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The First National Conference on Antimicrobial Resistance

The First National Conference on Antimicrobial Resistance

Promoting Best Antimicrobial Practices in

Wash & Wills Hotel, Mbale

21st – 22nd November 2016

1 TABLE OF CONTENTS

WELCOME……………………………………………………………………...... 3 PARTICIPANTS IN THE ORGANIZATION OF THE CONFERENCE…..... 4 FUNDERS………………………………………………………………………...... 5 INFORMATION ABOUT MBALE…………………………………………...... 6 MESSAGES…………………………………………………………………….....…. 7

AGENDA DAY ONE……………………………………………………………...... 12 Plenary 1………………………………………………………………………...... ….. 12 Plenary 2………………………………………………………………………...... ….. 12 Breakout Session 1……………………………………………………………...….. 13 Plenary 3………………………………………………………………………...... …. 13 Breakout Session 2……………………………………………………………...….. 13

AGENDA DAY TWO…………………………………………………………...... … 14 Plenary 4…………………………………………………………………………...... 14 Plenary 5…………………………………………………………………………...... 14 Breakout Session 3………………………………………………………………..... 14 Round Table Discussion……………………………………………………………. 15 Plenary 6…………………………………………………………………………...... 15

ABSTRACTS……………………………………………………………………...... 16

COALITION AGAINST RESISTANCE TO PESTICIDES & ANTIMICROBIALS’...... 45

The First National Conference 2 on Antimicrobial Resistance The First National Conference Theon AntimicrobialFirst National Resistance Conference on Antimicrobial Resistance WELCOME

Dear Participants,

The Steering Committee warmly welcomes you to the First National Conference on Antimicrobial Resistance being hosted at Wash and Wills Hotel, Mbale, Eastern Uganda, from 21st – 22nd November 2016. The theme of the conference “Promoting Best Antimicrobial Practice in Uganda” resonates with the agenda of AMR Global Action Plan that Uganda has embraced.

Together for the first time in Uganda, various stakeholders have come together to listen to one another and to use this platform to accelerate formation of a multisector response. The different stakeholders include players that contribute to increasing resistance, those most adversely affected by it, and those critical to the control and prevention of the problem. This conference is being held at a crucial time in this country; the Ministry of Health has setup AMR surveillance system and it is engaging the Office of the Prime Minister to constitute a multi-sectoral National AMR Committee to draft the National Action Plan; Ministry of Agriculture, Animal Industry and Fisheries has developed a National Plan to contain resistance to acaricides, which in turn will reduce the need for antimicrobials; is developing guidelines towards responsible and prudent use of antibiotics in animals. The conference will synergize these and other upcoming efforts.

It is our sincere hope that this conference will enrich your perspective in the efforts to mitigate antimicrobial resistance in Uganda.

Sincerely

2016 National Steering Committee, AMR-Conference

3 PARTICIPANTS IN THE ORGANIZATION OF THE FIRST AMR-CONFERENCE

Allen Mukhwana, Uganda Virus Research Institute Bonaventure Ahaisibwe, Seed Global Health Charles Mutabazi, Faculty of Health Sciences Christian Acemah, from Uganda National Academy of Sciences Constance Basirika, Busitema University Faculty of Health Sciences Franklin Kizito, Infectious Diseases Institute George Mutumba, Busitema University Faculty of Health Sciences Grace Nakuku, Busitema University Faculty of Health Sciences Jacobs Iramoit, Busitema University Faculty of Health Sciences Jenifer Lasman, Busitema University Faculty of Health Sciences Jolly Akullo, Busitema University Faculty of Agriculture Joseph L. Mpagi, Busitema University Faculty of Health Sciences Kenneth Mugabi, Ministry of Agriculture, Animal Industry and Fisheries Lamorde Mohammed, Infectious Diseases Institute Paul Kyambadde, Ministry of Health Paul Oboth, Busitema University Faculty of Health Sciences , Busitema University Faculty of Health Sciences Pauline Byakika, University College of Health Sciences Peter Masaba, Busitema University Faculty of Health Sciences Peter Olupot-Olupot, Busitema University Faculty of Health Sciences Priscilla Kanziga, Infectious Diseases Institute Rebecca Arakit, Busitema University Faculty of Health Sciences Rebecca Nekaka, Busitema University Faculty of Health Sciences Richard Walwema, Infectious Diseases Institute Stephen Baguma, Uganda National Academy of Sciences Vincent Kayizzi, National Drug Authority William Lali Ziras, World Health Organization Winnie Wafula, Busitema University Faculty of Health Sciences Yahaya Gavamukulya, Busitema University Faculty of Health Sciences

The First National Conference 4 on Antimicrobial Resistance The First National Conference on Antimicrobial Resistance

FUNDERS

• Busitema University Faculty of Health Sciences (Uganda), • Epicentre (France) • -Institute of Infectious Disease GHSP (Uganda) • Massachusetts General Hospital (US) • Medilink Lab and Surgicals (Kenya) • Peace Corps (Us) • President’s Emergency Plan for Aids Relief (US) • Seed Global Health (US) • USAID/Uganda Health Supply Chain (Uganda)

5 INFORMATION ABOUT MBALE

Mt Elgon Region

Mount Elgon, an extinct volcano that straddles Uganda-Kenya border, is the 8th highest mountain in Africa and has the largest base area of any freestanding volcano in the world. Total area is 2,304 km2, of which 2045 km2 is a protected and makes up the Mt Elgon National Park. The Region comprises the districts of Manafwa, Bududa, Mbale, Sironko, Bulambuli, Kapchorwa, Kween, and Bukwo. It is home to two main tribes, Bagisu and Sabinyi. Most people in Mt Elgon region live in rural areas; only 6.6 percent of the population lives in urban areas compared to the national average at 25.6 per cent.

Mbale District Mbale District is named after the largest city in the district, Mbale, which also serves as the main administrative and commercial centre in the Region. It is located approximately 245 kilometres by road, northeast of , the capital of Uganda.

Mbale Town Mbale town is relatively safe which makes it safe to walk the main streets at night without too much fear of getting mugged or robbed. The center of the city is relatively clean, the bars and nightclubs are fun, and there are plenty of restaurants. Most of the large banks, offices and big hotels are situated in the Town centre.

Things to Do in Mbale Hiking experience on Mt Elgon Enjoy game drive in Mt Elgon National Park Enjoy Weekend at Sipi Falls Witness Traditional Male Circumcision (taking place in 2016)

Tourist Attractions in Mbale Mount Elgon National Park Wanale Forest Reserve Sipi Falls Bull fighting competition Simu and Sisi Falls Bukigai Hills

The First National Conference 6 on Antimicrobial Resistance The First National Conference on Antimicrobial Resistance

MESSAGE FROM AMR-CONFERENCE CHAIRMAN

One of the most fascinating qualities of humanity is our ability to adapt. There is no other species that has been able to sustain existence on every continent and even venture past the boundaries of this planet. Human beings have been able to adapt to different conditions through observation, persistence, reasoning and luck.

It was by luck that a little less then one hundred years ago, Alexander Fleming transformed health care. It was on the morning of 3rd September, 1928 that this researcher observed that his cultures of Staphylococci had accidently become infected by a fungus, from the Penicillium genus. Dr. Fleming observed that the bacteria near the fungus were dying off but the bacteria farther away from the fungus survived. From this observation, Dr. Fleming hypothesized that the fungus was producing some agent that was toxic to the bacteria. This marked the beginning of the revolutionary age of antimicrobials.

Since the discovery of Penicillin, many more antimicrobials have been found and this has led to the reduction of morbidity and mortality. Combining the effects of antimicrobial medications together with improvements in vaccinations, humanity was thought to have a found a way to adapt to the antimicrobial world. Unfortunately, we see that the tide is turning. There is growing evidence that microorganisms are developing resistance to available antimicrobial drugs.

During the next two days, we will discuss researchers’ findings on resistance patterns currently being reported in Uganda. We will be hearing from a variety of stakeholders during this conference. Antimicrobial resistance is a multi-sectorial problem and will involve all of us to work together to adapt to this changing microorganism environment. Through this meeting, I call upon members to develop a unified antimicrobial stewardship program for Uganda.

Dr. Joseph L. Mpagi, Head Department of & Immunology, Busitema University Faculty of Health Sciences

7 MESSAGE FROM THE DEAN OF BUSITEMA UNIVERSITY FACULTY OF HEALTH SCEINCES

I take pleasure to welcome you all to Mbale town. We are pleased that a number of distinguished scholars have joined us to share their thoughts about the emerging global challenge of resistance to antimicrobial agents and pesticides. This challenge is compounded by the ever changing trends in globalization. As a young faculty we are positioning ourselves to play a critical role in the economic and social development of Africa through the training of distinguished health professionals and establishing a distinguished research base, focused on areas in which we can make a unique contribution. We believe that the partnership exhibited in the preparation for this meeting is requisite to meeting our aspirations.

Reflecting on the challenge of antimicrobial and pesticide resistance, we all need to appreciate the task that lies ahead of us in trying to control the development and spread of resistant strains of organisms together with mitigating the impact of existing resistant strains. This is a huge task that calls for multidisciplinary actions and inter-sector collaboration. I believe that the next two days will provide exciting and beneficial interactions among the various experts gathered here today and the resolutions of this meeting will contribute to national, regional and global responses to this problem.

I thank all the collaborating partners at this conference; Seed Global Health, American Peace Corps, Massachusetts General Hospital, Ministry of Health, Ministry of Agriculture Animal Industry and Fisheries, National Drug Authority, World Health Organization, Epicentre – Medecins Sans Frontieres, Uganda National Academy of Sciences, Makerere Univesity-Institute of Infectious Diseases, USAID/Uganda Health Supply Chain and Medilink Lab and Surgicals Ltd. I thank all presenters who have spent time to prepare and travel to Mbale for this conference. I also thank the organizing committee that has worked tireless over several month for the success of this conference.

Prof. Paul Waako MBChB. MSc. PhD. Dip Mgt Dean Busitema University Faculty of Health Sciences

The First National Conference 8 on Antimicrobial Resistance The First National Conference on Antimicrobial Resistance

MESSAGE FROM THE VICE CHANCELLOR, BUSITEMA UNIVERSITY

I take this opportunity to welcome you to Busitema University Faculty of Health Sciences in Mbale.

Busitema University was established in 2007 as Multi-campus University and has six operational campuses, most of them located in rural parts of the country. The University was established with the main objective of fostering socio-economic transformation and sustainable development of rural areas of this country. In September 2013 we opened the Faculty of Health Sciences at Mbale with a mission to improve the health of underserved communities of Uganda through innovative ways of teaching, research and health delivery. The Faculty is also intended to serve as a platform for research that will provide evidence to solve health problems of communities in the country in general, and this region in particular.

Resistance to antimicrobial agents is an emerging global problem which needs to be tackled at national and regional levels by all stakeholders. Antimicrobial resistance surpasses the boundaries of any one discipline. It is therefore appropriate that this conference has been a collaborative effort between Busitema University, Ministry of Health, Ministry of Agriculture Animal Industry and Fisheries, National Drug Authority, World Health Organization, Uganda National Academy of Sciences and has participants from various sectors. I congratulate the Faculty of Health Sciences for this initiative.

I extend our gratitude to the Seed Global Health, the Ministry of Health, World Health Organization and a number of organizations which have contributed generously to support this conference. I really hope that the recommendations from this meeting will impact on the health of our people.

Pursuing Excellence

Professor Mary J. N. Okwakol BSc, MSc, PhD, FRES, FUNAS VICE CHANCELLOR

9 STATEMENT FROM THE MINISTRY OF HEALTH

Antimicrobial resistance is a global problem that is shaking the very foundations of modern medicine. Infections that had been rendered benign with the discovery of antibiotics are resurging as major threats to human life. For us in Uganda where infectious diseases notably HIV, malaria, tuberculosis, respiratory tract infections, meningitis, neonatal sepsis and diarrhoea account for 8 of the top 10 causes of premature death, antimicrobial resistance is particularly urgent.

With nearly 900,000 people on anti-retroviral therapy, resistance to first line agents shall inevitably increase from the current 5 - 10%. Of the estimated 45,000 patients started on anti-tuberculous treatment, about 300 have multi-drug resistant tuberculosis. Resistant strains of any pathogen require second line therapy that is not only prohibitively costly but is also much more toxic than first line therapy. Resistance therefore carries great human and economic costs, particularly in developing countries like Uganda.

