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'Macroeconomics in Context' lays out the principles of macroeconomics in a manner that is thorough, up to date, and relevant to students. Like its counterpart, 'Microeconomics in Context', the book is attuned to economic realities. These books offer affordability, engaging treatment of high-interest topics from sustainability to financial crisis and rising inequality, and clear, straightforward presentation of economic theory. Policy issues are presented in context - historical, institutional, social, political, and ethical - and always with reference to human well-being.

Cryptococcusgattii infections are being reported in the United States (US) with increasing frequency. Initially, US reports were primarily associated with an ongoing C. gattii outbreak in the Pacific Northwest (PNW) states of Washington and Oregon, starting in 2004. However, reports of C. gattii infections in patients from other US states have been increasing since 2009. Whether this is due to increasing frequency of disease, greater recognition within the clinical community, or both is currently unknown. During 2005-2013, a total of 273 C. gattii isolates from human and veterinary sources in 16 US states were collected. Of these, 214 (78%) were from the Pacific Northwest (PNW) and comprised primarily the clonal C. gattii genotypes VGIIa (64%), VGIIc (21%) and VGIIb (9%). The 59 isolates from outside the PNW were predominantly molecular types VGIII (44%) and VGI (41%). Genotyping using multilocus sequence typing revealed small clusters, including a cluster of VGI isolates from the southeastern US, and an unrelated cluster of VGI isolates and a large cluster of VGIII isolates from California. Most of the isolates were mating type MATα, including all of the VGII isolates, but one VGI and three VGIII isolates were mating type MATa. We provide the most comprehensive report to date of genotypic diversity of US C. gattii isolates both inside and outside of the PNW. C. gattii may have multiple endemic regions in the US, including a previously-unrecognized endemic region in the southeast. Regional clusters exist both in California and the Southeastern US. VGII strains associated with the PNW outbreak do not appear to have spread substantially beyond the PNW.

In May 2011, a tornado struck Joplin, Missouri. A cluster of mucormycosis infections was identified in 13 patients injured during the tornado. All cases were associated with penetrating trauma. Mucormycosis (formerly known as zygomycosis) is a rare infection caused by molds belonging to the subphylum Mucoromycotina in the order Mucorales. 1 These fungi are ubiquitous in nature, particularly in soil, decaying wood, and other organic matter. 2 Mucormycetes have an affinity for iron-rich, acidic environments; iron-overload states and acidemia are risk factors for infection. 3 A classic feature of mucormycosis is tissue necrosis as a result of vascular invasion and subsequent thrombosis. 3 , 4 Although mucormycosis predominantly affects immunocompromised persons, cutaneous mucormycosis may also occur after trauma in immunocompetent persons. 4 – 6 On May 22, 2011, a tornado rated EF-5 (the highest category on . . .

Early infant diagnosis (EID) facilitates early initiation into HIV care for identified HIV-positive infants. According to the Uganda Ministry of Health, EID testing algorithm, testing for infants exposed to HIV (IEH) should occur at <6 weeks, 9 and 18 months of age, and 6 weeks after stopping breastfeeding. Uganda has faced challenges with loss to follow-up (LTFU) of IEH for EID. We assessed complete testing coverage (CTC) to the EID algorithm for IEH and associated factors. We analyzed data from the 'Impact of the National Program for the Prevention of Vertical Transmission (PVT) of HIV in Uganda (2017-2019)' study. Mothers living with HIV whose infants tested HIV-negative at 4-12 weeks were enrolled in a prospective cohort (2017 - 2018) and followed until the IEH tested positive, died, was LTFU, or reached 18 months of age. We computed the proportion of IEH tested according to the EID algorithm among surviving infants. CTC was defined as undergoing HIV tests at three designated time points (excluding the 6 weeks after breastfeeding cessation) if HIV negative. IEH who were diagnosed with HIV but were tested at all recommended tests until that point were also considered to have CTC. We evaluated factors associated with CTC using modified Poisson regression. Among 1,804 IEH, 912 (51%) were male. Of the 1,804 IEH at baseline, 27 (1%) died. Among the 1,777 IEH included in the primary outcome analysis, 1,282 (72%) completed the study and 941 (53%) infants had CTC according to the EID testing algorithm including 40 (2%) who tested HIV-positive. Perceived discrimination due to HIV status [RR = 0.77, 95%CI (0.65-0.92)], having fewer pregnancies [RR = 0.97, 95%CI (0.68-0.99)], and reporting sexual violence [RR = 0.82, 95%CI (0.73-0.93)] by the mother of IEH were associated with non-CTC. About half of IEH were tested at the recommended time points. Interventions to address stigma and sexual violence for mothers may improve CTC for the EID algorithm. Investigations are needed to explore associations between sexual violence, parity, and CTC for the EID algorithm.

