Organophosphate poisoning temporal trends and spatial distribution, Uganda, 2017─2022

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As a country with an agriculture-based economy, Uganda has widespread use of pesticides, creating an elevated risk for OP poisoning. We assessed the distribution and temporal and spatial trends of OP poisoning admissions in Uganda during 2017─2022 to guide control and prevention interventions. Methods We analysed OP poisoning surveillance data from the District Health Information System version 2 (DHIS2). As per DHIS2, OP poisoning admissions were defined as a hospital stay due to suspected OP poisoning while deaths were defined as inpatient deaths with OP poisoning listed as the cause of death. We calculated annual incidence of OP poisoning admissions per 100,000 population and case-fatality rates per patient admitted with OP at national, regional, and health facility levels. We used the Mann-Kendall (MK) test to determine the strength and direction of the trend. Results A total of 37,883 (average: 6,314 per year) OP admissions and 1,599 (average: 267 per year) deaths were reported (case-fatality rate [CFR] = 4.2%) during 2017─2020. Males (incidence = 18/100,000), children < 5 years (incidence = 20/100,000), and residents of Ankole Region (incidence = 26/100,000) were the most affected. CFRs increased with the increasing healthcare level of the admitting health facility. The incidence of OP declined by over 3-fold over the study period (MK=-13, p = 0.02). Kiruhura and Bukwo Districts had consistently high incidences (> 50/100,000) throughout the study period. Conclusion There was a significant reduction in incidence of OP poisoning in Uganda during 2017─2020. Males, children < 5 years, and residents in Ankole Region were the most affected. Strengthening sensitization among agricultural and livestock farming communities about the risks of pesticide poisoning and building capacity of health workers and equipping lower-level health facilities to effectively manage medical emergencies including OP poisoning could reduce the OP burden and mortality in Uganda. Toxicology Organophosphate poisoning pesticides Uganda Figures Figure 1 Figure 2 Figure 3 Introduction Organophosphates are a group of highly toxic chemical compounds that are commonly used as agricultural pesticides and insecticides[ 1 ]. They are one of the main agents of poisoning, responsible for over 3,000,000 poisonings and an estimated 300,000 deaths per year worldwide [ 2 ]. These poisonings, which lead to substantial morbidity and mortality among the exposed, may occur due to occupational or accidental exposure, deliberate ingestion in cases of suicide, or during chemical warfare [ 3 , 4 ]. Most organophosphate poisonings have involved exposures to agricultural pesticides [ 5 ]. The major routes of exposure for organophosphates are the respiratory tract, gastrointestinal tract, skin, and eyes [ 6 ].The clinical features of organophosphate poisoning are based in the central nervous system and include salivation, lacrimation, urination, defecation, abdominal pain, general body weakness, vomiting, loss of consciousness, anxiety, tremors, and convulsions [ 7 ]. Once exposed, symptoms occur within minutes to hours depending on the type of organophosphate poison, route of exposure, and dose [ 8 ]. In low and middle-income countries (LMIC), the significant reliance on pesticides for agricultural production results in an elevated risk of exposure to organophosphates [ 4 ]. The widespread availability and indiscriminate use of pesticides in such settings, coupled with poor storage and handling practices and lack of awareness about the consequences of poisoning make LMIC particularly vulnerable [ 9 ]. Uganda has a largely agricultural economy [ 10 ] and a development strategy hinged on rapid industrialization in agriculture [ 11 ], which results in the widespread use of pesticides among agricultural farmers [ 12 ]. In Uganda, pesticides, including organophosphates, are widely available in animal drug shops and shops that sell general merchandise, and can be found on farms and in homes [ 13 ]. There have been previous reports of organophosphate poisoning in Uganda linked to both intentional and unintentional pesticide exposures. [ 12 – 14 ]. Prevention efforts for pesticide poisoning in Uganda have included health education and sensitization on proper use of pesticides among farming communities [ 15 ]. There are other measures which the limit the availability and toxicity of pesticides, such as regulation to limit sales to trained and licensed vendors [ 16 ]. Additionally, the replacement of highly toxic pesticides with less toxic and equally potent ones has also been implemented [ 17 ]. Despite the risk potential, little is known about the burden of organophosphate poisoning in Uganda. We assessed the distribution, temporal, and spatial trends of organophosphate poisoning in Uganda 2017─2022, to guide targeted control and prevention interventions. Methods Study design and data source We analysed organophosphate poisoning surveillance data captured in the District Health Information System version 2 (DHIS2). The DHSI2 is an open-source web based platform that is used to collect, report, and analyse aggregate data that is routinely generated across health facilities in Uganda[ 18 ]. Uganda has 146 districts which are distributed across the 15 regions as designated by the Ministry of Health. The healthcare system comprises government and privately owned health facilities which are organized in a hierarchical order [ 19 ] from Health Centre (HC) II (found at parish level), HCIII (found at sub-county level), HCIV (found at county/health sub-district level), district hospital (found at district level), regional referral hospital found at regional level), and the national referral hospital (found at national level). The DHIS2 collects data on priority diseases, conditions, and events of public health importance including organophosphate poisoning from the Health Management Information system (HMIS). All cases suspected of organophosphate poisoning are recorded in HMIS as admissions/in-patient occurrences. The HMIS is a paper-based system in which health facilities record patient data on conditions of interest. These data are later entered into the electronic DHIS2 and aggregated from all health centres in the country. Study variables, data abstraction, analysis, and management We abstracted aggregate data on organophosphate poisoning admissions and deaths from the inpatient monthly reports in the Health Management