Despite being prescription only medicines, antibiotics are readily accessible over the counter in pharmacies and community drug shops. The limited laboratory capacity in the country dictates that antibiotic use is largely empirical. The national guidelines on which empirical therapy depends are based mainly on expert opinion as there is no surveillance system to generate resistance data. Studies from research groups indicate very high rates of resistance to commonly used agents like penicillins, flouroquinolones and cotrimoxazole. Phenotypes of public health concern including methicillin resistant S.aureus and resistance to 3rd generation cephalosporin and carbapenems have been reported at alarming prevalence. Inadequate infection prevention and control practices and crowding in many health facilities provides the potential for amplifying the problem. Studies also suggest widespread misuse and resistance in animal husbandry despite the regulatory policies by the National Drug Authority.

The above challenges notwithstanding, successes in some areas of public health provide lots of promise to our efforts in combating AMR. Immunization currently at 96% for the 3rd dose of Hib-Hep-DPT has virtually eliminated conditions like H. influenzae associated meningitis with similar results expected for the pneumococcus vaccine that was introduced in 2013 and rotavirus that is due in April 2017. This together with the improving access to safe water which now stands at 73% for urban and 65% for rural areas should reduce the need for antimicrobials and mitigate the drivers of resistance.

Having adopted the AMR Global action plan, the country is taking the initial steps towards development of a National Action Plan. A situation analysis

The First National Conference 10 on Antimicrobial Resistance The First National Conference on Antimicrobial Resistance was performed in 2014 and the Ministry is in the process of constituting the multi-sectoral National AMR Committee to draft the Plan. In the meantime, we have developed the national antibiotic resistance surveillance plan based on the Global Antimicrobial Surveillance System (GLASS) and intend to start implementation and reporting during 2017. By dedicating an entire conference to antimicrobial resistance, Busitema University has offered a unique opportunity for mobilizing stakeholders from the various sectors including player that generate resistance, those most affected by it as well as those critical for its control and prevention. We encourage every participant to take advantage and identify their role in this partnership. Working together, we shall ‘ensure, for as long as possible, continuity of successful treatment and prevention of infectious diseases with effective and safe medicines that are quality assured, used responsibly and accessible to all that need them’.

Thank you

For God and My Country

11 NATIONAL AMR-CONFERENCE AGENDA 2016:

FIRST NATIONAL AMR-CONFERENCE: PROMOTING BEST ANTIMICROBIAL PRACTICES IN UGANDA

DAY 1 MONDAY, 21ST NOVEMBER, 2016 07:00 – 08:20 REGISTRATION LOCATION: WASH & WILLS HOTEL, MAIN HALL PLENARY 1: MAIN HALL OPENNNING SESSION Moderator: Prof. Paul Waako, Dean - Busitema University Faculty of Health Sciences (BUFHS) 08:20 – 10:20 Welcome remarks: Name: Dr. Joseph L. Mpagi, Conference chair, Head Dept. of Microbiology, Busitema University Faculty of Health Sciences Name: Prof. Mary J. N. Okwakol, the Vice Chancellor Busitema University Keynote address: Perspective of Uganda National Academy of Sciences on containment of AMR in Uganda Name: Prof. Nelson Sewankambo, National Academy of Sciences Topic: Antimicrobial Resistance – A call for action Name: Dr. Wondimagegnehu Alemu, WHO Country Representative Topic: Infectious diseases as a neglected dimension to global security Name: Prof. , Executive Director, African Centre for Global Health and Social Transformation (ACHEST) and Chancellor Busitema University Speech by the Guest of Honor Name: Hon. Dr. Jane R. Aceng, the Minister of Health, Uganda 10:20 – 10:50 Break tea & Poster Viewing PLENARY 2: MAIN HALL Moderator: Dr. Peter Masaba, Department Head of , Busitema University Faculty of Health Sciences 10:50 – 11:30 Topic: Epidemiology of AMR Name: Florence C. Najjuka, Department of Microbiology, Makerere University College of Health Sciences Topic: Progress on the National HIV Drug Resistance Prevention, Surveillance and Monitoring Program Activities in Uganda Name: Pontiano Kaleebu, Director MRC/UVRI Uganda Research Unit on AIDS Deputy Director, Uganda Virus Research Institute 11:30 – 11:50 Discussion Breakout 1 session Topic: HIV/TB Moderator: Dr. Hannah Kibuuka, Executive Director Makerere University Walter Reed Project Topic: Resistance to Protease Inhibitors (PI) among Patients Evaluated for Third-line ART in Kampala 11:50 -13:10 Name: Francis Ssali, Joint Clinical Research Centre Topic: A snap shot into HIV Viral load monitoring among HIV Pregnant and lactating women in government health facilities in Eastern Uganda Name: Agnes Napyo Kasede, Busitema University Faculty of Health Sciences Topic: In Vitro evaluation of anti-tuberculosis activity of selected medicinal plants against multi-drug resistant Mycobacterium tuberculosis Name: Kevin Komakech, Makerere University Topic: Non compliance and associated factors leading to the prevalence of multi-drug resistant tuberculosis in Uganda Name: Bosco Ssemanda, Bugema University

The First National Conference 12 on Antimicrobial Resistance The First National Conference on Antimicrobial Resistance Breakout 2 Session Topic: Agriculture and Veterinary 11:50 – 13:10 Moderator: Mr. Augustine Mwendya, Chief Executive Secretary, Uganda National Farmers Federation Topic: Guidelines to farmers on use of acaricides and other animal drugs in Uganda Name: Rose Ademun, Ag. Commissioner for Animal Health, Ministry of Agriculture Animal Industry and Fisheries Topic: Experiences and challenges of antimicrobial susceptibility testing Name: Francis Ejobi, Makerere University College of Veterinary, Animal Resources and Biosecurity Topic: Challenges in the use of drugs to treat animals in Uganda Name: Farmers’ representative 13:10 – 14:10 Lunch break PLENARY 3: MAIN HALL Moderator: Dr. Juliet A. Mwanga, Director of Epicentre, Mbarara Research Centre, Uganda. Topic: Distribution of antimicrobials in the public sector and mitigation of AMR 14:10-15:10 Name: Mr. Moses Kamabare, General manager, National medical stores Topic: Distribution of antimicrobials in private sector and mitigation of AMR Name: Bildard Baguma, Executive Director, Joint Medical Stores Topic: Distribution of veterinary antimicrobials and mitigation of AMR Name: Vincent Kayizzi, National Drug Authority 15:10 – 15:30 Discussion Breakout 3 session Topic: Bacterial/Laboratory Moderator – Dr. Bonaventure Ahaisibwe, Country Representative, Seed Global Health Topic: A situational analysis of multi-drug resistance among clinical isolates of 15:30 -17:50 Staphylococcus aureus in Mbale Regional Referral Hospital Name: Jacobs Iramiot, Busitema University Faculty of Health Sciences Topic: Antimicrobial resistance surveillance in Uganda: Barriers and Recommendations Name: G., Nsubuga, Infectious Disease Institute, Makerere University Topic: Microbial colonization of Ugandan women in labor Name: Josephine Tumuhamye, University of Bergen, Norway Topic: Antimicrobial resistance of sexually transmitted diseases in sub-Saharan Africa: A systematic review Name: Meklit Workneh, Johns Hopkins School of Medicine Breakout 4 session Topic: Malaria Moderator: Dr. Adoke Yeka, Makerere University Infectious Disease Research Collaboration 15:30-17:50 Topic: Use of antimalarials in outpatient department in Mubende Regional Referral Hospital, Period July 2014 to June 2016 Name: Maria Kabaisera Ainomugisha, Mubende Regional Referral Hospital Topic: Adherence to the test and treat strategy in the control of Malaria at Naguru Referral Hospital – Kampala, Uganda 2013-2014 Name: Julius Kuule, Uganda Malaria Research Centre Topic: Bio-efficacy of selected synergistically enhanced pyrethroid and pyrethroid-only impregnated long-lasting insecticidal nets against pyrethroid resistant Anopheles gambiaes l. from Eastern Uganda Name: Myers Lugemwa, Deputy Manager, Malaria Control Program, Ministry of Health 17:50-18:50 Tea & Poster Viewing

13

DAY 2 TUESDAY, 22N NOVEMBER, 2016

7.30 – 8.00 REGISTRATION CONT. LOCATION: WASH & WILLS HOTEL, MAIN HALL PLENARY 4: MAIN HALL Moderator: Prof. David Kabasa, Principal, Makerere University College of Veterinary, Animal Resources and Biosecurity 8:00-10:00 Review of Day 1: Chief Rapporteur Topic: Agriculture and veterinary practices contributing to AMR Name: Nicholas Kauta, Director Animal Resources, Ministry of Agriculture Animal Industry and Fisheries Topic: Policy, regulation and AMR Name: Donna Kusemererwa, Executive Director, National Drug Authority Topic: Surveillance of AMR in Uganda Name: Henry Kajumbula, Chair, MOH Task Force on AMR-Surveillance 10:00-10:30 Break tea & Poster viewing PLENARY 5: MAIN HALL Moderator: Prof. D. Byarugaba, Dept. of Microbiology, Makerere University College of Veterinary, Animal Resources and Biosecurity Breakout 5 session Topic: Bacterial/Laboratory Moderator: Prof. Moses Joloba, Dean, School of Biomedical Sciences, Makerere University College of Health Sciences Topic: Species of yeasts isolated in high vaginal swabs from women with symptomatic vulvo-vaginal Candidiasis at the Antenatal Clinic, Hospital Name: Ronald Mugume, Makerere University Topic: Characterisation of inhibitors of the PqsR quorum sensing regulator in Psudomonas 10:30 -11:30 aweruginosa Name: Fred Athanasius Dratibi, Univeristy of Nottingham Topic: Antimicrobial resistance in pathogenic aerobic bacteria causing surgical site infections in Mbarara Regional Referral Hospital, Southwestern Uganda Name: Derick Hope, MSF/Epicentre Mbarara Research Centre Topic: Antibiotic sensitivity patterns of amniotic fluid cultures from women with premature rupture of membranes in Mulago Hospital Kampala Uganda: A cross sectional study Name: Milton Musaba, Mbale Regional Referral Hospital Topic: Antimicrobial susceptibility and resistance patterns of Salmonella Typhi during the 2015 Typhoid outbreak in Kampala, Uganda Name: Juliet Nsimire, Medical Research Council/Uganda Virus Research Institute Research Unit on AIDS, Entebbe Breakout 6 Topic: Hospital acquired infection Moderator – Dr. M. Ogwang, St. Mary's Hospital Lacor, Gulu, Uganda Topic: Characterization of antimicrobial susceptibility patterns of isolates from ward fomite Name: Bashir Mwambi, International Health Sciences University 10:30-11:30 Topic: Contamination of urine obtained from children participating in Epicentre studies and admitted to Mbarara Regional Referral Hospital by ESBL-producing Enterobacteria Name: Deborah Nanjebe, Epicentre, Mbarara Research Centre Topic: Babygel pilot: A pilot cluster randomized trial of the provision of alcohol handgel to postpartum mothers to prevent neonatal infective morbidity in the home. Name: J. Ditai, – Sanyu Africa Research Institute, University of Liverpool Topic: Alcohol-based hand gel use and incidence of healthcare associated infections in Mbale Regional Referral Hospital, Rural Eastern Uganda Name: J. Ditai, – Sanyu Africa Research Institute, University of Liverpool

The First National Conference 14 on Antimicrobial Resistance The First National Conference on Antimicrobial Resistance

11:30 – 13:00 Round Table Discussion 1. Nicholas Kauta, Director Animal Resources, Ministry of Agriculture Animal Industry and Fisheries 2. Patric Tusiime, Commissioner National Disease Control, Ministry of Health 3. Donna Kusemererwa, Executive Director, National Drug Authority 4. Nelson Sewankambo, President of Uganda National Academy of Sciences 5. Henry Kajumbula, Chair, MOH Task Force on AMR-Surveillance 6. Mohammed Lamorde, Principal Investigator, IDI-GHSP Project 7. Bildard Baguma, Executive Director, Joint Medical Stores 13:00-14:00 Lunch Break 14:00-15:20 PLENARY 6: MAIN HALL Moderator – Dr. Crispus Tegu, Department Head of Paediatrics, Busitema University Faculty of Health Sciences Topic: Artesunate/amodiaquine versus artemether/lumefantrine for the treatment of uncomplicated malaria in Uganda: randomized clinical trial at three sites in Uganda Name: Adoke Yeka, Makerere University Infectious Disease Research Collaboration Topic: From Antiretroviral therapy access to provision of third line regimens: Evidence of HIV drug resistance mutations to first and second line regimens among Ugandan adults Name: Ivan Namakoola, MRC/UVRI Uganda Research Unit on AIDS Topic: Cultural, Ecological and Environmental drivers of AMR Name: Paul Kyambadde, Ministry of Health Topic: Changes and issues in antibiotic therapy in UCG 2016 Name: Juliet Kitutu, Appropriate Medicine Use Unit, Pharmacy Division, Ministry of Health Topic: Analysis of National SPARS data on antibiotic use from 2010 to 2016 Name: Morries Seru, Ag. Assistant Commissioner Health Services Pharmacy

15:20 – 15:50 Discussion

15:50 – 16:30 Way forward: Chief Rapporteur

Closing Speech by H.E. Deborah Malac, American US Ambassador to Uganda

16:30-17:30 Tea & Departure

15 PLENARY ABSTRACTS

Progress on the National HIV Drug Resistance Prevention, Surveillance and Monitoring Program Activities in Uganda

Authors: Pontiano Kaleebu1/2, Christine Watera1, Wilford Kirungi3, Cissy Kityo4, Paula Munderi2, Tom Lutalo1/5, Kaggwa Mugagga6, Francis Ssali4, Deogratius Ssemwanga1/2, Juliet Asio1, Helen Byomire7, Norah Namuwenge3, Edward Katongole-Mbidde1 and The HIV Drug Resistance Working group

Affliations: 1Uganda Virus Research Institute, Entebbe, 2MRC/UVRI Uganda Research Unit on AIDS, Entebbe, 3AIDS Control Programme, Ministry of Health, Kampala, 4Joint Clinical Research Centre, Kampala, 5Rakai Health Sciences Program, 6World Health Organization, Kampala, 7National Drug Authority, Kampala

Background: Emergence of HIV drug resistance (HIVDR) is inevitable, due to the high replication and mutation rates of HIV and anti-retroviral therapy (ART) being life-long. WHO recommended countries to develop a public-health strategy for prevention and monitoring of HIVDR, a plan Uganda adopted in 2007.

