Last data update: Apr 29, 2024. (Total: 46658 publications since 2009)
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Query Trace: Nelson LJ [original query] |
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Temporal dynamics and drivers of durable HIV viral load suppression and persistent high- and low-level viraemia during Universal Test and Treat scale-up in Uganda: a population-based study
Rosen JG , Ssekubugu R , Chang LW , Ssempijja V , Galiwango RM , Ssekasanvu J , Ndyanabo A , Kisakye A , Nakigozi G , Rucinski KB , Patel EU , Kennedy CE , Nalugoda F , Kigozi G , Ratmann O , Nelson LJ , Mills LA , Kabatesi D , Tobian AAR , Quinn TC , Kagaayi J , Reynolds SJ , Grabowski MK . J Int AIDS Soc 2024 27 (2) e26200 INTRODUCTION: Population-level data on durable HIV viral load suppression (VLS) following the implementation of Universal Test and Treat (UTT) in Africa are limited. We assessed trends in durable VLS and viraemia among persons living with HIV in 40 Ugandan communities during the UTT scale-up. METHODS: In 2015-2020, we measured VLS (<200 RNA copies/ml) among participants in the Rakai Community Cohort Study, a longitudinal population-based HIV surveillance cohort in southern Uganda. Persons with unsuppressed viral loads were characterized as having low-level (200-999 copies/ml) or high-level (≥1000 copies/ml) viraemia. Individual virologic outcomes were assessed over two consecutive RCCS survey visits (i.e. visit-pairs; ∼18-month visit intervals) and classified as durable VLS (<200 copies/ml at both visits), new/renewed VLS (<200 copies/ml at follow-up only), viral rebound (<200 copies/ml at initial visit only) or persistent viraemia (≥200 copies/ml at both visits). Population prevalence of each outcome was assessed over calendar time. Community-level prevalence and individual-level predictors of persistent high-level viraemia were also assessed using multivariable Poisson regression with generalized estimating equations. RESULTS: Overall, 3080 participants contributed 4604 visit-pairs over three survey rounds. Most visit-pairs (72.4%) exhibited durable VLS, with few (2.5%) experiencing viral rebound. Among those with any viraemia at the initial visit (23.5%, n = 1083), 46.9% remained viraemic through follow-up, 91.3% of which was high-level viraemia. One-fifth (20.8%) of visit-pairs exhibiting persistent high-level viraemia self-reported antiretroviral therapy (ART) use for ≥12 months. Prevalence of persistent high-level viraemia varied substantially across communities and was significantly elevated among young persons aged 15-29 years (vs. 40- to 49-year-olds; adjusted risk ratio [adjRR] = 2.96; 95% confidence interval [95% CI]: 2.21-3.96), males (vs. females; adjRR = 2.40, 95% CI: 1.87-3.07), persons reporting inconsistent condom use with non-marital/casual partners (vs. persons with marital/permanent partners only; adjRR = 1.38, 95% CI: 1.10-1.74) and persons reporting hazardous alcohol use (adjRR = 1.09, 95% CI: 1.03-1.16). The prevalence of persistent high-level viraemia was highest among males <30 years (32.0%). CONCLUSIONS: Following universal ART provision, most persons living with HIV in south-central Uganda are durably suppressed. Among persons exhibiting any viraemia, nearly half exhibited high-level viraemia for ≥12 months and reported higher-risk behaviours associated with onward HIV transmission. Intensified efforts linking individuals to HIV treatment services could accelerate momentum towards HIV epidemic control. |
Strengthening capacity of health workers to diagnose birth defects in Ugandan hospitals from 2015 to 2021
Namale-Matovu J , Kusolo R , Serunjogi R , Barlow-Mosha L , Mumpe-Mwanja D , Niombi N , Kalibbala D , Williamson D , Valencia D , Moore CA , Mwambi K , Nelson LJ , Namukanja-Mayambala PM , Williams JL , Mai CT , Qi YP , Musoke P . BMC Med Educ 2023 23 (1) 766 BACKGROUND: Limited diagnostic capabilities, resources and health worker skills have deterred the advancement of birth defects surveillance systems in most low- and middle-income countries (LMICs). Empowering health workers to identify and diagnose major external birth defects (BDs) is crucial to establishing effective hospital-based BD surveillance. Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration BD Surveillance System consists of three diagnostic levels: (1) surveillance midwives, (2) MU-JHU clinical team, and (3) U.S. Centers for Disease Control and Prevention (CDC) birth defects subject matter experts (SMEs) who provide confirmatory diagnosis. The diagnostic concordance of major external BDs by surveillance midwives or MU-JHU clinical team with CDC birth defects SMEs were estimated. METHODS: Study staff went through a series of trainings, including birth defects identification and confirmation, before surveillance activities were implemented. To assess the diagnostic concordance, we analyzed surveillance data from 2015 to 2021 for major external BDs: anencephaly, iniencephaly, encephalocele, spina bifida, craniorachischisis, microcephaly, anophthalmia/microphthalmia, anotia/microtia, cleft palate alone, cleft lip alone, cleft lip with cleft palate, imperforate anus, hypospadias, talipes equinovarus, limb reduction, gastroschisis, and omphalocele. Positive predictive value (PPV) as the proportion of BDs diagnosed by surveillance midwives or MU-JHU clinical team that were confirmed by CDC birth defects SMEs was computed. PPVs between 2015 and 2018 and 2019-2021 were compared to assess the accuracy of case diagnosis over time. RESULTS: Of the 204,332 infants examined during 2015-2021, 870 infants had a BD. Among the 1,245 BDs identified, 1,232 (99.0%) were confirmed by CDC birth defects SMEs. For surveillance midwives, PPV for 7 of 17 BDs was > 80%. For the MU-JHU clinical team, PPV for 13 of 17 BDs was > 80%. Among surveillance midwives, PPV improved significantly from 2015 to 2018 to 2019-2021, for microcephaly (+ 50.0%), cleft lip with cleft palate (+ 17.0%), imperforate anus (+ 30.0%), and talipes equinovarus (+ 10.8%). Improvements in PPV were also observed among MU-JHU clinical team; however, none were significant. CONCLUSION: The diagnostic accuracy of the midwives and clinical team increased, highlighting that BD surveillance, by front-line health care workers (midwives) in LMICs is possible when midwives receive comprehensive training, technical support, funding and continuous professional development. |
Temporal dynamics and drivers of durable HIV viral load suppression and persistent high- and low-level viremia during Universal Test and Treat scale-up in Uganda: a population-based study (preprint)