Information System (HMIS) from 2017 to 2022. As per HMIS, organophosphate poisoning admissions were defined as a hospital stay due to suspected organophosphate poisoning as a primary diagnosis. Organophosphate poisoning deaths were defined as inpatient deaths with organophosphate poisoning listed as the cause of death in DHIS2. Data were imported into Stata version 16 software (Stata Corporation, College Station, Texas, USA) for analysis. We calculated the annual incidence of OP poisoning as annual admissions due to OP poisoning per 100,000 population. Population data was obtained from the Uganda Bureau of Statistics population estimates[ 20 ]. Additionally, we calculated the case fatality rate (CFR) of OP poisoning as a percentage of number of deaths due to OP poisoning divided by the number of OP admissions. We calculated annual incidence of organophosphate poisoning and the overall case fatality rates at national, regional, and health facility level. We used line graphs to describe national trends of OP admissions and CFR. The Mann-Kendall test was used to determine the significance of the trends. Choropleth maps were drawn using QGIS software to show the spatial distribution of organophosphate incidence in the country. To further contextualize the findings, we also abstracted data on reporting rates, calculated as the percentage of complete submitted monthly reports over the study period divided by the number of expected reports. Results Incidence and case fatality rate of organophosphate poisoning, Uganda, 2017–2022 Overall, a total of 37,883 (average: 6,314 per year) organophosphate poisoning cases. The overall average incidence was 15 organophosphate admissions per 100,000 persons. Residents of Ankole Region were more affected while those in Lango Region were least affected. (Incidence: 26/100,000 vs 7/100,000 persons). (Table 1 ). Males had a higher incidence of organophosphate poisoning than females (18 vs 13/100,000, p = 0.03). Children < 5 years had a higher incidence than persons ≥ 5 years (20 vs 14/100,000, p = 0.01). Overall, 1,599 (average: 267 per year) deaths were reported (CFR) = 4.2% during 2017–2022. Residents in Kampala Region had the highest overall CFR while those in Teso Region had the lowest (CFR: 8.5% vs 2.2%) (Table 1 ). Table 1 Incidence and case fatality rate of organophosphate poisoning, Uganda, 2017─2022 Cases Average population Incidence /100,000 Deaths Case fatality rate (%) Sex Female 2,772 20,951,652 13 75 2.7 Male 3,542 20,100,565 18 192 5.4 Age group < 5 years 1,570 7,715,064 20 48 3.1 ≥ 5 years 4,744 33,337,153 14 219 4.6 *Health facility level Health Centre III 1,253 - - 29 2.3 Health Centre IV 1,374 - - 37 2.7 District Hospital 2,911 - - 141 4.8 Regional Referral 684 - - 52 7.6 National Referral 92 - - 9 9.7 *Ownership Government 3,769 - - 163 4.3 Private 2,545 - - 104 4.0 Region Ankole 871 3,308,524 26 38 4.4 Bukedi 511 2,269,307 23 12 2.3 Tooro 677 3,030,632 22 33 4.8 Teso 613 2,877,800 21 14 2.2 Bugisu 431 2,124,113 20 15 3.4 Acholi 332 1,890,706 18 22 6.6 Kigezi 290 1,637,823 18 17 5.8 North Central 624 4,869,437 13 32 5.1 Bunyoro 327 2,638,612 12 15 4.6 Kampala 222 1,848,566 12 19 8.5 Karamoja 118 1,168,481 10 4 3.3 South Central 536 5,782,964 9 20 3.7 West Nile 278 3,202,789 9 10 3.8 Busoga 323 4,227,008 8 12 3.7 Lango 162 2,444,762 7 7 4.3 Total 6,314 41,052,217 15 267 4.2 *Population data for health facility level and ownership was not available to calculate incidence There was no difference between in CFR by age or sex. CFRs increased with increasing admitting health care level of the health facility. Lower-level health facilities like HCIII had low CFR and compared to high level health facilities-the National Referral Hospitals (CFR: 2.3% Vs 9.7%) (Table 1 ). Overall trend of incidence of organophosphate poisoning admissions, Uganda 2017─2022 There was a 350% (more than 3-fold) decline (MK=-13, p = 0.02) in incidence of OP poisoning admissions per 100,000 population from 2017─2022. The greatest decline was between 2019 and 2020 (Fig. 1 ). Reporting rates were high and stable over the study period (Range: 86–94%). Trend of case fatality rate of organophosphate poisoning, Uganda 2017─2022 There was no significant change (MK=-9, p = 0.13) in the incidence of organophosphate poisoning deaths from 2017─2022 (Fig. 2 ). The greatest decline was between 2018 and 2019 (Fig. 2 ). Spatial distribution of organophosphate poisoning admission incidence, district level, Uganda, 2017─2022 Overall, the incidence of organophosphate poisoning admissions declined across all districts. The number of districts reporting > 100 cases per 100,000 admissions reduced from seven districts in 2017 to one district in 2022. Spatial clustering of high-incidence districts was observed in the east and south-western parts of the country. The incidences in Kiruhura and Bukwo districts remained high every year over the study period (Fig. 3). Discussion We assessed the trends and spatial distribution of organophosphate poisoning admissions incidence and deaths in Uganda, 2017─2022. The incidence of organophosphate poisoning admissions declined over the study period with an overall CFR of4.2%. Males, children < 5 years, and residents of Ankole Region were the most affected. Two districts (Kiruhura and Bukwo) had the highest incidences throughout the study period. The incidence of organophosphate poisoning admissions declined throughout the study period. Since 2014, Uganda has implemented periodic public awareness campaigns about safe use of pesticides for small-holder farmers and pesticide dealers [ 21 ]. These campaigns have included sensitization about responsible handling to reduce risk of poisoning and environmental pollution. Additional campaigns targeting government pesticide regulators, non-governmental organisations, and media have also been implemented to address the dangers of organophosphate poisoning [ 22 ]. These have included information about safe handling and use of pesticides and sensitization about banned and counterfeit pesticides. Similar health education and hazard assessment programs have been shown to have contributed to a reduction in organophosphate incidences amongst livestock farmers in Zambia [ 23 ]. Additionally, in 2008, Uganda ratified the Rotterdam Convention, which banned the importation and use of highly toxic pesticides [ 24 ]; Uganda has also implemented the Agricultural Chemical Control Act to use less toxic pesticides [ 25 ]. Together, these may be contributing to the reduction in the incidence of organophosphate poisonings. To continue