Description: The elements of this plan include: establishment of a national HIVDR Technical Working Group and a 5 year plan; regular assessment of HIVDR early warning indicators (EWI) from all or representative ART sites; monitoring emerging HIVDR and associated factors in sentinel ART sites; survey for transmitted DR (TDR); development of a national HIVDR database; surveillance of HIVDR in treatment-naïve children < 18 months of age; establishment of an in-country WHO- accredited HIVDR genotyping laboratory; implementation of HIVDR prevention activities and annual HIVDR report with appropriate recommendations.

Progress and Lessons learnt: Nearly all the elements have been achieved. EWI in 2012 and 2014 show that prescribing practices, loss to follow up, patient drug pick up, clinical appointment keeping and ART supply continuity were below the WHO targets. Seventy one and ninety nine percent of the ART facilities in 2012 and 2014 respectively, retained their patients on frst line ART 12 months after initiation, meeting the target of ≥ 70% retained. Two laboratories one at UVRI and another at JCRC are accredited by WHO. Data from several surveys indicate that the prevalence of TDR ranges from below 5% among pregnant women in Entebbe (2006) to 8.6% among young adults in Kampala (2011). We continue monitoring for TDR among sero-converters in various cohorts. The prevalence of acquired HIVDR among adult patients receiving frst-line and second-line ART (2012-2013) was 11% of 321 patients at 12 months at three clinics in Eastern, Central and South Western regions. Our work has infuenced policy including genotyping at time of 2nd line ART regimen failure to guide treatment options and use of EWI in programme monitoring.

Next steps: We are conducting another pre-treatment and acquired DR survey. Another EWI survey is planned and a cross-sectional HIVDR survey of those failing 2nd line is to start in order to inform 3rd line regimen needs.

The First National Conference 16 on Antimicrobial Resistance The First National Conference on Antimicrobial Resistance

Title: From Antiretroviral Therapy Access to provision of Third Line regimens: evidence of HIV Drug Resistance Mutations to frst and second line regimens among Ugandan adults

Authors: Ivan Namakoola1, Ivan Kasamba1, 2, Billy N. Mayanja1, Patrick Kazooba1, Joseph Lutaakome1, Fred Lyagoba1, Anne A. Kapaata1, Pontiano Kaleebu1, 3, Paula Munderi1, on behalf of the CoLTART study team

Affliations: 1 MRC/UVRI Uganda Research Unit on AIDS. P.O. Box 49, Entebbe, Uganda. 2MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine. Keppel Street, London WC1E 7HT, 3Department of Clinical Research, London School of Hygiene and Tropical Medicine. Keppel, Street, London WC1E 7HT

Background: HIV care programs in resource-limited settings have hitherto concentrated on antiretroviral therapy (ART) access, but HIV drug resistance is emerging. In a cross-sectional study of HIV positive adults on ART for ≥6months enrolled into a prospective cohort in Uganda, plasma HIV RNA was measured and genotyped if ≥ 1000 copies/ml at enrollment. Identifed drug resistance mutations (DRMs) were interpreted using the Stanford database, 2009 WHO list of DRMs and the IAS 2014 update on DRMs, and examined and tabulated by ART drug classes.

Findings: Between July 2013 and August 2014, 953 individuals were enrolled, 119 (12.5%) had HIVRNA≥ 1000 copies/ml and 110 were successfully genotyped; 75 (68.2%) were on frst-line and 35 (31.8%) on second-line ART regimens. The commonest clinically signifcant major resistance mutations associated with the highest levels of reduced susceptibility or virological response to the relevant NRTI were M184V -20.7 %, K65R -8.0%, and thymidine analogue mutations (TAMS); M41L -8% and K70R -8%, while major NNRTI mutations were K103N -19.0%, G190A - 7.0% and Y181C - 6.0%. A relatively nonpolymorphic accessory mutation A98G - 12.0%, was also common. Seven of the 35 patients on second line ART had the most common clinically signifcant PI-resistance mutations associated with the highest levels of phenotypic resistance and/or with the strongest clinical evidence for interfering with successful PI therapy. These were V82A - 7.0%, I54V, M46I, and L33I (all 5.0%). Also common were L10I - 27.0%, L10V -12.0% and L10F-5.0% accessory PI-selected mutations that either reduce PI susceptibility or increase the replication of viruses containing PI-resistance mutations. Of the 7 patients with major PI DRMs, fve had high level resistance to boosted Lopinavir and Atazanavir, with Duranavir as the only susceptible PI tested.

Conclusions: In resource-limited settings, HIV care programs that have previously concentrated on ART access, should now consider provision of access to routine HIV viral load monitoring, targeted HIV drug resistance testing and availability of third-line ART regimens.

17 Artesunate/amodiaquine versus artemether/lumefantrine for the treatment of uncomplicated malaria in Uganda; randomized clinical trial at three sites in Uganda

Adoke Yeka1,2, Ruth Kigozi2, Melissa Conrad3, Myers Lugemwa4, Peter Okui4, Charles Katureebe5, Kassahun Belay6,10, B.K. Kapella7,10, Michelle A. Chang7, Moses R. Kamya2,8, Sarah G. Staedke2,9, Grant Dorsey3, Philip J. Rosenthal3

1Makerere University School of Public Health, College of Health Sciences, Kampala, Uganda; 2Infectious Diseases Research Collaboration, Kampala, Uganda; 3Department of Medicine, University of California, San Francisco, California, USA; 4National Malaria Control Program, Ministry of Health, Kampala, Uganda; 5World Health Organization, Kampala, Uganda; 6U.S. Agency for International Development, Kampala, Uganda; 7Malaria Branch, Division of Parasitic Diseases and Malaria, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, USA; 8Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda; 9London School of Hygiene and Tropical Medicine, London, UK; 10President’s Malaria Initiative Corresponding author: Adoke Yeka, mail [email protected] phone 0772473533

Background: With older therapies limited by widespread drug resistance, standard treatment for uncomplicated falciparum malaria is now artemisinin-based combination therapy, with nearly all endemic countries in sub-Saharan Africa recommending either artemether/lumefantrine (AL) or artesunate/amodiaquine (AS/AQ). In Uganda, AL has shown superior effcacy compared to AS/AQ and is the frst-line regimen. However, recent changes in treatment practices and evidence of shifting drug sensitivities prompted a reassessment of the relative effcacies of these regimens.

Methods: We enrolled 602 patients aged 6-59 months from health centers in Apac, Mubende, and Kanungu Districts in Uganda in 2013-14. Children with uncomplicated falciparum malaria were randomly assigned treatment with AL or AS/AQ, and 594 (98.7%) of those enrolled were followed for 28 days. Recurrent infections were genotyped to distinguish recrudescence from new infection, and Plasmodium falciparum resistance-mediating polymorphisms were characterized for all infections.

Results: The risk of recurrent parasitemia was lower in children treated with AS/AQ, compared to those treated with AL, at all three sites (overall 28.6% vs. 44.6%, respectively; p <0.001). Recrudescences were uncommon, but all occurred in the AL treatment arm (0% vs. 2.5%; p = 0.006). Improvement from baseline hemoglobin was greater in the AS/AQ arm (1.73 vs. 1.39 g/ dl, p = 0.04). Both regimens were well tolerated; serious adverse events were uncommon (1.7% for AS/AQ and 1.0% for AL). Considering new infections after therapy, the two regimens selected for opposite polymorphisms in pfcrt and pfmdr1, with each drug selecting for polymorphisms associated with decreased sensitivity to the partner drug. Polymorphisms in the propeller domain of the K13 gene, which have been associated with artemisinin resistance in Asia, were uncommon and not associated with recurrent parasitemia.

Conclusion And Recommendations: Both AL and AS/AQ were highly effcacious, however, overall, AS/AQ showed superior antimalarial effcacy contrasting with older data and consistent with recent changes in parasite drug sensitivity. Malaria treatment guidelines should consider multiple or rotating regimens to maintain the effcacies of leading treatments.

The First National Conference 18 on Antimicrobial Resistance The First National Conference on Antimicrobial Resistance

BREAKOUT 1 – HIV/TB ABSTRACTS

Resistance to Protease Inhibitors (PI) among Patients Evaluated for Third-line ART in Kampala

Authors: Francis Ssali1 Hellen Musana1, Amanda Wanyana1, Eva Natukunda1, Immaculate Nankya1, Emmanuel Ndashimiye1, Ronald Ssenyonga1 1. Joint Clinical Research Centre

Introduction: Access to third-line ART is still limited in Uganda and patients are often kept for long, on failing second-line ART, with potential for accumulated resistance Mutations that can potentially impact on susceptibility to darunavir, which is the reserved third-line ART in Uganda.

Methods: We analyzed the genotypic resistance Mutations found among HIV-1 viral isolates from individuals that had virologically failed second-line ART. The samples were from patients attending the JCRC Clinic in Kampala and those referred from other ART clinics from July 2005 to March 2015. Only samples with major resistance mutation to protease inhibitors are included in this analysis.

Results: Samples were from 177 patients (60.8% male), median age 34 years (IQR 27, 42) with a mean Log viral load 11.4 (SD 1.9). The 3 commonest HIV-subtype were A(48%), D(37%) and C(3%). The median number of major PI mutations per isolate was 3(IQR 2,5) and the major NRTI and NNRTI mutations were 4.6(IQR 2,8) and 1.7(IQR 1,4) respectively. The 4 commonest major PI mutations were at positions V82(35%), I54(31%), M46(30%) and L62(30%). The prevalence of Intermediate to high level resistance to darunavir, Lopinavir and Atazanavir was 20%, 75% and 72% respectively. The accumulation of 3 or more major PI mutations was associated with an increased risk developing darunavir –associated mutations OR 4.6 [95%CI 1.43 – 19.62], p=0.0103.

Conclusion: Accumulation of multiple major PI mutations is the major risk factor for darunavir resistance among patients on Second-line ART in Kampala. Early virologic recognition of failure to second-line ART and timely switch to 3rd line ART will maximize the beneft of darunavir in third-line ART.

19 A SNAP SHOT INTO THE HIV VIRAL LOAD MONITORING AMONG HIV PREGNANT AND LACTATING WOMEN IN GOVERNMENT HEALTH FACILITIES IN EASTERN UGANDA

Napyo Agnes Kasede1,2,4, James K. Tumwine2, Thorkild Tylleskär4, Paul Waako1, Victoria Nankabirwa3,4,5,

1Faculty of Health Sciences, Busitema University, Mbale, Uganda; 2Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda; 3School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda; 4Centre for International Health, University of Bergen, Norway; 5Centre for Intervention Science in Maternal and Child Health (www.cismac.org), Centre for International health, University of Bergen

Objective: The Ministry of Health is in the process of rolling out viral load (VL) testing services nationally for the monitoring of anti-retroviral treatment responses among HIV positive persons. This roll-out is especially important for pregnant and lactating women as VL suppression is key in reducing the risk of mother to child transmission. We describe the VL testing service processes and context for pregnant and lactating women at health facilities in Eastern Uganda.

