UNIPH Quarterly Epidemiological Bulletin-Vol-1 Issue-2

Uganda is at increased risk of polio outbreaks due to the political unrest in its neighbors, the porous nature of our borders, massive cross border movements and an influx of refugees especially in areas with low performance in routine immunization and poor surveillance indicators.

An outbreak of polio in South Sudan was confirmed on 24th November 2014, where 2 cases of circulating vaccine-derived polio (cVDPV2) wereidentified in Unity state. Presence of cVDPV2 is an indication of ongoing weak- nesses in routine immunization efforts in affected areas. Such cVDPV2 incidence9s need to be eliminated before the withdrawal of trivalent oral polio vaccine (tOPV). Therefore multiple supplemental immunization campaigns with tOPV have been planned in all countries with an on-going cVDPV2 outbreak or at high risk for such an outbreak if the end game strategic plan goals are to be realized.

Uganda therefore has planned several supplemental immunization activities (SIAs) with tOPV to ensure full protection of all children <59 months before the switch. This switch from tOPV to bOPV is scheduled for April 2016. It’s a globally synchronized replacement of all tOPV with bivalent OPV (bOPV) containing only types 1 and 3 polioviruses. To prepare for the global switch from tOPV to bOPV, as recommended in the Polio eradication and endgame strategic plan 2013–2018, the WHO strategic advisory group of experts (SAGE) on immunization recommended that at least one inactivated Polio Vaccine (IPV) dose be introduced into routine immunization schedules in all countries.

The IPV will help protect against paralytic polio caused by type 2 polioviruses, provide a degree of population protection against type2 poliovirus out- breaks, facilitate responses to any cVDPV2 outbreaks after the switch to bOPV, and aid in eradicating wild polio virus by boosting immunity to types 1 and 3 polioviruses.

The first round of SIAs was implemented from 21st-23rd January 2016 in 57 high risk districts.

This will be followed by the national house to house polio campaign from 1st to 3rd April 2016 that will cover children <5years using tOPV. Subsequently inactivated polio vaccine (IPV) will be introduced into routine immunization at 14 weeks together with OPV3 starting 18th April, 2016.

This will then be followed by another round of SIAs using tOPV in 65 high risk districts before the national switch day on 29th April, 2016.

CPHL moves to its new home

On 15th January 2016, the CPHL offices was officially handed over to MOH. The CPHL block, located in Butabika, just opposite the Butabika national mental

Referral hospital main gate, was constructed with support from the US Centers for Diseases Control (CDC).

Disease Outbreaks

Yellow fever : On 24/03/2015 Masaka district alerted MoH of a strange illness that had killed 3 people in in one family. Investigations confirmed yellow fever. Response including case management at Masaka RRH social mobilization and active case finding are ongoing. By 15th March 2015, a total of 18 suspected cases including 5 laboratory confirmed cases, with 9 deaths (CFR=50%) were documented. Buwungu subcounty is the most affected (attack rate=)

EDITORIAL

Dear Reader,
Welcome to the second issue of the quarterly epi- demiological bulletin of the Uganda National Institute of Public Health (UNIPH). This bulletin aims to inform district, national and global stakeholders on the public health interventions under- taken in disease prevention and control. In this issue, we share with you some highlights such as the supplemental polio im- munization campaign, and a number of outbreaks responded to and investigated such as Rift Valley Fever (RVF) in Kabale district, Podoconiosis, Measles among others. We also bring you an Evaluation of Acute Flaccid Paralysis Surveillance System in Northern Uganda – a very timely assessment as the country transitions to the bivalent Polio vaccine and also introduces the inactivated Polio Vaccine. In case you would like to access references used in this issue, feel free to contact us at: lnabuken- ya@yahoo.com OR ckihembo@musph.ac.ug. We will appreciate any feedback regarding the content and general outlook of this issue and we will be delighted to hear from you. 

Thank you.

Discussion: Podoconiosis has been documented to be as a result of interplay between environmental risk and personal factors that predispose an individual to prolonged exposure with irritant soils[2, 5, 6].
In this study we found that much as there were no differences in occupation among cases and controls, not wearing shoes while at work or at home before onset of the disease was strongly associated with disease. More still those who wore gumboots while at work where there is maximum risk of exposure, and those who washed to get rid of soil from their skins by quickly washing their feet were less at risk of Podoconiosis.
This is in keeping with previous studies conducted in Ethiopia[7-9]. Unlike in the previous studies, this study however found no association between floor cover and disease.