this decline, it is important to monitor and strengthen these interventions. The overall CFR was 4.2%. This is lower than the CFR in two other Uganda studies on organophosphate poisonings done in hospital emergency centres in Uganda in 2022 (18%; 11/61) and 2018 (7.3%; 7/96) [ 26 , 27 ]. Mortality in organophosphate poisoning depends on the route of administration, the exposure dose, obtaining early diagnosis, and availability of appropriate medical care [ 28 , 29 ]. It is possible that since patients included in this study were inpatients, they may have had access to appropriate treatment, including activated charcoal and atropine, which are known to decrease mortality after organophosphate ingestion [ 3 , 30 ]. High CFRs were reported in a retrospective study; CFR = 7.8% (51/656) and a prospective study CFR = 5.6% (13/230) conducted in Tanzania[ 31 ]. This was attributed to challenges in clinical management of patients due to lack of specific details on the OP chemicals responsible for poisoning during hospital care. Ensuring that hospitals are stocked with equipment and antidotes for organophosphate could help further reduce the mortality associated with this exposure. Males in our study were more affected than females. In Uganda, men are more involved than women in agricultural activities which involve spraying of pesticides and these put them at high risk of occupational exposure [ 32 – 34 ]. Occupational exposures can occur through unintentional ingestion, inhalation, and skin and eye contact [ 35 ]. Studies in India have similarly identified higher incidence of organophosphate poisoning among men than women [ 36 , 37 ]. There is need to sensitize the public, especially men involved in agricultural work, about the importance of wearing personal protective gear like gloves, boots, and gloves during pesticide application. Children below 5 years were more affected by organophosphate poisoning than persons who were above 5 years. Studies in Uganda and China in 2017 also found that children were more affected than adults [ 38 – 40 ]. Globally, most organophosphate poisoning cases in children are accidental and occur after they ingest pesticide that was poorly stored in households [ 41 , 42 ]. In Uganda, there is often poor storage practices of pesticides in the households [ 38 ], leading to easy access by children. The exploratory and inquisitive behaviour together with frequent hand-mouth movements puts children at a risk of pesticide poisoning through the oral route [ 43 ]. Interventions that facilitate further reduction in the incidence of organophosphate poisoning amongst children are advisable. For instance, care takers to safely keep pesticides away from reach of children and packaging pesticides in containers that cannot easily be breached by children. Residents in Ankole Region were the most affected by organophosphate poisonings. Additionally, the incidences of Kiruhura and Bukwo districts remained high every year during the study period. Ankole Region (which includes Kiruhura District) is one of several regions engaged in both agriculture and livestock farming [ 44 ]. This region implements the intensive mixed farming model of growing of crops (banana-coffee) and rearing of cattle unlike other regions which exclusively apply either the crops (banana, coffee, millet, tea, cotton, millet, maize and cassava) or rearing animals (cattle-goats) only models[ 45 ]. This may lead to increased circulation of organophosphate agro-chemicals in Ankole Region as opposed to other regions. Additionally, poor handling likely plays a role. A study in Ankole Region about the usage of pesticides amongst dairy livestock farmers revealed that most farmers handled highly toxic agrochemicals without following proper instructions or having personal protective equipment [ 46 ]. However, similar data are not available for other regions. Like Kiruhura District, Bukwo District is also heavily involved in agriculture and livestock farming [ 47 , 48 ]. Further investigation is needed to understand the reason for persistently elevated levels of organophosphate poisoning in these districts, compared to other districts with similarly agricultural and livestock-based economies. Higher-level admitting health facilities recorded a higher CFR compared to lower-level health facilities. Lower-level health facilities (which act as the first point of care) may not have the staff, stock, or equipment to handle emergency poisoning cases [ 49 , 50 ] and often refer cases to higher-level facilities, which can incur treatment delays. In addition, more severe cases may be more likely to attend the higher-level facilities as their first point of care. Together, these may contribute to the higher CFRs in higher-level facilities. These findings are consistent with those in the Tanzanian study which showed that higher level health level facilities had a higher CFR than lower level primary health facilities [ 31 ]. This was attributed to lack of clinical capacity amongst healthcare workers to diagnose and treat such cases at primary healthcare level. It is important that rapid referrals are done from lower-level health facilities to higher level health facilities. In areas in which organophosphate poisonings comprise a high proportion of patient visits, it may be worthwhile to stock antidotes and train staff to manage such cases until they can reach higher-level facilities. Higher-level health facilities should additionally be equipped to handle organophosphate poisoning emergencies. Limitation Our study only utilized secondary data from the DHIS2, which are limited in terms of variables available for analysis. Secondly, the study utilized information of only admitted patients, and thus outpatients and persons who did not seek care from the health facilities were excluded, resulting in an under-estimation of the incidence of organophosphate poisoning in Uganda. Community-level studies using primary data to determine the factors associated with organophosphate poisoning may be beneficial in understanding the trends of organophosphate poisoning in Uganda. Conclusion There was a reduction in both incidence and mortality of organophosphate poisoning among admitted persons in Uganda during 2017–2022. Males, children < 5 years, and residents of highly agricultural districts were most affected. CFRs increased with increasing administrative level of the health facility. A detailed study into the reasons for the decline and strengthening interventions that can be directly linked to the decline nationally could facilitate continued reductions