Methods: Eight high-volume health facilities with a combined total 1,741 deliveries per year in Eastern Uganda were visited between September and October 2016. Midwives, clinicians and laboratory staff were interviewed using an interview guide and assessments of their respective departments made using an observation checklist

Results: VL samples are taken off as Dried Blood Spots (DBS), at all the facilities. In each facility, DBS samples collected are picked up by a hub rider and dropped off at a central hub from where the samples are shipped to the Central Public Health Laboratory (CPHL). Two out of the 8 health facilities were hubs. In all the health facilities, the turn-around time for VL results was 3 – 4 weeks. Ninety percent of the VL samples shipped to CPHL get their results sent back to the facility. One out eight midwives knew how to collect a DBS sample. In 7 out of 8 health facilities, the DBS samples collected from HIV+ pregnant and lactating women are taken off from the main laboratory and not mother-baby care point. In all facilities, there were challenges with use of VL data collection tools.

Conclusion: The national roll-out of VL testing services in Uganda still has challenges. This assessment serves as a preamble for a more extensive study on the factors associated with VL monitoring among HIV infected pregnant and lactating women in Uganda.

The First National Conference 20 on Antimicrobial Resistance The First National Conference on Antimicrobial Resistance

INVITRO EVALUATION OF ANTI-TUBERCULOSIS ACTIVITY OF SELECTED MEDICINAL PLANTS AGAINST MULTI-DRUG RESISTANT Mycobacterium tuberculosis

Komakech Kevin1*, Kateregga John1, Namaganda Carolyn2,Semugenze Derrick2, AloysiusLubega3

1Department of Veterinary Pharmacology, College of Veterinary Medicine, Animal Resources and Biosecurity, Makerere University, P.O. Box 7062, Kampala, Uganda. [email protected] Tel: +256 705358866, [email protected]; Tel: +256 779251040 2Department of Microbiology, Mycobacteriology (BSL3 ) Laboratory, College of Health Science, Makerere University, P.O. Box 7072, Kampala, Uganda [email protected] Tel: +256 782663266, [email protected] Tel: +256 703024583 3Department of Pharmacology and Therapeutics, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda. [email protected] Tel: +256 779577233

Introduction & Objectives: Tuberculosis (TB) is the second leading killer infectious disease after Human Immunodefciency Virus (HIV). Its incidence is worsened by development of multi-drug resistant and extensive drug resistant TB strainsand HIV co-infection. Available treatment regimens are expensive, toxic and lengthy resulting to problems of non-adherence and inadequate response. Medicinal plants on the other hand may offer hope for developing alternative medicine for treatment of TB. The present study was done to evaluate in vitro anti-tuberculosis activity of Echinops amplexicaulis and Cassia nigricans. Methods: Total crude and aqueous extracts of E. amplexicaulis and C. nigricans were tested in vitro for their activity against a wild strain resistant to both Rifampicin and Isoniazid (MDR), a fully susceptible laboratory strain (H37Rv) and on Mycobacterium bovis using disk diffusion method on Middlebrook 7H10 medium for susceptibility and Middlebrook 7H9 broth for Minimum Inhibitory Concentration (MIC). Susceptibility was evaluated by measuring zones of inhibition while MIC was obtained as the lowest concentration with no signifcant growth as shown by its optical density. Isoniazid was used as a positive control. Results:: Both extracts of the two plants exhibited anti-mycobacterial activity. However, the total crude extract of E. amplexicaulishad the highest activity with MIC of 0.78mg/ml for MDR, H37Rv and M. bovis as compared to the total crude methanol extract ofC. nigricanswith a MIC of 12.5, 6.25 and 3.13mg/ml for the three strains respectively.For the aqueous extracts, E. amplexicaulisextract was the most active against H37Rv (MIC = 25mg/ml) as compared to C. nigricans extract (MIC = 50mg/ml). However, both extracts did not show activity on MDR and M. bovis. Terpenoids, alkaloids, tannins and saponins were present in both extracts from both plants except favonoids.

Conclusion: The results support the local use of these plants in the treatment of TB as suggested in an ethnobotanical survey done in Ngai and Otwol subcounty. However to obtain the most promising anti-mycobacterial activity, further investigations are needed to isolate chemical constituents responsible for eliciting the observed activity in these plants.Anti-mycobacterial activityof these plant extracts are also being reported for the frst time. 21 NONCOMPLIANCE AND ASSOCIATED FACTORS LEADING TO THE PREVALENCE OF MULTI-DRUG RESISTANT TUBERCULOSIS IN UGANDA

Bosco Ssemanda1JK. Amoah2 1.Clinical Instructor, Department of Nursing and Midwifery, Bugema University 2.Dean,School of Health and Natural Sciences, Bugema University Department of Nursing and Midwifery [email protected], +256772285390

Background: Multi-Drug Resistant Tuberculosis (MDR-TB) remains a global health threat to progress made in tuberculosis (TB) care and control worldwide. Uganda has unknown rates of anti-tuberculosis drug resistance. The frst national survey showed a multi-drug resistant tuberculosis prevalence of 1.4% and 12.1% among new and previously treated sputum smear-positive TB patients respectively. High incidence of development of multi drug resistance tuberculosis has been linked with drug non-compliance. The authors carried out a study to investigate the factors associated with non- compliance.

Objectives: The objectives of the study were to identify the factors that lead to poor anti-TB drug compliance and to draw practical, cost-effective interventions to combat MDR-TB

Methods: Literature review of peer reviewed journals, government publications and relevant textbooks was done. The main databases for retrieving journals were EBSCOHOST and HINARI. Search engines such as Google, Google Scholar were also used. Only journals published from 2010-2016 were used. The key word tuberculosis in Uganda was keyed in to search engines and came up with 87 journals. To narrow down the number of journals of relevancy, the key words multi drug resistant tuberculosis and drug adherence was keyed in to EBSCOHOST and HINARI, and came up with 22 journals. The articles were narrowed down to those that provided relevant information on factors affecting compliance to anti-TB drugs leading to MDR-TB in Uganda.

Results and Conclusions: Non-compliance to anti-tuberculosis drugs was due to social/economic, health system/healthcare team and therapy related factors. Four approaches to combat MDR-TB were drawn: community empowerment through Village Health Teams and tuberculosis ambassadors; tax incentives to agencies that promote community awareness about MDR-TB; coexistence of tuberculosis and HIV/ AIDS programmes and promotion of research to develop enhanced therapeutic regimens. The political and other stakeholders’ will is therefore urgently needed to effect these approaches.

The First National Conference 22 on Antimicrobial Resistance The First National Conference on Antimicrobial Resistance

BREAKOUT SESSION 2 – AGRICULTURE AND VETERINARY ABSTRACT

EXPERIENCES AND CHALLENGES OF ANTI-MICROBIAL SUSCEPTIBILITY TESTING IN UGANDA

Francis Ejobi and Sarah Tegule Department of Biosecurity, Ecosystem and Veterinary Public Health, College of Veterinary Medicine, Animal Resources and Biosecurity, Makerere University

*Corresponding Author: Dr Francis Ejobi, E-mail: [email protected], Tel: +256-772- 492236

Abstract: This paper presents preliminary results, experiences and challenges of antimicrobial susceptibility testing conducted in a World Health Organization funded project at Makerere University.A total of 50 samples of beef were collected in May and June 2015 from butcher shops in suburban areas of Kampala, the capital city of Uganda. The samples were cultured for E.coli and Salmonella organisms using standard laboratory methods. E. coli was isolated in 46 out of the 50 samples tested. Salmonella organisms were not isolated in all samples. E.coli isolates were tested for antibiotic susceptibility using Kirby-Bauer technique. Multiple drug resistance was recorded in 43% (20/46) of E.coli isolates. All isolates were resistant to erythromycin. Least resistance of 0.02% (1/46) was found for gentamycin. Resistance to other antibiotics was recorded as follows: ampicillin (24%, 11/46), ceftriaxone (0.04%, 2/46), chloramphenicol (13%, 6/46), nalidixic acid (11%, 5/46), tetracycline (35%, 16/46) and trimethoprim/sulphamethoxazole (22%, 10/46). The major challenges of antimicrobial susceptibility testing in Uganda are: inadequate laboratory infrastructure, disconnected reporting systems in human and animal health sectors and lack of enabling policies. We conclude that One Health approach should be promoted to generate inter- sectoral data required to fght antimicrobial resistance in Uganda.

23 BREAKOUT SESSION 3 – BACTERIAL/ LABORATORY ABSTRACTS

A SITUATIONAL ANALYSIS OF MULTI-DRUG RESISTANCE AMONG CLINICAL ISOLATES OF STAPHYLOCOCCUS AUREUS IN MBALE REGIONAL REFERRAL HOSPITAL

J. Iramiot & J. Lasman Bustiema University

Background: There is presently little information as to the extent of antibiotic resistance in Eastern Uganda. Staphylococcus aureus has been identifed as an organism that has a high rate of resistance to antimicrobial agents. This microorganism is also responsible for a signifcant degree of morbidity and mortality. Given these characteristics, it has been identifed as a sentinel organism in the understanding of antibiotic resistance.

Aims: Determining S. aureus’ rate of resistance to antibiotics, found in Mbale Regional Referral Hospital.

Methods: One hundred and three samples were taken from various body fuids from various patients throughout Mbale Regional Referral Hospital and cultured on MacConkey, chocolate and Blood agar for maximum recovery of Staphylococcus Biochemical identifcation was carried out to phenotypically characterize the organism. Methicillin Resistant staphylococcus aureus (MRSA) was detected using Cefoxitin disc (30µg)and Inducible Clindamycin was detected using a D-test. Antibiotic susceptibility patterns were done on Mueller Hinto agar using the Kirby-Bauer disc diffusion test and interpreted using the CLSI guidelines.

Results: The highest resistance patterns were recorded in Trimethoprim/sulfamethoxazole, Ampicillin, Erythromycin and Penicillin G (75, 67, 60 and 51 )% respectively. Linezolid, Imipenem and Vancomycin had resistance patterns below fve percent. The prevalence of MRSA was 30% where as that of Inducible Clindamycin resistance was 14.5% of Staphylococcus isolated were multi drug resistant.

Conclusion: This data indicates a signifcant amount of antibiotic resistance is present in Mbale Regional Referral Hospital.

The First National Conference 24 on Antimicrobial Resistance The First National Conference on Antimicrobial Resistance

ANTIMICROBIAL RESISTANCE SURVEILLANCE IN UGANDA: BARRIERS AND RECOMMENDATIONS

Nsubuga G.A1, Nanyondo J1, Walwema R1, Lamorde M1 1. Infectious Disease Institute, Makerere University- College of Health Sciences Background: Antimicrobial resistance is an increasingly serious threat to global public health. However, there is no antimicrobial resistance surveillance program in Uganda. We therefore evaluated the barriers related to antimicrobial resistance surveillance in Uganda. Objective: To identify barriers to antimicrobial resistance surveillance in 24 referral health facilities in Uganda.

Methods: The evaluation focused on policies/guidelines; defnition of roles and mechanisms; human resources and infrastructure; knowledge and skills; tools in14 Regional Referral Hospitals, 9 General Hospitals and 1 Health Centre IV. A cross-sectional study design using focus group discussions, checklists and questionnaires was employed. 19 physicians, 27 pharmacists/dispensers, 4 medical records offcers, 50 laboratory technologists/staff, 20 laboratory in-charges, 18 hospital directors/health facility in-charges and 18 District Health Team members participated. In addition, relevant documents/records were reviewed. Results: 37.5% of the Health facilities reported the ability to identify and perform susceptibility testing on some priority WHO antimicrobial resistance pathogens. Health workers possessed scanty knowledge on antimicrobial resistance and how the respective data could be generated. Registers collecting some data elements on microbiology as well as antibiotic drug usage were available at the facilities. These included Health Management Information System data collecting tools such as laboratory microbiology and serology registers, dispensing logs and stock cards. However, these registers didn’t suffciently provide for variables and space to collect all the required antimicrobial resistance surveillance data. All the Health Facilities neither had policies/guidelines on antimicrobial resistance surveillance nor a plan for combating antimicrobial resistance. Conclusion: There was no routine collection of antimicrobial resistance data to support surveillance. Efforts should therefore be geared towards strengthening the laboratories’ capacity to conduct susceptibility tests, developing and cascading antimicrobial resistance surveillance guidelines/plans, revising the existing tools to cater for antimicrobial resistance data elements and improving health workers’ skills and knowledge.

