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Background During January 2017-December 2018, multiple human anthrax outbreaks in Arua, Kween, and Kiruhura districts, Uganda were caused by exposure to domestic ruminants that died of anthrax. We investigated to determine the scope of anthrax outbreaks in domestic ruminants, identify possible exposures, and recommend evidence-based control measures. Methods We defined a suspected case-animal as sudden death of a domestic ruminant with unclotted blood oozing from body orifices during January 2016–December 2018 in Arua, Kween and Kiruhura districts. A probable case-animal was a suspected case-animal with a positive rapid diagnostic test using the Active Anthrax Detect Rapid Diagnostic Test, and/or the microscopic identification of Gram-positive rods in biological samples. A case-kraal was defined as an enclosure of cattle/sheep or mixed species with ≥1 suspected case-animal. We reviewed district veterinary records and actively searched for case-livestock. We conducted separate case-control studies in the affected districts to compare exposures between case-kraals and control-kraals (i.e., kraals with no suspected case-livestock during the same time period as the case-kraal), frequency-matched by village, with ratios of 1:1 in Arua, 1:4 in Kiruhura, and 1:2 in Kween. We estimated overall associations in all three districts using pooled analysis. Results We identified 1,971 suspected case-livestock (attack rate [AR] =1.4/1000) in 229 (7.3/1,000) of 31,500 kraals. Cattle (AR=2.1/1,000), goats (AR=0.48/1,000), and sheep (AR=0.10/1,000) were all affected. Of the three districts, Arua was the most affected (AR=3.1/1,000), followed by Kween (AR=1.8/1,000) and Kiruhura (AR=0.065/1,000). The epidemic curve indicated continuous outbreaks in Arua and Kween districts. Human outbreaks were reported during or after the onset of livestock outbreaks in all three districts. Having livestock that died of suspected anthrax butchered

Background: SARS-CoV-2 has been identified in the feces of COVID-19 patients. However, fecal transmission has never been shown epidemiologically. In April 2020, a COVID-19 outbreak occurred in a low-income community in Guangzhou, China. We investigated this outbreak to identify the mode of transmission. Methods: A home quarantined order was issued in the community. We collected throat swab samples from the residents and environmental samples from the surfaces inside and around the houses, and conducted RT-PCR testing and genome sequencing. We defined a case as a resident in this community with a positive RT-PCR test. We conducted a retrospective cohort study among the residents living in the same building as the cases to identify transmission risk factors. Findings: We found eight cases (four couples) in this community of 2888 residents (attack rate=2.8/1000), with onset from April 5 to 21, 2020. During their incubation periods, Cases 1 and 2 frequented a Market T, where an outbreak was ongoing. Cases 3-8 never visited Market T during incubation periods, lived in separate buildings from, and never interacted with, Cases 1 and 2. Retrospective cohort study showed that working as cleaners or street scavengers (RR=13, 95% CI: 1.8-99), not changing to clean shoes after returning home (RR=7.4, 95% CI: 1.7-33), collating and cleaning dirty shoes after returning home (RR=6.3, 95% CI: 1.4-28) were significant exposure risk factors. Of 63 samples collected from street sewage puddles and sewage pipes, 19% tested positive for SARS-CoV-2. Of 50 samples taken from the cases’ apartments, 24% tested positive. RNA sequencing showed that the viruses identified from the squat toilet and the shoe-bottom dirt from the apartments of Cases 1 and 2 are homologous with those from Cases 3-8 and those identified from the sewage samples. The sewage pipe leading from the apartment of Cases 1 and 2 down to the drainage had a large crack above the ground. Rainfalls after the onset of Cases 1 and 2 flooded the streets. Interpretation: Our investigation has for the first time provided epidemiologic evidence that SARS-CoV-2 can be spread by sewage. This finding highlighted the importance of sewage management, especially in densely-populated places with poor hygiene and sanitation measures, such as urban slums and other low-income communities in developing countries. Funding: No. Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: This study was approved by the ethics committees of GZCDC (approval number GZCDC-ECHR-2020A0004).

On October 25, 2016, media reports alerted the Uganda Ministry of Health to an outbreak of >80 cases of vomiting, syncope, and acute diarrhea among workers at a flower farm in central Uganda; 27 workers were hospitalized. On November 1, an investigation was undertaken by the Uganda Public Health Fellowship Program.* A case-control study found that working inside greenhouse 7, which had been fumigated with the organosulfur compound metam sodium the night of October 13, was strongly associated with illness. Employees who worked in this greenhouse during October 14-21 reported a strong "suffocating" smell in the greenhouse. Investigation revealed that, in violation of safety protocols, workers did not properly cover the soil after fumigation, allowing vapors to become trapped inside the greenhouse. The farm management, unaware of the lapse, failed to inform workers to avoid the vicinity of the fumigation. Respiratory protective measures were not routinely available for workers, which likely contributed to the severity and extent of the outbreak. Although metam sodium is generally considered to be of low risk when used according to manufacturer's instructions (1), occupational exposure in the absence of recommended safety measures can have serious health consequences. The investigation highlighted the importance of identifying potential occupational hazards to workers, as well as establishing safety protocols in occupational settings, training workers at risk, such as pesticide sprayers and flower pickers,† and ensuring enforcement of safety protocols. After this outbreak, the farm management reviewed, revised, and trained the workers on safety protocols to prevent future outbreaks.

Background Anthrax is a zoonotic disease that can be transmitted to humans from infected animals. During May–June 2017, three persons with probable cutaneous anthrax were reported in Arua District, Uganda; one died. All had recently handled carcasses of livestock that died suddenly and a skin lesion from a deceased person tested positive by PCR for Bacillus anthracis. During July, a bull in the same community died suddenly and the blood sample tested positive by PCR for Bacillus anthracis. The aim of this investigation was to establish the scope of the problem, identify exposures associated with illness, and recommend evidence-based control measures. Methods A probable case was defined as acute onset of a papulo-vesicular skin lesion subsequently forming an eschar in a resident of Arua District during January 2015–August 2017. A confirmed case was a probable case with a skin sample testing positive by polymerase chain reaction (PCR) for B. anthracis. Cases were identified by medical record review and active community search. In a case-control study, exposures between case-patients and frequency- and village-matched asymptomatic controls were compared. Key animal health staff were interviewed to learn about livestock deaths. Results There were 68 case-patients (67 probable, 1 confirmed), and 2 deaths identified. Cases occurred throughout the three-year period, peaking during dry seasons. All cases occurred following sudden livestock deaths in the villages. Case-patients came from two neighboring sub-counties: Rigbo (attack rate (AR) = 21.9/10,000 population) and Rhino Camp (AR = 1.9/10,000). Males (AR = 24.9/10,000) were more affected than females (AR = 0.7/10,000). Persons aged 30–39 years (AR = 40.1/10,000 population) were most affected. Among all cases and 136 controls, skinning (ORM-H = 5.0, 95%CI: 2.3–11), butchering (ORM-H = 22, 95%CI: 5.5–89), and carrying the carcass of livestock that died suddenly (ORM-H = 6.9, 95%CI: 3.0–16) were associated with illness. Conclusions Exposure to carcasses of animals that died suddenly was a likely risk factor for cutaneous anthrax in Arua District during 2015–2017. The recommendations are investigation of anthrax burden in livestock, prevention of animal infections through vaccinations, safe disposal of the carcasses, public education on risk factors for infection and prompt treatment of illness following exposure to animals that died suddenly., Author summary We are honored to submit an original research article entitled “Cutaneous anthrax associated with handling carcasses of animals that died suddenly of unknown cause: Arua District, Uganda, January 2015–August 2017”. Anthrax is a vaccine-preventable disease that can be transmitted to humans from infected animals. Our paper is based on 68 cutaneous anthrax case-patients and cases occurred throughout the three-year period, peaking during dry seasons in Arua District of Uganda. All cases occurred following sudden livestock deaths in the villages. Our findings are based on outbreak investigation which gives a better representation of the actual situation. Our article looks at the scope of the anthrax outbreak, exposures associated with illness, and evidence-based control measures. In this manuscript, we show that exposure to carcasses of animals that died suddenly was a risk factor for cutaneous anthrax in Arua District during 2015–2017. We believe the content and objectives of our work provide knowledge on epidemiology of cutaneous anthrax.