in organophosphate poisoning burden in Uganda. It is also important to build the capacity of health workers and equip lower-level health facilities to appropriately manage organophosphate poisoning incidents. Abbreviations CFR Case Fatality Rate DHIS2 District Health Information System-2 HC Health Centre HMIS Health Management Information System LIC Low-income country MK Mann-Kendall OP Organophosphate Declarations Acknowledgements The authors thank the staff of the Uganda Public Health Fellowship Program for the technical support and guidance offered during this study. The authors also extend their appreciation to the Ministry of Health, National Public Health Emergency Operations Centre for the technical support they offered during this study. Finally, we appreciate the biostatisticians and surveillance officers who ensure reporting of surveillance data from their respective districts, as well as the team managing the DHIS2 platform; your hard work enabled the availability of data we used for this analysis. Authors’ Contributions RZ: participated in the conception, design, analysis, interpretation of the study and wrote the draft manuscript; MWW, GZ, PK, RM, DK, BK, PEO, RM, LB and FLA reviewed the report, reviewed the drafts of the manuscript for intellectual content and made multiple edits to the draft manuscript; RM, DK, FLA, BK, LB, JK, IM and ARA reviewed the manuscript to ensure intellectual content and scientific integrity. All authors read and approved the final manuscript. Funding The project was supported by the President’s Emergency Plan for AIDS (PEPFAR) through the United States Centers for Disease Control and Prevention Cooperative Agreement number GH001353-01 through Makerere University School of Public Health to the Uganda Public Health Fellowship Program, Ministry of Health. The contents of this manuscript are solely the responsibility of the authors and do not necessarily represent the official views of the US Centers for Diseases Control and Prevention, the Department of Health and Human Services, Makerere University School of Public Health, or the Ministry of Health. The funders had no role in the study design, data collection, data analysis and decision to publish or preparation of the manuscript Availability of data and materials The datasets upon which our findings are based belong to the Uganda Public Health Fellowship Program. For confidentiality reasons, the datasets are not publicly available. The datasets can be availed upon reasonable request from the corresponding author with permission from the Uganda Public Health Fellowship Program. Ethics approval and consent to participate Because our study used routinely collected surveillance data reported by health facilities in the DHIS2 which were also aggregated with no individual patient identifiers, we did not seek for ethical approval. However, we sought permission to use the data from the Uganda MoH. The US Centers for Disease Control and Prevention (CDC) also provided the non-research determination (NRD) for non-human subjects which is equivalent to a waiver. Data were only accessed by the study team. Consent to publication Not applicable Competing interests The authors declare that they have no competing interests. References Kushwaha M, Verma S, Chatterjee S: Profenofos, an Acetylcholinesterase ‐ Inhibiting Organophosphorus Pesticide: A Short Review of Its Usage, Toxicity, and Biodegradation . Journal of environmental quality 2016, 45 (5):1478-1489. Gunnell D, Eddleston M, Phillips M, Konradsen F: Worldwide patterns of fatal pesticide self-poisoning . 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3903010","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":269599052,"identity":"1d1e5969-bc5d-4006-b4e9-2a20d800a810","order_by":0,"name":"Robert Zavuga","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3klEQVRIiWNgGAWjYBADORDBTJIWY9K1JDYQrcW8//AzaZ5fdulrZ6Q/e1zAYCfPIJF+Aa8WmQPHzKR5+5Jzt93IMTeewZBs2CCRU4BXiwRjg7Exbw8zSAubNA8DcwKDRE4Cfi3M7J+BWurTzW6kA13IUE+EFjYew8c8Pw4nmN1IMANqOQzUkn4AvxYensKHcxuOG24788bcmMfguGEbzxu8Ohgk+I9vOPDmT7W82XFgiPFUVMvzs6c/wK8HBBjbwBQbA4MBiOQxIKyF4Q9MCxiwE2HLKBgFo2AUjCQAAHTwPgmd/hioAAAAAElFTkSuQmCC","orcid":"","institution":"Uganda Public Health Fellowship Program, Uganda National Institute of Public Health, Kampala, Uganda","correspondingAuthor":true,"prefix":"","firstName":"Robert","middleName":"","lastName":"Zavuga","suffix":""}],"badges":[],"createdAt":"2024-01-27 12:54:25","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-3903010/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3903010/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":50381019,"identity":"ba8a7304-1aef-459e-9016-b32256071106","added_by":"auto","created_at":"2024-01-30 16:59:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":72828,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTrend of incidence of organophosphate poisoning admissions, Uganda 2017─2022\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3903010/v1/8896b5dd012d3237382d240c.png"},{"id":50381017,"identity":"c00cab08-936f-4df6-9c4c-4ec9ff54d489","added_by":"auto","created_at":"2024-01-30 16:59:52","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":68678,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTrend of case fatality rate of organophosphate poisoning, Uganda, 2017─2022\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-3903010/v1/806576862a6ae2e680abab72.png"},{"id":50381018,"identity":"8187f7b4-98e9-40f1-a89a-dd8bd8e60ffe","added_by":"auto","created_at":"2024-01-30 16:59:52","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":546054,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSpatial distribution of organophosphate poisoning admissions, Uganda, 2017─2022\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-3903010/v1/cc55aaf9018ab4cef1b96ded.png"},{"id":50381542,"identity":"5dc47228-cdfb-4d96-85e1-f0015fa48f3b","added_by":"auto","created_at":"2024-01-30 17:07:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2106701,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3903010/v1/f60fe795-5c45-45fa-851b-613051d0bffc.