Podoconiosis has been noted to have a genetic predisposition. Our investigation also found family clustering of the disease[3]. Much as more case -persons reported knowing at least one family member who had experienced similar symptoms, the association was not statistically significant when stratified in line of blood relations. The observed clustering could therefore be explained by family members being experiencing same risk factors.
Important to note is the fact that much as the case patients were observed to be using shoes after disease had been established, children and the general population in Kamwenge remained at risk, going about their business while with bare feet. Moreover, household members and other members of the public interfaced with during the study expressed not being in position to afford gumboots or shoes.

Introduction: Measles is a highly contagious infection spread by droplet transmission.. In 2013 there were 145,700 measles deaths globally, majority of whom were below 5years [1]. From January – August 2015, Uganda experienced measles outbreaks in several districts in the western region including Kyenjojo, Mubende ,Isingiro and Kamwenge[2]. On 18 August 2015, Kyegegwa District reported a cluster of 8 suspected measles deaths. We went out to investigate the causes and risk factors for deaths in this outbreak.

Methods: We defined a probable measles diagnosis as onset of high fever (≥38OC), generalized maculopapular rash plus any of: conjunctivitis, cough or coryza between 1st February and 15th September in a Rwentuha sub-county Kyegegwa District resident; a case, as a death in a child (<5 years) with a probable measles diagnosis in the same period, and a control

as a child (<5years) with a measles diagnosis in the same period who survived. We rigorously searched for cases and controls by working together with the village health team members. Using standard questionnaires, we interviewed parents/caretakers for both case and control-persons and also reviewed patient’s records. It is scientifically known that prior measles vaccination and vitamin A supplementation during illness reduces the se- verity of illness and thus risk for measles death. Additionally malnutrition, young age and inadequate treatment are risk factors for mea- sles deaths.
We subsequently reviewed vitamin A supplementation during illness, treatment according to standard guidelines and mea- sles vaccination status among 16 cases and 48 controls-persons matched by age and village of residence in a case control study. We col- lected blood specimen for measles diagnosis from the sick children.

Discussion : Our findings indicated that deaths were under the age of five (>5), indicating great danger of measles to infants as compared older age. These findings are in line with a study conducted in Niger, Nigeria and Chad [3, 4].The study also showed that a big proportion of deaths were not vaccinated. For the small fraction of cases who were vaccinated, it could have been ineffectiveness of vaccine as a result poor storage. For instance, towards the end of 2014, there was a cold chain break down in the district which could have affected the quality of vaccine. Meanwhile, almost a quarter of the cases were below vaccine eligible age (9 months) recommended for measles vaccination in Uganda. A numbers of factors affect the vaccination performance in the study area like in the study conducted in Nigeria [5]. Those identified include; people’s negative perception towards vaccine, distance to the health centers, poor health education and poverty, and inadequate health facilities and personnel in the area of study. It was revealed that that Vitamin A supplementation

during illness plays great role in boosting immunity, lack of vitamin A supplementation was associated with death of measles patients in this investigation and elsewhere [6]. Our findings also revealed that less than 10% among the deceased compared to 92% sought treatment from health facilities.
This was in line with the high numbers of deaths that occurred at home compared to those that took place at health facilities. Similarly, the study done in Niger, Nigeria and Chad, 6% did not report to the any health facility citing reasons such as poverty, distance and ignorance [3].
The high percentage of death that occurred at home suggests that the locals still trust traditional treatment to conventional medicine in the cure of measles. It was noted that the community believed in the myth “ that a measles case would die if at all he/she crossed a road.” Others believe that treating measles with an injection causes death”. Tradition- al behaviors in the study area influence the management of measles as in many other less developed countries [7].

Introduction: Uganda documented the first cholera outbreak in 1971[1]. Since then, the country has experienced sporadic cases and localized cholera outbreaks, occasionally resulting in prolonged widespread cholera epidemics. The frequency of these reported cholera cases varies among districts in Uganda [2].The most at risk areas include the border areas neighboring the democratic republic of Congo (DRC), Sudan and
Kenya as well as urban slums in Kampala.

