The potential for the double risk of rabies and antimicrobial resistance in a high rabies endemic setting: detection of antibiotic resistance in bacterial isolates from infected dog bite wounds in Uganda.

BACKGROUND: Post-exposure treatment for dog bites in humans aims at alleviating the risk of rabies and promoting wound healing. Wound healing may be complicated by bacteria. This study identified the different bacteria and their antibiotic susceptibilities in infected dog bite wounds (DBWs) in Uganda. METHODS: A cross-sectional study was conducted among 376 dog bite patients. Wound swabs from patients with infected DBWs were collected and inoculated into recommended media. They were cultured for both aerobic and anaerobic bacteria. All isolated bacteria were identified based on colony characteristics, gram stain, and standard biochemical tests. Molecular identification was performed for strains that were resistant to three or more antibiotics. Antibiotic susceptibility testing was conducted using the disc diffusion method following the modified Kirby-Bauer method. The data were analysed using Stata version 15 software. RESULTS: Approximately half of the patients (52.9%, 199/376) presented with infected wounds. Majority of the swabs (84.4%, 168/199) were culture positive, and yielded a total of 768 isolates where about half (52.9%, 406/768) were gram positive bacteria, and about two-thirds (64.6%, 496/768) were recovered from category II wounds. Among the gram positive bacteria, 339 (83.5%) were aerobes where Staphylococcus aureus (103, 30.4%), Coagulase-negative staphylococci (68, 20.1%), and Corynebacterium spp (33, 9.7%) had the highest prevalence. For the 362 Gram negative isolates, 217 (59.9%) were aerobes and the commonest isolates were P. maltocida (64, 29.5%), Capnocytophaga canimorsus (36, 16.6%) and P. canis (26, 12.0%). Gram-positive isolates were resistant to metronidazole (93.6%), oxacillin (68.5%), ceftriaxone (14.6%) and amoxicillin/clavulanic acid (14.0%). Gram negative isolates were resistant to metronidazole (100%), ampicillin (30.7%), oxacillin (29.3%), and doxycycline (22.9%). Multidrug resistance was in 105 (29.0%) and 121/406 (29.8%) of the gram-negative and gram-positive isolates, respectively. All gram-positive isolates were susceptible to vancomycin and ciprofloxacin. CONCLUSIONS: Infection rates of DBWs in Uganda are high and the dominant bacterial isolates are Staphylococcus aureus, Pasteurella spps, and Capnocytophaga canimorsus. Multidrug resistance to commonly used antibiotics is high. The recommendation in the Uganda Clinical Guidelines to use metronidazole in the management of DBWs should be reviewed. DBWs should be enlisted for routine antimicrobial resistance surveillance and rational use of antimicrobial agents should be promoted.

"As long as the patient tells you it was a dog that bit him, why do you need to know more?" A qualitative study of how healthcare workers apply clinical guidelines to treat dog bite injuries in selected hospitals in Uganda.

Dog-mediated rabies is on the increase in Uganda despite the availability of post-exposure prophylaxis (PEP). PEP procedures are expounded in the Uganda Clinical Guidelines (UCG) of 2016. We assessed adherence by health workers to UCG while managing dog bites in two PEP centers and obtained insights into motivations of their practices. Using qualitative methods, we observed the health worker-patient encounters, reviewed medical records, and interviewed 14 health workers that were involved in managing dog bite injuries. We used deductive thematic analysis to identify codes in themes developed from UCG. We found that much of the history of the bites was taken, but it was neither verified nor written down on the patient's file. Classification of wounds was inaccurate and ancillary laboratory assessments like culture and sensitivity tests were not conducted in all cases. Although antibiotics were given for both treatment and prophylactic purposes, the prescription was based on availability and affordability, not UCG recommendations. Rabies immunoglobulin (RIG) was not administered to deserving patients due to unavailability and high costs to the patient. Anti-rabies vaccine (ARV) was prescribed indiscriminately and some health workers attributed this to pressure from patients. Health education regarding prevention of dog bites was not given to patients due to time constraints on the side of the providers as a result of high caseloads at the emergency departments. Challenges to adherence to guidelines were identified as frequent ARV stock outs; inadequate cooperation among health facilities; and insufficient knowledge and skills on how injuries and rabies should be managed. We conclude that clinical management of dog bites is not fully in line with UCG. We argue that adoption of an integrated bite case management and cost-saving strategies as well as continuing medical education programs on rabies control and management could improve the clinical management of dog bites.

