National legislation for the IHR(2005)
The laws governing surveillance and response for infectious diseases in Uganda were contained in the Public Health (PH) Act (CAP 281). The PH Act provided for cross-border surveillance and the implementation of control measures during a PH emergency. The Act mandated the Minister of Health to declare a disease notifiable. However, the list of notifiable diseases did not include several IHR(2005) notifiable conditions, such as Severe Acute Respiratory Syndrome (SARS), influenza caused by a new sub-type, and smallpox. Similarly, the list of notifiable diseases did not require mandatory notification of chemical and radio-nuclear hazards by public health officers.
The Animal Diseases Act (CAP 38) and the Rabies Act (CAP 44) provided for the notification, surveillance and response to zoonotic events like brucellosis, anthrax, avian influenza and rabies. The Wild Life Act (CAP 200) existed but did not provide for the mandatory notification of zoonoses in wildlife.
The National Environment Act (CAP 153) empowered the local environment committees in districts to report any events or activities which had or were likely to have significant impacts on the environment to the District Environment Officer. There was, however, a need to create mechanisms to ensure that events with public health implications were reported to the District Health Officer and eventually to the IHR NFP.
The Atomic Energy Act of 2008 (CAP 143) provided guidance on the utilization of atomic energy for socio-economic development and ensured that safety standards were upheld through regular inspections of radio-nuclear facilities by the Atomic Energy Council. The legislation, however, did not provide for mandatory notification of accidents, leakage or theft of radioactive sources at radio-nuclear facilities.
The National Food and Drugs Act (CAP 278) provided for the notification of cases of food poisoning to the District Health Officer and the withdrawal of contaminated foods from the shelves.
Coordination and National Focal Point (NFP) communications
IHR coordination
The coordination of emergencies was a mandate of the Office of the Prime Minister (OPM) and was executed by a multi-sectoral Disaster Preparedness and Management committee. There was no disaster management policy and strategic plan addressing the IHR(2005) multi-hazards approach. Public health emergencies were, however, coordinated by a multi-sectoral National Task Force that is chaired by the Ministry of Health. The frequency of the meetings was determined by the presence and nature of a disease outbreak or public health emergency. At the district level, the corresponding structures for coordination of disasters and public health emergencies were the District Disaster Management Committee (DDMC) and the District Epidemic Preparedness and Response committees, respectively. These were functional in 92% (12/13) of the districts, but they only met when there was an emergency.
NFP communications and operations
There was a designated IHR NFP that was located in the National Surveillance Unit in the Ministry of Health. Communications from the IHR NFP were done within the IDSR context and were limited to the health sector at the time of this assessment. Operational communication was therefore lacking between the IHR NFP and the other IHR stakeholders located outside the health sector. There were no designated sectoral IHR Focal Points (FPs) to facilitate communications with the IHR NFP in preventing and responding to zoonotic, foodborne, chemical and radio-nuclear hazards. However, the IHR NFP monitored events at the international level through the WHO event information site. Three epidemiologists in the IHR NFP had access to the site and received e-mail alerts of events notified by other countries to the WHO.
The IHR NFP was mandated to provide technical and logistical support to district rapid response teams to conduct the initial health risk assessment and to initiate public health responses during public health emergencies. Further more, the IHR NFP was the national authority responsible for notification of PH emergencies to the WHO. However, systematic use of the decision instrument (Annex 2 of the IHR[2005]) to guide notification by the IHR NFP to the WHO IHR FP was lacking. Only one public health emergency, pandemic influenza (H1N1), had been notified by the IHR NFP to the WHO IHR FP within the 12 months preceding the assessment.
National advocacy for the IHR(2005)
A sensitisation workshop of key stakeholders on the IHR(2005) had been conducted at the national level by the IHR NFP. However, sub-national sensitisations had not been undertaken and a committee relevant to IHR(2005) implementation had not been established. Similarly, information packages on the IHR(2005) for different target groups and the IHR webpage had not been instituted. At the district level, none of the districts visited had undertaken activities to increase IHR(2005) awareness. Similarly, the IHR information packages were not available in all the districts for distribution to the health facilities.
