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Background Despite the growing number of people on antiretroviral therapy (ART), there is limited information about virological non-suppression and its determinants among HIV-positive (HIV+) individuals enrolled in HIV care in many resource-limited settings. We estimated the proportion of virologically non-suppressed patients, and identified the factors associated with virological non-suppression. Methods We conducted a descriptive cross-sectional study using routinely collected program data from viral load (VL) samples collected across the country for testing at the Central Public Health Laboratories (CPHL) in Uganda. Data were generated between August 2014 and July 2015. We extracted data on socio-demographic, clinical and VL 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 The study was composed of 100,678 patients; of these, 94,766(94%) were for routine monitoring, 3492(4%) were suspected treatment failures while 1436(1%) were repeat testers after suspected failure. The overall proportion of non-suppression was 11%. Patients on routine monitoring registered the lowest (10%) proportion of non-suppressed patients. Virological non-suppression was higher among suspected treatment failures (29%) and repeat testers after suspected failure (50%). Repeat testers after suspected failure were six times more likely to have virological non-suppression (OR adj  = 6.3, 95%CI = 5.5–7.2) when compared with suspected treatment failures (OR adj  = 3.3, 95%CI = 3.0–3.6). The odds of virological non-suppression decreased with increasing age, with children aged 0–4 years (OR adj  = 5.3, 95%CI = 4.6–6.1) and young adolescents (OR adj  = 4.1, 95%CI = 3.7–4.6) registering the highest odds. Poor adherence (OR adj  = 3.4, 95%CI = 2.9–3.9) and having active TB (OR adj  = 1.9, 95%CI = 1.6–2.4) increased the odds of virological non-suppression. However, being on second/third line regimens (OR adj  = 0.86, 95%CI = 0.78–0.95) protected patients against virological non-suppression. Conclusion Young age, poor adherence and having active TB increased the odds of virological non-suppression while second/third line ART regimens were protective against non-suppression. We recommend close follow up and intensified targeted adherence support for repeat testers after suspected failure, children and adolescents.

Anthrax is a zoonotic disease that remains endemic in Uganda, particularly in cattle-keeping areas. On December 28, 2023, the first suspected human case of anthrax was detected in Amudat District. We investigated to determine the outbreak's magnitude, identify risk factors, and recommend prevention and control measures. We defined a suspected cutaneous anthrax case as acute onset of ≥2 of the following: skin lesions (papule, vesicle, or eschar) on exposed areas such as the hands, forearms, shoulders, back, thighs or face, localized itching, redness, swelling, or regional lymphadenopathy, in Amudat residents from December 2023-June 2024. A confirmed case was a suspected case with PCR-positive test for Bacillus anthracis. In unmatched case-control study (1:3 ratio), we compared exposures among 40 cases and 120 controls. We identified cases through house-to-house search, medical record reviews, and snowballing among case-persons. Human and animal samples were collected and tested, alongside an environmental assessment. We used multivariable logistic regression to identify associated risk factors. We identified 102 cutaneous anthrax cases, including 7 confirmed cases; none died. The outbreak lasted 7 months, peaking in March 2024, with an overall attack rate of 169/100,000 (males: 196/100,000; females: 138/100,000). Use of cattle hides as bedding (OR=12; 95% CI:2.7-52) and butchering cattle carcasses (OR=6; 95% CI:1.8-19) were significantly associated with anthrax. The highest infection risk was observed among individuals with multiple exposures: butchered only (OR = 6.9, 95% CI:2.6-18), butchered and carried cattle parts (OR = 11, 95% CI:1.2-96), butchered and skinned (OR = 14, 95% CI:3.5-56), and butchered, carried, and skinned (OR = 17, 95% CI:1.6-219). No livestock had been vaccinated prior to the outbreak. The outbreak was associated to use of cattle hides as bedding and the butchering of cattle carcasses. We recommended community education, livestock vaccination, and safe carcass handling to prevent future outbreaks.