In September 2022, Uganda experienced an outbreak of Sudan virus disease (SVD), mainly in central Uganda. As a result of enhanced surveillance activities for Ebola disease, samples from several patients with suspected viral hemorrhagic fever (VHF) were sent to the VHF Program at Uganda Virus Research Institute (UVRI), Entebbe, Uganda, and identified with infections caused by other viral etiologies. Herein, we report the epidemiologic and laboratory findings of Crimean-Congo hemorrhagic fever (CCHF) cases that were detected during the SVD outbreak response. Whole blood samples from VHF suspected cases were tested for Sudan virus (SUDV) by real-time reverse transcription-polymerase chain reaction (RT-PCR); and if negative, were tested for CCHF virus (CCHFV) by RT-PCR. CCHFV genomic sequences generated by metagenomic next generation sequencing were analyzed to ascertain strain relationships. Between September 2022 and January 2023, a total of 2,626 samples were submitted for VHF testing at UVRI. Overall, 13 CCHF cases (including 7 deaths; case fatality rate of 53.8%), aged 4 to 60 years, were identified from 10 districts, including several districts affected by the SVD outbreak. Four cases were identified within the Ebola Treatment Unit (ETU) at Mubende Hospital. Most CCHF cases were males engaged in livestock farming or had exposure to wildlife (n = 8; 61.5%). Among confirmed cases, the most common clinical symptoms were hemorrhage (n = 12; 92.3%), fever (n = 11; 84.6%), anorexia (n = 10; 76.9%), fatigue (n = 9; 69.2%), abdominal pain (n = 9; 69.2%) and vomiting (n = 9; 69.2%). Sequencing analysis showed that the majority of identified CCHFV strains belonged to the Africa II clade previously identified in Uganda. Two samples, however, were identified with greater similarity to a CCHFV strain that was last reported in Uganda in 1958, suggesting possible reemergence. Identifying CCHFV from individuals initially suspected to be infected with SUDV emphasizes the need for comprehensive VHF testing during filovirus outbreak responses in VHF endemic countries. Without expanded testing, CCHFV-infected patients would have posed a risk to health care workers and others while receiving treatment after a negative filovirus diagnosis, thereby complicating response dynamics. Additionally, CCHFV-infected cases could acquire an Ebola infection while in the ETU, and upon release because of a negative Ebola virus result, have the potential to spread these infections in the community.

Background Malaria outbreaks are detected by applying the World Health Organization (WHO)-recommended thresholds (the less sensitive 75th percentile or mean + 2 standard deviations [2SD] for medium-to high-transmission areas, and the more sensitive cumulative sum [C-SUM] method for low and very low-transmission areas). During 2022, > 50% of districts in Uganda were in an epidemic mode according to the 75th percentile method used, resulting in a need to restrict national response to districts with the highest rates of complicated malaria. The three threshold approaches were evaluated to compare their outbreak-signaling outputs and help identify prioritization approaches and method appropriateness across Uganda. Methods The three methods were applied as well as adjusted approaches (85th percentile and C-SUM + 2SD) for all weeks in 2022 for 16 districts with good reporting rates ( ≥ 80%). Districts were selected from regions originally categorized as very low, low, medium, and high transmission; district thresholds were calculated based on 2017–2021 data and re-categorized them for this analysis. Results Using district-level data to categorize transmission levels resulted in re-categorization of 8/16 districts from their original transmission level categories. In all districts, more outbreak weeks were detected by the 75th percentile than the mean + 2SD method (p < 0.001). For all 9 very low or low-transmission districts, the number of outbreak weeks detected by C-SUM were similar to those detected by the 75th percentile. On adjustment of the 75th percentile method to the 85th percentile, there was no significant difference in the number of outbreak weeks detected for medium and low transmission districts. The number of outbreak weeks detected by C-SUM + 2SD was similar to those detected by the mean + 2SD method for all districts across all transmission intensities. Conclusion District data may be more appropriate than regional data to categorize malaria transmission and choose epidemic threshold approaches. The 75th percentile method, meant for medium- to high-transmission areas, was as sensitive as C-SUM for low- and very low-transmission areas. For medium and high-transmission areas, more outbreak weeks were detected with the 75th percentile than the mean + 2SD method. Using the 75th percentile method for outbreak detection in all areas and the mean + 2SD for prioritization of medium- and high-transmission areas in response may be helpful.

