July – September 2016

Uganda Declares End of Yellow Fever Outbreak

On 6th September, 2016 the Ag. Director General Health Services Prof. Anthony K. Mbonye, released a press statement declaring the end of the yellow fever outbreak which had begun in March 2016. On 24th March 2016, an alert of a suspected Viral Haemorrhagic Fever (VHF) outbreak in Masaka district (Kaloddo village) was received by the Ministry of Health through the Public Health Emergency Operations Centre (PHEOC). Three cases from a single family had presented to Masaka Regional Referral Hospital with high-grade fever that was non-responsive to anti-malarial treatment with haemorrhagic and acute neurological signs and symptoms (convulsions and unconsciousness).

A rapid response team (RRT) from MoH head- quarters was deployed immediately to work with Masaka District Health Office to further investigate and respond to the suspected outbreak. The Masaka district task force was activated, a treatment centre set up at Masaka Region- al Referral Hospital, active community case finding conducted and more samples collected and referred to the Uganda Virus Research Institute (UVRI) for laboratory testing. On 7th April 2016, Yellow Fever was confirmed. Intensified surveillance also confirmed Yellow Fever in Rukungiri and Kalangala districts on 13th April 2016 and 4th May 2016 respectively. Subsequently, from 24th March to 4th May 2016, 65 suspected Yellow Fever cases were reported from districts in the greater Masaka region, out of which 7 cases were confirmed. These were from Masaka (5), Rukungiri (1) and Kalangala (1). Three of the confirmed cases died giving a case fatality rate of 4.6%. With support from World Health Organization (WHO), CDC, Yellow Fever Vaccination in the three affected districts. Between May-June 2016. A total of 627,706 people (≥6months) were vaccinated; 273,447 in Masaka, 304,605 in Rukungiri district and 49,654 in Kalangala. Overall, a vaccination coverage of 94% (above the WHO recommended 90% coverage) was achieved in the 3 districts; Masaka-91%, Rukungiri-97% and Kalangala-95% . There has been no evidence of subsequent active Yellow Fever since then.

Uganda Excels at the 2016 AFENET Conference

Every two years, Field Epidemiology and Laboratory Training Pro- grams (FELTPs) are presented with a strategic platform to show- case their contribution to the public health community via the AFENET scientific conference.
The conference also provides an opportunity for Residents and graduates of FELTPS to network with other stakeholders as they develop a common agenda to address critical public health challenges in Africa and beyond.

The 6th AFENET scientific conference under the theme “ Enhancing Global Health Security through Field Epidemiology Training Programs” was held be- tween 8th and 12th August 2016 at the Transcorp Hilton Hotel Abuja, Nigeria and Uganda scooped two (2) awards. Residents and FELTP graduates made outstanding presentations

Inside this Issue;

Dr Monica Musenero |
ACHS ESD, Ministry of Health


Dr Immaculate Nabukenya |
ESD, Ministry of Health


Dr Alex Riolexus Ario |
Ag. Director, Uganda National 
Institute of Public Health, 
Ministry of Health


Dr Christine Kihembo |
FETP Fellow, ESD Ministry of Health


Lilian Bulage |
FETP Fellow, CPHL Ministry of Health


Dr Ben Masiira |
FETP Fellow, ESD Ministry of Health


Allen E. Okullo |
FETP Fellow, NMCP Ministry of Health

Susan Nakubulwa |
FETP Fellow, Mildmay Uganda

Jimmy Ogwal |

Continued from Page 1

on outbreak investigations and research on issues of public health priority. Over 360 scientific presentations on current public health issues such as IHR, Global Health Security Agenda, antimicrobial resistance, one health concept, building resilient public health systems among others were made at this conference. Uganda was ably represented by a delegation from the Ministry of Health led by the Minister, Hon. Jane Ruth Aceng, Fellows from the Public Health Fellowship Program, graduates from the Makerere University School of Public Health, epidemiology subject matter experts among others.

