Browsing by Author "Walwema, Richard"

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    Blood Culture Testing Outcomes among Non-Malarial Febrile Children at Antimicrobial Resistance Surveillance Sites in Uganda, 2017–2018
    (Tropical medicine & infectious disease, 2018) Kisame, Rogers; Najjemba, Robinah; Griensven, Johan van; Kitutu, Freddy Eric; Takarinda, Kudakwashe; Thekkur, Pruthu; Delamou, Alexandre; Walwema, Richard; Kakooza, Francis; Mugerwa, Ibrahim; Sekamatte, Musa; Robert, Kimera; Katairo, Thomas; Opollo, Marc Sam; Otita, Morgan; Lamorde, Mohammed
    Blood culture (BC) processes are critical to the utility of diagnostic testing, bloodstream infection (BSI) management, and antimicrobial resistance (AMR) surveillance. While Uganda has established BC guidelines, often laboratory practice does not meet the desired standards. This compromises pathogen recovery, reliability of antimicrobial susceptibility testing, and diagnostic test utility. This study assessed laboratory BC process outcomes among non-malarial febrile children below five years of age at five AMR surveillance sites in Uganda between 2017 and 2018. Secondary BC testing data was reviewed against established standards. Overall, 959 BC specimens were processed. Of these, 91% were from female patients, neonates, infants, and young children (1–48 months). A total of 37 AMR priority pathogens were identified; Staphylococcus aureus was predominant (54%), followed by Escherichia coli (19%). The diagnostic yield was low (4.9%). Only 6.3% of isolates were identified. AST was performed on 70% (18/26) of identified AMR priority isolates, and only 40% of these tests adhered to recommended standards. Interventions are needed to improve laboratory BC practices for effective patient management through targeted antimicrobial therapy and AMR surveillance in Uganda. Further research on process documentation, diagnostic yield, and a review of patient outcomes for all hospitalized febrile patients is needed.
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    A Cross-Cutting Approach to Surveillance and Laboratory Capacity as a Platform to Improve Health Security in Uganda
    (Health security, 2018) Lamorde, Mohammed; Mpimbaza, Arthur; Walwema, Richard; Kamya, Moses; Kajumbula, Henry; Sserwanga, Asadu; Namuganga, Jane Frances
    Global health security depends on effective surveillance for infectious diseases. In Uganda, resources are inadequate to support collection and reporting of data necessary for an effective and responsive surveillance system. We used a cross-cutting approach to improve surveillance and laboratory capacity in Uganda by leveraging an existing pediatric inpatient malaria sentinel surveillance system to collect data on expanded causes of illness, facilitate development of real-time surveillance, and provide data on antimicrobial resistance. Capacity for blood culture collection was established, along with options for serologic testing for select zoonotic conditions, including arboviral infection, brucellosis, and leptospirosis. Detailed demographic, clinical, and laboratory data for all admissions were captured through a web-based system accessible at participating hospitals, laboratories, and the Uganda Public Health Emergency Operations Center. Between July 2016 and December 2017, the expanded system was activated in pediatric wards of 6 regional government hospitals. During that time, patient data were collected from 30,500 pediatric admissions, half of whom were febrile but lacked evidence of malaria. More than 5,000 blood cultures were performed; 4% yielded bacterial pathogens, and another 4% yielded likely contaminants. Several WHO antimicrobial resistance priority pathogens were identified, some with multidrug-resistant phenotypes, including Acinetobacter spp., Citrobacter spp., Escherichia coli, Staphylococcus aureus, and typhoidal and nontyphoidal Salmonella spp. Leptospirosis and arboviral infections (alphaviruses and flaviviruses) were documented. The lessons learned and early results from the development of this multisectoral surveillance system provide the knowledge, infrastructure, and workforce capacity to serve as a foundation to enhance the capacity to detect, report, and rapidly respond to wide-ranging public health concerns in Uganda. Fever may be the initial or sole symptom of many infectious diseases, including some with outbreak potential.1,2 Although clinical practice in many