Capacities for public health surveillance
Detection
Uganda was using the IDSR strategy to conduct surveillance and initiate interventions for the control of infectious and zoonotic diseases in the general population. The national list of priority conditions was limited to the list of IDSR priority conditions, and hence did not include SARS, influenza caused by a new subtype, smallpox, or chemical, radiological, and nuclear hazards.
All the districts (13/13) visited had designated public health surveillance offices, most had IDSR technical guidelines (92%, or 12/13), and all (13/13) had case definitions for guidance in case detection of infectious and zoonotic diseases. However, only 57% (35/61) and 66% (40/61) of the health facilities had IDSR technical guidelines and case definitions, respectively, for infectious and zoonotic diseases surveillance (Figure 1). The surveillance guidelines and case definitions on SARS, smallpox, radiological, nuclear and foodborne hazards were lacking at all levels.
Reporting
Standardized patient registers and report forms were used to collect and report data on infectious and zoonotic events at the health facility level. The forms, however, lacked provision for reporting several IHR priority diseases and hazards. The immediate and weekly reporting of infectious and zoonotic events in humans were largely communicated to the district and national levels by telephone and Short Message Service (SMS) (77%, or 10/13), and to a lesser extent by e-mail and radio call. The National Surveillance Unit, the designated IHR NFP, received the surveillance reports from the districts. The average completeness and timeliness of weekly reporting were assessed for the four weeks preceding the interview. During the period from 31 August to 27 September 2009, the average completeness and timeliness for weekly public health surveillance reporting from the district to the national level was 83% (range 46-100%) and 68% (range 44-100%), respectively. During the same period, the average completeness and timeliness of weekly public health surveillance reporting from the health facility to district level was 88% (range 52-100%) and 73% (range 48-100%), respectively (Figure 2).
Data management
The data received at the national level underwent verification and analysis and was thereafter compiled into a weekly epidemiological newsletter for disseminated to all the IDSR stakeholders. All the districts had the capacity to systematically analyze data in terms of person, time and place using either Microsoft Excel, Epi Info™ or paper-based manual analysis. However, only 62% (38/61) of the health facilities had the capacity to systematically conduct basic analysis of epidemiologic data. The majority, 69% (9/13), of the districts reported the availability of a computerized system to analyze epidemiologic data. On the contrary, only 16% (10/61) of the health facilities reported the availability of a computerized system to analyze epidemiologic data.
Supervision and feedback
Supervisory visits by the MoH to the districts were few and inconsistent. Only 15% (2/13) of the districts benefited from the supervision of surveillance activities by the MoH in the six months that preceded the assessment. The dissemination of the weekly epidemiologic data was done through weekly newsletters, publication of the data in the newspapers, e-mail, and the monthly IDSR meetings.
Cross-border and international surveillance
Cross-border surveillance activities like screening, isolation, quarantine and provision of information were under taken in response to the SARS outbreak in 2003 and pandemic influenza (H1N1) in 2009. The cross-border activities were therefore not routine and barely lasted beyond the prevailing public health threat. However, there were periodic joint cross-border planning and simulation exercises for pandemic influenza under the East African Community (EAC) Secretariat and these could be used to strengthen the IHR(2005) cross-border surveillance capacities as well.
Capacities for public health response
National and district rapid response teams (RRT) were functional, but their composition did not meet the expertise required for the multi-hazards approach of the IHR(2005). National clinical guidelines for case management of common infections and zoonoses were found in all the districts and in 52% (32/61) of the health facilities. The guidelines, however, lacked procedures for management of chemical and radio-nuclear events. National and district emergency teams, including health care workers at health facility level, had been trained in the management of emergencies due to common infectious and zoonotic hazards. Corresponding training for managing chemical and radio-nuclear hazards had not been undertaken. Projects like Making Medical Injections Safe (MMIS) and other district-based programs were vital in building infection control capacity in the districts, but the country lacked an in-service infection control training program. Medical isolation wards were lacking in all the health facilities visited since they were not included in the standard MoH health facility building plans. Similarly, public health decontamination capabilities for chemical and radio-nuclear hazards were lacking at the national and district levels.