Rosen JG , Ssekubugu R , Chang LW , Ssempijja V , Galiwango RM , Ssekasanvu J , Ndyanabo A , Kisakye A , Nakigozi G , Rucinski KB , Patel EU , Kennedy CE , Nalugoda F , Kigozi G , Ratmann O , Nelson LJ , Mills LA , Kabatesi D , Tobian AAR , Quinn TC , Kagaayi J , Reynolds SJ , Grabowski MK . medRxiv 2023 16 Introduction: Population-level data on durable HIV viral load suppression (VLS) following implementation of Universal Test and Treat (UTT) in Africa are limited. We assessed trends in durable VLS and viremia among persons living with HIV in 40 Ugandan communities during UTT scale-up. Method(s): In 2015-2020, we measured VLS (defined as <200 RNA copies/mL) among participants in the Rakai Community Cohort Study, a longitudinal population-based HIV surveillance cohort in southern Uganda. Persons with unsuppressed viral loads were characterized as having low-level (200-999 copies/mL) or high-level (>1,000 copies/mL) viremia. Individual virologic outcomes were assessed over two consecutive RCCS survey visits (i.e., visit-pairs; ~18 month visit intervals) and classified as durable VLS (<200 copies/mL at both visits), new/renewed VLS (<200 copies/mL at follow-up only), viral rebound (<200 copies/mL at initial visit only), or persistent viremia (<200 copies/mL at neither visit). Population prevalence of each outcome was assessed over calendar time. Community-level prevalence and individual-level predictors of persistent high-level viremia were also assessed using multivariable Poisson regression with generalized estimating equations. Result(s): Overall, 3,080 participants contributed 4,604 visit-pairs over three survey rounds. Most visit-pairs (72.4%) exhibited durable VLS, with few (2.5%) experiencing viral rebound. Among those with viremia at the initial visit (n=1,083), 46.9% maintained viremia through follow-up, 91.3% of which was high-level viremia. One-fifth (20.8%) of visit-pairs exhibiting persistent high-level viremia self-reported antiretroviral therapy (ART) use for >12 months. Prevalence of persistent high-level viremia varied substantially across communities and was significantly elevated among young persons aged 15-29 years (versus 40-49-year-olds; adjusted risk ratio [adjRR]=2.96; 95% confidence interval [95%CI]:2.21-3.96), men (versus women; adjRR=2.40, 95%CI:1.87-3.07), persons reporting inconsistent condom use with non-marital/casual partners (versus persons with marital/permanent partners only; adjRR=1.38, 95%CI:1.10-1.74), and persons exhibiting hazardous alcohol use (adjRR=1.09, 95%CI:1.03-1.16). The prevalence of persistent high-level viremia was highest among men <30 years (32.0%). Conclusion(s): Following universal ART provision, most persons living with HIV in south-central Uganda are durably suppressed. Among persons exhibiting viremia, nearly half maintain high-level viremia for >12 months and report higher-risk behaviors associated with onward HIV transmission. Enhanced linkage to HIV care and optimized treatment retention could accelerate momentum towards HIV epidemic control. Copyright The copyright holder for this preprint is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. All rights reserved. No reuse allowed without permission. |
A Moving Target: Impacts of Lowering Viral Load Suppression Cutpoints on Progress Towards HIV Epidemic Control Goals (preprint)
Rosen JG , Reynolds SJ , Galiwango RM , Kigozi G , Quinn TC , Ratmann O , Ndyanabo A , Nelson LJ , Nakigozi G , Nalugemwa M , Rucinski KB , Kennedy CE , Chang LW , Kagaayi J , Serwadda D , Grabowski MK . medRxiv 2023 20 Redefining viral load suppression (VLS) using lower cutpoints could impact progress towards the UNAIDS 95-95-95 targets. We assessed impacts of lowering the VLS cutpoint on achieving the 95-95-95 VLS target in the Rakai Community Cohort Study. Population VLS fell from 86% to 84% and 76%, respectively, after lowering VLS cutpoints from <1,000 to <200 and <50 copies/mL. The fraction of viremic persons increased by 17% after lowering the VLS cutpoint from <1,000 to <200 copies/mL. Copyright The copyright holder for this preprint is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license. |
A moving target: impacts of lowering viral load suppression cutpoints on progress towards HIV epidemic control goals
Rosen JG , Reynolds SJ , Galiwango RM , Kigozi G , Quinn TC , Ratmann O , Ndyanabo A , Nelson LJ , Nakigozi G , Nalugemwa M , Rucinski KB , Kennedy CE , Chang LW , Kagaayi J , Serwadda D , Grabowski MK . AIDS 2023 37 (9) 1486-1489 Redefining viral load suppression (VLS) using lower cutpoints could impact progress towards the United Nations Programme on HIV/AIDS 95-95-95 targets. We assessed impacts of lowering the VLS cutpoint on achieving the 'third 95' in the Rakai Community Cohort Study. Population VLS would fall from 86% to 84% and 76%, respectively, after lowering VLS cutpoints from <1000 to <200 and <50 copies/ml. The fraction of viremic persons increased by 17% after lowering the VLS cutpoint from <1000 to <200 copies/ml. |
Uganda's experience in establishing an electronic compendium for public health emergencies
Ario AR , Aliddeki DM , Kadobera D , Bulage L , Kayiwa J , Wetaka MM , Kyazze S , Ocom F , Makumbi I , Mbaka P , Behumbiize P , Ayebazibwe I , Balinandi SK , Lutwama JJ , Crawley A , Divi N , Lule JR , Ojwang JC , Harris JR , Boore AL , Nelson LJ , Borchert J , Jarvis D . PLOS Glob Public Health 2023 3 (2) e0001402 Uganda has implemented several interventions that have contributed to prevention, early detection, and effective response to Public Health Emergencies (PHEs). However, there are gaps in collecting and documenting data on the overall response to these PHEs. We set out to establish a comprehensive electronic database of PHEs that occurred in Uganda since 2000. We constituted a core development team, developed a data dictionary, and worked with Health Information Systems Program (HISP)-Uganda to develop and customize a compendium of PHEs using the electronic Integrated Disease Surveillance and Response (eIDSR) module on the District Health Information Software version 2 (DHIS2) platform. We reviewed literature for retrospective data on PHEs for the compendium. Working with the Uganda Public Health Emergency Operations Center (PHEOC), we prospectively updated the compendium with real-time data on reported PHEs. We developed a user's guide to support future data entry teams. An operational compendium was developed within the eIDSR module of the DHIS2 platform. The variables for PHEs data collection include those that identify the type, location, nature and time to response of each PHE. The compendium has been updated with retrospective PHE data and real-time prospective data collection is ongoing. Data within this compendium is being used to generate information that can guide future outbreak response and management. The compendium development highlights the importance of documenting outbreak detection and response data in a central location for future reference. This data provides an opportunity to evaluate and inform improvements in PHEs response. |