malaria-endemic areas has been to presumptively treat febrile patients for malaria, improved access to malaria diagnostics in recent years has revealed that a substantial proportion of acutely ill, febrile patients in sub-Saharan Africa do not have malaria.3-5 Yet, many countries lack resources and capacity for accurate diagnosis of most infectious conditions. Rapid response to diverse and emerging public health threats is severely challenged by lack of appropriate laboratory capacity and timely surveillance networks.6 These gaps foster antimicrobial and antimalarial resistance, limit evidence-based care and policy to improve population health, and hinder the ability to detect outbreaks early. Uganda, an inland East African country with a rapidly growing population estimated at 43 million people in 2017, has made progress in recent decades to improve life expectancy, reduce poverty and food insecurity, and expand access to immunizations and clean water.7 Yet, as with many African countries, Uganda faces diverse health challenges in a weak health infrastructure that limits the rapid detection and confirmation of infections with epidemic potential. In the past 2 decades, Uganda has experienced outbreaks of emerging and reemerging infectious diseases including Ebola, Marburg, Crimean-Congo hemorrhagic fever, Rift Valley fever, yellow fever, hepatitis E, cholera, typhoid fever, plague, and anthrax.8-16 Effective laboratory capacity and disease surveillance are critical to global health security and the basis for the 2005 International Health Regulations (IHR) signed by all World Health Organization (WHO) member states. IHR compliance has proven challenging for many low-income countries, including Uganda.17,18 The Global Health Security Agenda (GHSA), a multisectoral and multilateral partnership intended to support countries toward IHR compliance, launched officially in 2014 (www.ghsagenda.org). The government of Uganda and the US Centers for Disease Control and Prevention (CDC) jointly implemented a demonstration project a year earlier, in 2013. The pilot project improved specimen referral networks and information systems associated with outbreak response and created an emergency operations center; these activities set the stage for multiple GHSA activities in the country.19 Through GHSA-initiated partnerships, we introduced a cross-cutting surveillance approach to advance ability to detect unusual health events in Uganda. As conceived, this effort would provide comprehensive patient data and facilitate electronic systems infrastructure that could ultimately improve early detection of novel infections or outbreaks, define conditions causing human illness to inform appropriate and targeted laboratory capacity building efforts, and generate data for an antimicrobial resistance surveillance and intervention program in its infancy.
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    Implementation of the World Health Organization Global Antimicrobial Resistance Surveillance System in Uganda, 2015-2020: Mixed-Methods Study Using National Surveillance Data
    (JMIR public health and surveillance, 2021) Nabadda, Susan; Kakooza, Francis; Kiggundu, Reuben; Walwema, Richard; Bazira, Joel; Mayito, Jonathan; Mugerwa, Ibrahimm; Sekamatte, Musa; Kambugu, Andrew; Lamorde, Mohammed; Kajumbula, Henry; Mwebasa, Henry
    Antimicrobial resistance (AMR) is an emerging public health crisis in Uganda. The World Health Organization (WHO) Global Action Plan recommends that countries should develop and implement National Action Plans for AMR. We describe the establishment of the national AMR program in Uganda and present the early microbial sensitivity results from the program. Objective: The aim of this study is to describe a national surveillance program that was developed to perform the systematic and continuous collection, analysis, and interpretation of AMR data. Methods: A systematic qualitative description of the process and progress made in the establishment of the national AMR program is provided, detailing the progress made from 2015 to 2020. This is followed by a report of the findings of the isolates that were collected from AMR surveillance sites. Identification and antimicrobial susceptibility testing (AST) of the bacterial isolates were performed using standard methods at both the surveillance sites and the reference laboratory. Results: Remarkable progress has been achieved in the establishment of the national