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The aetiology of nodding syndrome remains unclear, and comprehensive genotyping and phenotyping data from patients remain sparse. Our objectives were to characterize the phenotype of patients with nodding syndrome, investigate potential contributors to disease aetiology, and evaluate response to immunotherapy. This cohort study investigated members of a single-family unit from Lamwo District, Uganda. The participants for this study were selected by the Ugandan Ministry of Health as representative for nodding syndrome and with a conducive family structure for genomic analyses. Of the eight family members who participated in the study at the National Institutes of Health (NIH) Clinical Center, three had nodding syndrome. The three affected patients were extensively evaluated with metagenomic sequencing for infectious pathogens, exome sequencing, spinal fluid immune analyses, neurometabolic and toxicology testing, continuous electroencephalography and neuroimaging. Five unaffected family members underwent a subset of testing for comparison. A distinctive interictal pattern of sleep-activated bursts of generalized and multifocal epileptiform discharges and slowing was observed in two patients. Brain imaging showed two patients had mild generalized cerebral atrophy, and both patients and unaffected family members had excessive metal deposition in the basal ganglia. Trace metal biochemical evaluation was normal. CSF was non-inflammatory and one patient had CSF-restricted oligoclonal bands. Onchocerca volvulus-specific antibodies were present in all patients and skin snips were negative for active onchocerciasis. Metagenomic sequencing of serum and CSF revealed hepatitis B virus in the serum of one patient. Vitamin B6 metabolites were borderline low in all family members and CSF pyridoxine metabolites were normal. Mitochondrial DNA testing was normal. Exome sequencing did not identify potentially causal candidate gene variants. Nodding syndrome is characterized by a distinctive pattern of sleep-activated epileptiform activity. The associated growth stunting may be due to hypothalamic dysfunction. Extensive testing years after disease onset did not clarify a causal aetiology. A trial of immunomodulation (plasmapheresis in two patients and intravenous immunoglobulin in one patient) was given without short-term effect, but longer-term follow-up was not possible to fully assess any benefit of this intervention.

As of August 2021, coronavirus disease (COVID-19) had caused >199 million cases and >4.2 million deaths worldwide (1). Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, [...]

Scale-up of human immunodeficiency virus (HIV) testing and antiretroviral therapy (ART) for people living with HIV has been increasing in sub-Saharan Africa. As a result, areas with high HIV prevalence are finding a declining proportion of people testing positive in their national testing programmes. In eastern and southern Africa, where there are settings with adult HIV prevalence of 12% and above, the positivity from national HIV testing services has dropped to below 5%. Identifying those in need of ART is therefore becoming more costly for national HIV programmes. Annual target-setting assumes that national testing positivity rates approximate that of population prevalence. This assumption has generated an increased focus on testing approaches which achieve higher rates of HIV positivity. This trend is a departure from the provider-initiated testing and counselling strategy used early in the global HIV response. We discuss a new indicator, treatment-adjusted prevalence, that countries can use as a practical benchmark for estimating the expected adult positivity in a testing programme when accounting for both national HIV prevalence and ART coverage. The indicator is calculated by removing those people receiving ART from the numerator and denominator of HIV prevalence. Treatment-adjusted prevalence can be readily estimated from existing programme data and population estimates, and in 2019, was added to the World Health Organization guidelines for HIV testing and strategic information. Using country examples from Kenya, Malawi, South Sudan and Zimbabwe we illustrate how to apply this indicator and we discuss the potential public health implications of its use from the national to facility level. Le depistage du virus de l'immunodeficience humaine (VIH) et le traitement antiretroviral (TAR) pour les personnes vivant avec le VIH ont