Zoonotic diseases continue to be a public health burden globally. Uganda is especially vulnerable due to its location, biodiversity, and population. Given these concerns, the Ugandan government in collaboration with the Global Health Security Agenda conducted a One Health Zoonotic Disease Prioritization Workshop to identify zoonotic diseases of greatest national concern to the Ugandan government. The One Health Zoonotic Disease Prioritization tool, a semi-quantitative tool developed by the U.S. Centers for Disease Control and Prevention, was used for the prioritization of zoonoses. Workshop participants included voting members and observers representing multiple government and non-governmental sectors. During the workshop, criteria for prioritization were selected, and questions and weights relevant to each criterion were determined. We used a decision tree to provide a ranked list of zoonoses. Participants then established next steps for multisectoral engagement for the prioritized zoonoses. A sensitivity analysis demonstrated how criteria weights impacted disease prioritization. Forty-eight zoonoses were considered during the workshop. Criteria selected to prioritize zoonotic diseases were (1) severity of disease in humans in Uganda, (2) availability of effective control strategies, (3) potential to cause an epidemic or pandemic in humans or animals, (4) social and economic impacts, and (5) bioterrorism potential. Seven zoonotic diseases were identified as priorities for Uganda: anthrax, zoonotic influenza viruses, viral hemorrhagic fevers, brucellosis, African trypanosomiasis, plague, and rabies. Sensitivity analysis did not indicate significant changes in zoonotic disease prioritization based on criteria weights. One Health approaches and multisectoral collaborations are crucial to the surveillance, prevention, and control strategies for zoonotic diseases. Uganda used such an approach to identify zoonoses of national concern. Identifying these priority diseases enables Uganda's National One Health Platform and Zoonotic Disease Coordination Office to address these zoonoses in the future with a targeted allocation of resources.

Introduction Disease surveillance provides vital data for disease prevention and control programs. Incomplete and untimely data are common challenges in planning, monitoring, and evaluation of health sector performance, and health service delivery. Weekly surveillance data are sent from health facilities using mobile tracking (mTRAC) program, and synchronized into the District Health Information Software version 2 (DHIS2). The data are then merged into district, regional, and national level datasets. We described the completeness and timeliness of weekly surveillance data reporting on epidemic prone diseases in Uganda, 2020–2021. Methods We abstracted data on completeness and timeliness of weekly reporting of epidemic-prone diseases from 146 districts of Uganda from the DHIS2.Timeliness is the proportion of all expected weekly reports that were submitted to DHIS2 by 12:00pm Monday of the following week. Completeness is the proportion of all expected weekly reports that were completely filled and submitted to DHIS2 by 12:00pm Wednesday of the following week. We determined the proportions and trends of completeness and timeliness of reporting at national level by year, health region, district, health facility level, and facility ownership. Results National average reporting timeliness and completeness was 44% and 70% in 2020, and 49% and 75% in 2021. Eight of the 15 health regions achieved the target for completeness of ≥ 80%; Lango attained the highest (93%) in 2020, and Karamoja attained 96% in 2021. None of the regions achieved the timeliness target of ≥ 80% in either 2020 or 2021. Kampala District had the lowest completeness (38% and 32% in 2020 and 2021, respectively) and the lowest timeliness (19% in both 2020 and 2021). Referral hospitals and private owned health facilities did not attain any of the targets, and had the poorest reporting rates throughout 2020 and 2021. Conclusion Weekly surveillance reporting on epidemic prone diseases improved modestly over time, but timeliness of reporting was poor. Further investigations to identify barriers to reporting timeliness for surveillance data are needed to address the variations in reporting.