Tuberculosis preventive therapy among persons living with HIV, Uganda, 2016-2022
Lukoye D , Gustavson G , Namuwenge PM , Muchuro S , Birabwa E , Dejene S , Ssempiira J , Kalamya JN , Baveewo S , Ferroussier-Davis O , Mills LA , Dirlikov E , Nelson LJ , Turyahabwe S . Emerg Infect Dis 2023 29 (3) 609-613 During October 2016-March 2022, Uganda increased tuberculosis (TB) preventive therapy coverage among persons living with HIV from 0.6% to 88.8%. TB notification rates increased from 881.1 to 972.5 per 100,000 persons living with HIV. Timely TB screening, diagnosis, and earlier treatment should remain high priorities for TB/HIV prevention programming. |
Scale-up of HIV antiretroviral therapy and estimation of averted infections and HIV-related deaths - Uganda, 2004-2022
Dirlikov E , Kamoga J , Talisuna SA , Namusobya J , Kasozi DE , Akao J , Birabwa E , Ward JA , Elur B , Shiraishi RW , Corcoran C , Vasireddy V , Nelson R , Nelson LJ , Borgman M , Magongo EN , Kisaakye LN , Katureebe C , Kirungi W , Musinguzi J . MMWR Morb Mortal Wkly Rep 2023 72 (4) 90-94 On January 28, 2003, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the largest commitment by any nation to address a single disease in history, was announced.* In April 2004, the first person in the world to receive PEPFAR-supported antiretroviral therapy (ART) was a man aged 34 years in Uganda. Effective ART reduces morbidity and mortality among persons with HIV infection (1) and prevents both mother-to-child transmission (MTCT) (2) and sexual transmission once viral load is suppressed to undetectable levels (<200 viral copies/mL) (3). By September 2022, more than 1.3 million persons with HIV infection in Uganda were receiving PEPFAR-supported ART, an increase of approximately 5,000% from September 2004. As indicators of the ART program's effectiveness, a proxy MTCT rate decreased 77%, from 6.4% in 2010 to 1.5% in 2022, and the viral load suppression rate (<1,000 viral copies/mL) increased 3%, from 91% in 2016 to 94% in September 2022. During 2004-2022, ART scale-up helped avert nearly 500,000 HIV infections, including more than 230,000 infections among HIV-exposed infants, and approximately 600,000 HIV-related deaths. Going forward, efforts will focus on identifying all persons with HIV infection and rapidly linking them to effective ART. PEPFAR remains committed to continued strong partnership with the Government of Uganda, civil society, and other development partners toward sustainable solutions aligned with the Joint United Nations Programme on HIV/AIDS (UNAIDS) fast-track strategy to ending the global AIDS epidemic by 2030(†) and safeguarding impact achieved in the long term. |
Improving the effectiveness of Field Epidemiology Training Programs: characteristics that facilitated effective response to the COVID-19 pandemic in Uganda.
Harris JR , Kadobera D , Kwesiga B , Kabwama SN , Bulage L , Kyobe HB , Kagirita AA , Mwebesa HG , Wanyenze RK , Nelson LJ , Boore AL , Ario AR . BMC Health Serv Res 2022 22 (1) 1532 BACKGROUND: The global need for well-trained field epidemiologists has been underscored in the last decade in multiple pandemics, the most recent being COVID-19. Field Epidemiology Training Programs (FETPs) are in-service training programs that improve country capacities to respond to public health emergencies across different levels of the health system. Best practices for FETP implementation have been described previously. The Uganda Public Health Fellowship Program (PHFP), or Advanced-FETP in Uganda, is a two-year fellowship in field epidemiology funded by the U.S. Centers for Disease Control and situated in the Uganda National Institute of Public Health (UNIPH). We describe how specific attributes of the Uganda PHFP that are aligned with best practices enabled substantial contributions to the COVID-19 response in Uganda. METHODS: We describe the PHFP in Uganda and review examples of how specific program characteristics facilitate integration with Ministry of Health needs and foster a strong response, using COVID-19 pandemic response activities as examples. We describe PHFP activities and outputs before and during the COVID-19 response and offer expert opinions about the impact of the program set-up on these outputs. RESULTS: Unlike nearly all other Advanced FETPs in Africa, PHFP is delinked from an academic degree-granting program and enrolls only post-Master's-degree fellows. This enables full-time, uninterrupted commitment of academically-trained fellows to public health response. Uganda's PHFP has strong partner support in country, sufficient technical support from program staff, Ministry of Health (MoH), CDC, and partners, and full-time dedicated directorship from a well-respected MoH staff member. The PHFP is physically co-located inside the UNIPH with the emergency operations center (EOC), which provides a direct path for health alerts to be investigated by fellows. It has recognized value within the MoH, which integrates graduates into key MoH and partner positions. During February 2020-September 2021, PHFP fellows and graduates completed 67 major COVID-related projects. PHFP activities during the COVID-19 response were specifically requested by the MoH or by partners, or generated de novo by the program, and were supervised by all partners. CONCLUSION: Specific attributes of the PHFP enable effective service to the Ministry of Health in Uganda. Among the most important is the enrollment of post-graduate fellows, which leads to a high level of utilization of the program fellows by the Ministry of Health to fulfill real-time needs. Strong leadership and sufficient technical support permitted meaningful program outputs during COVID-19 pandemic response. Ensuring the inclusion of similar characteristics when implementing FETPs elsewhere may allow them to achieve a high level of impact. |
Protecting the gains: analysis of HIV treatment and service delivery programme data and interventions implemented in 19 African countries during COVID-19.