Background In May 2015, a cholera outbreak that had lasted 3 months and infected over 100 people was reported in Kasese District, Uganda, where multiple cholera outbreaks had occurred previously. We conducted an investigation to identify the mode of transmission to guide control measures. Methods We defined a suspected case as onset of acute watery diarrhoea from 1 February 2015 onwards in a Kasese resident. A confirmed case was a suspected case with Vibrio cholerae O1 El Tor, serotype Inaba cultured from a stool sample. We reviewed medical records to find cases. We conducted a case-control study to compare exposures among confirmed case-persons and asymptomatic controls, matched by village and age-group. We conducted environmental assessments. We tested water samples from the most affected area for total coliforms using the Most Probable Number (MPN) method. Results We identified 183 suspected cases including 61 confirmed cases of Vibrio cholerae 01; serotype Inaba, with onset between February and July 2015. 2 case-persons died of cholera. The outbreak occurred in 80 villages and affected all age groups; the highest attack rate occurred in the 5–14 year age group (4.1/10,000). The outbreak started in Bwera Sub-County bordering the Democratic Republic of Congo and spread eastward through sustained community transmission. The first case-persons were involved in cross-border trading. The case-control study, which involved 49 confirmed cases and 201 controls, showed that 94% (46/49) of case-persons compared with 79% (160/201) of control-persons drank water without boiling or treatment (ORM-H=4.8, 95% CI: 1.3–18). Water collected from the two main sources, i.e., public pipes (consumed by 39% of case-persons and 38% of control-persons) or streams (consumed by 29% of case-persons and 24% control-persons) had high coliform counts, a marker of faecal contamination. Environmental assessment revealed evidence of open defecation along the streams. No food items were significantly associated with illness. Conclusions This prolonged, community-wide cholera outbreak was associated with drinking water contaminated by faecal matter and cross-border trading. We recommended rigorous disposal of patients’ faeces, chlorination of piped water, and boiling or treatment of drinking water. The outbreak stopped 6 weeks after these recommendations were implemented.

Podoconiosis, a noninfectious elephantiasis, is a disabling neglected tropical disease. In August 2015, an elephantiasis case-cluster was reported in Kamwenge District, western Uganda. We investigated to identify the disease's nature and risk factors. We defined a suspected podoconiosis case as onset in a Kamwenge resident of bilateral asymmetrical lower limb swelling lasting ≥ 1 month, plus ≥ 1 of the following associated symptoms: skin itching, burning sensation, plantar edema, lymph ooze, prominent skin markings, rigid toes, or mossy papillomata. A probable case was a suspected case with negative microfilaria antigen immunochromatographic card test (ruling out filarial elephantiasis). We conducted active case-finding. In a case-control investigation, we tested the hypothesis that the disease was caused by prolonged foot skin exposure to irritant soils, using 40 probable case-persons and 80 asymptomatic village control-persons, individually matched by age and sex. We collected soil samples to characterize irritants. We identified 52 suspected (including 40 probable) cases with onset from 1980 to 2015. Prevalence rates increased with age; annual incidence (by reported onset of disease) was stable over time at 2.9/100,000. We found that 93% (37/40) of cases and 68% (54/80) of controls never wore shoes at work (Mantel-Haenszel odds ratio [ORMH] = 7.7; 95% [confidence interval] CI = 2.0-30); 80% (32/40) of cases and 49% (39/80) of controls never wore shoes at home (ORMH = 5.2; 95% CI = 1.8-15); and 70% (27/39) of cases and 44% (35/79) of controls washed feet at day end (versus immediately after work) (OR = 11; 95% CI = 2.1-56). Soil samples were characterized as rich black-red volcanic clays. In conclusion, this reported elephantiasis is podoconiosis associated with prolonged foot exposure to volcanic soil. We recommended foot hygiene and universal use of protective shoes.

Objective To explore the correlation of the reversely increased results of 75g oral glucose tolerance test (OGTT) during pregnancy to the pregnancy outcome, so as to provide a reliable theoretical basis of the early intervention for the pregnant women with high plasma glucose. Methods The clinical data of 461 cases were retrospectively analyzed. Patients were chosen from the pregnant women undergoing routine antenatal examination in our hospital during 2014. According to the results of 75g OGTT, 226 patients were analyzed as the observation group, in whom the level of postprandial 2-hour plasma glucose was higher than that of postprandial 1-hour plasma glucose. Meanwhile 235 pregnant women with or without gestational diabetes mellitus (GDM) were randomly selected as the control group. Results The levels of fasting plasma glucose and 1-hour postprandial plasma glucose were lower, but those of 2-hour postprandial plasma glucose was higher in observation group than in control group (P0.05) in the incidences of polyhydramnios, oligohydramnios, fetal growth restriction (FGR), premature labor (PTL), pregnancy induced hypertension (PIH), complicated with premature rupture of membrane (PROM), intrauterine fetal death (IUFD) and non scar uterus cesarean section rate (CSR). Compared with the observation group, the rates of neonatal dysplasia and neonatal asphyxia and the newborn transfer rate were lower in the control group, of which the newborn transfer rate was statistically different (P

Background On 6 February 2015, Kampala city authorities alerted the Ugandan Ministry of Health of a “strange disease” that killed one person and sickened dozens. We conducted an epidemiologic investigation to identify the nature of the disease, mode of transmission, and risk factors to inform timely and effective control measures. Methods We defined a suspected case as onset of fever (≥37.5 °C) for more than 3 days with abdominal pain, headache, negative malaria test or failed anti-malaria treatment, and at least 2 of the following: diarrhea, nausea or vomiting, constipation, fatigue. A probable case was defined as a suspected case with a positive TUBEX® TF test. A confirmed case had blood culture yielding Salmonella Typhi. We conducted a case-control study to compare exposures of 33 suspected case-patients and 78 controls, and tested water and juice samples. Results From 17 February–12 June, we identified 10,230 suspected, 1038 probable, and 51 confirmed cases. Approximately 22.58% (7/31) of case-patients and 2.56% (2/78) of controls drank water sold in small plastic bags (ORM-H = 8.90; 95%CI = 1.60–49.00); 54.54% (18/33) of case-patients and 19.23% (15/78) of controls consumed locally-made drinks (ORM-H = 4.60; 95%CI: 1.90–11.00). All isolates were susceptible to ciprofloxacin and ceftriaxone. Water and juice samples exhibited evidence of fecal contamination. Conclusion Contaminated water and street-vended beverages were likely vehicles of this outbreak. At our recommendation authorities closed unsafe water sources and supplied safe water to affected areas.

Uganda is currently implementing the Global Health Security Agenda (GHSA), aiming at accelerating compliance to the International Health Regulations (IHR) (2005). To assess progress toward compliance, a Joint External Evaluation (JEE) was conducted by the World Health Organization (WHO). Based on this evaluation, we present the process and lessons learned. Uganda's methodological approach to the JEE followed the WHO recommendations, including conducting a whole-of-government in-country self-assessment prior to the final assessment, using the same tool at both assessments, and generating consensus scores during the final assessment. The in-country self-assessment process began on March 24, 2017, with a multisectoral representation of 203 subject matter experts from 81 institutions. The final assessment was conducted between June 26 and 30, 2017, by 15 external evaluators. Discrepancies between the in-country and final scores occurred in 27 of 50 indicators. Prioritized gaps from the JEE formed the basis of the National Action Plan for Health Security. We learned 4 major lessons from this process: subject matter experts should be adequately oriented on the scoring requirements of the JEE tool; whole-of-government representation should be ensured during the entire JEE process; equitable multisectoral implementation of IHR activities must be ensured; and over-reliance on external support is a threat to sustainability of GHSA gains.

Background A cholera outbreak started on 29 February in Bwikhonge Sub-county, Bulambuli District in Eastern Uganda. Local public health authorities implemented initial control measures. However, in late March, cases sharply increased in Bwikhonge Sub-county. We investigated the outbreak to determine its scope and mode of transmission, and to inform control measures. Methods We defined a suspected case as sudden onset of watery diarrhea from 1 March 2016 onwards in a resident of Bulambuli District. A confirmed case was a suspected case with positive stool culture for V. cholerae. We conducted descriptive epidemiologic analysis of the cases to inform the hypothesis on mode of transmission. To test the hypothesis, we conducted a case-control study involving 100 suspected case-patients and 100 asymptomatic controls, individually-matched by residence village and age. We collected seven water samples for laboratory testing. Results We identified 108 suspected cases (attack rate: 1.3%, 108/8404), including 7 confirmed cases. The case-control study revealed that 78% (78/100) of case-patients compared with 51% (51/100) of control-persons usually collected drinking water from the nearby Cheptui River (ORMH = 7.8, 95% CI = 2.7–22); conversely, 35% (35/100) of case-patients compared with 54% (54/100) of control-persons usually collected drinking water from borehole pumps (ORMH = 0.31, 95% CI = 0.13–0.65). The index case in Bwikhonge Sub-county had onset on 29 February but the outbreak had been on-going in the neighbouring sub-counties in the previous 3 months. V. cholera was isolated in 2 of the 7 river water samples collected from different locations. Conclusions We concluded that this cholera outbreak was caused by drinking contaminated water from Cheptui River. We recommended boiling and/or treating drinking water, improved sanitation, distribution of chlorine tablets to the affected villages, and as a long-term solution, construction of more borehole pumps. After implementing preventive measures, the number of cases declined and completely stopped after 6th April.