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eOrganophosphate poisoning temporal trends and spatial distribution, Uganda, 2017─2022\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOrganophosphates are a group of highly toxic chemical compounds that are commonly used as agricultural pesticides and insecticides[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. They are one of the main agents of poisoning, responsible for over 3,000,000 poisonings and an estimated 300,000 deaths per year worldwide [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. These poisonings, which lead to substantial morbidity and mortality among the exposed, may occur due to occupational or accidental exposure, deliberate ingestion in cases of suicide, or during chemical warfare [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Most organophosphate poisonings have involved exposures to agricultural pesticides [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The major routes of exposure for organophosphates are the respiratory tract, gastrointestinal tract, skin, and eyes [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].The clinical features of organophosphate poisoning are based in the central nervous system and include salivation, lacrimation, urination, defecation, abdominal pain, general body weakness, vomiting, loss of consciousness, anxiety, tremors, and convulsions [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Once exposed, symptoms occur within minutes to hours depending on the type of organophosphate poison, route of exposure, and dose [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn low and middle-income countries (LMIC), the significant reliance on pesticides for agricultural production results in an elevated risk of exposure to organophosphates [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The widespread availability and indiscriminate use of pesticides in such settings, coupled with poor storage and handling practices and lack of awareness about the consequences of poisoning make LMIC particularly vulnerable [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUganda has a largely agricultural economy [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] and a development strategy hinged on rapid industrialization in agriculture [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], which results in the widespread use of pesticides among agricultural farmers [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In Uganda, pesticides, including organophosphates, are widely available in animal drug shops and shops that sell general merchandise, and can be found on farms and in homes [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. There have been previous reports of organophosphate poisoning in Uganda linked to both intentional and unintentional pesticide exposures. [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Prevention efforts for pesticide poisoning in Uganda have included health education and sensitization on proper use of pesticides among farming communities [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. There are other measures which the limit the availability and toxicity of pesticides, such as regulation to limit sales to trained and licensed vendors [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Additionally, the replacement of highly toxic pesticides with less toxic and equally potent ones has also been implemented [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Despite the risk potential, little is known about the burden of organophosphate poisoning in Uganda. We assessed the distribution, temporal, and spatial trends of organophosphate poisoning in Uganda 2017─2022, to guide targeted control and prevention interventions.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and data source\u003c/h2\u003e \u003cp\u003eWe analysed organophosphate poisoning surveillance data captured in the District Health Information System version 2 (DHIS2). The DHSI2 is an open-source web based platform that is used to collect, report, and analyse aggregate data that is routinely generated across health facilities in Uganda[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Uganda has 146 districts which are distributed across the 15 regions as designated by the Ministry of Health. The healthcare system comprises government and privately owned health facilities which are organized in a hierarchical order [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] from Health Centre (HC) II (found at parish level), HCIII (found at sub-county level), HCIV (found at county/health sub-district level), district hospital (found at district level), regional referral hospital found at regional level), and the national referral hospital (found at national level).\u003c/p\u003e \u003cp\u003eThe DHIS2 collects data on priority diseases, conditions, and events of public health importance including organophosphate poisoning from the Health Management Information system (HMIS). All cases suspected of organophosphate poisoning are recorded in HMIS as admissions/in-patient occurrences. The HMIS is a paper-based system in which health facilities record patient data on conditions of interest. These data are later entered into the electronic DHIS2 and aggregated from all health centres in the country.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy variables, data abstraction, analysis, and management\u003c/h2\u003e \u003cp\u003eWe abstracted aggregate data on organophosphate poisoning admissions and\u003c/p\u003e \u003cp\u003edeaths from the inpatient monthly reports in the Health Management Information System (HMIS) from 2017 to 2022. As per HMIS, organophosphate poisoning admissions were defined as a hospital stay due to suspected organophosphate poisoning as a primary diagnosis. Organophosphate poisoning deaths were defined as inpatient deaths with organophosphate poisoning listed as the cause of death in DHIS2.\u003c/p\u003e \u003cp\u003eData were imported into Stata version 16 software (Stata Corporation, College Station, Texas, USA) for analysis. We calculated the annual incidence of OP poisoning as annual admissions due to OP poisoning per 100,000 population. Population data was obtained from the Uganda Bureau of Statistics population estimates[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Additionally, we calculated the case fatality rate (CFR) of OP poisoning as a percentage of number of deaths due to OP poisoning divided by the number of OP admissions. We calculated annual incidence of organophosphate poisoning and the overall case fatality rates at national, regional, and health facility level. We used line graphs to describe national trends of OP admissions and CFR. The Mann-Kendall test was used to determine the significance of the trends. Choropleth maps were drawn using QGIS software to show the spatial distribution of organophosphate incidence in the country. To further contextualize the findings, we also abstracted data on reporting rates, calculated as the percentage of complete submitted monthly reports over the study period divided by the number of expected reports.