connu un veritable essor en Afrique subsaharienne. Par consequent, les regions touchees par une forte prevalence du VIH detectent un pourcentage moins eleve de personnes testees positives dans leurs programmes de depistage nationaux. En Afrique orientale et australe, la ou certains endroits affichent une prevalence du VIH chez l'adulte egale ou superieure a 12%, le taux de positivite des services de depistage nationaux est passe sous la barre des 5%. Identifier les personnes necessitant un TAR devient donc plus couteux pour les programmes nationaux consacres au VIH. Pour definir les objectifs annuels, on part du principe que les taux de positivite nationaux se rapprochent du taux de prevalence au sein de la population. Cette supposition a oriente les demarches vers des methodes de depistage permettant d'obtenir des taux de positivite plus eleves; une tendance qui s'ecarte de la strategie des services de depistage et de conseil a l'initiative des prestataires, utilisee a l'aube de la lutte mondiale contre le VIH. Dans le present document, nous nous interessons a un nouvel indicateur, la prevalence ajustee sur le traitement. Cet indicateur peut servir de reference concrete pour les pays qui souhaitent evaluer le taux de positivite attendu chez l'adulte dans un programme de depistage, en tenant compte de la prevalence du VIH au niveau national ainsi que de la portee du TAR. Le calcul consiste a enlever les personnes recevant un TAR du numerateur et du denominateur de la prevalence du VIH. La prevalence ajustee sur le traitement peut aisement etre determinee en fonction des donnees de programme et estimations de population existantes. En 2019, elle a egalement ete ajoutee aux lignes directrices de l'Organisation mondiale de la Sante pour l'information strategique et le depistage du VIH. En nous inspirant d'exemples issus du Kenya, du Malawi, du Soudan du Sud et du Zimbabwe, nous expliquons comment employer cet indicateur et abordons les potentielles implications liees a son utilisation en matiere de sante publique, en partant du niveau national jusqu'aux etablissements. La ampliacion de las pruebas de deteccion del virus de la inmunodeficiencia humana (VIH) y del tratamiento antirretrovirico (TAR) para las personas infectadas por el VIH ha aumentado en el Africa subsahariana. En consecuencia, el porcentaje de personas que dan positivo en las pruebas de deteccion del VIH en los programas nacionales esta disminuyendo en las zonas con alta prevalencia del virus. En Africa meridional y oriental, donde hay entornos con una prevalencia del VIH en adultos del 12 % o superior, la tasa de positividad de los servicios nacionales de pruebas de deteccion del VIH ha descendido a menos del 5 %. Por lo tanto, la identificacion de las personas que necesitan TAR es cada vez mas costosa para los programas nacionales de VIH. El establecimiento de objetivos anuales supone que las tasas de positividad de las pruebas nacionales se aproximan a las de la prevalencia de la poblacion. Esta suposicion ha generado una mayor atencion a los enfoques de las pruebas que logran tasas mas altas de positividad del VIH. Esta tendencia se aleja de la estrategia del asesoramiento y las pruebas que iniciaron los proveedores y que se utilizo al principio de la respuesta mundial al VIH. Se analiza un nuevo indicador, la prevalencia ajustada segun el tratamiento, que los paises pueden emplear como punto de referencia practico para estimar la tasa de positividad esperada en adultos en un programa de pruebas de deteccion cuando se tiene en cuenta tanto la prevalencia nacional del VIH como la cobertura del TAR. El indicador se calcula eliminando del numerador y el denominador de la prevalencia del VIH a las personas que reciben TAR. La prevalencia ajustada segun el tratamiento se puede estimar con facilidad a partir de los datos de los programas existentes y de las estimaciones de poblacion, ademas, en 2019, se incluyo en las directrices de la Organizacion Mundial de la Salud para las pruebas de deteccion del VIH y en la informacion estrategica. A traves de ejemplos de paises como Kenia, Malaui, Sudan meridional y Zimbabue, se demuestra como aplicar este indicador y se discuten las posibles implicaciones para la salud publica de su uso desde el nivel nacional hasta el de los centros. [phrase omitted], Introduction Globally, there has been substantial scale-up of human immunodeficiency virus (HIV) testing services and antiretroviral therapy (ART), and it is now estimated that 78% (16 million) of the 20.6 [...]