Background In August 2017, the Uganda Ministry of Health was notified of increased cases of multidrug-resistant tuberculosis (MDR-TB) in Arua District, Uganda during 2017. We investigated to identify the scope of the increase and risk factors for infection, evaluate health facilities’ capacity to manage MDR-TB, and recommend evidence-based control measures. Methods We defined an MDR-TB case-patient as a TB patient attending Arua Regional Referral Hospital (ARRH) during 2013–2017 with a sputum sample yielding Mycobacterium tuberculosis resistant to at least rifampicin and isoniazid, confirmed by an approved drug susceptibility test. We reviewed clinical records from ARRH and compared the number of MDR-TB cases during January–August 2017 with the same months in 2013–2016. To identify risk factors specific for MDR-TB among cases with secondary infection, we conducted a case-control study using persons with drug-susceptible TB matched by sub-county of residence as controls. We observed infection prevention and control practices in health facilities and community, and assessed health facilities’ capacity to manage TB. Results We identified 33 patients with MDR-TB, of whom 30 were secondary TB infection cases. The number of cases during January–August 2017 was 10, compared with 3–4 cases in January–August from 2013 to 2016 (p = 0.02). Men were more affected than women (6.5 vs 1.6/100,000, p 15 months from symptom onset (aOR = 11, 95% CI: 1.5–87) were associated with MDR-TB. All ten facilities assessed reported stockouts of TB commodities. All 15 ambulatory MDR-TB patients we observed were not wearing masks given to them to minimize community infection. The MDR-TB ward at ARRH capacity was 4 patients but there were 11 patients. Conclusion The number of cases during January–August in 2017 was significantly higher than during the same months in 2013–2016. Poor adherence to TB drugs and delayed treatment initiation were associated with MDR-TB infection. We recommended strengthening directly-observed treatment strategy, increasing access to treatment services, and increasing the number of beds in the MDR-TB ward at ARRH.

Background Cesarean section (CS) is an important intervention in complicated births when the safety of the mother or baby is compromised. Despite worldwide concerns about the overutilization of CS in recent years, many African women and their newborns still die because of limited or no access to CS services. We evaluated temporal and spatial trends in CS births in Uganda and modeled future trends to inform programming. Methods We performed secondary analysis of total births data from the Uganda National Health Management Information System (HMIS) reports during 2012–2016. We reviewed data from 3461 health facilities providing basic, essential obstetric and emergency obstetric care services in all 112 districts. We defined facility-based CS rate as the proportion of cesarean deliveries among total live births in facilities, and estimated the population-based CS rate using the total number of cesarean deliveries as a proportion of annual expected births (including facility-based and non-facility-based) for each district. We predicted CS rates for 2021 using Generalised Linear Models with Poisson family, Log link and Unbiased Sandwich Standard errors. We used cesarean deliveries as the dependent variable and calendar year as the independent variable. Results Cesarean delivery rates increased both at facility and population levels in Uganda. Overall, the CS rate for live births at facilities was 9.9%, increasing from 8.5% in 2012 to 11% in 2016. The overall population-based CS rate was 4.7%, and increased from 3.2 to 5.9% over the same period. Health Centre IV level facilities had the largest annual rate of increase in CS rate between 2012 and 2016. Among all 112 districts, 80 (72%) had a population CS rate below 5%, while 38 (34%) had a CS rate below 1% over the study period. Overall, Uganda’s facility-based CS rate is projected to increase by 36% (PRR 1.36, 95% CI 1.35–1.36) in 2021 while the population-based CS rate is estimated to have doubled (PRR 2.12, 95% CI 2.11–2.12) from the baseline in 2016. Conclusion Cesarean deliveries are increasing in Uganda. Health center IVs saw the largest increases in CS, and while there was regional heterogeneity in changes in CS rates, utilization of CS services is inadequate in most districts. We recommend expansion of CS services to improve availability.

Introduction In October 2017, a blood sample from a resident of Kween District, Eastern Uganda, tested positive for Marburg virus. Within 24 hour of confirmation, a rapid outbreak response was initiated. Here, we present results of epidemiological and laboratory investigations. Methods A district task force was activated consisting of specialised teams to conduct case finding, case management and isolation, contact listing and follow up, sample collection and testing, and community engagement. An ecological investigation was also carried out to identify the potential source of infection. Virus isolation and Next Generation sequencing were performed to identify the strain of Marburg virus. Results Seventy individuals (34 MVD suspected cases and 36 close contacts of confirmed cases) were epidemiologically investigated, with blood samples tested for MVD. Only four cases met the MVD case definition; one was categorized as a probable case while the other three were confirmed cases. A total of 299 contacts were identified; during follow- up, two were confirmed as MVD. Of the four confirmed and probable MVD cases, three died, yielding a case fatality rate of 75%. All four cases belonged to a single family and 50% (2/4) of the MVD cases were female. All confirmed cases had clinical symptoms of fever, vomiting, abdominal pain and bleeding from body orifices. Viral sequences indicated that the Marburg virus strain responsible for this outbreak was closely related to virus strains previously shown to be circulating in Uganda. Conclusion This outbreak of MVD occurred as a family cluster with no additional transmission outside of the four related cases. Rapid case detection, prompt laboratory testing at the Uganda National VHF Reference Laboratory and presence of pre-trained, well-prepared national and district rapid response teams facilitated the containment and control of this outbreak within one month, preventing nationwide and global transmission of the disease., Author summary Marburg virus disease (MVD) is caused by the virus that belongs to the same family as that of Ebola Virus disease. The disease is characterized by severe clinical symptoms such as high fever, diarrhoea and vomiting, and severe bleeding from most body openings. On average, 54% of the people who get infected with Marburg virus die from it [1]. In October 2017, Uganda reported an outbreak of MVD in the eastern district of Kween that borders Kenya in the Mount Elgon plains. This was the first time MVD was being detected in this part of the country since previous MVD outbreaks had been reported in the western part of Uganda. The Ministry of Health together with partners instituted rapid outbreak response for control. Investigations revealed a cluster of one family involving four cases whereby only one survived. The outbreak was traced back into bat caves in Kween district. Rock salt mining in the cave led to a spill-over of the virus into the human population with the subsequent person-to-person transmission. Through contact tracing and isolation of the infected people among other approaches, the outbreak was brought under control as explained in this article.

Uganda is prone to epidemics of deadly infectious diseases and other public health emergencies. Though significant progress has been made in response to emergencies during the past 2 decades, system weaknesses still exist, including lack of a robust workforce with competencies to identify, investigate, and control disease outbreaks at the source. These deficiencies hamper global health security broadly. To address need for a highly competent workforce to combat infectious diseases, the Uganda Ministry of Health established the Public Health Fellowship Program (PHFP), the advanced-level Field Epidemiology Training Program (FETP), closely modeled after the CDC's Epidemic Intelligence Service (EIS) program. The 2-year, full-time, non-degree granting program is the first absolute post-master's FETP in Africa for mid-career public health professionals. Fellows gain competencies in 7 main domains, which are demonstrated by deliverables, while learning through service delivery 80% of the time in the ministry of health. During 2015-2017, PHFP enrolled 3 cohorts of 31 fellows. By January 2018, PHFP had graduated 2 cohorts (2015 and 2016) of 19 fellows. Fellows were placed in 17 priority areas of the ministry of health. They completed 153 projects (including 60 outbreak investigations, 12 refugee assessments, 40 surveillance projects, and 31 applied epidemiologic studies), of which 49 involved potential bioterrorism agents or epidemic-prone diseases. They made 132 conference presentations, prepared 40 manuscripts for peer-reviewed publication (17 published as of December 2017), and produced 3 case studies. Many of these projects have resulted in public health interventions that led to improvements in disease control and surveillance systems. The program has produced 19 issues of ministry of health bulletins. One year after graduation, graduates have been placed in key public health decision-making positions. Within 3 years, PHFP has strengthened global health security through improvement in public health emergency response; identification, investigation and control of outbreaks at their sources; and documentation and dissemination of findings to inform decision making by relevant stakeholders.