Knowledge, perceptions and effects of Ebola virus disease outbreak on the pig value chain in the agro-pastoralist district of Luwero, Central Uganda.

BACKGROUND: Ebola Virus Disease (EVD) outbreaks have a significant impact on the health and wellbeing, and livelihoods of communities. EVD response interventions particularly affect the food value chain, and income security of pig farmers in agro-pastoral communities. Despite the enormous effort of EVD response interventions, there is paucity of information towards EVD among those involved in the pig value chain, as well as the effect of EVD outbreaks on the pig value chain. This study therefore, assessed the knowledge, perceptions on the occurrence of Ebola and its effects on the pig value chain in the agro-pastoral district of Luweero, Central Uganda. METHODS: A cross sectional study was conducted in two parishes of Ssambwe and Ngalonkulu, Luwero district. A total of 229 respondents were included in the study. Structured questionnaires, key informant interviews and focus group discussions were conducted to collect data. Quantitative data was analysed using SPSS version 22 while qualitative data was analysed using thematic content analysis. RESULTS: Of the 229 respondents, 95.6% could recall the occurrence of the last EVD outbreak in their locality. About 24.5% associated EVD with touching pigs or eating pork. Regarding knowledge, 194 (84.7%) correctly associated EVD with handling Ebola infected persons, 191 (83.4%) with migration of people from endemic areas, 148 (64.9%) eating monkey meat, 127 (55.5%) with eating bats, and 198 (64.9%) with conducting public meetings where there is an Ebola infected person. Out of 142 farmers, 55 (38.7%) believed that Ebola outbreaks affected demand and sale of pigs. The EVD outbreak significantly led to a reduction in the average number of pigs sold (P = 0.001), the average number of pigs bought by traders (P = 0.04), and the number of pigs sold/ slaughtered by butcher men at pork eating places (P = 0.03). CONCLUSION: This study showed that EVD outbreak negatively affected the pig value chain i.e., the demand and supply of pigs and pork. Therefore, there is need to sensitize the stakeholders in the pig value chain on EVD in order to minimize the negative economic impacts associated with EVD outbreaks.

Delays in initiating rabies post-exposure prophylaxis among dog bite victims in Wakiso and Kampala districts, Uganda.

Background   Although rabies in dog bite patients is preventable through timely initiation of post-exposure prophylaxis (PEP), a number of barriers to achieving PEP exist. This study investigated the delays to initiation of PEP among dog bite patients in the emergency departments of two PEP centers in Uganda. Methods A cross-sectional study was conducted among dog-bite patients that presented to two selected rabies PEP centers. A semi-structured questionnaire was used to collect data. Delay to receive PEP was defined as reporting for PEP beyond 24 hours after the bite event. Generalized linear models were used to calculate prevalence ratios and the 95% confidence intervals as a measure of association between delay and patient factors. Results Out of 376 participants, just over half (53.5%) were males. The majority of participants (54.0%) were 15 years or older and 28.5% had no formal education. Just over three-quarters (77.9%) had category II dog bite wounds. Nearly 40% delayed to receive PEP, and median (inter quartile range) lag time between bite event and seeking medical care of 18 (41) hours. Compared to education level of secondary or above, patients with no formal education (adj. PR=4.06, 95% CI: 2.69 -  6.10) or primary education (adj.PR=2.15, 95% CI: 1.37 -  3.35), belonging to the lowest socio-economic tertile as compared to the highest (adj.PR=1.58, 95% CI: 1.10 - 2.28), knowing the owner of the biting dog (adj.PR=1.30, 95% CI: 1.02 - 1.65) and having category II wounds (adj.PR=2.31, 95% CI: 1.43 - 3.71) were all associated with delayed presentation for PEP. Conclusions and recommendations Delays to receive PEP are common and are associated with poor level of education or low socio-economic status, knowledge of who the dog owner is and less severity of bite wounds. Seeking care irrespective of wound severity or knowledge of dog owner should be promoted.

Epidemiology and preclinical management of dog bites among humans in Wakiso and Kampala districts, Uganda: Implications for prevention of dog bites and rabies.