Objective To describe an intervention to scale up tuberculosis preventive treatment for people living with human immunodeficiency virus (HIV) in South Sudan, 2017-2020. Methods Staff of the health ministry and United States President's Emergency Plan for AIDS Relief designed an intervention targeting the estimated 30 400 people living with HIV on antiretroviral therapy across South Sudan. The intervention comprised: (i) developing sensitization and operational guidance for clinicians to put tuberculosis preventive treatment delivery into clinical practice; (ii) disseminating monitoring and evaluation tools to document scale-up; (iii) implementing a programmatic pilot of tuberculosis preventive treatment; and (iv) identifying a mechanism for procurement and delivery of isoniazid to facilities dispensing tuberculosis preventive treatment. Staff aggregated routine programme data from facility registers on the numbers of people living with HIV who started on tuberculosis preventive treatment across all clinical sites providing this treatment during July 2019-March 2020. Findings Tuberculosis preventive treatment was implemented in 13 HIV treatment sites during July-October 2019, then in 26 sites during November 2019-March 2020. During July 2019-March 2020, 6503 people living with HIV started tuberculosis preventive treatment. Conclusion Lessons for other low-resource settings may include supplementing national guidelines with health ministry directives, clinician guidance and training, and an implementation pilot. A cadre of field supervisors can rapidly disseminate a standardized approach to implementation and monitoring of tuberculosis preventive treatment, and this approach can be used to strengthen other tuberculosis-HIV services. Procuring a reliable and steady supply of tuberculosis preventive treatment medication is crucial. Objectif Decrire une intervention destinee a intensifier le traitement preventif contre la tuberculose chez les individus vivant avec le virus de l'immunodeficience humaine (VIH) au Soudan du Sud entre 2017 et 2020. Methodes Le personnel du ministere de la Sante et du Plan d'urgence du President des Etats-Unis pour la lutte contre le sida (PEPFAR) a imagine une intervention qui cible les quelque 30 400 individus vivant avec le VIH sous traitement antiretroviral au Soudan du Sud. Cette intervention consistait a: (i) developper une sensibilisation et un encadrement operationnel pour les medecins afin qu'ils incluent la lutte preventive contre la tuberculose dans leur pratique; (ii) diffuser des outils de controle et d'evaluation pour documenter l'intensification; (iii) instaurer un programme pilote de traitement preventif contre la tuberculose; et enfin, (iv) identifier un mecanisme d'acquisition et de livraison d'isoniazide aux etablissements qui dispensent un traitement preventif contre la tuberculose. Le personnel a preleve les donnees relatives au programme de routine dans les registres des etablissements afin de determiner le nombre d'individus vivant avec le VIH et ayant entame un traitement preventif contre la tuberculose dans tous les centres cliniques qui proposaient ce traitement entre juillet 2019 et mars 2020. Resultats Le traitement preventif contre la tuberculose a ete mis en oeuvre dans 13 etablissements de prise en charge du VIH entre juillet et octobre 2019, puis dans 26 centres entre novembre 2019 et mars 2020. Durant la periode allant de juillet 2019 a mars 2020, 6503 individus vivant avec le VIH ont entame un traitement preventif contre la tuberculose. Conclusion Divers enseignements peuvent etre tires pour d'autres