Conference highlights

Several Ministers of Health attended the conference and held a ministerial dialogue on how to improve IDSR in their respective countries through FELTPs.
Special emphasis was put on the recent Ebola pandemic in West Africa specifically the nature in which the outbreak was swatted in Nigeria.
Several networking activities were held including an international and cultural night where participants showcased their unique cultures and a sports gala

Risk factors associated with typhoid intestinal perforations during a large outbreak of typhoid,
Kampala Uganda, 2015

L. Bulage1 , B. Masiira1, A. R. Ario1, F. Kaharuza2, V. Nankabirwa3
1Public Health Fellowship Program, Kampala, Uganda, 2African Field Epidemiology Network, Kampala, Uganda, 3Makerere University
School of Public Health, Kampala, Uganda

Between January-June, 2015, a large typhoid outbreak occurred in Kampala, causing 10,230 suspected infections. An increase in the number of intestinal perforations (TIP) was observed by surgeons during the 2015 outbreak period. In this study, we ascertained if there was an increase in the number of TIP and identified risk factors associated with TIPs during a large outbreak of typhoid fever that occurred in Kampala in 2015. A sharp increase in the number of both TIPs and other IPs was observed between January to March 2015. Delay in seeking treatment, self medication, not having heard of typhoid before and not being aware of the typhoid outbreak increased the risk of TIPs. We recommended active community case finding for early and appropriate treatment, health education about typhoid fever and TIPs, and raising awareness among physicians about the risk of perforations during future typhoid outbreaks.

RESULTS: Of the 88 TIP cases identified, 77% (68/88) occurred during the outbreak period. Both TIPs and other IPs sharply increased in January and peaked in March, coinciding with the outbreak period (Figure 1). The prevalence of TIPs and other IPs during the outbreak period was each estimated to be 5

TIPs/100,000 population (68 TIPs, 70 other IPs/1,516,210). The case fatality rate for TIPs was 10% (7/68). Compared with 29% (13/45) of cases and 63% (86/137) of controls who sought treatment with- in 3 days of onset, 42% (19/45) of TIP cases and 32% (44/137) of controls sought treatment after 4-9 days (ORadj=3.0, 95% CI=1.3-6.3); 29% (13/45) of cases and 5.1% (7/137) of controls sought treatment after ≥10 days (ORadj=12, 95%CI=4.1-37). Additionally, 57% (26/46) of cases and 31% (43/137) of controls had self-medication (ORadj=2.9, 95%CI=1.4-6.2); 36% (25/39) of cases and 18% (116/142) of controls had not heard about ty- phoid (ORadj=2.5, 95%CI=1.1-5.5); and 59% (23/39) of cases and 25% (35/142) of controls had not heard about the typhoid outbreak in Kampala (ORadj=4.9, 95%CI=2.0-12).

In conclusion, a sharp increase in the number of both TIPs and other IPs was observed between January 2015 and March 2015. Delay in seeking treatment, self medication, not having heard of typhoid before, not being aware of the typhoid outbreak increased the risk of TIPs.
Recommendation. We recommended active community case finding for early and appropriate treatment, health education about typhoid fever and TIPs, and raising awareness among physicians about the risk of perforations during future typhoid outbreaks.
The study presents two public health implications. As noted above, limited information about typhoid fever and the typhoid outbreak, and delay in seeking health care were strongly associated with TIPs. This suggests that we have an opportunity to reduce the burden of TIPs if only we improve access to care and management by ensuring appropriate and prompt antibiotic use and putting in place better surgical facilities.

References: 

1. Wain J, Hendriksen RS, Mikoleit ML, Keddy KH, Ochiai RL. Typhoid fever. Lancet (London, England). 
2015;385(9973):1136 -45.

2. Ekenze SO, Ikefuna AN. Typhoid intestinal perforation under 5 years of age. Annals of tropical 
paediatrics. 2008;28(1):53-8.

3. Van der Werf TS, Cameron FS. Typhoid perforations of the ileum. A review of 59 cases, seen at 
Agogo Hospital, Ghana, between 1982 and 1987. Tropical and geographical medicine. 1990;42(4):330-6.

4. Butler T, Knight J, Nath SK, Speelman P, Roy SK, Azad MA. Typhoid fever complicated by intestinal 
perforation: a persisting fatal disease requiring surgical management. Rev Infect Dis. 
1985;7(2):244-56.

5. Van Basten JP, Stockenbrugger R. Typhoid perforation. A review of the literature since 1960. 
Trop Geogr Med. 1994;46(6):336-9.

