title: Hepatitis E in Karamoja, Uganda, 2009-2012: epidemiology and challenges to control in a setting of semi-nomadic pastoralism.
abstract: BACKGROUND
  A prolonged hepatitis E outbreak occurred between 2009 and 2012 among a semi-nomadic pastoralist population in the Karamoja region of Uganda. As data on the public health problems of nomadic pastoralists in sub-Saharan Africa is limited, we sought to characterize the epidemiology and challenges to control of hepatitis E in such a setting.
  
  
  METHODS
  A retrospective case-series investigation was undertaken. Surveillance line-lists of suspected hepatitis E cases maintained during the outbreak were analyzed. Standardized interviews and focus group discussions were conducted with key informants involved in outbreak control activities.
  
  
  RESULTS
  Between August 2009 and September 2012, 987 hepatitis E cases with individual case-based data were identified. Of 22 total deaths, almost half occurred during the first 4 months of the outbreak. Infection attack rates were higher among males and young adults. The average time between onset of jaundice and presentation was approximately 1 week. Challenges to control were related to persistent consumption of untreated water, poor sanitation infrastructure, remote geography, nomadic movement and civil insecurity.
  
  
  CONCLUSIONS
  The hepatitis E outbreak in Karamoja highlights the emergence of sanitation and hygiene-related disease among semi-nomadic pastoralist populations. Improving sanitation and safe water access and extending health education programs to remote pastoralist communities is crucial to prevent such diseases from becoming endemic.
authors.affiliation: Albany Medical College, Albany, NY, 12208, USA mjc2244@columbia.edu.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Cummings
authors.affiliation: Epidemiology and Surveillance Division, Department of National Disease Control, Ministry of Health, P.O. Box 7272, Kampala, Uganda.
authors.forename: Joseph F
authors.initials: JF
authors.lastname: Wamala
authors.affiliation: Karamoja Field Office, World Health Organization, P.O. Box 4, Moroto, Uganda.
authors.forename: Innocent
authors.initials: I
authors.lastname: Komakech
authors.affiliation: Epidemiology and Surveillance Division, Department of National Disease Control, Ministry of Health, P.O. Box 7272, Kampala, Uganda Department of Epidemiology and Biostatistics, Makerere University School of Public Health, P.O. Box 22864, Kampala, Uganda.
authors.forename: Luswa
authors.initials: L
authors.lastname: Lukwago
authors.affiliation: Epidemiology and Surveillance Division, Department of National Disease Control, Ministry of Health, P.O. Box 7272, Kampala, Uganda.
authors.forename: Mugagga
authors.initials: M
authors.lastname: Malimbo
authors.affiliation: Moroto District Health Office, Ministry of Health, P.O. Box 4, Moroto, Uganda.
authors.forename: Michael E
authors.initials: ME
authors.lastname: Omeke
authors.affiliation: Albany Medical College, Albany, NY, 12208, USA.
authors.forename: Dan
authors.initials: D
authors.lastname: Mayer
authors.affiliation: Vaccine Preventable Disease-EPI Laboratory, Uganda Virus Research Institute, P.O. Box 49, Entebbe, Uganda.
authors.forename: Barnabas
authors.initials: B
authors.lastname: Bakamutumaho
mesh_terms: D000328:Adult; D017677:Age Distribution; D000368:Aged; D002648:Child; D002675:Child, Preschool; D019468:Disease Management; D004196:Disease Outbreaks / Q000517:prevention & control; D005260:Female; D017144:Focus Groups; D016751:Hepatitis E / Q000453:epidemiology* / Q000517:prevention & control*; D006801:Humans; D006920:Hygiene / Q000592:standards; D015994:Incidence; D007223:Infant; D008297:Male; D008875:Middle Aged; D011159:Population Surveillance; D012189:Retrospective Studies; D012499:Sanitation / Q000592:standards; D017678:Sex Distribution; D014171:Transients and Migrants; D014454:Uganda / Q000453:epidemiology; D055815:Young Adult
keywords: Hepatitis E; Nomadic pastoralism; Uganda