endroits disposant de ressources limitees, notamment l'elaboration de directives du ministere de la Sante pour completer les recommandations nationales, l'encadrement et la formation des medecins, ainsi que l'organisation d'un projet pilote. Une equipe de superviseurs presents sur le terrain peut rapidement promouvoir une approche standardisee d'application et de suivi du traitement preventif contre la tuberculose, et cette approche peut servir a renforcer d'autres services tuberculose/VIH. Et dernierement, il est essentiel de mettre en place un approvisionnement constant et fiable de medicaments pour assurer le traitement preventif de la tuberculose. Objetivo Describir una intervencion para ampliar el tratamiento preventivo de la tuberculosis de las personas que viven con el virus de la inmunodeficiencia humana (VIH) en Sudan del Sur, 2017-2020. Metodos El personal del Ministerio de Salud y del Plan de emergencia del presidente de los Estados Unidos para el alivio del sida diseno una intervencion dirigida a las 30 400 personas que se estima viven con el VIH y que reciben tratamiento antirretrovirico en toda la Republica de Sudan del Sur. La intervencion incluia: i) la elaboracion de orientaciones de sensibilizacion y operativas para que los medicos apliquen el tratamiento preventivo de la tuberculosis en la practica clinica; ii) la divulgacion de instrumentos de supervision y de evaluacion para documentar la ampliacion; iii) la aplicacion de un programa piloto para el tratamiento preventivo de la tuberculosis; y iv) la determinacion de un mecanismo para la obtencion y la distribucion de isoniacida a los establecimientos que ofrecen el tratamiento preventivo de la tuberculosis. El personal agrupo los datos de los programas de rutina de los registros de los establecimientos sobre la cantidad de personas que viven con el VIH que iniciaron el tratamiento preventivo de la tuberculosis en todos los centros clinicos que ofrecieron este tratamiento entre julio de 2019 y marzo de 2020. Resultados El tratamiento preventivo de la tuberculosis se aplico en 13 centros de tratamiento del VIH durante julio y octubre de 2019, y luego en 26 centros durante noviembre de 2019 a marzo de 2020. Durante julio de 2019 a marzo de 2020, 6503 personas que vivian con el VIH iniciaron el tratamiento preventivo de la tuberculosis. Conclusion Las lecciones para otros entornos de bajos recursos pueden incluir la complementacion de las directrices nacionales con directivas del Ministerio de Salud, la orientacion y la capacitacion de los medicos y un programa piloto de aplicacion. Un equipo de supervisores de campo puede difundir con rapidez un enfoque normalizado de la aplicacion y del seguimiento del tratamiento preventivo de la tuberculosis, que se puede aplicar para fortalecer otros servicios relacionados con la tuberculosis y el VIH. Es fundamental obtener un suministro fiable y constante de medicamentos para el tratamiento preventivo de la tuberculosis. [phrase omitted], Introduction South Sudan had an estimated 190 000 people living with human immunodeficiency virus (HIV) in 2018, and an HIV prevalence of 2.5% (95% confidence interval: 1.9-3.1) among an estimated [...]

Middle East respiratory syndrome coronavirus (MERS-CoV) was first identified in October 2012 in Saudi Arabia (1). By November 6, 2015, the World Health Organization (WHO) had received reports of 1,611 [...]

Nodding syndrome as a distinctive entity was reported from southern Sudan in the 1990s and investigated by local authorities and the World Health Organization (WHO) during 2001-2002 (1,2). In retrospect, [...]