6. WHO Guidelines for the regulatory assessment of Medicinal Products for use in 
self-medication. 2000

A Rapid Health Assessment of Refugees in Adjumani district, August 2016

Susan Nakubulwa1, Joy Kusiima1, Andrew Illukol2, Esther Kisakye2, Robert Oliga2, Ivan Masete2, Ibrahim Wabembere2, Joyce Nguna3, Daniel Kadobera1
1Public Health Fellowship Program – Field Epidemiology Track, 2 Makerere University School of Public Health,
3 Ministry of Health – Epidemiology and Surveillance Division

Fresh political clashes in South Sudan in June 2016 led to a large influx of refugees to Uganda through the Elegu border post in Adjumani district. 41,154 refugees entered Uganda in July 2016, leading to an overstretch on supplies like water and shelter, posing a risk for communicable diseases outbreaks. The Ministry of Health (MoH) conducted a Rapid Health Assessment in Adjumani district on refugees who arrived in Uganda from June to August 2016 in order to; access their general health status, identify potential public health threats and service delivery gaps and recommend public health actions for rapid response. Findings revealed a shortage of community workers, health workers, shelters and human waste disposal facilities. Refugees had poor hygiene practices and a negative attitude towards health services. In conclusion, there was a shortage of health workers, shelter and waste disposal facilities for the refugees and they had poor hygiene practices. The recommendations were to increase health facility staffing levels, decongest the refugee reception centers, construct more pit latrines and provide health promotion packages ad-

FINDINGS Coordination; There was a high level of coordination and communication between the Adjumani District Health team and Implementing Partners regarding refugee related affairs. There were daily inter-organization meetings at health facilities and Patient management: There was a shortage of human resources for health; the Nurse: Population ratio was 1:2000 , Clinical Officer: Population ratio was 1:6725. These were overstretched given the frequent demand for medical attention. There was a negative attitude towards HIV prevention services like condom use and care services like ART. At Elegu border, there was triage and deworming for all, immunization of polio (0-5 years) and measles (6 months to 15 years), TT for expectant mothers, Nutritional assessment and Vitamin A supplementation (children 6 – 59 months)

Treatment protocols: There were no job aides and treatment e.g., Uganda Clinical Guidelines and IMCI charts.
Maternal and child health services: Pagirinya HC III offered maternal delivery services and Expanded Program on Immunization (EPI) services. Expectant mothers were provided with mosquito bed nets. Ambulances services on call for emergency referrals was available. It was noted that mothers delayed or failed to consent for caesarean sections as they relied on and waited for husbands’ consent, some of whom were soldiers way on duty back home in Sudan. Uptake of PMTCT services was poor.
Disease surveillance: Weekly Health Information System (HIS) reports were submitted by health facilities to Medical Teams International (MTI) . MTI was officially contracted by UNHCR to handle health related issues among refugees. MTI disseminated HIS reports to the Adjumani District Health office and other Implementing Partners (IPs). There had been cholera outbreak in the sites and by assessment time 16 suspects cases had been documented. Consumption of contaminated water was suspected to be the driver of the outbreak.
Infection control and medical supplies: Hand washing facilities with soap were available at health facilities. There was evidence of segregation of medical wastes in separate boxes although the waste cans were inadequate in number. There were no incinerators for disposal of medical waste. However, there was sufficient supply of medicines with a broad range of antibiotics, basic medical equipment and supplies such as gloves at health facilities.
Nutrition services: Nutrition assessment conducted on 7,275 children revealed Severe Acute Malnutrition in 2%, Moderate Acute Malnutrition in 4.9% . Global Acute Malnutrition among children was 6.8%. Nutrition surveillance was in place and food for lunch and supper was served only once a day. This meant cold food was consumed aiding transmission of food borne illnesses.
Shelter: There was overcrowding within the shelters at the reception centers.
Water, Sanitation and Hygiene (WASH): There was open defecation at reception centers. The water supply was over stretched . Each at Pagirinya received 7.8 litres of water per day (15 litres/day recommended). Some refugees resorted to use of river water for household use. Open pits and incomplete latrine pits with stagnant water were observed at reception centers. Pit latrines and hand washing facilities were available but insufficient in number.
Individual refugee interviews: The median age of inter- viewed refugees was 24 years. 42% (82/197) were males, 67% (131/197) of the refugees reported having health problems with cough as the prominent symptom in 20% (40/197). 37% (49/131) of those with health problems had not accessed health services. They of basic commodities like jerry cans 68% (134/197), soap 79% (156/197) and blankets 84% (166/197).
Dissemination of findings for policy engagement :The findings were disseminated at feedback meeting in Adjumani on 12th August 2016, MOH National Task Force meeting on 16th August, 2016, the inter-agency meeting on South Sudan, Office of the Prime Minister, Department of Refugees on 17th Au- gust, 2016 among others