Background Seasonal malaria chemoprevention (SMC) refers to monthly administration of full treatment courses of anti-malarial medicine to children <5 years during high malaria transmission seasons. SMC has demonstrated effectiveness in Sahel and sub-Sahel countries in Africa. However, it was not implemented in Uganda until April 2021, when the country began SMC in the highly malaria-endemic Kotido and Moroto Districts. This study assessed the effect of SMC on malaria incidence among children <5 years of age in Kotido and Moroto Districts. Methods An interrupted time-series analysis was conducted using monthly national health data from the Uganda Ministry of Health District Health Information System 2. The monthly data for outpatient (uncomplicated) malaria among children <5 years was extracted for the 52 months before SMC implementation (Jan 2017–Apr 2021) and 8 months during SMC implementation (May–Dec 2021). The monthly incidence of uncomplicated malaria per 1000 children <5 years was computed before and during SMC implementation. Results In Kotido District, malaria incidence was 693/1000 during SMC implementation period, compared to an expected 1216/1000 if SMC had not been implemented. The mean monthly malaria incidence was 87/1000, compared to an expected mean of 152/1000 if SMC had not been implemented. This represents a statistically significant mean monthly change of −65.4 (95% CI = −104.6, −26.2) malaria cases/1000 during SMC implementation, or a 43.0% decline. In Moroto District, malaria incidence was 713/1000 during SMC implementation period, compared to an expected 905/1000 if SMC had not been implemented. The mean monthly malaria incidence was 89/1000, compared to an expected 113/1000 if SMC had not been deployed. This represents a statistically significant mean monthly change of −24.0 (95% CI = −41.1, −6.8) malaria cases/1000 during SMC implementation, or a 21.2% decline. Conclusion Implementation of SMC substantially reduced the incidence of uncomplicated malaria among children <5 years in Moroto and Kotido Districts. Scaling up SMC in other districts with high malaria transmission could reduce malaria on a large scale across Uganda.

During the past 20 years, enormous efforts have been expended globally to eliminate lymphatic filariasis (LF) through mass drug administration (MDA). However, small endemic foci (microfoci) of LF may threaten the presumed inevitable decline of infections after MDA cessation. We conducted microsimulation modeling to assess the ability of different types of surveillance to identify microfoci in these settings. Five or ten microfoci of radius 1, 2, or 3 km with infection marker prevalence (intensity) of 3, 6, or 10 times background prevalence were placed in spatial simulations, run in R Version 3.2. Diagnostic tests included microfilaremia, immunochromatographic test (ICT), and Wb123 ELISA. Population size was fixed at 360,000 in a 60 x 60 km area; demographics were based on literature for Sub-Saharan African populations. Background ICT prevalence in 6-7 year olds was anchored at 1.0%, and the prevalence in the remaining population was adjusted by age. Adults≥18 years, women aged 15-40 years (WCBA), children aged 6-7 years, or children≤5 years were sampled. Cluster (CS), simple random sampling (SRS), and TAS-like sampling were simulated, with follow-up testing of the nearest 20, 100, or 500 persons around each infection-marker-positive person. A threshold number of positive persons in follow-up testing indicated a suspected microfocus. Suspected microfoci identified during surveillance and actual microfoci in the simulation were compared to obtain a predictive value positive (PVP). Each parameter set was referred to as a protocol. Protocols were scored by efficiency, defined as the most microfoci identified, the fewest persons requiring primary and follow-up testing, and the highest PVP. Negative binomial regression was used to estimate aggregate effects of different variables on efficiency metrics. All variables were significantly associated with efficiency metrics. Additional follow-up tests beyond 20 did not greatly increase the number of microfoci detected, but significantly negatively impacted efficiency. Of 3,402 protocols evaluated, 384 (11.3%) identified all five microfoci (PVP 3.4-100.0%) and required testing 0.73-35.6% of the population. All used SRS and 378 (98.4%) only identified all five microfoci if they were 2-3 km diameter or high-intensity (6x or 10x); 374 (97.4%) required ICT or Wb123 testing to identify all five microfoci, and 281 (73.0%) required sampling adults or WCBA. The most efficient CS protocols identified two (40%) microfoci. After limiting to protocols with 1-km radius microfoci of 3x intensity (n = 378), eight identified all five microfoci; all used SRS and ICT and required testing 31.2-33.3% of the population. The most efficient CS and TAS-like protocols as well as those using microfilaremia testing identified only one (20%) microfocus when they were limited to 1-km radius and 3x intensity. In this model, SRS, ICT, and sampling of adults maximized microfocus detection efficiency. Follow-up sampling of more persons did not necessarily increase protocol efficiency. Current approaches towards surveillance, including TAS, may not detect small, low-intensity LF microfoci that could remain after cessation of MDA. The model provides many surveillance protocols that can be selected for optimal outcomes.