Bachanas PJ , Chun HM , Mehta N , Aberle-Grasse J , Parris K , Sherlock MW , Lloyd S , Zeh C , Makwepa DK , Kapanda ML , Dokubo EK , Bonono L , Balachandra S , Ehui E , Fonjungo P , Nkoso AM , Mazibuko S , Okello VN , Tefera F , Getachew M , Katiku EM , Mulwa A , Asiimwe FM , Tarumbiswa TF , Auld AF , Nyirenda R , Dos Santos De Louvado AP , Gaspar I , Hong SY , Ashipala L , Obanubi C , Ikpeazu A , Musoni C , Yoboka E , Mthethwa S , Pinini Z , Bunga S , Rumunu J , Magesa DJ , Mutayoba B , Nelson LJ , Katureebe C , Agolory S , Mulenga LB , Nyika P , Mugurungi O , Ellerbrock T , Mitruka K . J Int AIDS Soc 2022 25 (11) e26033 INTRODUCTION: The potential disruption in antiretroviral therapy (ART) services in Africa at the start of the COVID-19 pandemic raised concern for increased morbidity and mortality among people living with HIV (PLHIV). We describe HIV treatment trends before and during the pandemic and interventions implemented to mitigate COVID-19 impact among countries supported by the US Centers for Disease Control and Prevention (CDC) through the President's Emergency Plan for AIDS Relief (PEPFAR). METHODS: We analysed quantitative and qualitative data reported by 10,387 PEPFAR-CDC-supported ART sites in 19 African countries between October 2019 and March 2021. Trends in PLHIV on ART, new ART initiations and treatment interruptions were assessed. Viral load coverage (testing of eligible PLHIV) and viral suppression were calculated at select time points. Qualitative data were analysed to summarize facility- and community-based interventions implemented to mitigate COVID-19. RESULTS: The total number of PLHIV on ART increased quarterly from October 2019 (n = 7,540,592) to March 2021 (n = 8,513,572). The adult population (≥15 years) on ART increased by 14.0% (7,005,959-7,983,793), while the paediatric population (<15 years) on ART declined by 2.6% (333,178-324,441). However, the number of new ART initiations dropped between March 2020 and June 2020 by 23.4% for adults and 26.1% for children, with more rapid recovery in adults than children from September 2020 onwards. Viral load coverage increased slightly from April 2020 to March 2021 (75-78%) and viral load suppression increased from October 2019 to March 2021 (91-94%) among adults and children combined. The most reported interventions included multi-month dispensing (MMD) of ART, community service delivery expansion, and technology and virtual platforms use for client engagement and site-level monitoring. MMD of ≥3 months increased from 52% in October 2019 to 78% of PLHIV ≥ age 15 on ART in March 2021. CONCLUSIONS: With an overall increase in the number of people on ART, HIV programmes proved to be resilient, mitigating the impact of COVID-19. However, the decline in the number of children on ART warrants urgent investigation and interventions to prevent further losses experienced during the COVID-19 pandemic and future public health emergencies. |
Uganda National Institute of Public Health: Establishment and experiences, 2013-2021
Ario AR , Makumbi I , Kadobera D , Bulage L , Ocom F , Kwesiga B , Jarvis DF , Nabatanzi S , Homsy J , Banage F , Brown V , Harris JR , Boore AL , Nelson LJ , Binder S , Mwebesa HG , Aceng JR . Glob Health Sci Pract 2022 10 (4) Uganda is an ecological hot spot with porous borders that lies in several infectious disease transmission belts, making it prone to disease outbreaks. To prepare and respond to these public health threats and emergencies in a coordinated manner, Uganda established the Uganda National Institute of Public Health (UNIPH) in 2013.Using a step-by-step process, Uganda's Ministry of Health (MOH) crafted a strategy with a vision, mission, goal, and strategic objectives, and identified value additions and key enablers for success. A regulatory impact assessment was then conducted to inform the drafting of principles of the bill for legislation on the Institute.Despite not yet attaining legal status, the UNIPH has already achieved faster, smarter, and more efficient and effective prevention, detection, and response to public health emergencies. Successes include a more coordinated multisectoral, disciplined, and organized response to emergencies; appropriate, timely, and complete information receipt and sharing; a functional national lab sample and results transportation network that has enabled detection and confirmation of public health events within 48 hours of alert; appropriate response to a confirmed public health event in 24-48 hours; and real-time surveillance of endemic- and epidemic-prone diseases.In this article, we document success stories, lessons learned, and challenges encountered during the unique staged process used to develop the components of the UNIPH. The creation of an integrated disease control center has proven to yield better collaboration and synergies between different arms of epidemic preparedness and response. |
Establishing a public health emergency operations center in an outbreak-prone country: Lessons learned in Uganda, January 2014 to December 2021
Kayiwa J , Homsy J , Nelson LJ , Ocom F , Kasule JN , Wetaka MM , Kyazze S , Mwanje W , Kisakye A , Nabunya D , Nyirabakunzi M , Aliddeki DM , Ojwang J , Boore A , Kasozi S , Borchert J , Shoemaker T , Nabatanzi S , Dahlke M , Brown V , Downing R , Makumbi I . Health Secur 2022 20 (5) 394-407 Uganda is highly vulnerable to public health emergencies (PHEs) due to its geographic location next to the Congo Basin epidemic hot spot, placement within multiple epidemic belts, high population growth rates, and refugee influx. In view of this, Uganda's Ministry of Health established the Public Health Emergency Operations Center (PHEOC) in September 2013, as a central coordination unit for all PHEs in the country. Uganda followed the World Health Organization's framework to establish the PHEOC, including establishing a steering committee, acquiring legal authority, developing emergency response plans, and developing a concept