25 MICROBIAL COLONIZATION OF UGANDAN WOMEN IN LABOR

Josephine Tumuhamye1,5, James K Tumwine2, Freddie Bwanga3, Halvor Sommerfelt4, David Mukunya1,2, Victoria Nankabirwa1, 4,5

1Centre for International Health, University of Bergen, Norway, 2Department of and Child Health, Makerere University College of Health Sciences Kampala, Uganda, 3Depart. Medical Microbiology, School of Biomedical Sciences Makerere Univ. College of Health Sciences Kampala, Uganda, 4Centre for Intervention Science in Maternal and Child Health (www.cismac.org), Centre for International health, University of Bergen, 5School of Public Health, Makerere University College of Health sciences Kampala, Uganda

Objective: Microbial colonization of the genital tract is associated with early-onset neonatal sepsis. There is insuffcient data on the predominant pathogens colonizing the genital tract of pregnant women in labor. We described microbes colonizing the genital tract of Ugandan women in labor and their antibiotic susceptibility patterns.

Methodology: Between July and September 2016, vaginal swabs were collected from women in an ongoing cohort study linking pathogens from colonized pregnant women to those isolated from their neonates. A total of 81 specimens collected from women in labor at Kitebi, and Mukono Health Centers in Uganda were analyzed. Prior enrichment in Todd-Hewitt broth for Group B Streptococcus purifcation was done and culture performed using standard methods. Antibiotic susceptibility was performed using disc diffusion method.

Results: The enrolled pregnant women had a mean age 24 years (SD 4.4). Of 81 enrolled women, 25% were primigravida, 98% had vaginal delivery, 74% completed primary education and 83% were married/co-habiting. Microbial isolates (78) were recovered from 81 of the enrolled women. Pathogens isolated that can potentially cause neonatal infections include K. pneumoniae (8), S. aureus (4), E. coli (2), Group B Streptococcus (1) and Group A streptococcus (GAS) (1). Other microbes isolated include Candida spp (38), coagulase negative Staphylococcus (13), Bacillus (4), Lactobacillus (2), Corynebacteria (2), Acinebacter (1), Citrobacter (1) and Micrococcus (1). The four S. aureus isolates were methicillin resistant staphylococcus aureus (MRSA) but susceptible to vancomycin. GBS and GAS were susceptible to penicillin. Both E. coli isolates were susceptible to gentamycin and ceftriaxone however one was resistant to cefuroxime and ceftazidime. Four of eight K. pneumoniae isolates were susceptible to gentamycin, (6) were susceptible to ceftazidime, (5) to ceftriaxone and (2) to cefuroxime.

Conclusion: Pregnant women remain asymptomatic carriers of pathogens such as MRSA which can potentially cause serious infections in the newborn.

The First National Conference 26 on Antimicrobial Resistance The First National Conference on Antimicrobial Resistance

ANTIMICROBIAL RESISTANCE OF SEXUALLY TRANSMITTED DISEASES IN SUB-SAHARAN AFRICA: A SYSTEMATIC REVIEW

Meklit Workneh MD, MPHa, Stephen Ian Walimbwa MDb, Morgan Katz MD, MHSa, Mohammed Lamorde MRCP, PhDb, Yukari C Manabe MDa aDivision of Infectious Diseases, Department of Internal Medicine, Johns Hopkins School of Medicine bInfectious Diseases Institute, Makerere University College of Health Sciences

Background: Multi-drug resistant Neisseria gonorrhea infection is rapidly emerging as a public health threat but sparse epidemiologic data exist from sub-Saharan Africa (SSA) on antimicrobial resistance in gonoccocal infection, as well as other STDs. A prior review of antimicrobial resistance in SSA reporting studies from 1990 to 2013 showed a high median prevalence of Neisseria gonorrhea resistant to penicillin with median range by region 60-81% and to tetracyclines with a median range 22-78%. 0% median resistance to ciprofoxacin and ceftriaxone was reported with the exception of central and southern Africa which reported an 11.6% median prevalence of ceftriaxone resistance. We sought to update this review.

Methods: We reviewed the literature published since the Leopold et al. 2014 systematic review of AMR in SSA (Journal of Antimicrob Chemother). Four databases (PubMed, EMBASE, Cochrane and African Journals Online) were searched for articles published between February 2013 and March 2016. Studies conducted in South Africa were excluded.

Results: 229 studies were initially identifed. The following numbers were excluded during title and abstract screening (109) and full text screening (114). There were six eligible studies: fve gonococcal resistance studies and one Mycoplasma resistance study. Studies were conducted in the following countries: Ethiopia (2), Uganda (1), Gabon (1), Zimbabwe (1); one multicenter study included sites in Kenya, Ghana, and Djibouti. Studies were conducted between 2006 and 2012. The age range of participants was broad (13-76 years). Urethritis, cervicitis, discharge and pain during intercourse were cited as clinical inclusion criteria, however at least 2 sites enrolled asymptomatic female commercial sex workers. Diverse study designs included: a retrospective review of laboratory isolates of gonorrhea (1), male participants only (1), and female participants only (1); the remainder enrolled both men and women. Of studies that reported overall positivity rate, the range of samples that were positive for gonorrhea ranged from 5% to 83%. Only one study reported a positivity rate for Mycoplasma genitalium, 4.7%. Five studies reported on gonorrhea resistance testing to ceftriaxone. Of the fve, three (Uganda, Zimbabwe, Ethiopia) reported no resistance to ceftriaxone, the second study done in Ethiopia reported 27.8% resistance to ceftriaxone and the multi-center study reported rates of ceftriaxone resistance as follows at their African sites: Kenya (0), Ghana (0), Djibouti (13%). Prevalence of ciprofoxacin resistance ranged from 6.1% in Zimbabwe to 100% in Ghana. Penicillin resistance was high at fve of six sites (68% to 100%), with the exception of Kenya where 0% resistance was reported, though number of isolates tested at this particular site was low (6).

Conclusion: Reports of cephalosporin resistance on the continent remain low based on the few studies we have available. Compared to the Leopold et al. 2014 review, rates of ciprofoxacin resistance appear to have increased. However, the magnitude of the problem is not well delineated, and surveillance strategies varied across studies. Implementation of geographically diverse surveillance sites with standard protocols will be important to establish baseline data and to accurately and quickly identify changing resistance patterns to inform national treatment policies. 27 BREAKOUT SESSION 4 – MALARIA ABSTRACTS

USE OF ANTIMALARIALS IN OUTPATIENT DEPARTTMENT IN MUBENDE REGIONAL REFFERRAL HOSPITAL, PERIOD JULY 2014 TO JUNE 2016

By Kabaisera Ainomugisha Maria. Principal clinical offcer Mubende Regional referral Hospital(M.R.R.H.) Dip clinical Medicine, Mbale S.o.c.o, Dip ophthalmology, JINJA, Advanced Diploma Health services management Uganda Martyrs university, Nkozi. Background: Mubende R.R.H. is in central region. The location is approximately 160 kilometers west of Kampala. In outpatient department (O.P.D.) we treat an average of twenty thousand patients a year. Malaria is number one disease treated in O.P.D. Malaria attributes to more than 50% high fevers in O.P.D. More than 50% tests referred to laboratory in O.P.D. are to rule out malaria. Malaria is a key disease to study and determine how mentorship to staff and team work could affect prescription of antimalarials in relation to presentation of a fever and investigating in the laboratory.

Objectives: A study was made to target malaria patients treated with antimalarials; if tested positive. (R.D.T/ Microscopy.) Patients suspected to be having malaria, with or without a fever and tested negative not to be prescribed antimalarials. Research Methods: Outpatient department was collaborating with other units, viz; laboratory, Pharmacy, store, and Records. These units handle patients directly with O.P.D. for quality care. Principal clinical offcer mentored subordinates at work. The offcer was using a guide from ministry of health malaria control programe. There was a project Clinton Health Access Initiative (CHAI) which was also supporting mentorship process. Departments that work in a system as O.P.D. would convene in principal clinical offcer’s offce. The principal clinical offcer would chair the weekly evaluation meetings. At these meetings we would determine adherence to laboratory results to treat. The fgures were derived from O.P.D. register. Members would address problems causing poor results. The meeting would forge a way forward. Results: Ministry of health baseline 2014/2015 was 60% confrmatory and non adherence 40% . The target to 2015/2016 was 90% confrmatory and non adherence 10%. Conclusion/Recommendations: Mentorship to staff could be used as a tool to improve use of medicines in the institution as has been done with antimalarials.

1) Team work is a great value to improve management of medicines in an institution. There is need to study this. 2) Regular meetings assist quality management of medicines in the department as was with antimalarials. 3) There is need for another study to control results from laboratory to the clinician. This was our main challenge.

The First National Conference 28 on Antimicrobial Resistance The First National Conference on Antimicrobial Resistance

ADHERENCE TO THE TEST AND TREAT STRATEGY IN THE CONTROL OF MALARIA AT NAGURU REFERRAL HOSPITAL - KAMPALA, UGANDA, 2013 – 2014

Authors: Julius K Kuule1, Kagulire Charles1, Tayona Racheal1, Bwambale Joshua1, Naturinda Rogers1, Kalungi Denis1, Kyambadde Paul1 1, Uganda Malaria Research Centre (UMRC) Background: Operational research has the potential to improve outcomes of malaria programmes. Currently the ministry of health of Uganda is implementing the test and treat strategy in the control of malaria. However, the extent to which the test and treat strategy is being implemented has not been evaluated.

Objectives: This study was carried out to determine prevalence of malaria among patients presenting at Naguru Hospital and assess adherence to the test and treat strategy

Materials and Methods: We reviewed malaria records for patients of all ages presenting at medical, paediatric and general outpatient departments, for the years 2013 and 2014. We assessed adherence to the test and treat strategy and analysed laboratory data on the total malaria tests done. Data was cross checked by two study staff for consistence and then captured and analysed using excel. Results and Discussion: A total of 180,337 patients were seen at the hospital during the above period of whom 42,133 (23.4%) were treated for malaria. The testing rate for patients suspected to have malaria was 52.6% (22,141). Based on mRDT 18,609 were tested and 9.7% turned out to be positive. The use of microscopy for diagnosis of malaria was low at 23.4% of the patients suspected to have malaria Conclusion: Adherence to the test and treat strategy was substantially low and reasons for non-adherence and new approaches to re-emphasize the need to adhere to the test and treat strategy were needed

29 BIO-EFFICACY OF SELECTED SYNERGISTICALLY ENHANCED PYRETHROID AND PYRETHROID-ONLY IMPREGNATED LONG-LASTING INSECTICIDAL NETS AGAINST PYRETHROID RESISTANT ANOPHELES GAMBIAES.L. FROM EASTERN UGANDA

Author: Myer Lugemwa, Ministry of Health

Background: Uganda achieved universal coverage with on long-lasting insecticidal nets (LLINs) in August 2014. However, insecticide resistance to pyrethroids, used in net impregnation, is a threat to the effectiveness of LLINs in the feld in Uganda. Recent studies have shown the widespread resistance in vector populations to pyrethroids from various areas of Uganda. The present study was carried out as a follow-up of the 2012 laboratory net bio-effcacy study to investigate the feld bio-effcacy of selected synergistically enhanced pyrethroid and pyrethroid only impregnated long-lasting insecticidal nets against pyrethroid resistant Anopheles gambiaes.l. from Eastern Uganda.

Methods: Pyrethroid susceptibility status and bio-effcacy of Anopheles gambiaes.l.populations to synergistically enhanced pyrethroid and pyrethroid only impregnated long-lasting insecticidal nets in two districts in eastern Uganda were determined at intervals of six months in 2013 and 2014.

Results: Anopheles gambiaes.s. predominated in district (87.5% of Anopheles spp.) while An. Arabiensis predominated in Busia districts(82.6 of Anopheles spp.) with high kdr L1014S allelic frequency (0.80) in Soroti populations and moderate kdr L1014S allelic frequency (0.20) for Busia populations. Resistance (<90% mortality) to both permethrin was confrmed for An. gambiaepopulations from Soroti (20% and 62% mortality in 2013 and 2014 respectively) and to deltamethrin (42% and 70% mortality in 2013 and 2014 respectively), while in , resistance to permethrin was confrmed for An. gambiae populations (34% and 83% mortality) in 2013 and 2014 respectively) and to deltamethrin (64% mortality) in 2013, with possible resistance (96% mortality) in 2014.Susceptibility to the susceptible An. gambiaes.l. (Kisumu strain) remained at 100% in both districts in both 2013 and 2014. Mortality rates in both districts to both permethrin and deltamethrin insecticides in the two study districts improved in 2014 compared with 2013. It took half the time to knockdown down half of theAn. gambiaes.l. females exposed to the roof and the sides of PermaNet® 3.0 (17.5 and 24.8 minutes respectively) in Busia district compared to the time it took to knockdown half of the An. gambiaes.l. females exposed to the roof and the sides of PermaNet® 2.0 (45.5 and 53.0 minutes respectively) in . The % knockdown of An. gambiaes.l. females at 60 minutes post-exposure to the roof and sides of PermaNet® 3.0 in Busia district was 87.5% and 71.3% respectively compared to 48.3% and 48.1% respectively for An. gambiaes.l. females exposed to PermaNet® 2.0 in Soroti district. The % 24hr holding mortality of An. gambiaes.l. females exposed the and 47.1%respectively for An. gambiaes.l. females exposed to PermaNet® 2.0 in Soroti district.