In rabies endemic areas, appropriate management of dog bites is critical in human rabies prevention. Victims must immediately wash bite wound for 15 minutes with water, soap, and a disinfectant before seeking medical care. This study investigated the epidemiology of dog bites and the determinants of compliance to these pre-clinical guidelines requirements among dog bite victims from high rabies-burden areas of Wakiso and Kampala, Uganda. An explanatory sequential mixed-methods study design was used. Quantitative data were collected from 376 dog-bite patients at two healthcare facilities. Qualitative data were also collected through 13 in-depth interviews with patients, healthcare workers, herbalists, and veterinarians. Qualitative data were analyzed using a deductive thematic approach. Generalized linear models were used to determine factors associated with compliance. Nearly half (190, 51%) of the patients were from Wakiso District and 293 (77.9%) had grade II wounds. Most of the wounds (171, 45.5%) were on the legs. Two-thirds of the bites occurred in public places. Only 70 (19%) of the bite patients had complied with pre-clinical guidelines. Nearly half of the patients had applied substances that were not recommended e.g. herbs (47/193), antiseptics (46/193), "black stone" (25/193), and unknown creams (10/193). Factors negatively associated with compliance included: being aged 15 years or older, adjPR = 0.70 (0.47-0.92) and knowing the dog owner, adjPR = 0.65 (0.36-0.93). However, attainment of secondary or higher education, adjPR = 1.76 (1.24-3.79), being in employment, adjPR = 1.48 (1.09-2.31), perception that the dog was sick, adjPR = 1.47 (1.02-2.72) and knowledge about the dog's subsequent victim(s) adjPR = 0.35 (0.17-0.70) were positively associated with compliance. High occurrence of dog bites in public places by free-roaming dogs suggests the need for deliberate promotion of responsible dog ownership. Additionally, targeted health education may be required to improve the low compliance to pre-clinical guidelines.

Seroprevalence of brucellosis and risk factors associated with its seropositivity in cattle, goats and humans in Iganga District, Uganda.

INTRODUCTION: The burden of brucellosis among smallholder farmers is poorly-documented in Uganda. The disease burden is likely to be high, given the high levels of endemicity, lots of exposures and due to lack of control measures. In order to designate appropriate control measures, the magnitude and risk factors for brucellosis need to be known. We established the burden of and risk factors for Brucella seropositivity in cattle, goats, and humans in Iganga district, eastern Uganda. METHODS: A cross-sectional study was conducted in in Kigulamo Parish, Iganga District. We enrolled 226 households and administered a structured questionnaire to heads of households to capture data on socio-demographic characteristics, human brucellosis-related risk factors, and livestock farming practices. Human, cattle, and goat blood samples were collected and tested serologically using commercial indirect-ELISA kits manufactured by USDA, USA. RESULTS: Of 451 human blood samples, 20 (4.4%) were positive. Among 345 cattle blood samples, 4 (1.2%) were positive and among 351 goat blood samples, one (0.3%) was positive. Persons who reported consuming locally-made dairy products had 4 times higher odds of Brucella seropositivity (OR = 4.0, CI = 1.14-14.03, p = 0.031) than those who did not. None of the risk factors we asked about were significantly associated with seropositivity in cattle and goats. CONCLUSION: The seroprevalence of brucellosis in humans in smallholder households in Kigulamo was relatively low and associated with consumption of locally made dairy products. No risk factors were significantly associated with seropositivity in livestock, likely due to the small number of seropositive animals. We recommend a One Health approach to control brucellosis simultaneously in animals and humans needed to sustainably reduce the burden of brucellosis in Uganda and beyond.

Inorganic pollutants in edible grasshoppers (Ruspolia nitidula) of Uganda and their major public health implications.

BACKGROUND: Inorganic contamination of food products is associated with adverse health effects, however, information on grasshoppers in Africa is sparse. The objective of the study was to determine antioxidant, heavy metal and food safety status of edible grasshoppers of Uganda. METHODS: A cross-sectional study was conducted in central and southwestern Uganda, in which a questionnaire was administered to grasshopper harvesters. Grasshopper samples were collected from each harvesting point and analyzed in the laboratory for antioxidant and heavy metal content i.e. Lead (Pb), Chromium (Cr), Zinc (Zn) and Cadmium (Cd) using atomic absorbance spectrometric (AAS) method on the heads and abdomen of the insects. RESULTS: Major antioxidants were Catalase > Glutathione > Glutathione peroxidase. In addition concentrations of heavy metals were in the order of Pb > Cr > Zn > Cd in the heads and abdomens of the grasshoppers. Pb concentrations were found to be higher in the heads than the abdomens and the carcinogenic potential of the grasshoppers was over 10 times over the recommended levels. Grasshoppers were found not to be safe especially in children due to their small body weight in comparison to adults. CONCLUSION: Pb poisoning in the Ugandan children would be propagated through contaminated grasshoppers.