of operations. The same framework governs the PHEOC's daily activities. Between January 2014 and December 2021, Uganda's PHEOC coordinated response to 271 PHEs, hosted 207 emergency coordination meetings, trained all core staff in public health emergency management principles, participated in 21 simulation exercises, coordinated Uganda's Global Health Security Agenda activities, established 6 subnational PHEOCs, and strengthened the capacity of 7 countries in public health emergency management. In this article, we discuss the following lessons learned: PHEOCs are key in PHE coordination and thus mitigate the associated adverse impacts; although the functions of a PHEOC may be legalized by the existence of a National Institute of Public Health, their establishment may precede formally securing the legal framework; staff may learn public health emergency management principles on the job; involvement of leaders and health partners is crucial to the success of a public health emergency management program; subnational PHEOCs are resourceful in mounting regional responses to PHEs; and service on the PHE Strategic Committee may be voluntary. |
SARS-CoV-2 Breakthrough Infections among US Embassy Staff Members, Uganda, May-June 2021.
Harris JR , Owusu D , O'Laughlin K , Cohen AL , Ben Hamida A , Patel JC , Freeman MM , Nsibambi T , Nieves R , Marston BJ , Wasike S , Galbraith JS , Boore AL , Nelson LJ , Guagliardo SAJ , Klena JD , Patel K , Ma M . Emerg Infect Dis 2022 28 (6) 1279-1280 The SARS-CoV-2 Delta variant emerged shortly after COVID-19 vaccines became available in 2021. We describe SARS-CoV-2 breakthrough infections in a highly vaccinated, well-monitored US Embassy community in Kampala, Uganda. Defining breakthrough infection rates in highly vaccinated populations can help determine public health messaging, guidance, and policy globally. |
Uganda public health fellowship program's contributions to the National HIV and TB Programs, 2015-2020
Ario AR , Bulage L , Wibabara Y , Muwereza P , Eurien D , Kabwama SN , Kwesiga B , Kadobera D , Turyahabwe S , Musinguzi JB , Wanyenze RK , Nasirumbi PM , Lukoye D , Harris JR , Mills LA , Nelson LJ . Glob Health Sci Pract 2022 10 (2) Despite remarkable progress in controlling HIV and TB, Uganda is one of the 30 high-burden TB/HIV countries. Approximately 53,000 Ugandans had a new HIV diagnosis in 2019, and approximately 88,000 Ugandans had a TB diagnosis in 2020. Fellows in the Uganda Public Health Fellowship Program (UPHFP) work directly with the Ministry of Health AIDS and TB Control Programs, the U.S. Centers for Disease Control and Prevention, UPHFP supervisors, and implementing partners to investigate and evaluate HIV-related and TB-related issues. These activities have contributed to the Uganda HIV and TB programs. UPHFP fellows complete projects in 7 competency domains, including outbreak investigations, surveillance evaluations, and data quality improvement. Priority HIV/AIDS/TB information gaps/topics are identified in consultation with key stakeholders, and fellows complete projects to guide program improvements and policy decisions. During 2015-2020, UPHFP fellows implemented 127 HIV and TB projects covering key program areas in AIDS and TB control programs, including care and treatment (16 projects), TB/HIV (18), prevention of mother-to-child HIV transmission (24), key and priority populations (9), pre-exposure and post-exposure prophylaxis (7), adolescent girls and young women (6), service delivery (13), and diagnosis of TB including drug-resistant TB and TB in high-risk groups (32). These projects have helped improve retention, quality of care, and treatment outcomes for people living with HIV, HIV and TB coinfected patients, and TB patients. They have also contributed to the decrease in pediatric TB and infant HIV positivity rates and improved service delivery for key populations. UPHFP results were disseminated to relevant stakeholders such as government departments, implementing partners, districts, and the general community and guided decision making. UPHFP has significantly improved HIV and TB control in Uganda. Other countries with similar programs could benefit from this approach and utilize program fellows to support HIV and TB control. |
Uganda's experience in Ebola virus disease outbreak preparedness, 2018-2019
Aceng JR , Ario AR , Muruta AN , Makumbi I , Nanyunja M , Komakech I , Bakainaga AN , Talisuna AO , Mwesigye C , Mpairwe AM , Tusiime JB , Lali WZ , Katushabe E , Ocom F , Kaggwa M , Bongomin B , Kasule H , Mwoga JN , Sensasi B , Mwebembezi E , Katureebe C , Sentumbwe O , Nalwadda R , Mbaka P , Fatunmbi BS , Nakiire L , Lamorde M , Walwema R , Kambugu A , Nanyondo J , Okware S , Ahabwe PB , Nabukenya I , Kayiwa J , Wetaka MM , Kyazze S , Kwesiga B , Kadobera D , Bulage L , Nanziri C , Monje F , Aliddeki DM , Ntono V , Gonahasa D , Nabatanzi S , Nsereko G , Nakinsige A , Mabumba E , Lubwama B , Sekamatte M , Kibuule M , Muwanguzi D , Amone J , Upenytho GD , Driwale A , Seru M , Sebisubi F , Akello H , Kabanda R , Mutengeki DK , Bakyaita T , Serwanjja VN , Okwi R , Okiria J , Ainebyoona E , Opar BT , Mimbe D , Kyabaggu D , Ayebazibwe C , Sentumbwe J , Mwanja M , Ndumu DB , Bwogi J , Balinandi S , Nyakarahuka L , Tumusiime A , Kyondo J , Mulei S , Lutwama J , Kaleebu P , Kagirita A , Nabadda S , Oumo P , Lukwago R , Kasozi J , Masylukov O , Kyobe HB , Berdaga V , Lwanga M , Opio JC , Matseketse D , Eyul J , Oteba MO , Bukirwa H , Bulya N , Masiira B , Kihembo C , Ohuabunwo C , Antara SN , Owembabazi W , Okot PB , Okwera J , Amoros I , Kajja V , Mukunda BS , Sorela I , Adams G , Shoemaker T , Klena JD , Taboy CH , Ward SE , Merrill RD , Carter RJ , Harris JR , Banage F , Nsibambi T , Ojwang J , Kasule JN , Stowell DF , Brown VR , Zhu BP , Homsy J , Nelson LJ , Tusiime PK , Olaro C , Mwebesa HG , Woldemariam YT . Global Health 2020 16 (1) 24 BACKGROUND: Since the declaration of the 10th Ebola Virus Disease (EVD) outbreak in