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003eIncidence and case fatality rate of organophosphate poisoning, Uganda, 2017\u0026ndash;2022\u003c/h2\u003e\n \u003cp\u003eOverall, a total of 37,883 (average: 6,314 per year) organophosphate poisoning cases.\u003c/p\u003e\n \u003cp\u003eThe overall average incidence was 15 organophosphate admissions per 100,000 persons. Residents of Ankole Region were more affected while those in Lango Region were least affected. (Incidence: 26/100,000 vs 7/100,000 persons). (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Males had a higher incidence of organophosphate poisoning than females (18 vs 13/100,000, p\u0026thinsp;=\u0026thinsp;0.03). Children\u0026thinsp;\u0026lt;\u0026thinsp;5 years had a higher incidence than persons\u0026thinsp;\u0026ge;\u0026thinsp;5 years (20 vs 14/100,000, p\u0026thinsp;=\u0026thinsp;0.01). Overall, 1,599 (average: 267 per year) deaths were reported (CFR)\u0026thinsp;=\u0026thinsp;4.2% during 2017\u0026ndash;2022. Residents in Kampala Region had the highest overall CFR while those in Teso Region had the lowest (CFR: 8.5% vs 2.2%) (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eIncidence and case fatality rate of organophosphate poisoning, Uganda, 2017─2022\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCases\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAverage population\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eIncidence /100,000\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDeaths\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCase fatality\u003c/p\u003e\n \u003cp\u003erate (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2,772\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20,951,652\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3,542\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20,100,565\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e192\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1,570\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7,715,064\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ge;\u0026thinsp;5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4,744\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33,337,153\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e219\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e*Health facility level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHealth Centre III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1,253\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHealth Centre IV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1,374\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDistrict Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2,911\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e141\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRegional Referral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e684\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNational Referral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e*Ownership\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGovernment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3,769\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e163\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrivate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2,545\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e104\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eRegion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnkole\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e871\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,308,524\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBukedi\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e511\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,269,307\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTooro\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e677\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,030,632\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTeso\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e613\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,877,800\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBugisu\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e431\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,124,113\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAcholi\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e332\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,890,706\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKigezi\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e290\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,637,823\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNorth Central\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e624\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,869,437\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBunyoro\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e327\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,638,612\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKampala\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e222\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,848,566\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKaramoja\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e118\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,168,481\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSouth Central\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e536\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5,782,964\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWest Nile\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e278\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,202,789\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBusoga\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e323\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,227,008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLango\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e162\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,444,762\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6,314\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41,052,217\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e267\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003e*Population data for health facility level and ownership was not available to calculate incidence\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003eThere was no difference between in CFR by age or sex. CFRs increased with increasing admitting health care level of the health facility. Lower-level health facilities like HCIII had low CFR and compared to high level health facilities-the National Referral Hospitals (CFR: 2.3% Vs 9.7%) (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003ch2\u003eOverall trend of incidence of organophosphate poisoning admissions, Uganda 2017─2022\u003c/h2\u003e\n\u003cp\u003eThere was a 350% (more than 3-fold) decline (MK=-13, p\u0026thinsp;=\u0026thinsp;0.02) in incidence of OP poisoning admissions per 100,000 population from 2017─2022. The greatest decline was between 2019 and 2020 (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Reporting rates were high and stable over the study period (Range: 86\u0026ndash;94%).