Oral pre-exposure prophylaxis (PrEP) reduces HIV acquisition risk from sex by 99% and from injection drug use by ≥74% when used as recommended. The Joint United Nations Programme on HIV/AIDS (UNAIDS) has set a goal of 21.2 million persons using (initiating or continuing) PrEP globally in 2025. In 2016, CDC, with the U.S. President's Emergency Plan for AIDS Relief, joined ministries of health to implement PrEP globally. PrEP is beneficial for persons at substantial risk for acquiring HIV, including but not limited to key populations, which include female sex workers, men who have sex with men, persons in prisons and other enclosed settings, persons who inject drugs, and transgender persons. Annual country targets were used to guide scale-up. In 2023, CDC supported 856,816 PrEP initiations, which represents nearly one quarter of the 3.5 million persons globally who either initiated or continued PrEP that year. During 2017-2023, CDC supported PrEP initiations for 2,278,743 persons, 96.0% of whom were in sub-Saharan Africa. More than one half (64.0%) were female and 44.9% were aged 15-24 years. Overall, CDC achieved 118.7% of its PrEP initiation targets for the 7-year period. Among PrEP initiations for key populations, the majority in sub-Saharan Africa were female sex workers, whereas in Southeast Asia, Eurasia, and the Americas, the majority were men who have sex with men. Continued rapid scale-up is needed to meet the UNAIDS goal to end HIV as a public health threat., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

The U.S. President's Emergency Plan for AIDS Relief (PEPFAR) supports country programs in identifying persons living with HIV infection (PLHIV), providing life-saving treatment, and reducing the spread of HIV in countries around the world (1,2). CDC used Monitoring, Evaluation, and Reporting (MER) data* to assess the extent to which COVID-19 mitigation strategies affected HIV service delivery across the HIV care continuum † globally during the first year of the COVID-19 pandemic. Indicators included the number of reported HIV-positive test results, the number of PLHIV who were receiving antiretroviral therapy (ART), and the rates of HIV viral load suppression. Percent change in performance was assessed between countries during the first 3 months of 2020, before COVID-19 mitigation efforts began (January-March 2020), and the last 3 months of the calendar year (October-December 2020). Data were reviewed for all 41 countries to assess total and country-level percent change for each indicator. Then, qualitative data were reviewed among countries in the upper quartile to assess specific strategies that contributed to programmatic gains. Overall, positive percent change was observed in PEPFAR-supported countries in HIV treatment (5%) and viral load suppression (2%) during 2020. Countries reporting the highest gains across the HIV care continuum during 2020 attributed successes to reducing or streamlining facility attendance through strategies such as enhancing index testing (offering of testing to the biologic children and partners of PLHIV) § and community- and home-based testing; treatment delivery approaches; and improvements in data use through monitoring activities, systems, and data quality checks. Countries that reported program improvements during the first year of the COVID-19 pandemic offer important information about how lifesaving HIV treatment might be provided during a global public health crisis., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Early models predicted substantial COVID-19-associated morbidity and mortality across Africa (1-3). However, as of March 2021, countries in Africa are among those with the lowest reported incidence of COVID-19 worldwide (4). Whether this reflects effective mitigation, outbreak response, or demographic characteristics, (5) or indicates limitations in disease surveillance capacity is unclear (6). As countries implemented changes in funding, national policies, and testing strategies in response to the COVID-19 pandemic, surveillance capacity might have been adversely affected. This study assessed whether changes in surveillance operations affected reporting in South Sudan; testing and case numbers reported during April 6, 2020-February 21, 2021, were analyzed relative to the timing of funding, policy, and strategy changes.* South Sudan, with a population of approximately 11 million, began COVID-19 surveillance in February 2020 and reported 6,931 cases through February 21, 2021. Surveillance data analyzed were from point of entry screening, testing of symptomatic persons who contacted an alert hotline, contact tracing, sentinel surveillance, and outbound travel screening. After travel restrictions were relaxed in early May 2020, international land and air travel resumed and mandatory requirements for negative pretravel test results were initiated. The percentage of all testing accounted for by travel screening increased >300%, from 21.1% to 91.0% during the analysis period, despite yielding the lowest percentage of positive tests among all sources. Although testing of symptomatic persons and contact tracing yielded the highest percentage of COVID-19 cases, the percentage of all testing from these sources decreased 88%, from 