Background On 28 March, 2016, the Ministry of Health received a report on three deaths from an unknown disease characterized by fever, jaundice, and hemorrhage which occurred within a one-month period in the same family in central Uganda. We started an investigation to determine its nature and scope, identify risk factors, and to recommend eventually control measures for future prevention. Methods We defined a probable case as onset of unexplained fever plus ≥1 of the following unexplained symptoms: jaundice, unexplained bleeding, or liver function abnormalities. A confirmed case was a probable case with IgM or PCR positivity for yellow fever. We reviewed medical records and conducted active community case-finding. In a case-control study, we compared risk factors between case-patients and asymptomatic control-persons, frequency-matched by age, sex, and village. We used multivariate conditional logistic regression to evaluate risk factors. We also conducted entomological studies and environmental assessments. Results From February to May, we identified 42 case-persons (35 probable and seven confirmed), of whom 14 (33%) died. The attack rate (AR) was 2.6/100,000 for all affected districts, and highest in Masaka District (AR = 6.0/100,000). Men (AR = 4.0/100,000) were more affected than women (AR = 1.1/100,000) (p = 0.00016). Persons aged 30–39 years (AR = 14/100,000) were the most affected. Only 32 case-patients and 128 controls were used in the case control study. Twenty three case-persons (72%) and 32 control-persons (25%) farmed in swampy areas (ORadj = 7.5; 95%CI = 2.3–24); 20 case-patients (63%) and 32 control-persons (25%) who farmed reported presence of monkeys in agriculture fields (ORadj = 3.1, 95%CI = 1.1–8.6); and 20 case-patients (63%) and 35 control-persons (27%) farmed in forest areas (ORadj = 3.2; 95%CI = 0.93–11). No study participants reported yellow fever vaccination. Sylvatic monkeys and Aedes mosquitoes were identified in the nearby forest areas. Conclusion This yellow fever outbreak was likely sylvatic and transmitted to a susceptible population probably by mosquito bites during farming in forest and swampy areas. A reactive vaccination campaign was conducted in the affected districts after the outbreak. We recommended introduction of yellow fever vaccine into the routine Uganda National Expanded Program on Immunization and enhanced yellow fever surveillance.

Background On 12 October, 2016 a measles outbreak was reported in Mayuge District, eastern Uganda. We investigated the outbreak to determine its scope, identify risk factors for transmission, evaluate vaccination coverage and vaccine effectiveness, and recommend evidence-based control measures. Methods We defined a probable case as onset of fever (≥3 days) and generalized rash, plus ≥1 of the following: conjunctivitis, cough, and/or runny nose in a Mayuge District resident. A confirmed case was a probable case with measles-specific IgM (+) not explained by vaccination. We reviewed medical records and conducted active community case-finding. In a case-control investigation involving probable case-persons and controls matched by age and village, we evaluated risk factors for transmission for both cases and controls during the case-person’s likely exposure period (i.e., 7–21 days prior to rash onset). We estimated vaccine effectiveness (VE) using the formula: VE ≈ (1-ORprotective) × 100. We calculated vaccination coverage using the percentage of controls vaccinated. Results We identified 62 probable case-persons (attack rate [AR] = 4.0/10,000), including 3 confirmed. Of all age groups, children

Globally, even though improvements have been made to effective surveillance and response, communicable diseases such as cholera remain high priorities for national health programs, especially in Africa. High-quality surveillance information coupled with adequate laboratory facilities are effective in curbing outbreaks from such diseases, ultimately reducing morbidity and mortality. One way of building this capacity is through simulation of response to such health events. This case study based on a cholera outbreak investigated by FETP trainees in October 2015 in Uganda can be used to reinforce skills of frontline FETP trainees and other novice public health practitioners through a practical simulation approach. This activity should be completed in 2.5 hours.

Background In April 2015, Kamwenge District, western Uganda reported a measles outbreak. We investigated the outbreak to identify potential exposures that facilitated measles transmission, assess vaccine effectiveness (VE) and vaccination coverage (VC), and recommend prevention and control measures. Methods For this investigation, a probable case was defined as onset of fever and generalized maculopapular rash, plus ≥1 of the following symptoms: Coryza, conjunctivitis, or cough. A confirmed case was defined as a probable case plus identification of measles-specific IgM in serum. For case-finding, we reviewed patients’ medical records and conducted in-home patient examination. In a case-control study, we compared exposures of case-patients and controls matched by age and village of residence. For children aged 9 m-5y, we estimated VC using the percent of children among the controls who had been vaccinated against measles, and calculated VE using the formula, VE = 1 - ORM-H, where ORM-H was the Mantel-Haenszel odds ratio associated with having a measles vaccination history. Results We identified 213 probable cases with onset between April and August, 2015. Of 23 blood specimens collected, 78% were positive for measles-specific IgM. Measles attack rate was highest in the youngest age-group, 0-5y (13/10,000), and decreased as age increased. The epidemic curve indicated sustained propagation in the community. Of the 50 case-patients and 200 controls, 42% of case-patients and 12% of controls visited health centers during their likely exposure period (ORM-H = 6.1; 95% CI = 2.7–14). Among children aged 9 m-5y, VE was estimated at 70% (95% CI: 24–88%), and VC at 75% (95% CI: 67–83%). Excessive crowding was observed at all health centers; no patient triage-system existed. Conclusions The spread of measles during this outbreak was facilitated by patient mixing at crowded health centers, suboptimal VE and inadequate VC. We recommended emergency immunization campaign targeting children

Globalization has opened many fronts for disease outbreaks because of the quick movement of people and porous borders around the world. The emergence of zoonotic diseases and other communicable diseases highlights the need for implementation of the Global Health Security Agenda packages if countries are to achieve compliance with International Health Regulations (IHR 2005). Health workforce development is one of the critical components that must be addressed with utmost urgency if gaps in early disease detection and response are to be addressed. In this regard, this case study is based on a measles outbreak investigation in Uganda simulating a real-life outbreak investigation by field epidemiologists and seeks to demonstrate the principles of applied epidemiology outlining the critical steps in outbreak investigations and generation of evidence for decision making. It aims to shore up the health workforce capacity by providing practical training for field epidemiology students and professionals that builds their skills in outbreak investigation. This case study can be completed in less than three hours.

Introduction : on March 28, 2016 a cluster of deaths resulting from jaundice and hemorrhagic symptoms occurred in Masaka, Central Uganda. We investigated this outbreak to determine the nature of disease, identify risk factors, and recommend control and prevention measures. Methods : we defined a suspected case-person as onset in residents of Masaka, Rukungiri and Kalangala districts from January 2016 onwards of fever not responding to malaria treatment, plus ≥2 of the following: abdominal pain/diarrhea, headache, jaundice, unexplained bleeding. A confirmed case was a suspected case with positive IgM or PCR tests for yellow fever. We conducted medical record reviews and active community case-finding. In a case-control study we compared potential exposures between 32 case-persons and 128 asymptomatic controls matched by age, sex and village. We also conducted entomological studies and environmental assessments. Results : we identified 32 cases (7 confirmed). The overall attack rate (AR, per 100,000) was 0.48 overall (6.4 Masaka, 3.1 Rukungiri and 1.9 Kalangala); the case-fatality rate was 22% (7/32). Men (AR=1.2/10,000) and persons aged 30-39 years (AR = 4.0/10,000) were most affected. 20 (63%) of 32 case-persons and 35 (27%) of 128 control-persons cultivated in forest areas (ORM-H=4.3; 95%CI=1.9-9.7); 23 (71%) of 32 case-persons and 32 (25%) 128 control-persons cultivate in swampy areas (ORM-H=7.5; 95%CI=2.0-18). No one interviewed during this investigation was vaccinated against yellow fever. Sylvatic monkeys and Aedes mosquitoes were identified in the nearby forest areas. Conclusion : this was a sylvatic yellow fever outbreak that occurred in a susceptible population, likely transmitted by mosquito bites during cultivation in forest and swampy areas. We recommended yellow fever vaccination in affected districts and enhanced yellow fever surveillance in neighboring districts. The outbreak stopped following the vaccination.