DRC on 1st Aug 2018, several neighboring countries have been developing and implementing preparedness efforts to prevent EVD cross-border transmission to enable timely detection, investigation, and response in the event of a confirmed EVD outbreak in the country. We describe Uganda's experience in EVD preparedness. RESULTS: On 4 August 2018, the Uganda Ministry of Health (MoH) activated the Public Health Emergency Operations Centre (PHEOC) and the National Task Force (NTF) for public health emergencies to plan, guide, and coordinate EVD preparedness in the country. The NTF selected an Incident Management Team (IMT), constituting a National Rapid Response Team (NRRT) that supported activation of the District Task Forces (DTFs) and District Rapid Response Teams (DRRTs) that jointly assessed levels of preparedness in 30 designated high-risk districts representing category 1 (20 districts) and category 2 (10 districts). The MoH, with technical guidance from the World Health Organisation (WHO), led EVD preparedness activities and worked together with other ministries and partner organisations to enhance community-based surveillance systems, develop and disseminate risk communication messages, engage communities, reinforce EVD screening and infection prevention measures at Points of Entry (PoEs) and in high-risk health facilities, construct and equip EVD isolation and treatment units, and establish coordination and procurement mechanisms. CONCLUSION: As of 31 May 2019, there was no confirmed case of EVD as Uganda has continued to make significant and verifiable progress in EVD preparedness. There is a need to sustain these efforts, not only in EVD preparedness but also across the entire spectrum of a multi-hazard framework. These efforts strengthen country capacity and compel the country to avail resources for preparedness and management of incidents at the source while effectively cutting costs of using a "fire-fighting" approach during public health emergencies. |
Evaluation of infection prevention and control readiness at frontline health care facilities in high-risk districts bordering Ebola virus disease-affected areas in the Democratic Republic of the Congo - Uganda, 2018
Biedron C , Lyman M , Stuckey MJ , Homsy J , Lamorde M , Luvsansharav UO , Wilson K , Gomes D , Omuut W , Okware S , Semanda JN , Kiggundu R , Bulwadda D , Brown V , Nelson LJ , Driwale A , Fagan R , Park BJ , Smith RM . MMWR Morb Mortal Wkly Rep 2019 68 (39) 851-854 Infection prevention and control (IPC) in health care facilities is essential to protecting patients, visitors, and health care personnel from the spread of infectious diseases, including Ebola virus disease (Ebola). Patients with suspected Ebola are typically referred to specialized Ebola treatment units (ETUs), which have strict isolation and IPC protocols, for testing and treatment (1,2). However, in settings where contact tracing is inadequate, Ebola patients might first seek care at general health care facilities, which often have insufficient IPC capacity (3-6). Before 2014-2016, most Ebola outbreaks occurred in rural or nonurban communities, and the role of health care facilities as amplification points, while recognized, was limited (7,8). In contrast to these earlier outbreaks, the 2014-2016 West Africa Ebola outbreak occurred in densely populated urban areas where access to health care facilities was better, but contact tracing was generally inadequate (8). Patients with unrecognized Ebola who sought care at health care facilities with inadequate IPC initiated multiple chains of transmission, which amplified the epidemic to an extent not seen in previous Ebola outbreaks (3-5,7). Implementation of robust IPC practices in general health care facilities was critical to ending health care-associated transmission (8). In August 2018, when an Ebola outbreak was recognized in the Democratic Republic of the Congo (DRC), neighboring countries began preparing for possible introduction of Ebola, with a focus on IPC. Baseline IPC assessments conducted in frontline health care facilities in high-risk districts in Uganda found IPC gaps in screening, isolation, and notification. Based on findings, additional funds were provided for IPC, a training curriculum was developed, and other corrective actions were taken. Ebola preparedness efforts should include activities to ensure that frontline health care facilities have the IPC capacity to rapidly identify suspected Ebola cases and refer such patients for treatment to protect patients, staff members, and visitors. |
Impact of the Saving Mothers, Giving Life approach on decreasing maternal and perinatal deaths in Uganda and Zambia
Serbanescu F , Clark TA , Goodwin MM , Nelson LJ , Boyd MA , Kekitiinwa AR , Kaharuza F , Picho B , Morof D , Blanton C , Mumba M , Komakech P , Carlosama F , Schmitz MM , Conlon CM . Glob Health Sci Pract 2019 7 S27-s47 BACKGROUND: Maternal and perinatal mortality is a global development priority that continues to present major challenges in sub-Saharan Africa. Saving Mothers, Giving Life (SMGL) was a multipartner initiative implemented from 2012 to 2017 with the goal of improving maternal and perinatal health in high-mortality settings. The initiative accomplished this by reducing delays to timely and appropriate obstetric care through the introduction and support of community and facility evidence-based and district-wide health systems strengthening interventions. METHODS: SMGL-designated pilot districts in Uganda and Zambia documented baseline and endline maternal and perinatal health outcomes using multiple approaches. These included health facility assessments, pregnancy outcome monitoring, enhanced maternal mortality detection in facilities, and district population-based identification and investigation of maternal deaths in communities. RESULTS: Over the course of the 5-year SMGL initiative, population-based estimates documented a 44% reduction in the SMGL-supported district-wide