Anopheles gambiaes.s.predominated at all four sites (86 - 99% of Anopheles spp.) with moderate kdr L1014S allelic frequency (0.34 – 0.37). Resistance (< 80% mortality) to both permethrin and deltamethrin was confrmed for An. gambiaepopulations from Lira and and also to

The First National Conference 30 on Antimicrobial Resistance The First National Conference on Antimicrobial Resistance permethrin for the Kanungu population, with possible resistance (80 – 97% mortality) identifed to both pyrethroids for the Wakiso population and to deltamethrin for the Kanungu population. Reduced susceptibility to standard LLINs was observed for all four populations, with new nets associated with mortality rates as low as 45.8%. The combination LLIN PermaNet®3.0 showed the highest overall bioeffcacy against all four An. gambiaes.l. populations tested in cone bioassays, with mortality ranging from 98.5% against the Tororo population to 100% against the other three populations. Wireball assays provided a more sensitive indicator of comparative bioeffcacy, and PermaNet 3.0 was again associated with the highest bioeffcacy against all four populations (76.5 – 91.7% mortality after 30 mins). All nets exhibited optimal effcacy (100% mortality) against the susceptible laboratory An. gambiaes.s. strain and had acceptable chemical doses.

Conclusions: Anopheles gambiaes.s. in Uganda is resistant to most pyrethroid insecticides including permethrin and deltamethrin. PermaNet 3.0 performed better than PermaNet® 2.0 from both cone assays and wire-ball tests (based on the median knockdown time, percentage knock down at 60 minutes and the % 24hr holding mortality of An. gambiaes.l. exposed to the two net types.) Results of the current study and other studies clearly indicate that the combination net, PermaNet 3.0 and other synergized LLINs can be used as tools for malaria control and for the management of insecticide resistance in areas where malaria vectors have oxidative detoxifcation activity. The study also points to the need for routine annual monitoring of insecticide resistance and feld bio-effcacy of nets from around the country.

31 BREAKOUT SESSION 5 – BACTERIAL/ LABORATORY ABSTRACTS

SPECIES OF YEASTS ISOLATED IN HIGH VAGINAL SWABS FROM WOMEN WITH SYMPTOMATIC VULVO-VAGINAL CANDIDIASIS AT THE ANTENATAL CLINIC, MULAGO HOSPITAL

Ronald Mugume1, Henry Kajumbula1, Freddie Bwanga1 Department of Medical Microbiology Makerere University College of Health Sciences Background: Candida spp. are present as normal fora in the GIT, vaginal mucosa, skin, upper respiratory tract and also can be found on hospital devices or existing freely in the environment. Prolonged use of antibiotics may clear bacterial normal fora resulting in overgrowth of yeast species leading to Vulvovaginal candidiasis (VVC) and sometimes neonatal candidiasis. Recurrent VVC occurring despite repeated antifungal therapy is attributed to exact spp. underlying the disease since certain spp. like Candida krusei are intrinsically resistant to drugs like fuconazole. Data on species of Candida and other yeast causing disease is limited in sub-Saharan Africa.

Objectives: To determine the prevalence of Candida and other yeast species causing VVC in Symptomatic women and those on repeated antibiotics at Antenatal Clinic (ANC), Mulago Hospital. Materials and methods: In 2013, we used the in-house biochemical methods to speciate yeast isolates from high vaginal swabs obtained from the aforementioned women. In the recent 2015 study, 175 of these yeasts were re-identifed using a reference test - the API 20C AUX (bioMérieux, Marcy-l’Étoile, France).The API 20C Aux (bioMerieux, Marcy l’Etoile, France) Reliable results - gold standard test (Fenn et al., 1994 reported that 99% correct identifcation, while Campbell et al. 1999 found 88%).

Results: Of the 175 isolates recovered at subculture, 136 were Candida species while 39 were non-Candida species. Of the 136 Candida species, Candida albicans were 62 while 74 were other Candida species. Sensitivity and specifcity of Germ tube test was 66.1% and 46.9% respectively while that of In-house biochemical tests was 66.7% and 61.9% respectively. The overall sensitivity and specifcity of individual sugars was 87.9% and 70.8% respectively with a moderate kappa agreement of 0.5898.

Conclusion: Total isolates run on API 20C AUX (175), 136 (78%) were Candida spp. While 39(22%) were non-Candida spp. We recommend routine speciation of yeasts in women with VVC.

The First National Conference 32 on Antimicrobial Resistance The First National Conference on Antimicrobial Resistance

CHARACTERISATION OF INHIBITORS OF THE PQSR QUORUM SENSING REGULATOR IN PSEUDOMONAS AERUGINOSA

Authors: Fred Athanasius Dratibi1, Fadi Soukarieh2, Eduardo Vico-Oton3, Miguel Camara4 Centre for Biomolecular Sciences, School of Life Sciences, University of Nottingham, University Park, Nottingham, United Kingdom

1. [email protected] or [email protected] 2. [email protected] 3. [email protected] 4. [email protected]

Background: Combating microbes such as Pseudomonas aeruginosa that are intrinsically unresponsive to a broad-spectrum of antibiotics, requires novel therapeutic approaches that can negate selection pressure-mediated antimicrobial resistance. One such method being explored is the targeting of virulence regulatory processes such as quorum sensing (QS), without perturbing bacterial viability. P. aeruginosa, commonly causes severe chronic lung infections in cystic fbrosis and debilitated patients, using QS systems to regulate the production of virulence factors, bioflm formation, and antimicrobial resistance. The pathogen uses two classes of QS signal molecules N -acylhomoserine lactones (AHLs) and alkyl quinolones (AQs). The AQ system relies on mainly 2-heptyl-3-hydroxy- 4(1H)-quinolone (PQS) and its precursor, 2-heptyl-4(1H)- quinolone (HHQ) signal molecules, whose synthesis is driven by pqsABCDE and pqsH genes. The expression of the pqsABCDE operon is under the transcriptional regulation of PqsR which, upon binding PQS and HHQ positively regulates the operon.

Aim of the study: The aim of this project was to identify antagonists of PqsR and evaluate their therapeutic potential through the attenuation of virulence in P. aeruginosa.

Methods: Using ligand-based approach of drug design we characterised quinazolinone (QZNs) derivatives as PqsR antagonists, from a large chemical library. We performed bacterial conjugations to make P pqsA lux-based transcriptional reporters in clinical isolates to determine the IC50s of the compounds in inhibiting pqsA expression. We also assayed the impact of the QZNs on production of virulence factors pyocyanin and pyoverdine.

Results: We have identifed two novel compounds as antagonists of PqsR that can inhibit the expression of pqsA and the production of the AQ-controlled virulence determinant pyocyanin in various P. aeruginosa clinical isolates without affecting their growth.

Conclusion: Quinazolinone PqsR antagonists can be developed as the next-generation therapeutics against P. aeruginosa infections by attenuating virulence, lessen the severity of infection and minimise selection pressure-induced antimicrobial resistance. ux-based transcriptional reporters in clinical isolates to determine the IC50s of the compounds in inhibiting pqsA expression. We also assayed the impact of the QZNs on production of virulence factors pyocyanin and pyoverdine.

33 ANTIMICROBIAL RESISTANCE IN PATHOGENIC AEROBIC BACTERIA CAUSING SURGICAL SITE INFECTIONS IN MBARARA REGIONAL REFERRAL HOSPITAL, SOUTHWESTERN UGANDA

Authors: Derick Hope1, Ampaire Lucas4, Caesar Oyet3, Enoch Muwanguzi4, Hillary Twizerimana2 INSTITUTIONS: 1. MSF/Epicentre Mbarara Research Centre P.O BOX 1956, Mbarara, Uganda. 2. and Gynecology, Mbarara Regional Referral Hospital P.O.BOX 40, Mbarara, Uganda. 3. School of Allied Health, International Health Science University P.O.BOX 7782, Kampala, Uganda. 4. Medical Laboratory Sciences, Mbarara University of Science and Technology P.O.BOX 1410, Mbarara, Uganda.

Background: Surgical site infections (SSIs) are infections that occur at the surgical site postoperatively. Despite use of prophylactic antibiotics and other preventive measures, SSIs remain a burden to postoperative patients contributing to prolonged hospitalization, increased cost of treatment, morbidity and mortality. The increased incidence of SSIs has been ascribed to the injudicious use of antimicrobials that favors drug resistance and lack of surveillance including documenting antimicrobial susceptibility pattern. This study presents the bacterial isolates of SSIs, their antibiotic resistance pattern, and isolation rate by patients’ characteristics in Mbarara Regional Referral hospital, Southwestern Uganda.

Methods: A descriptive cross sectional study was carried out with a total of 83 postoperative patients with clinical SSIs recruited. Data regarding patients demographic, clinical and operation procedure was collected using structured data collection form. Two swabs were collected and analyzed microbiologically by culture, Gram staining, biochemical tests including API20E test. Antibiotic susceptibility test was done by Kirby-Bauer disc diffusion method.

Results: Out of the 83 samples analyzed, 81.93% showed culture positivity with Gram negative predominance (65.59%) and Klebsiella spp (29.03%) were the dominant isolates. Isolation rate was higher in emergency, males and dirty wounds in relation to nature of , gender and class of surgical wound respectively. 95.7% of the aerobic bacteria isolated were multidrug resistant. Gram negative isolates showed high resistance to all antibiotics tested except for ciprofoxacin with moderate resistance. E.coli demonstrated high resistance to all antibiotics tested. Gram positives showed low resistance to ciprofoxacin (37.5%), moderate resistance to sulfamethoxazole/trimethoprim, gentamicin and erythromycin, and high resistance to other antibiotics tested. Staphylococcus aureus demonstrated high resistance to all antibiotics tested except ciprofoxacin with moderate resistance.

Conclusion: The high isolation rate and multidrug resistant pattern necessitates antimicrobial susceptibility testing as guidance for antimicrobial administration, and calls for surveillance of SSIs periodically as well as implementation and practice of infection control measures.

The First National Conference 34 on Antimicrobial Resistance The First National Conference on Antimicrobial Resistance

ANTIBIOTIC SENSITIVITY PATTERNS OF AMNIOTIC FLUID CULTURES FROM WOMEN WITH PREMATURE RUPTURE OF MEMBRANES IN MULAGO HOSPITAL KAMPALA UGANDA; A CROSS SECTIONAL STUDY

Milton Musaba (Mbale Regional Referral Hospital)

Background: Ascending genital tract infection and premature rupture of membranes always occur together. In Uganda, sepsis causes 22% of all maternal deaths and 26% of all neonatal deaths. A combination of oral erythromycin& amoxicillin is the 1st line for prophylaxis against ascending infection in Uganda. It is not clear if this recommendation is based on current C&S patterns. A 2013 Cochrane review concluded that the choice of antibiotics for prophylaxis in PROM is not clear. Probably the associated organisms have changed or developed resistance. We aimed to establish the rate of positive bacterial amniotic fuid cultures, the prevalent bacteria and their antibiotic sensitivity patterns.

Methods: Amniotic fuid was collected aseptically from the pool in the posterior fornix of the vagina at admission. Aerobic cultures were performed on blood, chocolate & MacConkey agar and incubated at 35-37oC for 24-48 hrs. TODD-HEWITT & THIOGLYCOLATE enrichment media were utilized to culture for GBS and facultative anaerobes respectively. Isolates were identifed using colonial morphology, gram staining, and biochemical analysis. Sensitivity testing was performed via Kirby- Bauer disk diffusion & dilution method. Statistical signifcance was tested via the chi (χ2) test. The paired t-test was applied to measure the signifcance of factors associated with positive cultures. (P-value of 0.05).

Results: Thirty percent of the amniotic fuid cultures were positive. Aerobic isolates were 92%. Resistance to the most commonly used antibiotics like erythromycin, ampicillin, cotrimoxazole &ceftriaxone was 44%, 95%, 96% and 24% respectively.

Conclusions: The rate of positive amniotic fuid cultures has doubled, but the spectrum of bacteria associated with PROM has not changed since 1996. Resistance to the most commonly used antibiotics is high, and the 1st line for prophylaxis is not clear.