Sero-prevalence and associated risk factors of Brucellosis among Malaria negative febrile out-patients in Wakiso district, Central Uganda.

OBJECTIVE: Brucellosis is a zoonotic disease usually acquired through direct contact with the infected animals and consumption of contaminated milk and meat products. In humans Brucellosis presents similar signs with other febrile diseases like Malaria, typhoid and other febrile conditions. This study was carried out to determine the prevalence of Brucella abortus among patients with fever but were negative for Malaria. RESULTS: A cross-sectional study was carried out in Namayumba Health Centre IV, Wakiso district involving 200 participants. Blood samples was screened for B. abortus using Serum Agglutination Test and confirmed with Tube Agglutination test. A questionnaire was used to collect data on socio-demographic characteristics and human Brucellosis related risk factors. Human B. abortus sero-prevalence was at 7.5% (n = 200). The prevalence was high among participants aged 18-35 years (13.3%), muslims 12 (14.0%), those with no formal education (33.3%) and divorced 2 (14.3%). Consuming of raw milk (OR 2.162, 95% CI 0.021-1.379) and being a Muslim (OR 6.101, 95% CI 1.601-23.248) were associated with increased risk of Brucella abortus. It was concluded that human Brucella infection due to Brucella abortus is commonly associated with consumers of raw milk products and muslims in Wakiso district.

Phylogenetic Groups and Antimicrobial Susceptibility Patterns of Escherichia coli from Healthy Chicken in Eastern and Central Uganda.

Antimicrobial resistance is an emerging problem in both humans and animals due to misuse and excessive use of drugs. Resistance in commensal E. coli isolates can be used to predict emergence of resistance in other gut microflora. The aim of this study is to determine the phylogenetic groups and antimicrobial resistance patterns of E. coli from healthy chickens in Uganda. The phylogenetic grouping of 120 fecal E. coli isolates from eastern and central Uganda was derived using the triplex PCR assay and their susceptibility patterns determined by agar disc diffusion method to 5 antimicrobial drugs. Most E. coli is segregated into phylogenetic group A comprising 84%, while 12% and 4% were in groups D and B1, respectively. Similarly most E. coli from central (87%) and eastern Uganda (82%) belonged to group A. Overall, 85 (70%) of E. coli were resistant to antimicrobial drugs, of which 72/101 (70%) are in PG A, 10 of 14 (71.4%) in PG D, and 3 of 5 (60%) in PG B1. Significantly, most of the isolates in PG A from both central (66.7%) and (60.6%) eastern Uganda were resistant to one antimicrobial. Resistance to tetracycline alone or in combination with other drugs for central and eastern Uganda in PG A is 51% and 55%, respectively. Multidrug resistance to tetracycline and ciprofloxacin or nalidixic acid was 10% and 18% in isolates from central and 10% and 12% in isolates from eastern region, respectively. Phylogenetic group A accounts for most of the E. coli in chicken from Uganda. No difference in the resistance rates between the phylogenetic groups of E. coli has been observed. The high prevalence of resistant E. coli strains from different phylogenetic groups in healthy chickens suggests antimicrobial drug selection pressure due to excessive drug in the rearing layer chickens.

Assessing short evolution brucellosis in a highly brucella endemic cattle keeping population of Western Uganda: a complementary use of Rose Bengal test and IgM rapid diagnostic test.

BACKGROUND: Brucellosis is a worldwide and zoonotic disease often sadly misdiagnosed in endemic areas. Challenges of availability and accessibility of diagnostic tools are common in resource constrained populations where the most vulnerable are found, surveillance and diagnosis are limited too. METHODS: A cross-sectional study using a simple two stage cluster sampling method was conducted to measure short evolution brucellosis burden among cattle keeping households that are one of the highest risk populations to be exposed to Brucella infection. A total of 216 households were randomly selected from 18 rural villages from the Western Region of Uganda. Household blood samples were tested for Brucella antibodies using the highly sensitive Rose Bengal test (RBT) and IgM ELISA Lateral Flow Assay (LFA). RESULTS: Among the total tested population, 58.8% did not react with any of the tests, 13.4% reacted with both tests. Among those that reacted with both (N = 29), 62.1% had weak (+ 1) LFA staining, 34.5% had moderate (2+) LFA staining. Altogether, both weak and moderate staining (96.5%) are consistent with sub-acute disease, while only one (3.4%) had strong (3+) LFA staining consistent with acute infection. 19.4% of the samples tested positive only with RBT, consistent with chronic infection, eighteen samples (8.3%) reacted exclusively with IgM LFA. CONCLUSION: We identified a high prevalence of short evolution brucellosis in the cattle keeping household members. Prevalence of chronic infection diagnosed with RBT only was higher than the prevalence of short evolution brucellosis. IgM LFA results depict possible cases of cross reaction with Salmonella spp., Plasmodium etc. Ultimately, we identified a consistent prevalence of short evolution brucellosis in the cattle keeping household members. Indeed, the use of a combined diagnostic with LFA and RBT is easy and amenable for an active disease surveillance and accurate diagnosis in rural settings.