maternal mortality ratio (MMR) in Uganda (from 452 to 255 maternal deaths per 100,000 live births) and a 41% reduction in Zambia (from 480 to 284 maternal deaths per 100,000 live births). The MMR in SMGL-supported health facilities declined by 44% in Uganda and by 38% in Zambia. The institutional delivery rate increased by 47% in Uganda (from 45.5% to 66.8% of district births) and by 44% in Zambia (from 62.6% to 90.2% of district births). The number of facilities providing emergency obstetric and newborn care (EmONC) rose from 10 to 26 in Uganda and from 7 to 13 in Zambia, and lower- and mid-level facilities increased the number of EmONC signal functions performed. Cesarean delivery rates increased by more than 70% in both countries, reaching 9% and 5% of all births in Uganda and Zambia districts, respectively. Maternal deaths in facilities due to obstetric hemorrhage declined by 42% in Uganda and 65% in Zambia. Overall, perinatal mortality rates declined, largely due to reductions in stillbirths in both countries; however, no statistically significant changes were found in predischarge neonatal death rates in predischarge either country. CONCLUSIONS: MMRs fell significantly in Uganda and Zambia following the introduction of the SMGL interventions, and SMGL's comprehensive district systems-strengthening approach successfully improved coverage and quality of care for mothers and newborns. The lessons learned from the initiative can inform policy makers and program managers in other low- and middle-income settings where similar approaches could be used to rapidly reduce preventable maternal and newborn deaths. |
Trends and gaps in national blood transfusion services - 14 sub-Saharan African countries, 2014-2016
Kanagasabai U , Chevalier MS , Drammeh B , Mili FD , Qualls ML , Bock N , Benech I , Nelson LJ , Alemnji G , Watts DH , Kimani D , Selenic D . MMWR Morb Mortal Wkly Rep 2018 67 (50) 1392-1396 Ensuring availability of safe blood products through recruitment of voluntary, nonremunerated, blood donors (VNRDs) and prevention of transfusion-transmissible infections (TTIs), including human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and syphilis, is important for public health (1,2). During 2004-2016, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) provided approximately $468 million in financial support and technical assistance* to 14 sub-Saharan African countries(dagger) with high HIV prevalence to strengthen national blood transfusion services (NBTSs)( section sign) and improve blood safety and availability. CDC analyzed these countries' 2014-2016 blood safety surveillance data to update previous reports (1,2) and summarize achievements and programmatic gaps as some NBTSs begin to transition funding and technical support from PEPFAR to local ministries of health (MOHs) (2,3). Despite a 60% increase in blood supply since 2004 and steady declines in HIV prevalence (to <1% among blood donors in seven of the 14 countries), HIV prevalence among blood donors still remains higher than that recommended by the World Health Organization (WHO) (4). PEPFAR support has contributed to significant reductions in HIV prevalence among blood donors in the majority of PEPFAR-supported countries, and linking donors who screen HIV-positive to confirmatory testing and indicated treatment, as well as further reducing TTIs, remains a public health priority (5). |
Sustainable HIV treatment in Africa through viral-load-informed differentiated care
Phillips A , Shroufi A , Vojnov L , Cohn J , Roberts T , Ellman T , Bonner K , Rousseau C , Garnett G , Cambiano V , Nakagawa F , Ford D , Bansi-Matharu L , Miners A , Lundgren JD , Eaton JW , Parkes-Ratanshi R , Katz Z , Maman D , Ford N , Vitoria M , Doherty M , Dowdy D , Nichols B , Murtagh M , Wareham M , Palamountain KM , Chakanyuka Musanhu C , Stevens W , Katzenstein D , Ciaranello A , Barnabas R , Braithwaite RS , Bendavid E , Nathoo KJ , van de Vijver D , Wilson DP , Holmes C , Bershteyn A , Walker S , Raizes E , Jani I , Nelson LJ , Peeling R , Terris-Prestholt F , Murungu J , Mutasa-Apollo T , Hallett TB , Revill P . Nature 2015 528 (7580) S68-76 There are inefficiencies in current approaches to monitoring patients on antiretroviral therapy in sub-Saharan Africa. Patients typically attend clinics every 1 to 3 months for clinical assessment. The clinic costs are comparable with the costs of the drugs themselves and CD4 counts are measured every 6 months, but patients are rarely switched to second-line therapies. To ensure sustainability of treatment programmes, a transition to more cost-effective delivery of antiretroviral therapy is needed. In contrast to the CD4 count, measurement of the level of HIV RNA in plasma (the viral load) provides a direct measure of the current treatment effect. Viral-load-informed differentiated care is a means of tailoring care so that those with suppressed viral load visit the clinic less frequently and attention is focussed on those with unsuppressed viral load to promote adherence and timely switching to a second-line regimen. The most feasible approach to measuring viral load in many countries is to collect dried blood spot samples for testing in regional laboratories; however, there have been concerns over the sensitivity and specificity of this approach to define treatment failure and the delay in returning results to the clinic. We use modelling to synthesize evidence and evaluate the cost-effectiveness of viral-load-informed differentiated care, accounting for limitations of dried blood sample testing. We find that viral-load-informed differentiated care using dried blood sample testing is cost-effective and is a recommended strategy for patient monitoring, although further empirical evidence as the approach is rolled out would be of value. We also explore the potential benefits of point-of-care viral load tests that may become available in the future. |
Incidence and determinants of tuberculosis among adults initiating antiretroviral therapy - Mozambique, 2004-2008