35 ANTIMICROBIAL SUSCEPTIBILITY AND RESISTANCE PATTERNS OF SALMONELLA TYPHI DURING THE 2015 TYPHOID OUTBREAK IN KAMPALA UGANDA

Juliet Nsimire , Joshua Buule, Peter Hughes , Robert Downing, Issa Makumbi, Pontiano Kaleebu Medical Research Council / Uganda Virus Research Institute Research Unit on AIDS, Entebbe Global Health Security Agenda/UVRI Ministry of Health

Introduction: Antimicrobial resistance (AMR) in Salmonella enterica serovar Typhi is a growing, global, public- health threat. Between February and June 2015, a typhoid outbreak hit Kampala. Antimicrobial susceptibility and resistance testing was performed on confrmed strains. Methods: Blood cultures for 320 cases, were sub-cultured and suspected colonies identifed using biochemical tests and Salmonella antisera. Susceptibility testing was performed following the British Society for Antimicrobial Chemotherapy, 2015 Guidelines. Ciprofoxacin, Ceftriaxone, Cotri-moxazole, Chloramphenicol Ampicillin Nalidixic acid and Perfoxacin Ciprofoxacin were tested. Quality control was by CDC Atlanta. Testing for antimicrobial resistance genes was done using a DNA probe Micro-array (Alere Technologies GmbH, Germany).

Results: 44 Salmonella Typhi strains were isolated. Susceptibility to Ceftriaxone, Cotri-moxazole, Ampicillin and Chloramphenicol were 100%, 77.3%, 77.3%, and 72.7% respectively. All strains showed reduced susceptibility to Ciprofoxacin. Multidrug resistance (MDR) and AMR genes were detected in 22.7% of the strains. Integrase (int-l), Plasmid Vi(tviA) and Prob_intl-1 were virulence factors identifed in resistant strains. One strain susceptible to Cotri-moxazole, Ceftriaxone and Ampicillin had AMR genes to all the three agents.

Conclusion: These results indicate the presence in Uganda of Salmonella Typhi strains with reduced susceptibility to Ciprofoxacin, one of the frontline treatments of typhoid. The isolates are currently undergoing sequencing at the Sanger Laboratory UK. MDR Salmonella is widespread globally and is a threat to effective patient management. The development and implementation of strategies to contain the spread of AMR infections are urgently needed, not least the creation of national AMR surveillance systems linked to global systems.

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BREAKOUT SESSION 6 – HOSPITAL ACQUIRED INFECTION ABSTRACTS

CHARACTERIZATION AND ANTIMICROBIAL SUSCEPTIBILITY PATTERNS OF ISOLATES FROM WARD FOMITES

Farouk Segujja1,2*, Bashir Mwambi2, Charles Kato Drago1, Nathan Musisi Lubowa1, JosephMugambwa3 and Patrick Wabuyi2

1Department of Biomolecular Resources, College of Veterinary Medicine, Animal Resources and Biosecurity, Makerere University, P.O.Box 7062, Kampala, Uganda. 2Department of Medical Microbiology, International Health Sciences University, P.O.Box 7782, Kampala, Uganda. 3Department of Medical Microbiology, Faculty of Health Sciences, Habib Medical School, Islamic University in Uganda, Kampala Campus, P.O.Box 7689, Kampala, Uganda.

Background: Nosocomial infections constitute a major health concern to both patients and healthcare professionals worldwide. These have signifcantly led to prolonged hospital stays, high morbidity and mortality rates over the years. Contaminated environmental surfaces could be the most implicated source and reservoir of pathogens causing Hospital Acquired Infections among patients. Objectives: The study therefore aimed at investigating the presence, distribution, and antibiogram of isolates from ward fomites, and to detect resistances in the form of Macrolide Lincosamide StreptograminB (MLSB), Methicillin Resistant Staphylococcus aureus (MRSA), Extended Spectrum χ Lactamases (ESBLs), AmpC, and Multi Drug Resistant (MDR) pathogens. Methodology: We recruited 290 samples from the Surgical, Medical, Maternity and Pediatric wards as well as the Out Patient Department (OPD) at Kiwoko Hospital, a rural setting in the Central region of Uganda between January and June 2015. Samples were taken by swabbing the different surfaces and instruments which included; sphygmomanometers, stethoscopes, beds, nurses’ stations, staff/ visitors’ chairs, door handles, patients’ crepe bandages, curtains, switches, and sink handles among others. Susceptibility testing was done using the disc diffusion methods by Kirby Bauer for phenotypic expression of MLSB resistances, MRSA, MSSA, ESBL, MDR and AmpC. Co- resistances exhibited by isolated ESBL producers were also phenotypically tested. Results: Of the 290 surfaces and instruments swabbed, 57.59% (CI= 49.18 - 67.01) carried bacterial pathogens and by using standard surface agar plating methods, Staphylococcus aureus was the mostly isolated pathogen 43 (25.75%), followed by Klebsiella pneumoniae 35 (20.96%), Escherichia coli 31 (18.55%), Pseudomonas aeruginosa 20 (11.98%), Enterococcus faecalis 12 (7.19%),

37 Staphylococcus epidermidis 10 (5.98%), Proteus mirabilis 9 (5.39%), Bacillus spp. 4 (2.40%), and Staphylococcus saprophyticus 3 (1.80%). Among enterobacteriaceae, 5 (6.67%, CI= 2.16 – 15.56) were identifed as AmpC producers and 16 (21.33%, CI= 12.19 - 34.64) as ESBL producers out of which 4/16 (25.00%, CI = 6.81 – 64.01) showed ESBL co-resistance. Of the 43 Staphylococcus aureus isolates, 9.30% were MRSA (CI = 2.53 - 23.82) and 90.70% MSSA (CI = 64.49 - 100). In MLSB resistance patterns, 23.26% of the total S. aureus isolates were constitutive MLSB while 6.98% showed inducible MLSB as 27.91% exhibited an MS resistant phenotype. Out of all the isolates recovered from fomites, 27/167 (16.17%, CI = 10.65 – 23.52) were identifed as Multi Drug Resistant (MDR). Conclusion: Hospital fomites harboured resistant pathogens that could well persist for a long period of time thereby predisposing patients to Hospital acquired infections. Therefore, regular intermittent cleaning throughout the day and routine screening of clinical samples for MLSB, ESBL, AmpC, MRSA and MDR could signifcantly monitor potential treatment failures in the management of resistant bacterial in such a setting.

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CONTAMINATION OF URINE OBTAINED FROM CHILDREN PARTICIPATING IN EPICENTRE STUDIES AND ADMITTED AT MBARARA REGIONAL REFERRAL HOSPITAL BY ESBL-PRODUCING ENTEROBACTERIA

Deborah Nanjebe1, Dan Nyehangane1, Juliet Mwanga-Amumpaire1,2, Celine Langendorf3 1. Epicentre Mbarara Research Centre 2. Mbarara Regional Referral Hospital 3. Epicentre, Paris

Background: Observations from urine samples collected in the studies that Epicentre Mbarara Research Centre (EMRC) is conducting on the paediatric ward of Mbarara Regional Referral Hospital (MRRH) revealed that out of the 43 urines cultured between September 2015 and March 2016, 12 (28%) had a signifcant growth. ESBL Klebsiella pneumonia was the isolated organism. Of the positives, only 1 (8%) sample had a white cell count ≥104 cells/mL. These results were not consistent with UTIs. We imagined that this was a contaminant.

Objectives: To confrm the source and establish the point at which ESBL K.pneumoniae was introduced into the urine.

Methods: The one-day survey was conducted in the malnutrition corner of the pediatric ward and an annex ward on which all the children had been admitted and urine samples collected, respectively. Mattresses and metals for all six beds in the malnutrition corner and the one bed on which sample collection was done in the annex ward were swabbed. We cultured on selective and differential media for isolation and identifcation of enterobacteria. ESBL production was assessed by the disk diffusion method following EUCAST guidelines. We observed as a urine sample for a patient was being collected. Findings were discussed with stakeholders of MRRH and EMRC.

Results: Two isolates of K.pneumoniae were identifed from two mattresses in the malnutrition corner: an ESBL-producing strain and a susceptible one.During urine collection, the child was not completely undressed. The aiding nurse during catheterization didn’t change gloves before opening the catheter tip and some of the urine fowed onto the gloves, then into the container.

Conclusion: We believe the ESBL contamination of the urine was coming from the malnutrition corner. The sample contamination point was most probably during urine collection but this needs further investigation. Regular ward decontamination is a cheap option and is highly recommended.

39 BABYGEL PILOT: A PILOT CLUSTER RANDOMISED TRIAL OF THE PROVISION OF ALCOHOL HANDGEL TO POSTPARTUM MOTHERS TO PREVENT NEONATAL INFECTIVE MORBIDITY IN THE HOME

Ditai J1,2, Abeso J3, Mudoola M2, Faragher B4, Mobbs N2, Odeke N M1, Dusabe-Richards J4, Carrol E5, Olupot-Olupot P7, Storr J6, Gladstone M2, Medina-Lara A8, Weeks A2. 1 - Sanyu Africa Research Institute (SAfRI), Mbale, Uganda; 2 - Sanyu Unit, Women’s and Children’s Health, University of Liverpool, UK; 3 - Mbale Regional Referral Hospital, Uganda; 4 - Liverpool School of Tropical Medicine, UK; 5 - Institute of Infection and Global Health, University of Liverpool, UK; 6 - WHO Consultant, Geneva, Switzerland; 7 – Busitema University Faculty of Health sciences. 8 - University of Exeter, UK. For Correspondence, email: [email protected] Background: Neonatal sepsis causes 0.5 million deaths annually, mostly in low resource settings. Babies born in African rural homes without running water or toilet facilities are especially vulnerable. Alcohol- based hand rub (ABHR) is widely used in health/social facilities to prevent infection, but it is not known whether supplying it for regular perinatal use can prevent newborn sepsis in these settings. Methods: A cluster randomised trial was piloted in 10 villages (5 intervention and 5 control) in Mbale district, Eastern Uganda. Pregnant women of over 34 weeks’ gestation were recruited antenatally and followed up for 3 months postnatally. Women in intervention villages received supply of ABHR along with a clean birthing kit (Mama Kit) a whilst those in the control villages received the Mama kit only. Those with the ABHR were asked to use it for hand hygiene in late weeks of pregnancy, at birth as a single whole-body neonatal wash, on the cord stump and for 3 months postnatally. The primary outcome was a positive WHO infant infection screening test.

Results: All 103 eligible women agreed and participated in the study (55 in intervention and 48 in control clusters). Of these, one withdrew her consent at day 1 follow up, and 5 had perinatal death (3 still births, 1 early neonatal death before 24 hours of life and 1 late neonatal death). 98 participants gave birth to live babies and were followed up for day 1 visit. Almost all, 99% (97/98) participants who had live births were followed up until day 90. Many Village Health Workers were unable to complete the WHO screening tool, especially taking vital signs like Respiratory rate, pulse. Of the 98 live babies, 54 had evidence of infection. However, only 30 screened positive for sepsis, 16 had clinically diagnosed infection, and 44 women mothers reported their babies as having been infected. In total 21 babies received antibiotics for suspected infection without the screening test. There were fve (05) confrmed bacterial infections by positive culture and sensitivities. One of the neonatal deaths was due to infection. Conclusion: The trial instruments worked effciently with excellent recruitment and follow up. However, the primary outcome was problematic as many babies received antibiotics without the WHO IMCI Screening tool for sepsis. A primary outcome of maternally reported ‘antibiotic use’ is proposed, with a change to an individualized placebo-controlled randomised trial methodology to minimize bias. Trial Registration: ISRCTN 67852437

The First National Conference 40 on Antimicrobial Resistance The First National Conference on Antimicrobial Resistance

ALCOHOL-BASED HAND GEL USE AND INCIDENCE OF HEALTHCARE ASSOCIATED INFECTIONS IN MBALE REGIONAL REFERRAL HOSPITAL, RURAL EASTERN UGANDA

Ditai, J.1,2, Inoue, K.3, Saito, H.5, Abeso4, J., Wanume, B.4, Balyejussa, J.4, and Weeks, A.2 1Sanyu Africa Research Institute, Mbale, Uganda 2University of Liverpool, Liverpool, UK 3Nagasaki University, Nagasaki, Japan 4Mbale Regional Referral Hospital, Mbale, Uganda 5University of California Irvine School of Medicine, Irvine, CA, USA For Correspondence, email: [email protected]

Background: Use of alcohol-based hand gel (ABHG) at health facilities is limited in Uganda. Good hand hygiene practice is crucial to the effectiveness of bedside ABHG and reduced healthcare associated infections (HAIs). However, evidence of hand hygiene practice and HAIs is sparse in resource-limited settings. We conducted a study to evaluate hand hygiene practices of health care providers (HCPs) utilizing locally made ABHG and the incidence of HAIs.