Capacities for public health preparedness
There were disease-specific national preparedness plans for pandemic influenza, malaria, hepatitis E virus and cholera. The country, however, lacked a comprehensive plan incorporating the all-hazards approach of the IHR(2005). About half (54%) of the districts had preparedness plans, but these also lacked the all-hazards approach of the IHR(2005). The MoH had a roster of experts for supporting infectious hazards response, but it lacked food safety, chemical and radio-nuclear experts.
An assessment of public health emergency needs had not been undertaken at the national level or in 77% (10/13) of the districts visited. Nonetheless, the MoH had a national stockpile that included drugs like Tamiflu, meningitis vaccines and personal protective equipment (PPEs).
Capacities for risk communication
There was a designated unit in the MoH for risk communication during PH emergencies. The head of the unit was the designated spokesperson for the MoH emergencies. Similarly, all (13/13) of the districts had focal point officers that serve as spokespersons for coordinating risk communication during emergencies. Though the roles, responsibilities and procedures for coordination of risk communication stakeholders were well articulated as part of institutional memory, national guidelines on risk communication were lacking to backup the information.
The MoH had a website which was accessible to the media and public for information dissemination, though it was not regularly updated. Furthermore, the countrywide network of FM radio stations and Village Health Teams offered vital media for disseminating health messages and educating communities. Community messages and materials for the common epidemic diseases (e.g. cholera, meningitis, polio, measles, avian influenza [H5N1] and pandemic influenza [H1N1]) were available at the national level. However, the development of risk communication plans and the mass production of the materials were almost always done during the epidemic season. This therefore usually resulted in risk communication materials not being readily available when outbreaks started. In addition, the scope of the messages fell short of the IHR(2005) all-hazards approach.
Human resources
An assessment of human resource capacities and corresponding training needs in light of the IHR(2005) multi-hazards approach had not been undertaken. There were at least 17 health training institutions in the country for training public health specialists/epidemiologists, clinical medicine specialists, medical doctors, clinical officers, nurses and other paramedical professions. However, there were no training programs in epidemiology for diploma holders like the district public health surveillance officers and laboratory focal persons, yet they are at the centre of coordinating district surveillance and response activities.
Laboratory capacities
National capacity to deliver laboratory services for all hazards
The national laboratory policy of 2009 provided for the designation of a national laboratory coordinating office in the MoH and the definition of roles and responsibilities of laboratories at national, regional and district levels with regards to infectious and zoonotic investigations. A five-year strategic plan for strengthening national laboratory services was being drafted by the MoH and health partners. The laboratory standard operating procedures (SOPs) for infectious and zoonotic diseases were available at the national level. Most (77%, or 10/13) of the districts had the laboratory SOPs for infectious and zoonotic diseases. Similarly, most (77%, or 10/13) of the districts had conducted an inventory of laboratory capacity for the various health facility laboratories. However, only 54% (7/13) of the districts had operational plans to strengthen laboratory services and only 46% (6/13) of the districts reported that the plans were being implemented. Only 39% (5/13) of the districts had a plan for continuing professional development of laboratory staff (Figure 3).
At the health facility level, only 36% (22/61) had laboratory SOPs while only 26% (16/61) had conducted an inventory of their laboratory capacity. A paltry 13% (8/61) of health facilities had adequate specimen collection/ transport materials for routine investigations while 20% (12/61) and 15% (9/61) had adequate lab reagents and adequate lab equipment, respectively. Only 20% (12/61) of the health facilities had adequate staff according to national minimum staffing levels (Figure 4).