Crimean-Congo haemorrhagic fever (CCHF) is a tick-borne, zoonotic viral disease that causes haemorrhagic symptoms. Despite having eight confirmed outbreaks between 2013 and 2017, all within Uganda's 'cattle corridor', no targeted tick control programs exist in Uganda to prevent disease. During a seven-month-period from July 2018-January 2019, the Ministry of Health confirmed multiple independent CCHF outbreaks. We investigated to identify risk factors and recommend interventions to prevent future outbreaks. We defined a confirmed case as sudden onset of fever (≥37.5°C) with ≥4 of the following signs and symptoms: anorexia, vomiting, diarrhoea, headache, abdominal pain, joint pain, or sudden unexplained bleeding in a resident of the affected districts who tested positive for Crimean-Congo haemorrhagic fever virus (CCHFv) by RT-PCR from 1 July 2018-30 January 2019. We reviewed medical records and performed active case-finding. We conducted a case-control study and compared exposures of case-patients with age-, sex-, and sub-county-matched control-persons (1:4). We identified 14 confirmed cases (64% males) with five deaths (case-fatality rate: 36%) from 11 districts in western and central region. Of these, eight (73%) case-patients resided in Uganda's 'cattle corridor'. One outbreak involved two case-patients and the remainder involved one. All case-patients had fever and 93% had unexplained bleeding. Case-patients were aged 6-36 years, with persons aged 20-44 years more affected (AR: 7.2/1,000,000) than persons ≤19 years (2.0/1,000,000), p = 0.015. Most (93%) case-patients had contact with livestock ≤2 weeks before symptom onset. Twelve (86%) lived <1 km from grazing fields compared with 27 (48%) controls (ORM-H = 18, 95% CI = 3.2-∞) and 10 (71%) of 14 case-patients found ticks attached to their bodies ≤2 weeks before symptom onset, compared to 15 (27%) of 56 control-persons (ORM-H = 9.3, 95%CI = 1.9-46). CCHF outbreaks occurred sporadically during 2018-2019, both within and outside 'cattle corridor' districts of Uganda. Most cases were associated with tick exposure. The Ministry of Health should partner with the Ministry of Agriculture, Animal Industry and Fisheries to develop joint nationwide tick control programs and strategies with shared responsibilities through a One Health approach.

Background Widespread COVID-19 vaccine uptake can facilitate epidemic control. A February 2021 study in Uganda suggested that public vaccine uptake would follow uptake among leaders. In May 2021, Baylor Uganda led community dialogue meetings with district leaders from Western Uganda to promote vaccine uptake. We assessed the effect of these meetings on the leaders’ COVID-19 risk perception, vaccine concerns, perception of vaccine benefits and access, and willingness to receive COVID-19 vaccine. Methods All departmental district leaders in the 17 districts in Western Uganda, were invited to the meetings, which lasted approximately four hours. Printed reference materials about COVID-19 and COVID-19 vaccines were provided to attendees at the start of the meetings. The same topics were discussed in all meetings. Before and after the meetings, leaders completed self-administered questionnaires with questions on a five-point Likert Scale about risk perception, vaccine concerns, perceived vaccine benefits, vaccine access, and willingness to receive the vaccine. We analyzed the findings using Wilcoxon’s signed-rank test. Results Among 268 attendees, 164 (61%) completed the pre- and post-meeting questionnaires, 56 (21%) declined to complete the questionnaires due to time constraints and 48 (18%) were already vaccinated. Among the 164, the median COVID-19 risk perception scores changed from 3 (neutral) pre-meeting to 5 (strong agreement with being at high risk) post-meeting ( p  < 0.001). Vaccine concern scores reduced, with medians changing from 4 (worried about vaccine side effects) pre-meeting to 2 (not worried) post-meeting ( p  < 0.001). Median scores regarding perceived COVID-19 vaccine benefits changed from 3 (neutral) pre-meeting to 5 (very beneficial) post-meeting ( p  < 0.001). The median scores for perceived vaccine access increased from 3 (neutral) pre-meeting to 5 (very accessible) post-meeting ( p  < 0.001). The median scores for willingness to receive the vaccine changed from 3 (neutral) pre-meeting to 5 (strong willingness) post-meeting ( p  < 0.001). Conclusion COVID-19 dialogue meetings led to district leaders’ increased risk perception, reduced concerns, and improvement in perceived vaccine benefits, vaccine access, and willingness to receive the COVID-19 vaccine. These could potentially influence public vaccine uptake if leaders are vaccinated publicly as a result. Broader use of such meetings with leaders could increase vaccine uptake among themselves and the community.