Background Anthrax is a priority zoonotic disease in Uganda. Despite health education about risks of eating meat from animals found dead, some areas including Kazo District, experience repeated anthrax outbreaks associated with this practice. We assessed the knowledge, attitudes, and practices (KAP) around anthrax and consumption of meat of animals found dead in previously-affected communities in Kazo District. Methods A mixed-methods study was conducted in six villages in Kazo District from May 23-June 4, 2022. Structured questionnaires were administered to 200 systematically-sampled community respondents aged ≥ 18 years about anthrax-related KAP and experiences with livestock loss. Focus group discussions were conducted with community members identified as anthrax case-patients in previous outbreaks and those whose animals died suddenly in the previous year. Overall knowledge was assessed through a set of eight questions on anthrax; species affected, signs and symptoms, transmission and prevention in humans and animals. Participants’ responses were scored to KAP questions as 1 = correct or 0 = incorrect; adequate knowledge score was ≥ 4. One sample binomial test was used to find the difference in proportions. Qualitative data were analyzed using thematic analysis. Results Among 200 survey respondents, 65% were female; mean age was 45 (SD  ±  17.7) years. In total, 94% ( p  < 0.0001) had heard of anthrax, 65.5% ( p  < 0.0001) knew it was zoonotic; 74.5% ( p  < 0.0001) did not know any signs of anthrax in animals, though 78.5% ( p  < 0.0001) knew transmission could occur through eating animals found dead. Only 16% said they had lost their livestock suddenly in the last year; of these, 21% consumed the meat and 53% buried the carcasses. Overall, 77% ( p  < 0.0001) had adequate knowledge about anthrax. Qualitative data indicated that farmers did not vaccinate their animals against anthrax due to cost, and inadequate access to vaccine and veterinary services. Poverty, limited access to meat protein and economic challenges were cited as drivers for consuming meat from animals found dead despite the risk. Conclusion Good knowledge about anthrax among residents of a repeatedly-affected community may not have translated to safe practices. Compensating farmers for anthrax-positive carcasses in exchange for permitting safe animal disposal might reduce risk of transmission.

Background Cholera is a major public health threat in Uganda, especially in border districts prone to outbreaks from cross-border movement. We investigated and evaluated the initial response to a January 2024 cholera outbreak in Elegu Town, on the Uganda-South Sudan border, using the 7–1–7 timeliness metrics to assess detection, notification, and response capacities, highlighting Uganda's preparedness and challenges in managing cross-border outbreaks. Methods We defined a suspected case as the onset of acute watery diarrhea in an asylum seeker at the Elegu border point from January to February 2024. A confirmed case was a suspected case in which Vibrio cholerae was isolated in the stool by culture or PCR. We actively searched for cases and collected data on person characteristics, symptoms, and outbreak timeliness. We used semi-structured interviews to elicit insights from district health officials on the enabling factors and bottlenecks during the response. We used the 7–1–7 metric to assess detection, notification, and response capacities of the point of entry. Results Thirteen members of a refugee family from South Sudan were diagnosed with cholera within 6 h of arrival at the Elegu border, with 4 (31%) confirmed cases. No death occurred. The authorities detected, notified, and responded to the outbreak within the 7–1–7 timelines, with no major bottlenecks identified. The outbreak was detected and notified within one day and by the fifth day, a full response was mounted. The prompt response was attributed to the availability of a functional emergency operations center and the presence of trained surveillance frontline health workers. Conclusion Response to an imported cholera outbreak at Elegu border point demonstrated Uganda's preparedness in managing cross-border disease outbreaks. Achieving the 7–1–7 targets highlighted the country’s-built capacity to detect, notify, and respond to such events. Continued investment in local-level disease detection, communication, and national-level resource mobilization will be crucial to sustaining future effective cross-border outbreak prevention and control strategies.