AMR program, which is guided by the WHO Global Laboratory AMR Surveillance System (GLASS) in Uganda. A functional national coordinating center for AMR has been established with a supporting designated reference laboratory. WHONET software for AMR data management has been installed in the surveillance sites and laboratory staff trained on data quality assurance. Uganda has progressively submitted data to the WHO GLASS reporting system. Of the 19,216 isolates from WHO GLASS priority specimens collected from October 2015 to June 2020, 22.95% (n=4411) had community-acquired infections, 9.46% (n=1818) had hospital-acquired infections, and 68.57% (n=12,987) had infections of unknown origin. The highest proportion of the specimens was blood (12,398/19,216, 64.52%), followed by urine (5278/19,216, 27.47%) and stool (1266/19,216, 6.59%), whereas the lowest proportion was urogenital swabs (274/19,216, 1.4%). The mean age was 19.1 (SD 19.8 years), whereas the median age was 13 years (IQR 28). Approximately 49.13% (9440/19,216) of the participants were female and 50.51% (9706/19,216) were male. Participants with community-acquired infections were older (mean age 28, SD 18.6 years; median age 26, IQR 20.5 years) than those with hospital-acquired infections (mean age 17.3, SD 20.9 years; median age 8, IQR 26 years). All gram-negative (Escherichia coli, Klebsiella pneumoniae, and Neisseria gonorrhoeae) and gram-positive (Staphylococcus aureus and Enterococcus sp) bacteria with AST showed resistance to each of the tested antibiotics. Conclusions: Uganda is the first African country to implement a structured national AMR surveillance program in alignment with the WHO GLASS. The reported AST data indicate very high resistance to the recommended and prescribed antibiotics for treatment of infections. More effort is required regarding quality assurance of laboratory testing methodologies to ensure optimal adherence to WHO GLASS–recommended pathogen-antimicrobial combinations. The current AMR data will inform the development of treatment algorithms and clinical guidelines.
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    Pre-positioned Outbreak Research: The Joint Medical Emerging Diseases Intervention Clinical Capability Experience in Uganda
    (Health security, 2020) Martins, Karen A.; Ayebare, Rodgers R.; Bhadelia, Nahid; Kiweewa, Francis; Waitt, Peter; Mimbe, Derrick; Okello, Stephen; Naluyima, Prossy; Brett-Major, David M.; Lawler, James V.; Millard, Monica; Walwema, Richard; Cardile, Anthony P.; Ritchie, Chi; Kwiecien, Antonia; Badu, Helen; Espinosa, Benjamin J.; Beckett, Charmagne; Bavari, Sina; Zaman, Saima; Christopher, George; Clark, Danielle V.; Lamorde, Mohammed; Kibuuka, Hannah
    The West Africa Ebola virus disease outbreak of 2014-2016 demonstrated that responses to viral hemorrhagic fever epidemics must go beyond emergency stopgap measures and should incorporate high-quality medical care and clinical research. Optimal patient management is essential to improving outcomes, and it must be implemented regardless of geographical location or patient socioeconomic status. Coupling clinical research with improved care has a significant added benefit: Improved data quality and management can guide the development of more effective supportive care algorithms and can support regulatory approvals of investigational medical countermeasures (MCMs), which can alter the cycle of emergency response to reemerging pathogens. However, executing clinical research during outbreaks of high-consequence pathogens is complicated and comes with ethical and research regulatory challenges. Aggressive care and excellent quality control must be balanced by the requirements of an appropriate infection prevention and control posture for healthcare workers and by overcoming the resource limitations inherent in many outbreak settings. The Joint Mobile Emerging Disease Intervention Clinical Capability was established in 2015 to develop a high-quality clinical trial capability in Uganda to support rigorous evaluation of MCMs targeting high-consequence pathogens like Ebola virus. This capability assembles clinicians, laboratorians, clinical researchers, logisticians, and regulatory professionals trained in infection prevention and control and in good clinical and good clinical laboratory practices. The resulting team is prepared to provide high-quality medical care and clinical research during high-consequence outbreaks.