Burden of Cancer in Kampala, Uganda: Common Types, Incidence and Trends

Leocadia Kwagonza1*, Daniel Kadobera1, Annet Nakaganda3, Mary Phoebe Amulen2, Joy Kusiima Bbaale1, Sarah Nambooze2, Henry Wabinga2.
1Public Health Fellowship Program 2 Kampala Cancer Registry 3Uganda Cancer Institute

Comprehensive data on the burden and trends of cancer to inform public health action is limited in most Eastern African countries. The Kampala Cancer Registry (KCR) was established to fill this gap in Uganda. We described the trends, incidences, and morphological verification of top five cancers in males and females using data from Kampala Cancer Registry. We extracted data from the KCR CANREG5 system into EPI Info V7.2 for analysis. From January 2009 to December 2013, 8,168 new cancer cases were registered. 55% (4522/8168) were female. Cancer of the Cervix in females and Prostate in males were leading cancers while Kaposi Sarcoma affected mostly young age groups equally. The Morphological Verification was 54.3%. This study demonstrated that cancer is an important Public Health problem with high incidences. Cervical, KS and Prostate cancer are the leading cancers. We recommend integration of cancer screening services in HIV programs.

Methods: KCR covers Kyadondo County is comprised of Kampala district and surrounding Wakiso district. The population is mainly Baganda (50%); 30% are other ethnic groups from Uganda and 20% of immigrants from other countries. We used the UBoS 2010 census data and assumed that the population was stable over the study period. Total population was 2,100,305 (995,601 males and 1,104,704 females with the younger age groups being the majority. We extracted KCR records from 2009 to 2013. Data at KCR is extracted from health facilities, histopathology laboratories, and palliative centers such as Hospice Uganda.

Results: Between 1st January 2009 and 31st December 2013, 8168 new cases were registered. Of these, 55.4% (4522/8168) were females. 58% (4554/8168) of the new cases contributed to the top five cancers among males and females.
Top five cancers: Among females, Cervical cancer was most incident cancer at 20/100,000.followed by Breast, Kaposi Sarcoma, Esophagus and Ovarian cancer. Among males, Kaposi Sarcoma had the highest annual incidence of 18 per 100,000 Populations followed by Prostate, Esophagus, Leukemia and liver cancers.
Cumulative incidences of top five cancers: Among females, cervical cancer had the highest cumulative incidence of up to 6.4% followed by breast, Kaposi Sarcoma, Esophagus and Ovarian as shown in figure 2a. Among males, Prostate cancer had the highest cumulative incidence followed Esophagus, Kaposi sarcoma, Leukemia and Liver cancer.t

Trends in incidence of top five cancers: There were more incident cases of Cancer of the cervix registered in 2012 and 2013, compared to the incidence registered during the previous years. Kaposi Sar- coma (KS) was highest among cancers in Males as shown in Figure 1.0.
There was a gradual increase in the incidence of cancers with increase in age. Whereas majority of cancers affected the older age- groups, KS was more frequent among the younger age-
groups and then declined among adults as shown in the figures below.

Discussion: This study demonstrated that cancers are a important public health problem with high incidences in both men and women. Cancer of the cervix, prostate, breast and KS were the most incident cancers. Incidence of KS and cervical cancer is partly fueled by high HIV prevalence in Kampala and Wakiso Districts [5]. Several studies now clearly demonstrate an increased risk of pre-invasive cervical lesions among HIV- infected women [6] and the incidence of Kaposi Sarcoma among HIV patients. KS remains the most common AIDS- associated neoplasm [7]. AIDS-associated KS occurs with in- creased frequency in all HIV transmission groups compared with the general population[7].
The increased incidence in the trends of cancer in 2012 was due to the enhanced screening programs for both breast cancers and cervical cancer within Kyadondo county and neighboring com- munities and the launching of Uganda Breast Cancer early detection project at Fred Hutch cancer institute in Mulago [8].
The fairly good MV of cancers in the registry shows that a good number of cases are being captured through clinical assessment. Kaposi Sarcoma had the highest percentage Morphological Verification of 70%.

Kaposi sarcoma, one of the commonest cancers is much easier to diagnose clinically compared to other cancers. Leukemia had the lowest % MV of 29% yet it is expected to be diagnosed cytologically. Ideally we would have expected the leukemia %MV to be over 70%. This means that nonspecific methods such as clinical assessments, death certificates, or blood cell count are the basis of diagnosis for leukemia. This has implications of either under reporting or over reporting of leukemia.