Background In August 2022, an epidemiologic investigation into an outbreak of cases of black water fever, a severe and fatal complication of malaria, was conducted in Kakumiro District, Central Uganda. Findings revealed an association between self-medication and the development of severe malaria complications. Factors associated with self-medication for uncomplicated malaria were described for improved malaria management and prevention of malaria related mortality in Uganda. Methods A community-based cross-sectional survey was conducted in Kakumiro District in August 2023. Using multistage sampling, 592 households were selected. A semi-structured questionnaire was used to interview one participant per household about self-medication for malaria in a family member of any age who suffered from malaria 6 months prior to the interview. Data on demographics, socio-economic factors, health-seeking behaviour, self-medication and antimalarial storage at home were obtained. Modified Poisson regression model was used for multivariate analysis. Results Of the 592 participants interviewed, 368 (62%; 95% CI 58.2–65.9%) had self-medicated for malaria. Self-medication was significantly associated with household heads aged ≥ 35 years (adjusted prevalence ratio [APR]: 1.77; 95% CI 1.04–3.01); distances ≥ 5 km to the health facility (APR: 3.05; 95% CI 2.09–4.47), and storage of antimalarial drugs at home (APR: 2.21; 95% CI 1.36–3.59). Having malaria episodes ≥ 6 in the household within 6 months was protective (APR: 0.39; 95% CI 0.23–0.65). The major reason for self-medication was antimalarial stockouts at health facilities. Drugs used for self-medication were commonly known to 65% of the respondents and were bought from drug shops (75%). Although, 85% used the recommended drug for malaria treatment, the dose was inappropriate for 66% of the patients and despite the under dose, 85% of the patients recovered without hospitalization. Conclusion The common occurrence of self-medication for malaria and the high potential for malaria drug resistance and increased malaria mortality due to inappropriate treatment was demonstrated. Adequate antimalarial stock to health facilities, instituting policies prohibiting the sale of incomplete doses by drug shops, social behavioural change campaigns against drug storage in homes and sensitization of communities on the dangers of self-medication and the consumption of inappropriate doses could reduce self-medication practices and its eventual consequences.

Rabies is a vaccine-preventable fatal zoonotic disease. Uganda, through the veterinary surveillance system at National Animal Disease Diagnostics and Epidemiology Centre (NADDEC), captures animal bites (a proxy for rabies) on a monthly basis from districts. We established trends of incidence of animal bites and corresponding post-exposure prophylactic anti-rabies vaccination in humans (PEP), associated mortality rates in humans, spatial distribution of animal bites, and pets vaccinated during 2013–2017. We reviewed rabies surveillance data at NADDEC from 2013–2017. The surveillance system captures persons reporting bites by a suspected rabid dog/cat/wild animal, human deaths due to suspected rabies, humans vaccinated against rabies, and pets vaccinated. Number of total pets was obtained from the Uganda Bureau of Statistics. We computed incidence of animal bites and corresponding PEP in humans, and analyzed overall trends, 2013–2017. We also examined human mortality rates and spatial distribution of animal bites/rabies and pets vaccinated against rabies. We identified 8,240 persons reporting animal bites in Uganda during 2013–2017; overall incidence of 25 bites/ 100,000population. The incidence significantly decreased from 9.2/100,000 in 2013 to 1.3/100,000 in 2017 (OR = 0.62, p = 0.0046). Of the 8,240 persons with animal bites, 6,799 (82.5%) received PEP, decreasing from 94% in 2013 to 71% in 2017 (OR = 0.65, p<0.001). Among 1441 victims, who reportedly never received PEP, 156 (11%) died. Western region had a higher incidence of animal bites (37/100,000) compared to other regions. Only 5.6% (124,555/2,240,000) of all pets in Uganda were vaccinated. There was a decline in the reporting rate (percentage of annual district veterinary surveillance reports submitted monthly to Commissioner Animal Health by districts) of animal bites. While reported animal bites by districts decreased in Uganda, so did PEP among humans. Very few pets received anti-rabies vaccine. Evaluation of barriers to complete reporting may facilitate interventions to enhance surveillance quality. We recommended improved vaccination of pets against rabies, and immediate administration of exposed humans with PEP.