Auld AF , Mbofana F , Shiraishi RW , Alfredo C , Sanchez M , Ellerbrock TV , Nelson LJ . PLoS One 2013 8 (1) e54665 BACKGROUND: In Mozambique, tuberculosis (TB) is thought to be the most common cause of death among antiretroviral therapy (ART) enrollees. Monitoring proportions of enrollees screened for TB, and incidence and determinants of TB during ART can help clinicians and program managers identify program improvement opportunities. METHODOLOGY/PRINCIPAL FINDINGS: We conducted a retrospective cohort study among a nationally representative sample of the 79,500 adults (>14 years old) initiating ART during 2004-2007 to estimate clinician compliance with TB screening guidelines, factors associated with active TB at ART initiation, and incidence and predictors of documented TB during ART follow-up. Of 94 sites enrolling >50 adults on ART, 30 were selected using probability-proportional-to-size sampling; 2,596 medical records at these sites were randomly selected for abstraction and analysis. At ART initiation, median age of patients was 34, 62% were female, median baseline CD4(+) T-cell count was 153/microL, and 11% were taking TB treatment. Proportions of records with TB screening documentation before ART initiation improved from 31% to 66% during 2004-2007 (p<0.001). TB screening compliance varied widely by ART clinic [n = 30, 2%-98% (p<0.001)] and supporting non-Governmental Organization (NGO) [n = 7, 27%-83% (p<0.001)]. Receiving TB treatment at ART enrollment was associated with male sex (p<0.001), weight <45 kg (p<0.001) and CD4<50/microL (p = 0.001). Isoniazid preventive therapy (IPT) was prescribed to <1% of ART enrollees not taking TB treatment. TB incidence during ART was 2.32 cases per 100 person-years. Factors associated with TB incidence included adherence to ART <95% (AHR 2.06; 95% CI, 1.32-3.21). CONCLUSION: Variations in TB screening by clinic and NGO may reflect differing investments in TB screening activities. Future scale-up should target under-performing clinics. Scale-up of TB screening at ART initiation, IPT, and ART adherence interventions could significantly reduce incident TB during ART. |
Four-year treatment outcomes of adult patients enrolled in Mozambique's rapidly expanding antiretroviral therapy program
Auld AF , Mbofana F , Shiraishi RW , Sanchez M , Alfredo C , Nelson LJ , Ellerbrock T . PLoS One 2011 6 (4) e18453 BACKGROUND: In Mozambique during 2004-2007 numbers of adult patients (≥15 years old) enrolled on antiretroviral therapy (ART) increased about 16-fold, from <5,000 to 79,500. All ART patients were eligible for co-trimoxazole. ART program outcomes, and determinants of outcomes, have not yet been reported. METHODOLOGY/PRINCIPAL FINDINGS: In a retrospective cohort study, we investigated rates of mortality, attrition (death, loss to follow-up, or treatment cessation), immunologic treatment failure, and regimen-switch, as well as determinants of selected outcomes, among a nationally representative sample of 2,596 adults initiating ART during 2004-2007. At ART initiation, median age of patients was 34 and 62% were female. Malnutrition and advanced disease were common; 18% of patients weighed <45 kilograms, and 15% were WHO stage IV. Median baseline CD4(+) T-cell count was 153/microL and was lower for males than females (139/microL vs. 159/microL, p<0.01). Stavudine, lamivudine, and nevirapine or efavirenz were prescribed to 88% of patients; only 31% were prescribed co-trimoxazole. Mortality and attrition rates were 3.4 deaths and 19.8 attritions per 100 patient-years overall, and 12.9 deaths and 57.2 attritions per 100 patient-years in the first 90 days. Predictors of attrition included male sex [adjusted hazard ratio (AHR) 1.5; 95% confidence interval (CI), 1.3-1.8], weight <45 kg (AHR 2.1; 95% CI, 1.6-2.9, reference group >60 kg), WHO stage IV (AHR 1.7; 95% CI, 1.3-2.4, reference group WHO stage I/II), lack of co-trimoxazole prescription (AHR 1.4; 95% CI, 1.0-1.8), and later calendar year of ART initiation (AHR 1.5; 95% CI, 1.2-1.8). Rates of immunologic treatment failure and regimen-switch were 14.0 and 0.6 events per 100-patient years, respectively. CONCLUSIONS: ART initiation at earlier disease stages and scale-up of co-trimoxazole among ART patients could improve outcomes. Research to determine reasons for low regimen-switch rates and increasing rates of attrition during program expansion is needed. |
Global policies and practices for managing persons exposed to multidrug-resistant tuberculosis
Cain KP , Nelson LJ , Cegielski JP . Int J Tuberc Lung Dis 2010 14 (3) 269-74 SETTING: In the 1960s, treatment for latent tuberculosis infection (LTBI) with isoniazid proved to be so effective, safe, and inexpensive that research into alternative treatments virtually ceased. Now that multidrug-resistant tuberculosis (MDR-TB) is widespread, no data are available to guide the management of persons exposed to MDR-TB (contacts). METHODS: We surveyed National TB Program directors and MDR-TB program managers about current practices for managing MDR-TB contacts in countries with an MDR-TB prevalence of >2% in new patients and those with programs for managing MDR-TB. RESULTS: Of 35 countries that met the survey criteria, 25 (71%) responded; 24 of these (96%) have a guideline for managing TB contacts. Of these, 19 (76%) usually or always evaluated contacts and treated LTBI. In contrast, 10 (40%) countries reported having a guideline for managing MDR-TB contacts, 11 (44%) usually or always evaluated MDR-TB contacts, and 9 (36%) treated LTBI. Only two (8%) used a regimen that has activity against MDR-TB. Lack of evidence or guidelines was the main reason for not treating MDR-TB contacts. CONCLUSIONS: Management of MDR-TB contacts is inconsistent and ineffective due to lack of evidence-based guidelines. There is an urgent need to generate evidence to guide policy. |
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