\u003c/p\u003e\n\u003ch2\u003eTrend of case fatality rate of organophosphate poisoning, Uganda 2017─2022\u003c/h2\u003e\n\u003cp\u003eThere was no significant change (MK=-9, p\u0026thinsp;=\u0026thinsp;0.13) in the incidence of organophosphate poisoning deaths from 2017─2022 (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). The greatest decline was between 2018 and 2019 (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003eSpatial distribution of organophosphate poisoning admission incidence, district level, Uganda, 2017─2022\u003c/h2\u003e\n \u003cp\u003eOverall, the incidence of organophosphate poisoning admissions declined across all districts. The number of districts reporting\u0026thinsp;\u0026gt;\u0026thinsp;100 cases per 100,000 admissions reduced from seven districts in 2017 to one district in 2022. Spatial clustering of high-incidence districts was observed in the east and south-western parts of the country. The incidences in Kiruhura and Bukwo districts remained high every year over the study period (Fig. 3).\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe assessed the trends and spatial distribution of organophosphate poisoning admissions incidence and deaths in Uganda, 2017─2022. The incidence of organophosphate poisoning admissions declined over the study period with an overall CFR of4.2%. Males, children\u0026thinsp;\u0026lt;\u0026thinsp;5 years, and residents of Ankole Region were the most affected. Two districts (Kiruhura and Bukwo) had the highest incidences throughout the study period.\u003c/p\u003e \u003cp\u003eThe incidence of organophosphate poisoning admissions declined throughout the study period. Since 2014, Uganda has implemented periodic public awareness campaigns about safe use of pesticides for small-holder farmers and pesticide dealers [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. These campaigns have included sensitization about responsible handling to reduce risk of poisoning and environmental pollution. Additional campaigns targeting government pesticide regulators, non-governmental organisations, and media have also been implemented to address the dangers of organophosphate poisoning [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. These have included information about safe handling and use of pesticides and sensitization about banned and counterfeit pesticides. Similar health education and hazard assessment programs have been shown to have contributed to a reduction in organophosphate incidences amongst livestock farmers in Zambia [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Additionally, in 2008, Uganda ratified the Rotterdam Convention, which banned the importation and use of highly toxic pesticides [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]; Uganda has also implemented the Agricultural Chemical Control Act to use less toxic pesticides [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Together, these may be contributing to the reduction in the incidence of organophosphate poisonings. To continue this decline, it is important to monitor and strengthen these interventions.\u003c/p\u003e \u003cp\u003eThe overall CFR was 4.2%. This is lower than the CFR in two other Uganda studies on organophosphate poisonings done in hospital emergency centres in Uganda in 2022 (18%; 11/61) and 2018 (7.3%; 7/96) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Mortality in organophosphate poisoning depends on the route of administration, the exposure dose, obtaining early diagnosis, and availability of appropriate medical care [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. It is possible that since patients included in this study were inpatients, they may have had access to appropriate treatment, including activated charcoal and atropine, which are known to decrease mortality after organophosphate ingestion [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. High CFRs were reported in a retrospective study; CFR\u0026thinsp;=\u0026thinsp;7.8% (51/656) and a prospective study CFR\u0026thinsp;=\u0026thinsp;5.6% (13/230) conducted in Tanzania[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. This was attributed to challenges in clinical management of patients due to lack of specific details on the OP chemicals responsible for poisoning during hospital care. Ensuring that hospitals are stocked with equipment and antidotes for organophosphate could help further reduce the mortality associated with this exposure.\u003c/p\u003e \u003cp\u003eMales in our study were more affected than females. In Uganda, men are more involved than women in agricultural activities which involve spraying of pesticides and these put them at high risk of occupational exposure [\u003cspan additionalcitationids=\"CR33\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Occupational exposures can occur through unintentional ingestion, inhalation, and skin and eye contact [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Studies in India have similarly identified higher incidence of organophosphate poisoning among men than women [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. There is need to sensitize the public, especially men involved in agricultural work, about the importance of wearing personal protective gear like gloves, boots, and gloves during pesticide application.