Confirmation
There was national capacity to confirm priority conditions, namely malaria, Human Immunodeficiency Virus (HIV), tuberculosis (TB), polio, measles, influenza, cholera, Ebola, Marburg, meningococcal meningitis, trypanosomiasis, plague, and yellow fever. In addition, there was a government analytical laboratory with capacity to investigate chemical hazards. However, the country lacked laboratory capacity for investigating radio-nuclear events.
Laboratory networking
There was a national laboratory network that functioned through exchange of specimens, data/results, provision of reagents, conducting support supervision and conducting external quality assessments (EQA). The list of designated national reference laboratories was available at the national level and had been disseminated to all levels. The list of international collaborating laboratories for investigating infectious and zoonotic events was available and included the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia (USA), the National Institute of Communicable Diseases (NICD) in South Africa, and the Kenya Medical Research Institute (KEMRI) in Kenya. However, the list of inter national reference laboratories for radio-nuclear investigations was not available.
Specimen collection and transport
There were multiple program-based systems for collecting and transporting specimens to the laboratory. These included the expanded program on immunisation (EPI) system for measles and polio specimens; the influenza sentinel surveillance specimen referral to the National Influenza Centre (NIC); and the postal bus system for sending dry blood spots for early infant diagnosis of HIV. In that regard, 85% (11/13) of districts and 29% (19/65) of health facilities reported having emergency specimen collection kits. However, only 46% (6/13) of the districts and 15% (10/65) of health facilities had transport media while 69% (9/13) of districts and 43% (28/65) of the health facilities had specimen transport carrier boxes.
International air courier services were operating in the country with memoranda of understanding and export permits signed to ship biological specimens. The triple packaging materials were available at the national level and at least three staff working with the national reference laboratories were certified by International Air Transport Association (IATA) for safe shipment of biological specimens. There were, however, no national guide lines to streamline the referral of biological samples to reference international collaborating laboratories.
Biosafety and laboratory biosecurity
Despite the absence of a national laboratory biosafety committee, the corresponding guidelines had been developed and disseminated to the districts. The majority of the districts (62%, or 8/13) and a few of the health facilities (22%, or 14/65) reported having copies of the national biosafety SOPs. The country had one high-containment biosafety level (BSL) 3 laboratory and one BSL2+ laboratory, both in the Uganda Virus Research Institute (UVRI).
Laboratory quality assurance
Despite the absence of a national laboratory accreditation system, there were four internationally accredited WHO reference laboratories for investigating polio, influenza, plague and tuberculosis. National External Quality Assurance (EQA) schemes using panel testing for HIV, TB and malaria were available. Most of the districts (85%, or 11/13) and about half (49%, or 32/65) of the health facilities reported having a laboratory participating in at least one national EQA scheme. Similarly, the national reference laboratories were participating in international EQA schemes.
Laboratory-based surveillance
Standardised tools for collecting and reporting laboratory data were available at the national level. Most of the districts (85%, or 11/13) and 52% (34/65) of the health facilities had the laboratory reporting forms. However, since there was no system for relaying the reports from the district to the national level, the reporting was largely inconsistent, incomplete and not timely. An electronic database existed at the national level and was used for storing and analysing the data.
Participation in public health emergencies
The national laboratory services unit reported participating fully in responding to public health emergencies as a member of the National Task Force, national RRT and the IDSR committee.
Capacities for designated points of entry (PoE)
The country had one international airport (Entebbe), one international port (Port Bell) and several ground crossing points. Uganda had not designated any PoE for the implementation of the IHR(2005) by the time we conducted the assessment. There were no provisions for the application of the following IHR documents at all the points of entry: the International Certificate of Vaccination or prophylaxis; the pertinent health section of the Aircraft General Declaration; the Ship Sanitation Control Certificate/Ship Sanitation Control Exemption Certificate; or the maritime declaration of health. Public health emergency contingency response plans were lacking at all the PoE since there were no permanent public health authorities.