Conclusions and recommendation: Cervical cancer in females and Prostate cancer in males remain the leading cancers. Prostate cancer was most common among the elderly men while Kaposi Sarcoma affected the younger age groups in both males and females equally. The MV of cancer cases in the cancer registry was fair. We recommended integration of cancer screening into HIV programs to enhance early detection and treatment and enhanced advocacy for cancer screening programs .

References: 

1. World Health Organisation, GloboCan: Estimated Cancer incidence, mortality and prevalence 2012.
2. World Health Organisation, WHO International Agency for Research on Cancer (IARC): Globocan 
2008 Report IARC: Lyon; . 2008.

3. World Health Organisation, Cancer fact sheet no. 297. Geneva: 2011.

4. Msyamboza KP, N.B., Dzowela T et al., The Burden of Selected Chronic Non-Communicable Diseases 
and Their Risk Factors in Malawi: Nationwide STEPS Survey. PLoS One 2011, 6(5):e20316. 2011.

5. UBoS, Uganda AIDS Indicator survey. 2011.

6. Chirenje, Z.M., HIV and cancer of the cervix. Best Pract Res Clin Obstet Gynaecol, 2005. 19(2): 
p. 269-76.

7. Krown, S.E., Highly active antiretroviral therapy and incidence of cancer in human 
immunodeficiency virus-infected adults. . J Natl Cancer Inst, 2000. 92:1823-30.

8. https://www.fredhutch.org/en/news/center-news/2012/04/lehman-ge-uganda.html. Accessed on 15 
August 2016.

Awareness, Attitudes and Current Practices Related to Uganda’s Tobacco Control Act 2015 Prior to its Enforcement in Restaurants and Bars in Kampala City

1*Steven Ndugwa Kabwama, 1Daniel Kadobera, 2Sheila Ndyanabangi, 3David Guwatudde
1Public Health Fellowship Program, Field Epidemiology Track, Ministry of Health 2Mental Health and Control of Substance Abuse, Minis- try of Health 3Makerere University School of Public Health, Department of Epidemiology and Biostatistics

Summary: On 19 September 2015 the President of Uganda signed the Tobacco Control Bill 2014 into the Tobacco Control Act 2015. We assessed attitudes and awareness about the Act and current practices related to tobacco use and tobacco smoke exposure prior to implementation. The study involved 216 interviews and observations from 218 randomly selected estabishments around Kampala City. 61.5% of respondents were either unaware about the law or had a misconstrued message. Among respondents that self-acknowledged having sufficient information, 70.2% got it from media such as Radio, TV and print media. 39.4% agreed that the law would lead to financial losses. 63% of establishments that allowed for tobacco use on premises had designated smoking zones. 26.6% had in-door smoking and 11% had visible tobacco promotion and sponsorship signs. Although the new law has come into effect, the public is still not aware about it. We recommend dissemination and advocacy of the law to business owners and the public.

Discussion and Conclusions: The study found that 61.5% of respondents were either unaware about law or had a misconstrued message about the law.

There is a need for the government to disseminate the law. Although the public has responsibility of being aware about new legislation, an effective information program will ensure that owners of public places and clients are appropriately informed and not left vulnerable to the penal ramifications of violating the law [2]. Among those who felt adequately informed, most (70.2%) got it from media such as radio, television and newspapers. According the Uganda Demo- graphic Health Survey [3], in Kampala, 41.1% of women and 57.7% of men read a newspaper at least once a week, 77.4% of women and 88.7% of men watch television at least once a week and 73.5% of women and 86.1% of men listen to radio at least once a week.  This high level of media access presents an opportunity for how the new legislation can be disseminated.

The study also found that although 50% of establishments did not allow for products to be smoked on premises, only 17% had notice- able no-smoking signs. No-smoking signs deter initiation of smoking where it is prohibited [2]. Although some studies have found No-smoking signs deter initiation of smoking where it is prohibited [2].

Although some studies have found minimal changes in smoke exposure after placement of no-smoking signs [8, 9], others have found evidence of less smoking [10]. As the new legislation is being disseminated, owners of public places need to be informed of their responsibility to place no- smoking signs.
11% said they conducted tobacco product promotion. Tobacco product marketing promotes the initiation, continuation and re-uptake of smoking [14].
It has been shown that regulation of tobacco product marketing significantly decreases smokers’ awareness of pro- smoking cues [15]

Recommendations:
The National Tobacco Control Program should utilize media to disseminate and publicize the Tobacco Control Act.

References: 

1. Poluyi EO, Odukoya OO, Aina B, Faseru B. Tobacco related 
knowledge and support for smoke-free policies among community pharmacists in Lagos state, 
Nigeria. Pharmacy practice. 2015;13(1).

