Evaluation of public health surveillance systems in refugee settlements in Uganda, 2016-2019: lessons learned.

BACKGROUND: Civil wars in the Great Lakes region resulted in massive displacement of people to neighboring countries including Uganda. With associated disease epidemics related to this conflict, a disease surveillance system was established aiming for timely detection of diseases and rapid response to outbreaks. We describe the evaluation of and lessons learned from the public health surveillance system set up in refugee settlements in Uganda. METHODS: We conducted a cross-sectional survey using the US Centers for Disease Control and Prevention Updated Guidelines for Evaluating Public Health Surveillance Systems and the Uganda National Technical Guidelines for Integrated Disease Surveillance and Response in four refugee settlements in Uganda-Bidibidi, Adjumani, Kiryandongo and Rhino Camp. Using semi-structured questionnaires, key informant and focus group discussion guides, we interviewed 53 health facility leaders, 12 key personnel and 224 village health team members from 53 health facilities and 112 villages and assessed key surveillance functions and attributes. RESULTS: All health facilities assessed had key surveillance staff; 60% were trained on Integrated Disease Surveillance and Response and most village health teams were trained on disease surveillance. Case detection was at 55%; facilities lacked standard case definitions and were using parallel Implementing Partner driven reporting systems. Recording was at 79% and reporting was at 81%. Data analysis and interpretation was at 49%. Confirmation of outbreaks and events was at 76%. Preparedness was at 72%. Response was at 34%. Feedback was at 82%. Evaluate and improve the system was at 67%. There was low capacity for detection, response and data analysis and interpretation of cases (< 60%). CONCLUSION: The surveillance system in the refugee settlements was functional with many performing attributes but with many remaining gaps. There was low capacity for detection, response and data analysis and interpretation in all the refugee settlements. There is need for improvement to align surveillance systems in refugee settlements with the mainstream surveillance system in the country. Implementing Partners should be urged to offer support for surveillance and training of surveillance staff on Integrated Disease Surveillance and Response to maintain effective surveillance functions. Functionalization of district teams ensures achievement of surveillance functions and attributes. Regular supervision of and support to health facility surveillance personnel is essential. Harmonization of reporting improves surveillance functions and attributes and appropriation of funds by government to districts to support refugee settlements is complementary to maintain effective surveillance of priority diseases in the northern and central part of Uganda.

Sporadic Rift Valley Fever Outbreaks in Humans and Animals in Uganda, October 2017-January 2018.

Introduction: Rift Valley fever (RVF) is a mosquito-borne viral zoonosis. The Uganda Ministry of Health received alerts of suspected viral haemorrhagic fever in humans from Kiruhura, Buikwe, Kiboga, and Mityana districts. Laboratory results from Uganda Virus Research Institute indicated that human cases were positive for Rift Valley fever virus (RVFV) by polymerase chain reaction. We investigated to determine the scope of outbreaks, identify exposure factors, and recommend evidence-based control and prevention measures. Methods: A suspected case was defined as a person with acute fever onset, negative malaria test result, and at least two of the following symptoms: headache, muscle or joint pain, bleeding, and any gastroenteritis symptom (nausea, vomiting, abdominal pain, diarrhoea) in a resident of Kiruhura, Buikwe, Mityana, and Kiboga districts from 1st October 2017 to 30th January 2018. A confirmed case was defined as a suspected case with laboratory confirmation by either detection of RVF nucleic acid by reverse-transcriptase polymerase chain reaction (RT-PCR) or demonstration of serum IgM or IgG antibodies by ELISA. Community case finding was conducted in all affected districts. In-depth interviews were conducted with human cases that were infected with RVF who included herdsmen and slaughterers/meat handlers to identify exposure factors for RVF infection. A total of 24 human and 362 animal blood samples were tested. Animal blood samples were purposively collected from farms that had reported stormy abortions in livestock and unexplained death of animals after a short illness (107 cattle, 83 goats, and 43 sheep). Convenient sampling for the wildlife (10 zebras, 1 topi, and 1 impala) was conducted to investigate infection in animals from Kiruhura, Buikwe, Mityana, and Kiboga districts. Human blood was tested for anti-RVFV IgM and IgG and animal blood for anti-RVFV IgG. Environmental assessments were conducted during the outbreaks in all the affected districts. Results: Sporadic RVF outbreaks occurred from mid-October 2017 to mid-January 2018 affecting humans, domestic animals, and wildlife. Human cases were reported from Kiruhura, Buikwe, Kiboga, and Mityana districts. Of the 24 human blood samples tested, anti-RVFV IgG was detected in 7 (29%) human samples; 1 human sample had detectable IgM only, and 6 had both IgM and IgG. Three of the seven confirmed human cases died among humans. Results from testing animal blood samples obtained from Kiruhura district indicated that 44% (64/146) cattle, 46% (35/76) goats, and 45% (9/20) sheep tested positive for RVF. Among wildlife, (1/10) zebras, (1/1) topi, and (1/1) impala tested positive for RVFV by serological tests. One blood sample from sheep in Kiboga district tested RVFV positive. All the human cases were exposed through contact or consumption of meat from infected animals. Conclusion: RVF outbreaks occurred in humans and animals in Kiruhura, Buikwe, Mityana, and Kiboga districts. Human cases were potentially infected through contact with infected animals and their products.