52.6% to 6.3% after support for these activities was reduced. Collectively, testing increased over the project period, but shifted toward sources least likely to yield positive results, possibly resulting in underreporting of cases. Policy, funding, and strategy decisions related to the COVID-19 pandemic response, such as those implemented in South Sudan, are important issues to consider when interpreting the epidemiology of COVID-19 outbreaks., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Introduction: the coronavirus disease 2019 (COVID-19) was declared a pandemic on March 11, 2020. South Sudan, a low-income and humanitarian response setting, reported its first case of COVID-19 on April 5, 2020. We describe the socio-demographic and epidemiologic characteristics of COVID-19 cases in this setting., Methods: we conducted a cross-sectional descriptive analysis of data for 1,330 confirmed COVID-19 cases from the first 60 days of the outbreak., Results: among the 1,330 confirmed cases, the mean age was 37.1 years, 77% were male, 17% were symptomatic with 95% categorized as mild, and the case fatality rate was 1.1%. Only 24.7% of cases were detected through alerts and sentinel site surveillance, with 95% of the cases reported from the capital, Juba. Epidemic doubling time averaged 9.8 days (95% confidence interval [CI] 7.7 - 13.4), with an attack rate of 11.5 per 100,000 population. Test positivity rate was 18.2%, with test rate per 100,000 population of 53 and mean test turn-around time of 9 days. The case to contact ratio was 1: 2.2., Conclusion: this 2-month initial period of COVID-19 in South Sudan demonstrated mostly young adults and men affected, with most cases reported as asymptomatic. Systems´ limitations highlighted included a small proportion of cases detected through surveillance, low testing rates, low contact elicitation, and long collection to test turn-around times limiting the country´s ability to effectively respond to the outbreak. A multi-pronged response including greater access to testing, scale-up of surveillance, contact tracing and community engagement, among other interventions are needed to improve the COVID-19 response in this setting., Competing Interests: The authors declare no competing interests., (Copyright: Joy Luba Lomole Waya et al.)

Despite progress toward controlling the human immunodeficiency virus (HIV) epidemic, testing gaps remain, particularly among men and young persons in sub-Saharan Africa (1). This observational study used routinely collected programmatic data from 20 African countries reported to the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) from October 2018 to September 2019 to assess HIV testing coverage and case finding among adults (defined as persons aged ≥15 years). Indicators included number of HIV tests conducted, number of HIV-positive test results, and percentage positivity rate. Overall, the majority of countries reported higher HIV case finding among women than among men. However, a slightly higher percentage positivity was recorded among men (4.7%) than among women (4.1%). Provider-initiated counseling and testing (PITC) in health facilities identified approximately two thirds of all new cases, but index testing had the highest percentage positivity in all countries among both sexes. Yields from voluntary counseling and testing (VCT) and mobile testing varied by sex and by country. These findings highlight the need to identify and implement the most efficient strategies for HIV case finding in these countries to close coverage gaps. Strategies might need to be tailored for men who remain underrepresented in the majority of HIV testing programs.

On August 1, 2018, the Democratic Republic of the Congo (DRC) declared its 10th Ebola virus disease (Ebola) outbreak in an area with a high volume of cross-border population movement to and from neighboring countries. The World Health Organization (WHO) designated Rwanda, South Sudan, and Uganda as the highest priority countries for Ebola preparedness because of the high risk for cross-border spread from DRC (1). Countries might base their disease case definitions on global standards; however, historical context and perceived risk often affect why countries modify and adapt definitions over time, moving toward or away from regional harmonization. Discordance in case definitions among countries might reduce the effectiveness of cross-border initiatives during outbreaks with high risk for regional spread. CDC worked with the ministries of health (MOHs) in DRC, Rwanda, South Sudan, and Uganda to collect MOH-approved Ebola case definitions used during the first 6 months of the outbreak to assess concordance (i.e., commonality in category case definitions) among countries. Changes in MOH-approved Ebola case definitions were analyzed, referencing the WHO standard case definition, and concordance among the four countries for Ebola case categories (i.e., community alert, suspected, probable, confirmed, and case contact) was assessed at three dates (2). The number of country-level revisions ranged from two to four, with all countries revising Ebola definitions by February 2019 after a December 2018 peak in incidence in DRC. Case definition complexity increased over time; all countries included more criteria per category than the WHO standard definition did, except for the "case contact" and "confirmed" categories. Low case definition concordance and lack of awareness of regional differences by national-level health officials could reduce effectiveness of cross-border communication and collaboration. Working toward regional harmonization or considering systematic approaches to addressing country-level differences might increase efficiency in cross-border information sharing., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