Introduction : on 17th September 2015, the Ugandan Ministry of Health received reports from Buliisa District about mysterious death of people. The predominant symptom was hematemesis (vomiting of blood). By September 24, 2015, there had been 4 deaths. We investigated to verify existence of an outbreak, determine mode of disease transmission, and identify risk factors. Methods : we conducted a community-based active case-finding in Hoima and Buliisa districts, Western Uganda between 3 and 17 October 2015. A suspected case was defined as a resident of Hoima, Buliisa or neighbouring districts who had onset of hematemesis between 1 June 2015 and 15 October 2015. A control was an individual without any history of hematemesis. Biological specimens were collected from 19 cases and tested for viral haemorrhagic fevers (VHFs), including Ebola, Marburg, Crimean-Congo Haemorrhagic Fever and Rift Valley Fever viruses. Histopathology and bacterial examinations were also conducted. In a case-control study, we compared exposures of 21 cases and 81 controls. We used Mantel-Haenszel method to estimate odds ratios (OR) associated with exposures.

Introduction : in September 2015, a cholera outbreak occurred in a village in Hoima District, western Uganda. The Ministry of Health assembled a rapid response team, with support by CDC, UNICEF and WHO, to investigate the outbreak, establish the Kaiso Cholera Treatment Center (KCTC), and implement control measures. The team identified 120 cholera cases (with 5 deaths) and determined that drinking contaminated water from the lakeshore caused this outbreak. We sought to determine the cost of investigating and controlling this outbreak, and compare it to a would-be simple preventive measure, constructing deep wells to provide cleaner water. Methods : we collected cost data, including personnel and material costs at KCTC, health facilities, Hoima District Health Office, Uganda Public Health Fellowship Program, UNICEF, CDC, and WHO. We defined direct cost of responding to this outbreak as expenditure on medications, medical equipment and supplies, utilities, and allowances and transport for responders; indirect cost included salary and other compensations for responders. We did not include difficult-to-measure costs such as vehicle depreciation, building maintenance, and loss of productivity to case-persons due to illness and deaths. The cost of constructing deep wells was quoted by a U.S.-based NGO. Results : the total cost incurred in investigating and controlling this outbreak was $71,769, including $21,059 in direct cost ($19,225 for allowances and transportation, $1,774 for medical equipment and supplies, and $60 for utilities), and $50,620 in indirect cost (74,484 person-hours of salary and other compensations for responders). Conversely, constructing a deep well to provide cleaner water would cost approximately $2500. Essentially, the total cost incurred in this outbreak would have been enough to construct 28 (=71769/2500) deep wells; even the direct cost only would have been enough to construct 8 (=21059/2500) deep wells. One such deep well would have prevented this outbreak and averted future waterborne outbreaks. Conclusion : a simple prevention measure such as constructing deep wells for village residents can be substantially cost-effective for preventing waterborne diseases such as cholera. We recommend that the government should proactively implement prevention measures for waterborne outbreaks whenever possible, instead of passively responding to these outbreaks.

In June 2015, the District Health Officer of Kasese District, southwestern Uganda reported an outbreak of cholera in a fishing village. Two fellows of the Uganda Public Health Fellowship Program – Field Epidemiology Track conducted an investigation to verify the existence of an outbreak, determine the mode of transmission, and recommend control measures. This case study describes that investigation, which teaches the steps in an outbreak investigation and the details in each step, what needs to be done in each step to achieve the objectives of the investigation, and what might be the common pitfalls during an outbreak investigation. This case study can be used to teach the fundamental principles of an outbreak investigation and use of Epi Info for outbreak analysis. The audience are field epidemiologists at various levels in different settings.

Introduction : Bulambuli District, eastern Uganda experienced a cholera outbreak since January, 2016. Generic control measures implemented by the local public health authorities failed to contain the outbreak. In late-March, a sharp increase in the number of cases occurred in Bwikhonge Sub-county. We conducted an investigation to determine the scope of the outbreak, mode of transmission, and to inform control interventions. Methods : we defined a suspected case as sudden onset of watery diarrhea from 1 March 2016 onwards in a resident of Bulambuli District. A confirmed case was a suspected case with positive stool culture for V. Cholerae. We conducted active case-finding, performed descriptive epidemiologic analysis, and interviewed 40 suspected case-patients for hypothesis generation. We conducted a case-control study in which we interviewed 100 case-patients and 100 asymptomatic controls, matched by village of residence and age. We also conducted an environmental assessment. Results : we identified 108 suspected cases (attack rate: 1.3%, 108/8404), 8 of which were confirmed cases. Low-level transmission occurred between 2 and 21 March. Cases sharply increased on 24 March, followed by a six-day plateau and a rapid decline after 30th March, indicating a continuous common-source outbreak. The case-control study showed that 76% (76/100) of case-patients versus 54% (54/100) of control-persons usually collected drinking water from the nearby Cheptui River (ORMH=7.8, 95%CI=2.7-23); conversely, 36% (35/98) of case-patients and 54% (54/100) of control-persons usually collected drinking water from boreholes (ORMH=0.30, 95%CI=0.13-0.65). A case-patient with onset on 22 March defecated near the water-collection point in the river; subsequently, many case-patients washed their soiled clothes at the drinking-water collection point. Vibrio cholera 01 Ogawa was isolated in 2 of the 7 river water samples. Conclusion : this cholera outbreak was caused by drinking water from Cheptui River contaminated by a patient’s feces initially and washing of soiled clothes subsequently. We recommended health education on boiling and/or treating water, restriction on washing clothes near river water collection points, improved sanitation, and distributing chlorine tablets to the affected villages, and, as a long-term solution, construction of more boreholes. After implementing our recommendations, cases declined and completely stopped after 6 April.

Introduction : on 15 March 2016, Namayingo District reported a cholera outbreak in three locations, with four confirmed cases. We investigated to identify mode of transmission and recommend evidence-based control measures.

The Global Health Security Agenda (GHSA), a partnership of nations, international organizations, and civil society, was launched in 2014 with a mission to build countries' capacities to respond to infectious disease threats and to foster global compliance with the International Health Regulations (IHR 2005). The US Centers for Disease Control and Prevention (CDC) assists partner nations to improve IHR 2005 capacities and achieve GHSA targets. To assess progress through these CDC-supported efforts, we analyzed country activity reports dating from April 2015 through March 2017. Our analysis shows that CDC helped 17 Phase I countries achieve 675 major GHSA accomplishments, particularly in the cross-cutting areas of public health surveillance, laboratory systems, workforce development, and emergency response management. CDC's engagement has been critical to these accomplishments, but sustained support is needed until countries attain IHR 2005 capacities, thereby fostering national and regional health protection and ensuring a world safer and more secure from global health threats.

Introduction: On 17 September 2015, Buliisa District Health Office reported multiple deaths due to haemorrhage to the Uganda Ministry of Health. We conducted an investigation to verify the existence of an outbreak and to identify the disease nature, mode of transmission and risk factors. Methods: We defined a suspected case as onset of hematemesis between 1 June 2015 and 15 October 2015 in a resident of Hoima, Buliisa or neighbouring districts. We identified cases by reviewing medical records and actively searching in the community. We interviewed casepatients and health-care workers and performed descriptive epidemiology to generate hypotheses on possible exposures. In a case-control study we compared exposures between 21 cases and 81 controls, matched by age (± 10 years), sex and village of residence. We collected 22 biological specimens from 19 case-patients to test for Viral Haemorrhagic Fevers (VHF). We analysed the data using the Mantel-Haenszel method to account for the matched study design. Results: We identified 56 cases with onset from June to October (attack rate 15/100,000 in Buliisa District and 5.2/100,000 in Hoima District). The age-specific attack rate was highest in persons aged 31-60 years (15/100,000 in Hoima and 47/100,000 in Buliisa); no persons below 15 years of age had the illness. In the case-control study, 42% (5/12) of cases vs. 0.0% (0/77) of controls had liver disease (ORM-H = ∞; 95%CI = 3.7-∞); 71% (10/14) of cases vs. 35% (28/81) of controls had ulcer disease (ORM-H = 13; 95% CI = 1.6-98); 27% (3/11) of cases vs. 14% (11/81) of controls used indomethacin prior to disease onset (ORM-H = 6.0; 95% CI = 1.0-36). None of the blood samples were positive for any of the VHFs. Conclusion: This reported cluster of hematemesis illness was due to predisposing conditions and use of Non- Steroidal Anti-inflammatory Drugs (NSAID). Health education should be conducted on the danger of NSAIDs misuse, especially in persons with predisposing conditions. Keywords: Hematemesis, outbreak, case-control, Uganda