Background Uganda has a high burden of Neglected Tropical Diseases (NTDs), which particularly affect rural populations. Some NTDs are targeted for control/elimination using preventive chemotherapy administered annually or bi-annually to at-risk populations through mass drug administration (MDA). Schistosomiasis and soil-transmitted helminths (STHs) are two of these diseases. MDA for Schistosomiasis is given only to school-age children (SAC) and adults, whereas that for STHs is given only to SAC and pre-school-age children (pre-SAC). The MDA coverage target for both NTDs should be 75%. A decline in the size of the population at risk (PAR) and the number of cases are indicators of effective control/progress towards elimination. We describe the trends in the coverage of MDA and the outcomes of schistosomiasis and STHs. Methods We reviewed available data on MDA coverage, size of population at risk, and disease occurrence (case counts) for schistosomiasis and STHs from 2013 to 2023. We analysed the trends using the Mann Kendal test. Results From 2014 to 2022, there was an apparent increase in MDA coverage for schistosomiasis in both SAC (from 21 to 82%, p  = 0.5) and adults (from 34 to 36%, p  = 0.1); however, both trends were not significant. Similarly, for STHs, MDA coverage increased for both SAC (from 63 to 114%, p  = 0.09) and pre-SAC (from 65 to 76%, p  = 1.0); however, these trends were not significant. The PAR for schistosomiasis increased by 25% for SAC (2014: 4,777,189 vs 2022: 5,979,311, p  = 0.0025) and by 60% for adults (2014: 4,436,444 vs 2022: 7,091,933, p  = 0.03). For STHs, PAR increased by 19% for both SAC (2014:11,287,385 vs 2022:13,397,219, p  = 0.03) and pre-SAC (2014: 5,279,025 vs 2022: 6,299,355, p  = 0.047). From 2013 to 2023, there was a 62% reduction in reported cases of schistosomiasis (2013:6,518 vs. 2023:2501, p  = 0.7) and a 52% reduction in reported cases of STHs (2013:2,457,021 vs. 2023:1,176,463, p  = 0.5), but both trends were not significant. The increase in PAR indicates that transmission is spreading beyond previous extents despite ongoing MDA. Non-significant trends may be attributed to fluctuations across years, precluding a monotonic pattern., Nonetheless, the apparent changes can provide actionable insights to inform improvements in programmatic interventions. Conclusions Current efforts to control schistosomiasis and STHs using MDA should be strengthened to achieve sustainable control. Strategies to improve and maintain MDA coverage for both NTDs to a target of 75% are crucial, while the rise in PAR and unabating case counts necessitate targeted interventions, including improved sanitation, health education, and vaccine development.

Background In June 2019, surveillance data from the Uganda’s District Health Information System revealed an outbreak of malaria in Kole District. Analysis revealed that cases had exceeded the outbreak threshold from January 2019. The Ministry of Health deployed our team to investigate the areas and people affected, identify risk factors for disease transmission, and recommend control and prevention measures. Methods We conducted an outbreak investigation involving a matched case-control study. We defined a confirmed case as a positive malaria test in a resident of Aboke, Akalo, Alito, and Bala sub-counties of Kole District January–June 2019. We identified cases by reviewing outpatient health records. Exposures were assessed in a 1:1 matched case-control study (n = 282) in Aboke sub-county. We selected cases systematically from 10 villages using probability proportionate to size and identified age- and village-matched controls. We conducted entomological and environmental assessments to identify mosquito breeding sites. We plotted epidemic curves and overlaid rainfall, and indoor residual spraying (IRS). Case-control exposures were combined into: breeding site near house, proximity to swamp and breeding site, and proximity to swamp; these were compared to no exposure in a logistic regression analysis. Results Of 18,737 confirmed case-patients (AR = 68/1,000), Aboke sub-county residents (AR = 180/1,000), children < 5 years (AR = 94/1,000), and females (AR = 90/1,000) were most affected. Longitudinal analysis of surveillance data showed decline in cases after an IRS campaign in 2017 but an increase after IRS cessation in 2018–2019. Overlay of rainfall and case data showed two malaria upsurges during 2019, occurring 35–42 days after rainfall increases. Among 141 case-patients and 141 controls, the combination of having mosquito breeding sites near the house and proximity to swamps increased the odds of malaria 6-fold (OR = 6.6, 95% CI = 2.24–19.7) compared to no exposures. Among 84 abandoned containers found near case-patients’ and controls’ houses, 14 (17%) had mosquito larvae. Adult Anopheles mosquitoes, larvae, pupae, and pupal exuviae were identified near affected houses. Conclusion Stagnant water formed by increased rainfall likely provided increased breeding sites that drove this outbreak. Cessation of IRS preceded the malaria upsurges. We recommend re-introduction of IRS and removal of mosquito breeding sites in Kole District.