Molecular Characterization of Salmonella from Human and Animal Origins in Uganda.

Sporadic Salmonella outbreaks with varying clinical presentations have been on the rise in various parts of Uganda. The sources of outbreaks and factors underlying the different clinical manifestation are curtailed by paucity of information on Salmonella genotypes and the associated virulence genes. This study reports molecular diversity of Salmonella enterica and their genetic virulence profiles among human and animal isolates. Characterization was done using Kauffman-White classification scheme and virulence genes analysis using multiplex PCR. Overall, 52% of the isolates belonged to serogroup D, 16% to serogroup E, 15% to poly F, H-S, and 12% to serogroup B. Serogroups A, C1, and C2 each consisted of only one isolate representing 5%. Virulence genes located on SPI-1 [spaN and sipB] and on SPI-2 [spiA] in addition to pagC and msgA were equally distributed in isolates obtained from all sources. Plasmid encoded virulence gene spvB was found in <5% of isolates from both human epidemic and animal origins whereas it occurred in 80% of clinical isolates. This study reveals that serogroup D is the predominant Salmonella serogroup in circulation and it is widely shared among animals and humans and calls for joint and coordinated surveillance for one health implementation in Uganda.

Human brucellosis: sero-prevalence and associated risk factors in agro-pastoral communities of Kiboga District, Central Uganda.

BACKGROUND: Brucellosis remains a neglected zoonotic disease among agro-pastoral communities where unprocessed milk and milk products are consumed. A cross-sectional study was carried out in Kiboga district to determine the seroprevalence and risk factors associated with human brucellosis in communities where livestock rearing in a common practice. METHODS: A total of 235 participants were involved in the study. Blood samples from the participants were collected and screened for Brucella using Serum Agglutination Test and Rose Bengal Plate Test. A questionnaire was used to collect data on socio-demographic characteristics and human brucellosis related risk factors. RESULTS: Human Brucella seroprevalence was at 17.0 % (n = 235). The prevalence was highest among males (20.5 %, n = 78) and the elderly - above 60 years (22.2 %, n = 18). Residence in rural areas (OR 3.16, 95 % CI: 1.16-8.56), consuming locally processed milk products (OR 2.54, 95 % CI: 1.12-5.78) and being single (OR 2.44, 95 % CI: 1.05-5.68), were associated with increased risk of brucellosis. DISCUSSION: Human brucellosis seroprevalence was high at 17 %, this was parallel with animal brucellosis prevalence that has been reported to range from 10.2 % to 25.7 % in cattle in the region. The participants were from communities known to habitually consume raw milk and milk products, know to process milk products using bare hands which are major risk factors for brucellosis in humans. This also explains why consumption of unpasteurized milk products was associated with the occurrence of brucellosis in study area. This strengthened the argument that humans get infected through consumption of contaminated animal products as reported in other earlier studies. Males and elderly being more affected because of traditional roles of these groups they play in livestock care and management. The single were also to be more associated to brucellosis, due to the fact that this group consume milk and milk products more as it is readily available in the informal markets as highly nutritious fast foods in this community as also observed in USA. CONCLUSIONS: Brucellosis is highly prevalent in Kiboga district, and therefore, an important public health problem. The transmission risk was aggravated by consumption of unpasteurized milk products, residing in rural settings and being single. There is a need to initiate screening, treat infected humans early, and educate the public about risk factors and appropriate preventive measures of brucellosis.

Prevalence of Mycobacterium bovis skin positivity and associated risk factors in cattle from western Uganda.