2. Goodin M, McAllister I. Evaluating compliance with Australia's first smoke-free public places 
legislation. Tobacco Control. 1997;6(4):326-31.

3. Inc UBoSaII. The Uganda Demographic and Health Survey 2011. Kampala Uganda: UBOS and Calverton, 
Maryland: ICF International Inc, 2012.

4. Simpson D. Smoke-free laws do not harm profits: new global report. Tobacco control. 
2005;14(4):220

5.Dearlove JV, Bialous SA, Glantz SA. Tobacco industry manipulation of the hospitality industry 
to maintain smoking in public places. Tobacco control. 2002;11(2):94-104.

6. WHOFCTC WHOFCoTC. Guidelines for implementation of article 8. Guidelines on the protection 
from exposure to tobacco smoke. 2015

Measles outbreak and associated risk factors for measles transmission in Kamuli district, July
2016

Lydia Nakiire1,2, Paul Okello1, Fred Nsubuga1,4, Issa Makumbi2, Joan Kalyango5, Alex R. Ario1
1Public Health Fellowship Program, Field Epidemiology Track, Kampala, Uganda
2 Public Health Emergency Operation Center, 3Centers for Disease Prevention and Control , 4Uganda National Expanded Program on Immunization, 5Makerere University college of Health sciences

Summary: The Ministry of Health was notified of a measles outbreak in Kamuli district on 11th July, 2016. We con- ducted an investigation to establish the scope of and risk factors for the outbreak, estimate district measles vaccine effectiveness and vaccine coverage. We estimated the vaccine efficiency and measles coverage and in a case control study we compared exposures of 25 cases individually matched by age and village of residence with 100 asymptomatic controls. Children under 5years had the highest attack rates (5.3/ 10,000) compared to those 5 years and above (1.1/10,000). Butansi Sub County was the most affected (15cases/10,000 population). Lack of prior measles vaccination was associated with measles cases (ORMH= 6.8, CI: 1.8- 25). The estimated vaccine effectiveness was 82% and district immunization coverage was 58%. Lack of prior measles vaccination caused the measles outbreak. Measles vaccination coverage was lower than the recommended 90% national coverage. We recommend intensification of measles vaccination in the district.

Results: Children under 5 were most affected. No adults were affected in the outbreak. Males and females were equally affected with the attack rate of males slightly higher than that of females. ( table 1). Butansi sub-county was the most affected rate of 15/10000, followed by Kamuli Municipal Council with attack rate of 2.8/10000 as shown in figure 1.

The epidemic curve shows a propagated outbreak with the index case occurring on 5th June 2016. (figure 2). The probable index case was a 3 year old male from Buleta village, Bugeywa parish in Butansi subcounty. Successive peaks are observed on 27/06/16 and 17/07/16 with higher prevalence in each successive cluster.

Case control study findings: A case control study among 25 cases and 100 controls , ratio 1:4, revealed that not being vaccinated was associated with the measles. 21/25 (84 %) of case- patients and 51/100 (51%) of controls having measles, ORMH = 6.8, 95% 1.8-25) as shown in table 2: Visiting a school or church during the effective exposure period was associated with the diseases though this was not statistically significant.
Vaccination coverage: The proportion of cases line listed who were vaccinated was 12/71 (17 %). We computed the proportion of population vaccinated (PPV) using population of cases vaccinated (PCV) and assumed vaccine efficacy (VE) 85%.
PPV = PCV/(1-PCV) * VE
Assumptions made: the vaccination rate in case patients with unknown vaccination history was the same as in case patients with known vaccination history, ii) the case patients with un- known vaccination status were not vaccinated. The Proportion of population vaccinated (PPV) was 58%. This low vaccination coverage compared to the recommended target of 90%.
Vaccine effectiveness (VE) = (1-RR)* 100
ORMH (odds of vaccinated/ odds of unvaccinated in rare disease) ≈ RR
VE = (1-0.18 )* 100 = 82%
*Fishers exact 95% Confidence Intervals, MH-Mantel Henzel

Discussion: Children under-five years were the most affected in this outbreak. This is consistent with results from studies done in India (Bhuniya 2013, Sudipta 2015) . The reasons for the highest attack rate in this age group could be because of the diminishing maternal antibodies in children between 6 – 9 months. Children above 9 months could have missed getting vaccinated during the routine EPI scheduled vaccination at 9 months. These contribute to a pool of susceptible children who reduce the heard immunity of the population and thus out breaks. (Bhuniya 2013, Sudipta 2015). There was low vaccination coverage in this study compared to the target for Kamuli District at 90%. This is consistent with several studies done in developing countries which often show vaccine coverage computed during outbreaks being lower and probably more accurate than the administrative coverage. The very low vaccination coverage means there is no herd immunity in this population thus the out- break .