Methods: Hand hygiene compliance among HCPs and incidence of HAIs were assessed at Mbale Regional Referral Hospital, a referral hospital in rural Uganda. Inpatients on obstetrics/gynecology (OBGYN), pediatric and surgical wards were followed during their hospital stays and follow-up phone calls were made if appropriate. A 12-week baseline phase was followed by a 12-week intervention phase where training for hand hygiene practice was provided and ABHG was supplied on the wards. Incidence rate ratio of HAIs and SIRS was calculated between the baseline and intervention phases.

Results: A total 3626 patients were enrolled over a 24-weekperiod from October 2014 to April 2015. Hand hygiene compliance rate was signifcantly improved from 10.3% during the baseline phase to 55.7% during the intervention phase. The incident rate of HAIs and SIRS was 18.8 cases per 1000 patient-days during the whole study period and the incidence was not signifcantly changed between the baseline and intervention phases (incidence rate ratio (IRR) 1.03, 95% CI: 0.76 – 1.39). However, subgroup analyses showed signifcant reduction in HAIs/SIRS at the pediatric and surgical wards (IRR 0.17 (95% CI: 0.07 – 0.44) and IRR 0.37 (95% CI: 0.15 – 0.92), respectively) while signifcant increase in HAIs/SIRS at the OBGYN ward (IRR 2.90 (1.85 – 4.54)).

Conclusion: Little is known about HAIs in the resource limited countries, particularly in Africa. To our knowledge, our study is one of the largest studies that address HAIs in Africa. During the 24-week study, signifcant improvement in hand hygiene compliance was observed by providing the training and ABHG. It was associated with signifcant reduction in HAIs/SIRS on the pediatric and surgical wards. Given the fact that SIRS cases were more commonly identifed than HAIs by the CDC defnitions, further research is warranted to accurately survey HAIs in the resource limited settings.

41 POSTER PRESENTATION ABSTRACTS

PRE-TREATMENT AND ACQUIRED HIV DRUG RESISTANCE USING THE REVISED WORLD HEALTH ORGANISATION STRATEGY

Authors: Christine Watera1, Pontiano Kaleebu1/2, Deogratius Ssemwanga1/2, Juliet Asio1, Isaac Ssewanyana3, Grace Namayanja4, Kaggwa Mugagga5, Elizabeth Namagala6, Norah Namuwenge6, Wilford Kirungi6, Edward Katongole-Mbidde 1 and The HIV Drug Resistance Working group Affliations: 1Uganda Virus Research Institute, Entebbe , 2MRC/UVRI Uganda Research Unit on AIDS, Entebbe, 3Central Public Health Laboratories, 4United States Center for Disease Control and Prevention, 5World Health Research Organization, Kampala, 6AIDS Control Programme, Ministry of Health, Kampala Background: The previous World Health Organisation (WHO) HIV drug resistance (HIVDR) strategy of 2004 was used during the early phase of antiretroviral therapy (ART) scale-up when few people were on ART at sentinel sites which were mainly in urban settings. Estimates of HIVDR prevalence generated from surveys among patients attending such clinics were representative of the specifc clinic catchment area. WHO revised the HIVDR monitoring strategy in 2014 and HIVDR prevalence estimates from surveys conducted using this methodology are nationally representative. Uganda adopted this strategy and the Ministry of health in collaboration with Uganda Virus Research Institute is currently conducting pre-treatment (PDR) and acquired HIVDR (ADR) among adults initiating and receiving ART respectively. Description: Cross sectional surveys of populations initiating and receiving ART at 23 sites randomly selected using probability proportional to size sampling method. Stratifcation by region allowed selection of sites from 5 regions to generate a nationally representative sample of sites. Sample size for PDR and ADR surveys is 21 and 24 respectively. Participants provide written informed consent prior to enrolment. Whole blood is collected for preparation of DBS samples and plasma which are shipped to Central Public Health Laboratory. Viral load testing will be done for all ADR samples whereas PDR samples and ADR samples with non-suppressed viral loads will be shipped to MRC/UVRI for HIVDR genotyping. Prevalence of a nationally representative estimate HIV drug resistance and viral load suppression among adults initiating ART and among adults after 12 months of frst- line ART respectively will be determined.

Progress: Enrolment of participants commenced in August 2016 for both surveys. Enrolment on the PDR survey has been completed and samples received at CPHL for 15 sites (65%) and 13 (57%) for the ADR survey. We estimate that enrolment will be complete by end of November 2016. Plans are underway to start genotyping for HIV drug resistance by end of October. Viral load testing for the ADR samples is ongoing. Next steps: Complete pending laboratory work, analysis, report generation and dissemination of fndings including feedback of results to clinics to guide patient management.

The First National Conference 42 on Antimicrobial Resistance The First National Conference on Antimicrobial Resistance

HEPATITIS B VIRUS GENE MUTATIONS, GENOTYPE DIVERSITY AND HOST IMMUNE RESPONSE AS POTENTIAL CHALLENGES TO MANAGEMENT OF HBV-HIV CO-INFECTION IN UGANDA

Kafeero Hussein Mukasa Background and rationale: Hepatitis B virus (HBV) is the causative agent for liver diseases, including chronic hepatitis, liver cirrhosis, and hepatocellular carcinoma. The HBV virus is the second commonest known human carcinogen after tobacco. The virus shows diversity at serotype, genotype and sub-genotype levels. These are associated with distinct geographical distribution, clinical outcomes, response to anti- viral drugs and staging of the disease. According to the world health organization (WHO), countries of Africa, Asia and South America have carrier rates as high as greater than 8% with Sub-Saharan Africa accounting for 20% of global burden. In Uganda the burden of the disease varies from region to region with Northern Uganda having the highest prevalence of 17.6%. Hepatitis B virus is highly contagious and is 50 to 100 times more infectious than Human Immune defciency Virus (HIV) with extreme resilience that allows its survival for more than a week on dry surfaces complicating its epidemiology and explaining the increased risk of horizontal intra-familial transmission. Infection at infancy, child-hood, and HBV-HIV co-infection is most likely to result into chronic disease but infection in adult hood and immune competent people results into acute disease. Severe immune compromised status as in HBV-HIV co-infection results in lowered CD4 T-cell count and has been associated with loss of anti-HBs and development of anti-HBc in HIV+ patients complicating the management of HBV Selection pressures including the use of highly active antiretroviral therapy (HAART) in patients with HBV-HIV co-infection has resulted into the emergency of HBV mutants with reduced susceptibility to the current HBV treatment regimens including lamivudine, telbivudine, and entecavir. Patients with HBV genotype B co-infected with HIV are a higher risk of developing hepatitis fares, liver disease-related deaths and lamivudine resistance mutations than those with genotype C-HIV co- infection. Fidelity of the host immunity is paramount during infection and under pathological conditions. Single Nucleotide Polymorphisms (SNPs) mutations in the Toll-Like Receptors (TLRs) have been reported during infection. Genetic variations in the genes that express the TLRs can have a major impact on host defense resulting into the virus evading the host immune system which is thought to be associated with increased risk to chronic hepatitis B infection but recent studies are not conclusive and more studies are needed to translate TLRs pathogenesis into clinical practice. Conclusion: Identifying the circulating genotypes, serotypes, sub-genotypes as well as the associated mutations will guide physicians in the management of HBV infections in general and HBV-HIV co-infections in particular since response to antiviral therapy and vaccination is dependent on the aforementioned parameters. An insight into the mechanisms by which HIV infection affects host immune response to HBV disease progress culminating in chronic HBV is important. Describing the mutations in the TLRs in HIV-HBV co-infection as well as HIV naïve HBV infected individuals and understanding the evasion of host immunity will inform future research in this area.

43 A NEED TO SENSITIZE COMMUNITIES ON RATIONAL USE OF ANTIMALARIALS IN BUKEDEA, EASTERN UGANDA

Authors: P. Candiga, M. Kairanya, S. Karabyo, K. Katumwa, J O. Kintu, B. Namirimo and M V. Nannono (MBChB II) Busitema University faculty of health sciences. Background:

Busitema University Faculty of Health Sciences seeks to produce health professionals with a passion to serve in rural areas where they are most needed. To achieve this, the curriculum provides for a vibrant Community Based Education and Research program in which students spend four weeks annually for three years at a rural health facility. The frst placement focuses on community entry skills, the second on identifcation of community problems and design sustainable intervention(s), the fnal on understanding health system, delivery of primary healthcare, implementation and monitoring of the designed intervention. A group of second year students, at Bukedea health centre IV, undertook a comprehensive study on diseases afficting people in the three sub-counties of Bukedea, namely Kakere, Kachabule and Kamon. This report is on malaria in Bukedea. Methodology: Document reviews involved a study of Bukedea health unit registers and reports covering the period April 2015 to April 2016. This was followed by a descriptive cross sectional survey which was carried out in 3 three sub-counties of Bukedea. The survey was conducted using a pre-tested questionnaire administered to 59 household leaders. Survey information was enriched using Focus Group Discussions and home inspections with a predetermined check list. Results: Malaria was the top most common cause of inpatient admissions at Bukedea health centre IV. Malaria transmission occurred throughout the year in Bukedea. However, the patterns in pediatric malaria and malaria in adults differed. In the under 5 years, malaria picked in the months June to August, but this peak was not paralleled by a sharp increase in pediatric admissions due to malaria. Actually, pediatric admissions in the peak months were comparable to admissions in non-peak months. Cases of adult malaria were more than x2 higher than pediatric malaria, except for the months of June, August and January. Interestingly, hospital admissions due to adult malaria was low throughout the year, except for the month of January. At household level fever (malaria) was also the main cause of morbidity. Of the 59 households surveyed, 54% experienced at least one member treated for malaria on a monthly basis. As many as 56% of the households always treated malaria from home with coartem, while 29% preferred private clinics and only 15% sought treatment from government health facility. From the Focus Group Discussions, community members admitted faking symptoms of malaria for the purposes of collecting coartem from Bukedea health center health center, immediately they learnt of drug deliveries at the health unit, and stocking it in their homes for future use. On knowledge about malaria, 88% of household leaders cited mosquitoes as the cause, 81% knew the right treatment (coartem) and 95% knew what to do to prevent getting malaria.

Conclusion: The threat of malaria infection and politicization of management of pharmaceutical supplies has modifed the practices and behaviour of the people in the service area of Bukedea health centre IV. Though the knowledge on malaria treatment was good among the households, the practice of stocking medicines deceitfully not only poses the fear of irrational use of these medicines and development of microbial resistance, but also feeds the system with wrong data. The study recommends sensitization of the community on rational use of drugs at household level.

The First National Conference 44 on Antimicrobial Resistance The First National Conference on Antimicrobial Resistance

ANNOUNCING THE FORMATION OF ‘COALITION AGAINST RESISTANCE TO PESTICIDES AND ANTIMICROBIALS’ (CARPA)

Background Through the development of the frst national AMR-conference, the Steering Committee determined that a long term strategy was needed to combat resistance to antimicrobial medications in Uganda. This view gave birth to a network of universities against antimicrobial resistance that, after intense debate, metamorphosed into the ‘Coalition against Resistance to Pesticides and Antimicrobials’ (CARPA). Membership to the organization includes all Ugandan universities teaching health care providers, animal scientists and agriculturists. The generators of resistance namely, the Ministry of Health and the Ministry of Agriculture, Animal Industry and Fisheries were included. Membership will be expanded with time to include other key stakeholders.

Objectives I. To work with all stakeholders to reduce the development of pesticides’ resistance/antimicrobial resistance and mitigate their impact on society. II. To provide relevant training and training activities for health providers in the appropriate use of antimicrobial drugs. III. To support capacity development for sustainable surveillance systems for antimicrobial and pesticides resistance. IV. To provide relevant training and training activities for veterinary medicine professionals for proper antimicrobial use. V. To provide relevant training and training activities for agriculturalists on proper use of antimicrobials. VI. To conduct research relevant to the development of policies critical for the containment of microbial and pesticide resistance and its consequences. VII. To support public policy agencies in development and implementation of antimicrobial and pesticide stewardship. VIII. To carryout fundraising to further the objectives of the organization, through fundraising drives, conferences, and workshops among others. IX. To sensitize the public on the proper use of pesticides and antimicrobials in Uganda.

Aims I. Plan and organize future National Antimicrobial Resistance conferences. II. Provide a platform for various stakeholders to work together on containment of AMR

Secretariat The organization secretariat will be housed at Busitema University Faculty of Health Sciences, until such a time when it can generate funds to rent/build own premises.

Initial contacts Dr. Joseph L. Mpagi Ms. Constance Basirika; Tel. 0752-885-363

45 The First National Conference 46 on Antimicrobial Resistance The First National Conference NOTES on Antimicrobial Resistance

47 NOTES

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