PURPOSE: A cross-sectional study was undertaken to determine the prevalence of Mycobacterium bovis skin positivity and associated risk factors in cattle in western Uganda. METHODS: Herds were selected using multi-stage cluster sampling. The comparative cervical intradermal tuberculin test (CCT) was used to determine cattle tuberculosis status using US Department of Agriculture protocols. Risk factor data were collected from cattle owners through questionnaires collected by in-person interviews. Multivariable logistic regression models were used to measure the association between risk factors and herd CCT reactor prevalence. RESULTS: A total of 525 cattle from 63 herds were screened for M. bovis infection. Of the 525 cattle tested, 2.1 % were CCT reactors and 15.43 % were CCT suspects. Of herds tested, 14.28 % had at least 1 CCT reactor. Using a private water source for cattle and not introducing new cattle into the farm were associated with lower prevalence of M. bovis skin positivity. The herd-level prevalence of M. bovis reactors in Kashaari County of Mbarara District was 14.5 %, and the individual cattle prevalence was low (2.1 %). CONCLUSIONS: Using communal sources of drinking water for cattle and introducing new cattle on the farm were farm management practices associated with increased risk of M. bovis exposure in cattle. Despite the low prevalence of bovine tuberculosis (TB), there is a need to educate the populace on the possibility of human infection with zoonotic TB and for educating farmers on practices to reduce the risk of acquiring M. bovis in the Mbarara District.

Circulation of bluetongue virus in goats in the Karamoja region of Uganda.

The presence of bluetongue virus (BTV) in indigenous goats from the Karamoja region of northern Uganda was investigated. A total of 300 goats were sampled (serum and whole blood) from five districts within the Karamoja region. The samples were analysed for the presence of bluetongue (BT) antibodies using a commercial Enzyme-linked immunosorbent assay (ELISA) and for the presence of BTV viral RNA by real-time Reverse transcription polymerase chain reaction (RT-PCR), because BTV is an RNA virus. Of the 300 goats tested, 269 (90%) were positive for BTV antibodies, indicating high levels of BTV circulation within the region. Out of the 150 whole blood samples tested for the presence of the virus by real-time RT-PCR, 84 (56%) were positive for BTV RNA. This study, which is the first of its kind in Uganda, showed a high seroprevalence of BT antibodies and active circulation of BTV in a high proportion of goats in the Karamoja region.

A large outbreak of typhoid fever associated with a high rate of intestinal perforation in Kasese District, Uganda, 2008-2009.

BACKGROUND: Salmonella enterica serovar Typhi (Salmonella Typhi) causes an estimated 22 million typhoid fever cases and 216 000 deaths annually worldwide. In Africa, the lack of laboratory diagnostic capacity limits the ability to recognize endemic typhoid fever and to detect outbreaks. We report a large laboratory-confirmed outbreak of typhoid fever in Uganda with a high proportion of intestinal perforations (IPs). METHODS: A suspected case of typhoid fever was defined as fever and abdominal pain in a person with either vomiting, diarrhea, constipation, headache, weakness, arthralgia, poor response to antimalarial medications, or IP. From March 4, 2009 to April 17, 2009, specimens for blood and stool cultures and serology were collected from suspected cases. Antimicrobial susceptibility testing and pulsed-field gel electrophoresis (PFGE) were performed on Salmonella Typhi isolates. Surgical specimens from patients with IP were examined. A community survey was conducted to characterize the extent of the outbreak. RESULTS: From December 27, 2007 to July 30, 2009, 577 cases, 289 hospitalizations, 249 IPs, and 47 deaths from typhoid fever occurred; Salmonella Typhi was isolated from 27 (33%) of 81 patients. Isolates demonstrated multiple PFGE patterns and uniform susceptibility to ciprofloxacin. Surgical specimens from 30 patients were consistent with typhoid fever. Estimated typhoid fever incidence in the community survey was 8092 cases per 100 000 persons. CONCLUSIONS: This typhoid fever outbreak was detected because of an elevated number of IPs. Underreporting of milder illnesses and delayed and inadequate antimicrobial treatment contributed to the high perforation rate. Enhancing laboratory capacity for detection is critical to improving typhoid fever control.

Shiga toxin gene-containing Escherichia coli from cattle and diarrheic children in the pastoral systems of southwestern Uganda.

Shiga toxin-producing Escherichia coli (STEC) strains from cattle and diarrheic children in a pastoralist community in Uganda were investigated. The STEC strains belonged to a variety of different serogroups, and 70% of the strains were positive for the intimin gene, eae. STEC strains from two of the children were closely related to bovine strains.