Conclusion and recommendations: Lack of prior measles vaccination, low vaccination coverage and low vaccine effective- ness propagated this outbreak. The vaccination coverage is too low to confer any protection to the population. Intensify routine immunization services at the health facility and community outreaches. All health facilities should offer vaccination daily. Pay more attention to the quality of data used in calculating administrative coverage in the district

References: 

Bhuniya, e. a. (2013). "Measles outbreak among the Dukpa [17]tribe of Buxa hills in West Bengal, 
India: epidemiology and vaccine efficacy. Indian Journal of Public Health. ." Indian Journal of P
ublic Health 57: 272-275.

MOH (2015). Measles supplemental immunization activities, rollout of human Papilloma virus vaccine 
and introduction of inactivated polio vaccine. UNEPI, MOH.

Sudipta, E. A. B. (2015). "Root-Cause Analytical Survey for Measles Outbreak: Vaccination or 
Vaccine?- A Study From Madhepura District, Bihar, India." Journal of Clinical and Diagnostic 
Research : JCDR 9(6): SC04-SC07.

HIV Viral Load Sample Delivery Times, Rejection Rates and Results Dispatch Turnaround Time, August

2014-July 2015, Uganda

1,2 Lilian Bulage, 1Isaac Ssewanyana, 1,2 Okello Paul, 1 Aisu Stephen, 1 Charles Kiyaga
1Central Public Health Laboratories
2Public Health Fellowship Program-Field Epidemiology Track

Summary: Nationally, anti-retroviral therapy (ART) monitoring using viral load (VL) as a gold standard commenced in August 2014 in Uganda. We described VL samples delivery times , results dispatch turnaround time (TAT), rejection rates, and major reasons for sample rejection at CPHL between August 2014 and July 2015 as part of continuous performance improvement for the centralized VL testing pro- gram. Samples from Karamoja region had the highest TAT followed by samples from the Western region. As the sample volumes increased over the time, even the sample delivery time increased. The laboratory results dispatch time was highest at the start of the program. How- ever, as time went by, the laboratory gradually reduced the TAT despite the increasing sample volumes . 2% ( 2344/107609) of the submit- ted samples were rejected. Of the 2344 rejected samples, 93%(2179/2344) were rejected because of not meeting the sample quality criteria, 3%(63/2344) because of failure to complete the VL test lab request form with vital information and 4% (102/2344) because of patients not meeting the VL testing eligibility criteria. Expansion of the HUB and the VL programs should be critically thought about in line with all aspects likely to affect the desired outcomes. Additionally, standard operating procedures (SOPs) addressing good quality sample collection should be provided to sites. CPHL should routinely analyze and review sample quality trends and geographic hot spots for poor quality specimens. Results should routinely be disseminated to key stakeholders as part of routine supportive supervision and quarterly review meetings to facilitate improvement in specimen quality

INTRODUCTION: In Uganda, monitoring response to Antiretroviral therapy (ART) using viral load (VL) as a gold standard nationally started in August 2014. Blood samples are collected from HIV-positive patients who have been on ART for at-least 6 months [1, 2]. Dried blood spots (DBS) and or plasma samples are referred from both government and private health facilities all over the country and transported to Central Public Health Laboratories (CPHL) through the national laboratory sample transport system, commonly known as the Hub system as illustrated in figure 1 [3]. Before samples are accepted for testing, they must meet the quality criteria otherwise they are rejected. The quality criteria include; sample must come from a patient who is eligible for VL testing; the request form accompanying the sample must have all data fields filled in appropriately; the sample itself must meet the pack- aging criteria, timeliness in transportation to CPHL, volume and appearance. According to the CPHL standard operating procedures. The DBS are put into a sealable plastic bag and desiccant packets and humidity cards added before sealing the bag Sealing the bag. Dried blood spots can be transported without cold-chain and remain stable for one month after collection [11, 12]. The whole pack is then put in a pre-labeled envelope ready for transportation.
DBS samples should not go beyond 14 days during transportation. Plasma storage and transport requires that plasma is transported within 24 hours at 25°C in EDTA tubes, or within 5 days at 4°C for EDTA tubes or PPT, after centrifugation. If there is no access to centrifugation, whole blood in EDTA tubes or PPT cannot be stored for more than 6 hours at 25°C. At least 0.75mls of plasma is required for the sample to be processed.
Laboratory testing: Two Polymerase chain reaction (PCR) based methods are used (Roche Molecular System and Abbott) for viral load testing at CPHL. The time to results is approximately 8 hours for both systems[4].Laboratory testing: Two Polymerase chain reaction (PCR) based methods are used (Roche Molecular System and Abbott) for viral load testing at CPHL.
The time to results is approximately 8 hours for both systems [4].Laboratory testing: Two Polymerase chain reaction (PCR) based methods are used (Roche Molecular System and Abbott) for viral load testing at CPHL. The time to results is approximately 8 hours for both systems[4]. Given the infancy of the centralized VL testing program in Uganda, and the need to facilitate continued performance improvement of the program we carried out this operational assessment.