Background Between January and June, 2015, a large typhoid fever outbreak occurred in Kampala, Uganda, with 10,230 suspected cases. During the outbreak, area surgeons reported a surge in cases of typhoid intestinal perforation (TIP), a complication of typhoid fever. We conducted an investigation to characterize TIP cases and identify modifiable risk factors for TIP. Methods We defined a TIP case as a physician-diagnosed typhoid patient with non-traumatic terminal ileum perforation. We identified cases by reviewing medical records at all five major hospitals in Kampala from 2013 to 2015. In a matched case-control study, we compared potential risk factors among TIP cases and controls; controls were typhoid patients diagnosed by TUBEX TF, culture, or physician but without TIP, identified from the outbreak line-list and matched to cases by age, sex and residence. Cases and controls were interviewed using a standard questionnaire from 1st -23rd December 2015. We used conditional logistic regression to assess risk factors for TIP and control for confounding. Results Of the 88 TIP cases identified during 2013–2015, 77% (68/88) occurred between January and June, 2015; TIPs sharply increased in January and peaked in March, coincident with the typhoid outbreak. The estimated risk of TIP was 6.6 per 1000 suspected typhoid infections (68/10,230). The case-fatality rate was 10% (7/68). Cases sought care later than controls; Compared with 29% (13/45) of TIP cases and 63% (86/137) of controls who sought treatment within 3 days of onset, 42% (19/45) of cases and 32% (44/137) of controls sought treatment 4–9 days after illness onset (ORadj = 2.2, 95%CI = 0.83–5.8), while 29% (13/45) of cases and 5.1% (7/137) of controls sought treatment ≥10 days after onset (ORadj = 11, 95%CI = 1.9–61). 68% (96/141) of cases and 23% (23/100) of controls had got treatment before being treated at the treatment centre (ORadj = 9.0, 95%CI = 1.1–78). Conclusion Delay in seeking treatment increased the risk of TIPs. For future outbreaks, we recommended aggressive community case-finding, and informational campaigns in affected communities and among local healthcare providers to increase awareness of the need for early and appropriate treatment.

In recent years, outbreaks of hand, foot and mouth disease (HFMD) have increased, and more and more severe cases have appeared. We conducted a meta-analysis to generate large-scale evidence on the risk factors of severe HFMD.PubMed, Elsevier Science Direct, China National Knowledge Infrastructure (CNKI), and Wanfang (Chinese) were searched to identify relevant articles. All analyses were performed using Stata 11.0.We conducted a meta-analysis of 19 separate studies. Duration of fever ≥ 3 days (odds ratio (OR) 10.09, 95% confidence interval (CI) 6.22-16.35), body temperature ≥ 37.5°C (OR 4.91, 95% CI 1.26-19.18), lethargy (OR 7.75, 95% CI 3.78-15.89), hyperglycemia (OR 2.77, 95% CI 2.06-3.71), vomiting (OR 8.83, 95% CI 1.05-74.57), increased neutrophil count (weighted mean difference (WMD) 0.61, 95% CI 0.52-0.70), enterovirus 71 (EV71) infection (OR 5.13, 95% CI 3.11- 8.46), young age (WMD - 0.44, 95% CI - 0.69 to -0.19), and home care (OR 1.65, 95% CI 1.26-2.17) were significantly related to the risk of severe HFMD. We also found that a confirmed diagnosis at first visit to hospital significantly decreased the risk of severe HFMD (OR 0.30, 95% CI 0.09-0.99). We did not find an association between oral rash (OR 1.07, 95% CI 0.82-1.39), increased leukocyte count (WMD 0.51, 95% CI - 0.05-1.06), male sex (OR 1.06, 95% CI 0.91-1.24), or living in a rural area (OR 1.39, 95% CI 0.95-2.02) and the risk of severe HFMD.Duration of fever ≥ 3 days, body temperature ≥ 37.5°C, lethargy, hyperglycemia, vomiting, increased neutrophil count, EV71 infection, and young age are risk factors for severe HFMD. A confirmed diagnosis at first visit to hospital can significantly decrease the risk of severe HFMD.

In 2013, an oropharyngeal tularemia outbreak in Turkey affected 55 persons. Drinking tap water during the likely exposure period was significantly associated with illness (attack rate 27% vs. 11% among non-tap water drinkers). Findings showed the tap water source had been contaminated by surface water, and the chlorination device malfunctioned.

Background In February 2009, a high school student was diagnosed with sputum-smear positive pulmonary tuberculosis (TB). One year later, 2 other students in the same grade developed sputum-smear positive TB. Methods We used tuberculin skin testing (TST), chest radiography, sputum smear, and symptomatology for case identification. We defined latent TB infection (LTBI) as a TST induration of 15 mm or larger, probable TB as a chest radiograph indicative of TB plus productive cough/hemoptysis for at least 2 weeks or TST induration of 15 mm or larger, and confirmed TB as 2 or more positive sputum smears or 1 positive sputum smear plus a chest radiograph indicative of TB. Results Of students in the same grade as the primary case-student, 26% (122/476) had LTBI and 4.8% (23/476) had probable/confirmed TB. Of teachers, 43% (18/42) had LTBI and none had probable/confirmed TB. Sharing a classroom with the primary case-student increased risk for LTBI (rate ratio = 2.5; 95% CI: 1.9–3.4) and probable/confirmed TB (rate ratio = 17, 95% CI: 7.8–39). Of students with LTBI in February 2009 who refused prophylaxis, 50% (11/22) had probable/confirmed TB in April 2010. Conclusions This TB outbreak was likely started by delayed diagnosis of TB in the case-student and was facilitated by lack of post-exposure chemoprophylaxis. Post-exposure prophylaxis is strongly recommended for all TST-positive students.

To explore the relationship between vitamin D receptor (VDR) gene pol-ymorphisms at Fok I site and the risk of preterm birth for potential intervention of of preterm birth or threatened premature delivery.Fifty-seven women with preterm birth and 84 with full-term birth were included in this analysis. Polymerase chain reaction-restriction frag-ment length polymorphism (PCR-RFLP) was performed to identify VDR gene Fok I geno-types.No significant difference was found in age, D-dimer (DDI), fibrinogen (Fg), serum calcium (CaVDR gene Fok I site geno-types are related with preterm birth, and the FF genotype may serve as a potential risk factor for preterm birth.

Objective: During a nationwide measles epidemic in 2013, we conducted an investigation in Sanliurfa province to assess risk factors for measles infections. Methods: In a case-control design, we compared the history of hospital exposures for 189 randomly selected laboratory-confirmed patients (aged, ÖzetAmaç: Türkiye’de 2013 yılında kızamık vakalarında artış görülmüştür. Bu çalışma, vakaların en sık görüldüğü Şanlıurfa ilinde kızamık hastalığını etkileyen risk faktörlerini değerlendirmek için yapılmıştır. Yöntem: Bu vaka-kontrol çalışmasında, merkez ilçede yaşayan ve rasgele seçilen, 15 yaş altı, laboratuvarda doğrulanmış 189 vaka ile komşu ve yaş eşleştirmesi yapılan kontrolleri karşılaştırılmıştır. Aşı etkililiği (AE) hesaplanmıştır. Bulgular: Döküntü başlamadan bir ay öncesinde herhangi bir sağlık kuruluşuna başvuranlar; 0–11 aylık yaş grubunda vakaların %53.8’i, kontrollerin %23.8’i (TRRadj=3.7, %95 GA=1.6–8.6) 1–6 yaş grubunda vakaların % 48.2’i, kontrollerin %14.3 (TRRadj=5.5, %95 GA=2.5–12.8), 7–14 yaş grubunda ise vakaların %22.5’i, kontrollerin %12.8’idir (TRRadj=1.9, %95 GA=0.5–8.3). 12. aydaki kızamık aşı dozunu yaptırmayanlar; 1–6 yaş grubunda vakaların %59.7’si, kontrollerin %14.7’si (TRRadj=7.4, 95% GA=2.1–26.9; AE=%86, %95 GA=%52-96), 7– 14 yaş grubunda ise vakaların %53.8’i, kontrollerin %15.4’üdür (TRRadj=6.7,%95 GA=1.7–26.6; AE=%85, %95 GA=%41-96). Sonuç: Bu salgında hastanelerin kızamık bulaşını kolaylaştırdığı saptanmıştır. Çalışma sonuçlarına göre; ateş ve döküntülü vakalara triaj uygulanması ve kızamık aşı programının güçlendirilmesi önerilmiştir.Anahtar kelimeler: Kızamık, kızamık aşısı, hastane kaynaklı enfeksiyonlar, risk faktörleri, vaka kontrol çalışması.