In 2017, the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimated that worldwide, 36.9 million persons were living with human immunodeficiency virus (HIV) infection, the virus infection that causes acquired immunodeficiency syndrome (AIDS). Among persons with HIV infection, approximately 75% were aware of their HIV status, leaving 9.4 million persons with undiagnosed infection (1). Index testing, also known as partner notification or contact tracing, is an effective case-finding strategy that targets the exposed contacts of HIV-positive persons for HIV testing services. This report summarizes data from HIV tests using index testing in 20 countries supported by CDC through the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) during October 1, 2016-March 31, 2018. During this 18-month period, 1,700,998 HIV tests with 99,201 (5.8%) positive results were reported using index testing. The positivity rate for index testing was 9.8% among persons aged ≥15 years and 1.5% among persons aged <15 years. During the reporting period, HIV positivity increased 64% among persons aged ≥15 years (from 7.6% to 12.5%) and 67% among persons aged <15 years (from 1.2% to 2.0%). Expanding index testing services could help increase the number of persons with HIV infection who know their status, are initiated onto antiretroviral treatment, and consequently reduce the number of persons who can transmit the virus., Competing Interests: All authors have completed and submitted the ICMJE form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

As of February 17, 2016, a total of 14,122 cases (62% confirmed) of Ebola Virus Disease (Ebola) and 3,955 Ebola-related deaths had been reported in Sierra Leone since the epidemic in West Africa began in 2014. A key focus of the Ebola response in Sierra Leone was the promotion and implementation of safe, dignified burials to prevent Ebola transmission by limiting contact with potentially infectious corpses. Traditional funeral practices pose a substantial risk for Ebola transmission through contact with infected bodies, body fluids, contaminated clothing, and other personal items at a time when viral load is high; however, the role of funeral practices in the Sierra Leone epidemic and ongoing Ebola transmission has not been fully characterized. In September 2014, a sudden increase in the number of reported Ebola cases occurred in Moyamba, a rural and previously low-incidence district with a population of approximately 260,000. The Sierra Leone Ministry of Health and Sanitation and CDC investigated and implemented public health interventions to control this cluster of Ebola cases, including community engagement, active surveillance, and close follow-up of contacts. A retrospective analysis of cases that occurred during July 11-October 31, 2014, revealed that 28 persons with confirmed Ebola had attended the funeral of a prominent pharmacist during September 5-7, 2014. Among the 28 attendees with Ebola, 21 (75%) reported touching the man's corpse, and 16 (57%) reported having direct contact with the pharmacist before he died. Immediate, safe, dignified burials by trained teams with appropriate protective equipment are critical to interrupt transmission and control Ebola during times of active community transmission; these measures remain important during the current response phase.

Nodding syndrome (NS) is a seizure disorder of unknown etiology, predominately affecting children aged 3-18 years in three sub-Saharan countries (Uganda, South Sudan, and Tanzania), with the primary feature of episodic head nodding. These episodes are thought to be one manifestation of a syndrome that includes neurologic deterioration, cognitive impairment, and additional seizure types. NS investigations have focused on clinical features, progression, and etiology; however, none have provided a population-based prevalence assessment using a standardized case definition. In March 2013, CDC and the Ugandan Ministry of Health (MOH) conducted a single-stage cluster survey to perform the first systematic assessment of prevalence of NS in Uganda using a new consensus case definition, which was modified during the course of the investigation. Based on the modified definition, the estimated number of probable NS cases in children aged 5-18 years in three northern Uganda districts was 1,687 (95% confidence interval [CI] = 1,463-1,912), for a prevalence of 6.8 (CI = 5.9-7.7) probable NS cases per 1,000 children aged 5-18 years in the three districts. These findings can guide the MOH to understand and provide the health-care resources necessary to address NS in northern Uganda, and provide a basis for future studies of NS in Uganda and in other areas affected by NS.