Methods: On 20th June2015 Kasese District reported a cholera outbreak affecting more than 30 people within five(5) days in Katwe-Kabatoro Town council, Kasese district. We conducted an investigation to establish the mode of transmission and to recommend evidence-based control measures.
Katwe Kabatoro Town Council is located in Busongora South County in Queen Elizabeth National Park, Kasese district. The study population consisted of community members in Kyarukara village in Katwe-Kabatoro Town council.

We defined a suspected cholera case as onset of acute watery diarrhea in a Katwe Kabatoro Town council resident from 01st June 2015 onward; a confirmed case was a suspected case with culture-confirmed Vibrio cholerae in a stool sample.
We actively identified cases by visiting affected community and up- dated line -lists obtained from the cholera treatment center. We assessed sources of water for drinking and for household use and assessed human waste disposal practices. We conducted descriptive analysis and interviewed 10 random case-patients on food and water exposures during the most likely exposure period.

Analytic study: In a case control study, we compared drinking water source points among 36 cases and 179 controls. Controls were asymptomatic Kyaruka village residents.
One case per household was selected using simple random sampling in instances where there was more than one case

Introduction: On 24th November 2014, two cases of circulating vaccine-derived poliomyelitis were identified in South Su- dan bordering Uganda to the north. The strains were isolated from two acute flaccid paralysis (AFP) cases. Poliomyelitis is an infectious disease, highly communicable and infected persons can spread the disease for up to six weeks. The last poliomyelitis case in Uganda was in 1996 and Uganda was declared poliomyelitis-free in 2006. However there was WPV importation from South Sudan 2009 and from Kenya in 2010 and 2011. We therefore need to assess the effectiveness of the AFP surveillance system in the districts bordering South Sudan in responding to the imminent threat of poliomyelitis. The AFP surveillance system should entail investigation of all AFP cases within 48h of paralysis onset followed by collection of two adequate stool samples within 14 days of onset. The two stool samples should be received at a WHO accredited lab within three days of being sent and results sent within 28 days of being received. The investigation is completed by 

following up the cases investigated 60 days after initial investigation.
Methods: We defined an AFP case as sudden onset of weakness and floppiness of any limb in a child <15 years or paralysis of a person of any age in whom poliomyelitis is suspected. We found cases by AFP case investigation forms from 2012 to 2015. We also cross referenced the cases analyzed by the laboratory with those found in the records. The districts involved were Amuru, Moyo, Kitgum, Lamwo, Adjumani, Koboko and Yumbe. We analyzed the data to show surveillance performance indicators such as annualized non-poliomyelitis AFP rate /100 000 children <15 years, percentage of AFP cases with two adequate stool specimens collected 24-48 hours apart and <=14 days after onset, percentage of specimens arriving at a WHO-accredited laboratory within three days of being sent and percentage of specimens for which laboratory results sent within 28 days of receipt of specimens. These are WHO standard indicators and have been used in evaluations elsewhere (1, 2).

Discussion: The evaluation revealed that 88% of cases had received at least 3 poliomyelitis vaccine doses. Poliomyelitis immunization coverage is a critical indicator of poliomyelitis prevention efforts. The rationale is that if a sufficient number of people are vaccinated, then transmission can be interrupted and outbreaks can be prevented from occurring. In northern Nigeria between 2003 and 2004, there was a suspension of all immunization activities because the locals rumored a link between the immunization and infertility and the human immunodeficiency virus (3). The drop in immunization coverage created a gap in the herd immunity that was insufficient to interrupt transmission which led to several poliomyelitis outbreaks (4). Nigeria has in fact remained on the list of vulnerable countries at risk of importation of poliomyelitis (5). The poliomyelitis endgame requires that every last child is fully vaccinated against poliomyelitis. Routine immunization in these districts should be fortified with house to house and extensive house to house and child to child mop-up immunization campaigns of all children <5 years to ensure 100% immunization coverage.
Another indicator of the efficiency of poliomyelitis surveil- lance is the annualized non-polio AFP rate of >1 /100,000 children <15. It refers to the incidence of AFP due to illnesses other than polio. In 2012, Adjumani and Moyo districts had an annualized non-Poliomyelitis AFP rate less than 1/100,000 children under 15 years. By 2015, all districts but Kitgum had annualized non-Poliomyelitis AFP rates ≥1/100,000 children <15 years.
This implies that there has been a steady increase

