspected case as sudden onset of confusion, dizziness, convulsions, hallucinations, diarrhoea, or vomiting with no other medically plausible explanations in a resident of Napak or Amudat District from 1 March-30 April 2019. We reviewed medical records and canvassed all villages of the eight affected subcounties to identify cases. In a retrospective cohort study conducted in 17 villages that reported the earliest cases, we interviewed 211 residents about dietary history during 11-15 March. We used modified Poisson regression to assess suspected food exposures. Food samples underwent chemical (heavy metals, chemical contaminants, and toxins), proteomic, DNA, and microbiological testing in one national and three international laboratories. RESULTS: We identified 293 suspected cases; five (1.7%) died. Symptoms included confusion (62%), dizziness (38%), diarrhoea (22%), nausea/vomiting (18%), convulsions (12%), and hallucinations (8%). The outbreak started on 12 March, 2-12 h after Batch X of fortified corn-soy blend (CSB +) was distributed. In the retrospective cohort study, 66% of 134 persons who ate CSB + , compared with 2.2% of 75 who did not developed illness (RRadj = 22, 95% CI = 6.0-81). Samples of Batch X distributed 11-15 March contained 14 tropane alkaloids, including atropine (25-50 ppm) and scopolamine (1-10 ppm). Proteins of Solanaceae seeds and Jimsonweed DNA were identified. No other significant laboratory findings were observed. CONCLUSION: This was the largest documented outbreak caused by food contamination with tropane alkaloids. Implicated food was immediately withdrawn. Routine food safety and quality checks could prevent future outbreaks.

Patterns of wasting among pregnant and lactating women in Uganda, 2015-2018: analysis of Nutrition surveillance data.

BACKGROUND: Maternal nutrition is closely linked to the survival and development of children during the first 1000 days of life. Maternal wasting, a measure of malnutrition, is measured using the mid-upper arm circumference. However, in 2019, the rate and distribution of wasting among pregnant and lactating women was not known. We described annual trends and distribution of wasting among pregnant and lactating women (PLW), Uganda, 2015-2018, to inform programming on targeted nutritional interventions. METHODS: We analyzed nutrition surveillance data from the District Health Information System for all PLW from 2015 to 2018. We used the World Health Organization standard thresholds to determine wasting among PLW by year and region, drawing choropleth maps to demonstrate the geographic distribution of wasting among PLW. We used logistic regression to assess wasting trends. RESULTS: During 2015-2018, 268,636 PLW were wasted (prevalence = 5.5%). Of the 15 regions of Uganda, Karamoja (prevalence = 21%) and Lango (prevalence = 17%) registered the highest prevalence while Toro (prevalence = 2.7%) and Kigezi (prevalence = 2.0%) registered the lowest prevalence. The national annual prevalence of wasting among PLW declined by 31% from 2015 to 2018 (OR = 0.69, p < 0.001). Regions in the north had increasing trends of wasting over the period [Lango (OR = 1.6, p < 0.001) and Acholi (OR = 1.2, p < 0.001)], as did regions in the east [(Bugisu (OR = 3.4, p < 0.001), Bukedi (OR = 1.4, p < 0.001), and Busoga (OR = 1.3, p < 0.001)]. The other 11 regions showed declines. CONCLUSION: The trend of wasting among PLW nationally declined during the study period. Lango and Acholi regions, both of which were experiencing a nutrition state of emergency during this period, had both high and rising rates of wasting, as did the Karamoja region, which experienced the highest wasting rates. We recommended that the Ministry of Health increases its focus on nutrition monitoring for PLW and conduct an analysis to clearly identify the factors underlying malnutrition specific for PLW in these regions.

The yield of HIV testing during pregnancy and postnatal period, Uganda, 2015-2018: analysis of surveillance data.

BACKGROUND: Uganda has registered a reduction in new HIV infections among children in recent years. However, mother-to-child transmission of HIV still occurs, especially among pregnant women who present late. To eliminate this transmission, all HIV-positive pregnant women should be identified during antenatal HIV testing. We described women newly identified HIV-positive during pregnancy and postnatal period 2015-2018. METHODS: We extracted surveillance data for women identified as HIV-positive during pregnancy and the postnatal period reported through the Health Management Information System from 2015-2018. We calculated proportions newly positive at antenatal, labor, and postnatal periods nationally and at district levels. We disaggregated data into 'tested early' (during antenatal care) and 'tested late' (during labor or postnatal period) and calculated the proportion positive. We evaluated trends in these parameters at national and district levels. RESULTS: Overall, 8,485,854 mothers were tested for HIV during this period. Of these, 2.4% tested HIV-positive for the first time. While the total number of mothers tested increased from 1,327,022 in 2015 to 2,514,212 in 2018, the proportion testing HIV-positive decreased from 3.0% in 2015 to 1.7% in 2018 (43% decline over the study period, p < 0.001). Of 6,781,047 tested early, 2.2% tested HIV-positive. The proportion positive among those tested early dropped from 2.5% in 2015 to 1.7% in 2018. Of 1,704,807 tested late, 3.2% tested HIV-positive. The proportion positive among those tested late dropped from 5.2% in 2015 to 1.6% in 2018. At the district level, Kalangala District had the highest proportion testing positive at 13% (909/11,312) in 2015; this dropped to 5.2% (169/3278) in 2018. CONCLUSION: The proportion of women newly testing HIV-positive during pregnancy and postnatal declined significantly during 2015-2018. A higher proportion of mothers who tested late vs early were HIV-positive. Failure to identify HIV early represents an increased risk of transmission. Ministry of Health should strengthen Elimination of Mother to Child Transmission (eMTCT) services to sustain this decrease through targeted interventions for poorly-performing districts. It should strengthen community-based health education on antenatal care and HIV testing and enhance the implementation of other primary prevention strategies targeting adolescents and young women.