Objective Scrub typhus is an important febrile disease in Asia, and antibiotics have been used to treat this disease. The purpose of this study was to generate large-scale evidence of the efficacy of different antibiotic regimens for treating scrub typhus using a meta-analysis. Methods PubMed, Elsevier ScienceDirect, Chinese Biomedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), and Wanfang (Chinese) were searched to identify relevant articles. The data from eligible citations were extracted by two reviewers. All analyses were performed using the Cochrane Collaboration Review Manager 4.2 and Stata 10.0 software programs. Results We conducted a meta-analysis of 17 separate studies that evaluated the efficacy of treatment with the different antibiotic regimens for scrub typhus. The median time (h) to clearance of fever in the azithromycin-treated group was longer than that in the chloramphenicol-treated group (weighted mean difference [WMD] = 12.66, 95% confidence interval [CI]: 2.26,23.06). Adverse events were 2.95 (95%CI: 1.32, 6.61) times more likely to occur in the azithromycin-treated group than in the chloramphenicol-treated group. The clearance time (days) for the main symptoms (including fever, headache, rash and lymphadenectasis) in the doxycycline-treated group was shorter than that in the chloramphenicol-treated group (WMD = -0.4, 95%CI: -0.53, -0.26) in five trials. Adverse drug events occurred significantly less frequently in the azithromycin-treated group than in the doxycycline-treated group (relative risk [RR] = 0.47, 95%CI: 0.31,0.71). Conclusion Doxycycline was found to act more quickly, but more adverse drug events occur when using this regimen compared to azithromycin and chloramphenicol.

Background Glucocorticoids increase the risk of developing critical disease from viral infections. However, primary care practitioners in China use them as antipyretics, potentially exposing hundreds of millions to this risk. Methods We enrolled all patients with confirmed pandemic influenza A (pH1N1) virus infection aged ≥3 years with available medical records at 4 Shenyang City hospitals from 20 October to 30 November 2009. A critical patient was any confirmed, hospitalized pH1N1 patient who developed ≥1 of the following: death, respiratory failure, septic shock, failure or insufficiency of ≥2 nonpulmonary organs, mechanical ventilation, or ICU admission. In a retrospective cohort study, we evaluated the risk of developing critical illness in relation to early (≤72 hours of influenza-like illness [ILI] onset) glucocorticoids treatment. Results Of the 83 hospitalized case-patients, 46% developed critical illness, 17% died, and 37% recovered and were discharged. Critically ill and other patients did not differ by underlying conditions and severity, median temperature at first clinic visit, and other measured risk factors. Of 17 patients who received early glucocorticoid treatment, 71% subsequently developed critical disease compared with 39% of 66 patients who received late (>72 hours) or no glucocorticoid treatment (RR(M-H) = 1.8, 95% CI = 1.2-2.8, after adjusting for 2 summary variables; ie, presence of underlying diseases and presence of underlying risk factors). Proportional hazards modeling showed that use of glucocorticoids tripled the hazard of developing critical disease (hazard ratio [HR] = 2.9, 95% CI = 1.3-6.2, after adjusting for the same summary variables). Conclusions Early use of parenteral glucocorticoids therapy for fever reduction and pneumonia prevention increases the risk for critical disease or death from pH1N1 infection. We recommend that guidelines on glucocorticoid use be established and enforced.

BACKGROUND: Hygiene and social distancing are recommended control measures for hand, foot, and mouth disease (HFMD) and herpangina. However, empirical data to support this recommendation are limited. METHODS: During an outbreak of HFMD and herpangina due to infection by the human enterovirus 71, we defined a case as a vesicular papular rash on the hands, feet, buttocks, or oral mucosa and onset from April 30 to June 26, 2008. We selected 176 HFMD and herpangina case-children and a stratified random sample of 201 asymptomatic control-children; frequency matched according to residency status. We administered a questionnaire to the parents about their children's exposures and hygienic behaviors. RESULTS: Risk factors for HFMD and herpangina included playing with neighborhood children (odds ratio [OR]: 11 [95% confidence interval (CI): 6.2–17]), visiting an outpatient clinic for another reason ≤ 1 week before onset (OR: 20 [95% CI: 5.0–88]), and community exposures to crowded places (OR: 7.3 [95% CI: 4.1–13]). By using a score summarizing responses to 4 hand-washing questions, we found that 50% of the case-children and 2.5% of control-children had a poor score of 1 to 3, whereas 12% of the case-children and 78% of control-children had a good score of ≥7 (OR: 0.00069 [95% CI: 0.0022–0.022]) after we adjusted for residency, age, and community exposures by using logistic regression. CONCLUSIONS: Hand-washing by preschool-aged children and their caregivers had a significant protective effect against community-acquired HFMD and herpangina from the human enterovirus 71 infection.

On September 21, 2009, China began administering vaccines, obtained from 10 different manufacturers, against 2009 pandemic influenza A (H1N1) virus infection in priority populations. We aimed to assess the safety of this vaccination program.We designed a plan for passive surveillance for adverse events after immunization with the influenza A (H1N1) vaccine. Physicians or vaccination providers were required to report the numbers of vaccinees and all adverse events to their local Center for Disease Control and Prevention (CDC), which then reported the data to the Chinese CDC through the online National Immunization Information System's National Adverse Event Following Immunization Surveillance System. Data were collected through March 21, 2010, and were verified and analyzed by the Chinese CDC.A total of 89.6 million doses of vaccine were administered from September 21, 2009, through March 21, 2010, and 8067 vaccinees reported having an adverse event, for a rate of 90.0 per 1 million doses. The age-specific rates of adverse events ranged from 31.4 per 1 million doses among persons 60 years of age or older to 130.6 per 1 million doses among persons 9 years of age or younger, and the manufacturer-specific rates ranged from 4.6 to 185.4 per 1 million doses. A total of 6552 of the 8067 adverse events (81.2%; rate, 73.1 per 1 million doses) were verified as vaccine reactions; 1083 of the 8067 (13.4%; rate, 12.1 per 1 million doses) were rare and more serious (vs. common, minor events), most of which (1050) were allergic reactions. Eleven cases of the Guillain-Barré syndrome were reported, for a rate of 0.1 per 1 million doses, which is lower than the background rate in China.No pattern of adverse events that would be of concern was observed after the administration of influenza A (H1N1) vaccine, nor was there evidence of an increased risk of the Guillain-Barré syndrome.

BACKGROUND Human enterovirus 71 (HEV71) causes outbreaks of life-threatening diseases throughout the world. The genesis of these severe diseases is unknown. METHODS During an outbreak of HEV71 infection, we investigated risk factors for critical illness. We developed a modified pediatric index of mortality (mPIM) incorporating heart rate, temperature, white blood cell count, respiratory rate, chest infiltrates, skin color, reflexes, responsiveness, and mobility. We calculated the mPIM for 103 patients (22 deaths) using complete scoring criteria in the medical record. In a case-control study, we compared cases (mPIM > or =10 or death) with controls (mPIM = 0-9) by drugs received within 96 hours after onset of fever, initial temperature, age, and nutritional anthropometry. RESULTS About 66% (68/103) of the patients with an mPIM score (28 cases and 40 controls) had data on initial exposures. About 50% of the 28 cases and 18% of the 40 controls received an injection to treat fever during the first 96 hours after onset (Odds ratio [OR] = 7.0, 95% confidence interval [CI]: 1.8-28). Injections containing exclusively glucocorticoids (OR = 4.8, 95% CI: 1.2-21) or pyrazolones (OR = 4.1, 95% CI: 0.91-19, P = 0.047) were risk factors for severe HEV71 infection. About 25% of cases and 5% of controls received both drugs parenterally while 7% of cases and 30% of controls received neither (OR = 21, 95% CI: 1.8-305). Conversely, cases and controls had identical average initial temperature, and did not differ significantly by age, sex, nutritional measurements, use of other drugs, or timeliness of medical care received. CONCLUSION Fever treatment with glucocorticoids and/or pyrazolones is a risk factor for life-threatening HEV71 infection.