in the effective- ness poliomyelitis surveillance in the districts over the years. In this evaluation, none of the forms were filled for date of 60-day follow up and findings at 60-day follow up. This implies that while district surveillance focal persons make an effort to investigate AFP cases, there is reluctance to follow up the cases after collection and delivery of stool specimens at the lab. A distinguishing feature of paralytic poliomyelitis is that an infected person remains a carrier for several weeks (6) and paralysis could persist even after 60 days (7). The reluctance of surveillance personnel in following up cases after 60 days might be because they don’t see the need after they receive negative results from the lab. However the AFP cases could indicate outbreaks of paralytic neurological illnesses (such as Guillain-Barre syndrome, transverse myelitis, or tumors) among children <15 years (8) in those districts.
Koboko, Lamwo and Moyo performed poorly when it came to timely investigation of the AFP cases. In Lamwo and Moyo, most of the stool specimens were received at the lab after more than 3 days of being sent. On the roadmap leading to the eradication of poliomyelitis in the Americas, from 1992 until eradication, ≥80% of AFP cases were investigated within 48hours of notification (9). Also, the pro- portion of with adequate stool specimens collected gradually in- creased and consequently the number of wild poliomyelitis viruses reduced. The Ministry of Health should lobby for resources to be given to surveillance focal persons on delivery of stool samples that will ensure that AFP cases are investigated, the samples collected and received on time at the lab

Introduction: Cholera is an epidemic potential diarrheal dis- ease caused by gram negative bacteria, Vibrio cholerae. The pathogen produces a toxin which causes severe loss of water in patients [1, 2]. . Each year cholera outbreaks occur in Uganda with annual average of 11,000 cases and 60-182 deaths. Rural areas of Uganda particularly areas neighboring the Democratic Republic of Congo are prone to cholera outbreaks because of interaction of people from different traditional settings with diverse hygiene and sanitation practices [3]. Lake side areas have been described to be hot spots of cholera epidemics during heavy rainfall compared to others areas. Generic public health actions are frequently used in cholera epidemic responses without detailed field investigations to address the source and mode of transmission. This could partly explain why cholera outbreaks have occurred repeatedly in the same areas. 

In this article, we report a case where field investigation of a cholera outbreak generated evidence based recommendations that promptly controlled the outbreak.
On 12th October2015, the District Health Officer Hoima district reported an outbreak of cholera in Kaiso fishing village, located on the shoreline of Lake Albert. The disease had killed 2 people and many others. The district and the Ministry of Health responded by setting up a cholera treatment center (CTC) in the village and sensitizing the community.
Despite three weeks of the response, the number of cholera cases continued to increase till over 120 cases were reported and the outbreak persisted.
We conducted an epidemiological investigation to identify the source and mode of trans- mission in order to recommend evidence-based interventions to stop the outbreak.

Methods: Kaiso village is located in Buseruka Sub-county on the shoreline of Lake Albert, Hoima district. The village is made up of three zones, Fichama, Songa-Bakobya and Songa-Lendu. The major tribal groups are the Bagegere, Bakobya, Alur, Banyoro, Ba- gungu and Congolese tribes. The village has estimated population of 9000 people. Songa-Lendu has a population of 6500, Songa- Bakobya 2000 and Fichama 500.The major economic activities are fishing and casual businesses. The village settlement has a sloping landscape extending from the escarpment of the western rift valley to the shoreline of Lake Albert. Latrine coverage in the village is low (10%), hence open defecation is a common practice.
We defined a suspected case as onset of acute watery diarrhoea in a resident of Kaiso Village from 1st October 2015 onward; a con- firmed case was a suspected case with Vibrio cholerae isolated from stool. We line listed a total of 122 cases from the Cholera treatment center and community. We conducted a descriptive analysis of the updated line list to characterize the

outbreak by person, place and time. Out of the 122 cases line listed, we ob- tained information from 80 who were present in the village by then. We obtained rainfall data from Kabwoya wildlife reserve weather station Located 2 km from Kaiso village.From findings of descriptive epidemiology, we generated a hypothesis that drinking untreated lake water was the source of the outbreak.
We carried out a case control study in which we inter- viewed 60 cases (aged 5 years and above) and 124 village controls using a structured questionnaire to test our hypothesis. Controls were residents of Kaiso village without acute watery diarrhoea within the same period of our case definition. We asked cases and controls questions on the sources of drinking water and history of boiling or treatment of water prior to the outbreak .
We inspected shore line water collection sites in the three zones of the village to assess possible sources of contamination. We also observed practices of human fecal disposal in the village, alternative sources of water and latrine coverage.