title: Factors influencing passive surveillance for T. b. rhodesiense human african trypanosomiasis in Uganda.
abstract: BACKGROUND
  Sleeping sickness or Human African Trypanosomiasis (HAT) is a neglected tropical disease of public health importance across much of Sub-Saharan Africa. In Uganda, chronic T. b. gambiense HAT (gHAT) and acute T. b. rhodesiense HAT (rHAT) occur in two large but discrete geographical foci. Both forms are difficult to diagnose, expensive to treat and ultimately fatal in the absence of treatment. The area affected by zoonotic rHAT has been steadily expanding, placing a high burden on local health systems. HAT is a disease of neglected populations and is notorious for being under-reported. Here we examine the factors that influence passive rHAT surveillance within the district health system in four Ugandan districts into which the disease had recently been introduced, focusing on staff knowledge, infrastructure and data management.
  
  
  METHODS
  A mixed methods study was undertaken between 2011 and 2013 in Dokolo, Kaberamaido, Soroti and Serere districts to explore health facility capacity and clinical service provision, diagnostic capacity, HAT knowledge and case reporting. Structured interviews were undertaken with 86 medical personnel, including clinicians, nurses, midwives and technicians across 65 HC-II and HC-III medical facilities, where the health infrastructure was also directly observed. Eleven semi-structured interviews were undertaken with medical staff in each of the three designated HAT treatment facilities (Dokolo, Lwala and Serere HC-IV) in the area. HAT treatment centre case records, collected between 2009 and 2012, were analyzed.
  
  
  RESULTS
  Most medical staff in HC-II and HC-III facilities had been made aware of HAT from radio broadcasts, newspapers and by word of mouth, suggestive of a lack of formal training. Key knowledge as regards the causative agent, clinical signs and that HAT drugs are provided free of charge was lower amongst HC-II than HC-III staff. Many respondents did not know whether HAT was endemic in their district. In rHAT specialist treatment centres, staff were knowledgeable of HAT and were confident in their ability to diagnose and manage cases. Between 2009-2012, 342 people were diagnosed in the area, 54% in the late stage of the disease. Over the period of this study the proportion of rHAT cases identified in early stage fell and by 2012 the majority of cases identified were diagnosed in the late stage.
  
  
  CONCLUSIONS
  This study illustrates the critical role of the district health system in HAT management. The increasing proportion of cases identified at a late stage in this study indicates a major gap in lower tier levels in patient referral, diagnosis and reporting that urgently needs to be addressed. Integrating HAT diagnosis into national primary healthcare programs and providing training to medical workers at all levels is central to the new 2030 WHO HAT elimination goal. Given the zoonotic nature of rHAT, joined up active surveillance in human and animal populations in Uganda is also needed. The role of the Coordinating Office for Control of Trypanosomiasis in Uganda in implementing a One Health approach will be key to sustainable management of zoonotic HAT.
authors.affiliation: Centre for Infectious Diseases, Division of Infection and Pathway Medicine, Deanery of Biomedical Sciences, Edinburgh Medical School, The University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK.
authors.forename: Christine
authors.initials: C
authors.lastname: Acup
authors.affiliation: Centre for Infectious Diseases, Division of Infection and Pathway Medicine, Deanery of Biomedical Sciences, Edinburgh Medical School, The University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK.
authors.forename: Kevin Louis
authors.initials: KL
authors.lastname: Bardosh
authors.affiliation: Centre for Infectious Diseases, Division of Infection and Pathway Medicine, Deanery of Biomedical Sciences, Edinburgh Medical School, The University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK.
authors.forename: Kim
authors.initials: K
authors.lastname: Picozzi
authors.affiliation: Department of Pharmacy, Clinical and Comparative Medicine, School of Veterinary Medicine and Animal Resources, Makerere University, P.O. Box 7062, Kampala, Uganda; The Coordinating Office for Control of Trypanosomiasis in Uganda (COCTU), P.O. Box 16345, Wandegeya, Plot 76/78 Buganda Road, Kampala, Uganda.
authors.forename: Charles
authors.initials: C
authors.lastname: Waiswa
authors.affiliation: Centre for Infectious Diseases, Division of Infection and Pathway Medicine, Deanery of Biomedical Sciences, Edinburgh Medical School, The University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK. Electronic address: sue.welburn@ed.ac.uk.
authors.forename: Susan Christina
authors.initials: SC
authors.lastname: Welburn
mesh_terms: D000328:Adult; D000818:Animals; D044383:Black People; D005260:Female; D005843:Geography; D007722:Health Knowledge, Attitudes, Practice; D006282:Health Personnel / Q000193:education* / Q000523:psychology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D058069:Neglected Diseases / Q000175:diagnosis* / Q000453:epidemiology / Q000628:therapy; D011634:Public Health / Q000193:education*; D016833:Trypanosoma brucei rhodesiense / Q000302:isolation & purification*; D014353:Trypanosomiasis, African / Q000175:diagnosis* / Q000628:therapy*; D014454:Uganda / Q000453:epidemiology
keywords: Diagnostic capacity; HAT; Health systems; Human african trypanosomiasis; Sleeping sickness; Surveillance; Trypanosoma brucei gambiense; Tyrpanosoma brucei rhodesiense; Uganda; Under-reporting