Shigellosis outbreaks in daycare centers result in substantial disease and economic burdens in the United States. The emergence of multidrug resistant Shigella strains raises questions regarding control of transmission within daycare centers and treatment for children. From May to October 2005, 639 Shigella sonnei cases were reported in northwest Missouri, mostly among persons exposed to daycare centers.We conducted a case-control investigation among licensed daycare centers (LDCs) in northwest Missouri to determine transmission risk factors, tested isolates for antimicrobial resistance, and described treatment practices. Case LDCs had secondary attack rates of shigellosisor=2% (range, 2%-25%) and control LDCsor=2% (range, 0%-1.3%). We interviewed LDC staff and performed on-site inspections. Thirty-one outbreak isolates were tested for antimicrobial resistance. We interviewed physicians and reviewed health department outbreak-related treatment data.We enrolled 18 case and 21 control LDCs. LDCs withor=1 sink in every room (odds ratio [OR]: 0.1; 95% confidence interval [CI]: 0.02-0.5) or a diapering station in every room (OR: 0.1; 95% CI: 0.01-0.6) were less likely to be case-LDCs. Resistance to ampicillin and trimethoprim-sulfamethoxazole was found in 90% of the outbreak strains. Among 210 children treated with antimicrobial agents, azithromycin was used in 92 (44%) while a fluoroquinolone was used in 11 (5%) children.During a large daycare center-associated shigellosis outbreak, strains were highly resistant to ampicillin and trimethoprim-sulfamethoxazole. Children were frequently treated with azithromycin and occasionally fluoroquinolones. Appropriate handwashing and diapering infrastructure are necessary to minimize spread of shigellosis within daycare centers, and could reduce use of antimicrobial agents.

ObjectiveTo evaluate the effectiveness of the peer counselling (PC) programme on breast-feeding initiation among participants in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in Missouri, and to identify factors that facilitate breast-feeding initiation.DesignWe used the data from the 2006 Missouri Pregnancy Nutrition Surveillance System, Missouri Live Birth Records and the Missouri WIC programme to compare breast-feeding initiation rates between PC and non-PC agencies. We used multilevel logistic regression, with individual participants being nested within agencies, to control for individual- and agency-level characteristics.ResultsThe breast-feeding initiation rate in PC agencies was significantly higher than in non-PC agencies among prenatal participants, but the difference was not significant among postpartum participants. After controlling for maternal sociodemographic characteristics, compared with prenatal cases in non-PC agencies, prenatal cases in PC agencies were more likely to initiate breast-feeding (OR = 1·21; 95 % CI 1·03, 1·43), whereas postpartum cases were less likely to initiate breast-feeding. Among prenatal participants in PC agencies, longer duration of prenatal WIC enrolment was associated with a higher rate of breast-feeding initiation. After adjusting for maternal sociodemographic characteristics and other agency-level characteristics, participants of PC agencies with an international board-certified lactation consultant were more likely to initiate breast-feeding than participants of PC agencies without such a consultant (OR = 1·21; 95 % CI 1·01, 1·45).ConclusionsPrenatal participation in the WIC breast-feeding PC programme (especially participation early during pregnancy) was associated with an increased rate of breast-feeding initiation in Missouri.

Amyotrophic lateral sclerosis (ALS) cases diagnosed between 1998 and 2002 were identified to study ALS prevalence and spatial clustering in Jefferson County, Missouri, where an active lead smelter is located. The study used the El Escorial criteria for ALS diagnosis, the capture-recapture analysis for ALS case ascertainment, and the spatial scan statistic for cluster analysis. The estimated crude prevalence of ALS in Jefferson County was 3.9 per 100,000 population (95% CI, 1.7-7.7) at the time point on December 31, 2002. After age-adjustment to the 2002 U.S. population, the prevalence was 4.2 per 100,000 (95% CI, 1.9-6.6). This prevalence estimate was comparable to recent prevalence estimates from Western Europe. A small but significant cluster (p=0.04) was detected around the smelter area. An ALS registry utilizing outpatient, inpatient, and death certificate data is needed to provide comprehensive information for ALS case ascertainment. Etiologic studies are needed to assess whether living in proximity to a lead smelter is associated with the development of ALS.

Background: Between September and December 2003, an outbreak of pertussis occurred in Cass County, MO, mostly among adolescent school children. Methods: We conducted a 1:2 matched case-control study among school children and used conditional logistic regression to evaluate risk factors for pertussis, including the total number of vaccine doses received, age at administration of each dose of vaccine and the type of vaccine (whole cell or acellular). Results: Of all 127 pertussis cases reported in this outbreak, the majority were adolescents (10-19 years of age, 50%) and adults (20 years or older, 22%); only 10% were infants and children less than 5 years of age. Because the focus of our investigation was on school-aged children, we enrolled 237 students (79 cases and 158 controls) in our study. Students missing at least one dose of the vaccine had higher risk for pertussis than those who received all 5 doses (odds ratio [OR], 2.36; 95% confidence interval [CI], 1.17-4.77). Early administration of the fifth dose of the vaccine at age 4 years was significantly associated with risk for pertussis compared with vaccination at age 5 years (adjusted OR, 2.45; 95% CI, 1.16-5.16). A short time interval (

Improving personal hygienic practices may prevent and control MRSA outbreaks., Methicillin-resistant Staphylococcus aureus (MRSA) infections outside the healthcare setting are an increasing concern. We conducted a case-control study to investigate an MRSA outbreak during 2002–2003 in a Missouri prison and focused on hygiene factors. Information on sociodemographic characteristics, medical history, and hygiene practices of study participants was collected by interview and medical record review. Logistic regression was used to evaluate MRSA infection in relation to hygiene factors individually and as a composite hygiene score; potential confounding factors were controlled. Selected MRSA isolates were analyzed by pulsed-field gel electrophoresis (PFGE). MRSA infection was significantly associated with a low composite hygiene score. Transmission among prison inmates appeared to be responsible for this outbreak. PFGE analysis showed that isolates were indistinguishable and associated with community-onset MRSA infections in other US prisons. Improving hygiene practices and environmental conditions may help prevent and interrupt future MRSA outbreaks in prison settings.

Objective: To examine the relationship between interpregnancy interval and low birth weight (LBW), using the retrospective cohort design. Methods: We used the maternally linked Michigan livebirth data documented between 1989 and 2000 to evaluate LBW in relation to interpregnancy (i.e., delivery-to-conception) interval, overall and at levels of other reproductive risk factors. We fit separate logistic regression models for pairs of first-second, second-third, third-fourth, and fourth-fifth births to control for confounding. Results: Of the 565,911 infants identified, 5.5% had LBW. Univariate and stratified analyses showed that the risk for LBW was lowest when the interpregnancy interval was 18–23 months, and increased with shorter or longer intervals. This J-shaped relationship persisted after controlling for all risk factors simultaneously. For example, among the first-second birth pairs, the adjusted odds ratios (AORs) for LBW associated with interpregnancy intervals

ObjectiveTo identify the risk factors and source of infection leading to human infections with the Influenza A(H7N9) virus in urban and rural areas.MethodsWe conducted a case-control investigation to identify potential exposures and risk factors. Controls were randomly selected from the same community as the cases using random digit dialing. We used exact conditional logistic regression to evaluate the exposures and risk factors, stratified by urban and rural residence.ResultsBuying live or freshly slaughtered poultry from a market was significantly associated with illness onset among both urban [48% of 25 case-patients and 12% of 125 control-persons, adjusted odds ratio (AOR) = 19, 95% CI: 2.3-929] and rural (33% of 18 case-patients and 8.9% of 90 control-persons, AOR = 13, 95% CI:1.5-∞) residents. In rural area, tending to home-raised poultry (56% of 18 case-patients and 10% of 90 control-persons, AOR = 57, 95% CI: 7.5-∞) and existence of a poultry farm in the vicinity of the residence (28% of 18 case-patients and 5.6% of 90 control-persons, AOR = 37, 95% CI: 3.8-∞) were also significantly associated with disease onset. Presence of underlying medical conditions was a significant risk factor for urban residents (76% of 25 case-patients and 13% of 125 control-persons, AOR = 49, 95% CI: 7.1-2132).ConclusionsBuying live or freshly slaughtered poultry from a market is a risk factor for both urban and rural residents, tending to home-raised poultry and existence of a poultry farm in the vicinity of the residence are risk factors unique for rural residents. The virus might have been in stealth circulation in the poultry population before infecting humans. We recommend strict poultry market management and multisectoral collaboration to identify the extent of poultry infection in China.