In this study, we estimated the delivery time for VL samples, laboratory results dispatch turnaround time (TAT), proportion of VL samples rejected, described major reasons for rejection of samples and described the relationship between sample volume and sample delivery time, sample volume and results TAT between August 2014 and July 2015.

METHODS:

We extracted data generated between August 2014 and July 2015 from the central viral load testing data base at CPHL. We defined Sample delivery time as number of days from when a sample is collected at the health facility to the day when the sample is received at CPHL. Laboratory results dispatch turnaround time (TAT) as number of days from when the sample is received at CPHL to the day when the results are dispatched to their respective health facilities.

RESULTS: Majority of DBS samples arrived at CPHL between 0-14 days while most plasma samples arrived within 2-5 days. Samples from Karamoja region had the highest TAT followed by samples from the Western region. As the sample volumes increased over the months, even the sample delivery time increased. 51% per- cent of the results were dispatched within a week’s time. The laboratory results dispatch time was highest at the start of the program. However, as time went by, the laboratory gradually reduced the TAT despite the increasing sample volumes as shown in figure 3.

2% ( 2344/107609) of the submitted samples were rejected. Of the 2344 rejected samples, 93% (2179/2344) were rejected be- cause of failure to complete the VL test lab request form with vital information and 4% (102/2344) because of patients not meeting the VL testing eligibility criteria. Under the sample quality criteria, main reasons for rejection included DBS being less than the required size (49.7%), haemolysed samples ( 13.6%), blood samples being older than 3 weeks ( 12.1%) among others. Dispatch days were highest at the start of the program. However, as time went by, the laboratory gradually reduced the TAT de- spite the increasing sample volumes.

Discussion: In this study, 89% of the DBS samples were delivered within the recommended 2 weeks time while as 30% of plasma samples were delivered within the recommend 24hrs.

The laboratory results dispatch TAT was highest at the start of the program. As time went by, the laboratory gradually reduced the TAT despite the increasing sample volumes. Our findings also reveal that, as the sample volume increased over time due to expansion of the program, the sample delivery time increased as well. This could be explained by the possibility of the program expanding in terms of number of health facilities/health workers trained and oriented to start sending samples while as its other aspects like staff to manage transportation remain constant. The quality of training and lack of follow up mentorships could be the other contributing factors. As expansion of the program is planned, all aspects including sample transportation should be critically thought about and planned for. Otherwise, we risk reaching a time whereby the sample volumes are too high and hence compromising the sample quality.

On the contrary, as the sample volume increases over time, we observe the laboratory results TAT remaining under check. This could be explained by the laboratory putting in place extra measures to counteract the impact of the increasing sample volumes. Night and week- end shifts have played a big role in controlling of the TAT. Sometimes there is shift of staff from sections with less work to overloaded sections in order to reduce the overall results dispatch time. 93% of rejections were due to samples failing to meet the sample quality criteria. This may be attributed to the limited information about VL sample quality amongst health workers who do the actual sample collection and packaging. This may as well depend on to the selection of the people to be trained, sometimes the people trained, are not the ones who do actual sample collection and packaging. The quality of training and lack of follow-up mentorship may be contributory.

Recommendations. We recommend some operational changes like immediate feedback to health facilities sending poorly collected samples, through phone calls indicating reasons for rejection. Understand challenges providers face in ensuring that a good quality sample is obtained and trans- ported accordingly and provision of SOPs is crucial. Results should be disseminated at to key stakeholders routinely to facilitate improvement in specimen quality.

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