Fatal Methanol Poisoning Caused by Drinking Adulterated Locally Distilled Alcohol: Wakiso District, Uganda, June 2017.

Background: Methanol, an industrial solvent, can cause illness and death if ingested. In June 2017, the Uganda Ministry of Health was notified of a cluster of deaths which occurred after drinking alcohol. We investigated to determine the cause of outbreak, identify risk factors, and recommend evidence-based control measures. Methods: We defined a probable case as acute loss of eyesight and ≥1 of the following symptoms: profuse sweating, vomiting, dizziness, or loss of consciousness in a resident of either Nabweru or Nangabo Subcounty from 1 to 30 June 2017. In a case-control study, we compared exposures of case-patients and controls selected among asymptomatic neighbors who drank alcohol and matched by age and sex. We collected alcohol samples from implicated bars and wholesaler X for testing. Results: We identified 15 cases; 12 (80%) died. Among case-patients, 12 (80%) were men; the median age was 43 (range: 23-66) years. Thirteen (87%) of 15 case-patients and 15 (25%) of 60 controls last drank a locally distilled alcohol at one of the three bars supplied by wholesaler X (ORM-H = 15; 95% CI: 2.3-106). We found that alcohol sellers sometimes added methanol to drinking alcohol to increase their profit margin. Among the 10 alcohol samples from wholesaler X, the mean methanol content (1200 mg/L, range: 77-2711 mg/L) was 24 times higher than the safe level. Conclusion: This outbreak was caused by drinking a locally distilled alcohol adulterated with methanol from wholesaler X. We recommended enforcing existing laws governing alcohol manufacture and sale. We recommended timely intravenous administration of ethanol to methanol poisoning victims.

Marburg virus disease outbreak in Kween District Uganda, 2017: Epidemiological and laboratory findings.

INTRODUCTION: In October 2017, a blood sample from a resident of Kween District, Eastern Uganda, tested positive for Marburg virus. Within 24 hour of confirmation, a rapid outbreak response was initiated. Here, we present results of epidemiological and laboratory investigations. METHODS: A district task force was activated consisting of specialised teams to conduct case finding, case management and isolation, contact listing and follow up, sample collection and testing, and community engagement. An ecological investigation was also carried out to identify the potential source of infection. Virus isolation and Next Generation sequencing were performed to identify the strain of Marburg virus. RESULTS: Seventy individuals (34 MVD suspected cases and 36 close contacts of confirmed cases) were epidemiologically investigated, with blood samples tested for MVD. Only four cases met the MVD case definition; one was categorized as a probable case while the other three were confirmed cases. A total of 299 contacts were identified; during follow- up, two were confirmed as MVD. Of the four confirmed and probable MVD cases, three died, yielding a case fatality rate of 75%. All four cases belonged to a single family and 50% (2/4) of the MVD cases were female. All confirmed cases had clinical symptoms of fever, vomiting, abdominal pain and bleeding from body orifices. Viral sequences indicated that the Marburg virus strain responsible for this outbreak was closely related to virus strains previously shown to be circulating in Uganda. CONCLUSION: This outbreak of MVD occurred as a family cluster with no additional transmission outside of the four related cases. Rapid case detection, prompt laboratory testing at the Uganda National VHF Reference Laboratory and presence of pre-trained, well-prepared national and district rapid response teams facilitated the containment and control of this outbreak within one month, preventing nationwide and global transmission of the disease.

Neurologic complications and sequellae of infectious diseases in Uganda and Kenya: Analysis of 288 cases from two rural hospitals.

OBJECTIVE: Many infections occurring in area of Sub-Saharan Africa are associated with more or less serious neurologic symptoms or complications. The aim of this study was to assess the incidence of selected infectious diseases in the equatorial part of Uganda and Kenya and to monitor potential neurological complications of these infections. METHODS: The study was performed for May - August 2008. Patients suffering from cerebral malaria, AIDS, meningitis, typhoid, tuberculosis (TB), syphilis, leprosy, and trypanosomiasis patients were enrolled. Besides of standard examination, lumbar puncture (LP) and cerebrospinal fluid (CSF) examination was performed, and the occurrence of neurological disorders and sequellae was recorded and assessed. RESULTS: Altogether 288 patients with neurological manifestation were enrolled. Malaria was the most prevalent disease in this study (102 cases, 35.42%), followed by typhoid (47 cases, 16.2%) and meningitis (38 cases, 13.2%). Leprosy and trypanosomiasis were only rarely detected (2.3% and 1.4%, respectively). CONCLUSION: In malaria and HIV hyper-endemic area of rural Uganda, cerebral malaria is the leading tropical neuroinfection. Also, meningitis is still frequent probably due to insufficient access to vaccination.