\u003c/p\u003e \u003cp\u003eChildren below 5 years were more affected by organophosphate poisoning than persons who were above 5 years. Studies in Uganda and China in 2017 also found that children were more affected than adults [\u003cspan additionalcitationids=\"CR39\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Globally, most organophosphate poisoning cases in children are accidental and occur after they ingest pesticide that was poorly stored in households [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. In Uganda, there is often poor storage practices of pesticides in the households [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], leading to easy access by children. The exploratory and inquisitive behaviour together with frequent hand-mouth movements puts children at a risk of pesticide poisoning through the oral route [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Interventions that facilitate further reduction in the incidence of organophosphate poisoning amongst children are advisable. For instance, care takers to safely keep pesticides away from reach of children and packaging pesticides in containers that cannot easily be breached by children.\u003c/p\u003e \u003cp\u003eResidents in Ankole Region were the most affected by organophosphate poisonings. Additionally, the incidences of Kiruhura and Bukwo districts remained high every year during the study period. Ankole Region (which includes Kiruhura District) is one of several regions engaged in both agriculture and livestock farming [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. This region implements the intensive mixed farming model of growing of crops (banana-coffee) and rearing of cattle unlike other regions which exclusively apply either the crops (banana, coffee, millet, tea, cotton, millet, maize and cassava) or rearing animals (cattle-goats) only models[\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. This may lead to increased circulation of organophosphate agro-chemicals in Ankole Region as opposed to other regions. Additionally, poor handling likely plays a role. A study in Ankole Region about the usage of pesticides amongst dairy livestock farmers revealed that most farmers handled highly toxic agrochemicals without following proper instructions or having personal protective equipment [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. However, similar data are not available for other regions. Like Kiruhura District, Bukwo District is also heavily involved in agriculture and livestock farming [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Further investigation is needed to understand the reason for persistently elevated levels of organophosphate poisoning in these districts, compared to other districts with similarly agricultural and livestock-based economies.\u003c/p\u003e \u003cp\u003eHigher-level admitting health facilities recorded a higher CFR compared to lower-level health facilities. Lower-level health facilities (which act as the first point of care) may not have the staff, stock, or equipment to handle emergency poisoning cases [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e] and often refer cases to higher-level facilities, which can incur treatment delays. In addition, more severe cases may be more likely to attend the higher-level facilities as their first point of care. Together, these may contribute to the higher CFRs in higher-level facilities. These findings are consistent with those in the Tanzanian study which showed that higher level health level facilities had a higher CFR than lower level primary health facilities [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. This was attributed to lack of clinical capacity amongst healthcare workers to diagnose and treat such cases at primary healthcare level. It is important that rapid referrals are done from lower-level health facilities to higher level health facilities. In areas in which organophosphate poisonings comprise a high proportion of patient visits, it may be worthwhile to stock antidotes and train staff to manage such cases until they can reach higher-level facilities. Higher-level health facilities should additionally be equipped to handle organophosphate poisoning emergencies.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eLimitation\u003c/h2\u003e \u003cp\u003eOur study only utilized secondary data from the DHIS2, which are limited in terms of variables available for analysis. Secondly, the study utilized information of only admitted patients, and thus outpatients and persons who did not seek care from the health facilities were excluded, resulting in an under-estimation of the incidence of organophosphate poisoning in Uganda. Community-level studies using primary data to determine the factors associated with organophosphate poisoning may be beneficial in understanding the trends of organophosphate poisoning in Uganda.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThere was a reduction in both incidence and mortality of organophosphate poisoning among admitted persons in Uganda during 2017\u0026ndash;2022. Males, children\u0026thinsp;\u0026lt;\u0026thinsp;5 years, and residents of highly agricultural districts were most affected. CFRs increased with increasing administrative level of the health facility. A detailed study into the reasons for the decline and strengthening interventions that can be directly linked to the decline nationally could facilitate continued reductions in organophosphate poisoning burden in Uganda. It is also important to build the capacity of health workers and equip lower-level health facilities to appropriately manage organophosphate poisoning incidents.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCFR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCase Fatality Rate\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDHIS2\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDistrict Health Information System-2\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealth Centre\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHMIS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealth Management Information System\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLIC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLow-income country\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMK\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMann-Kendall\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOrganophosphate\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the staff of the Uganda Public Health Fellowship Program for the technical support and guidance offered during this study. The authors also extend their appreciation to the Ministry of Health, National Public Health Emergency Operations Centre for the technical support they offered during this study. Finally, we appreciate the biostatisticians and surveillance officers who ensure reporting of surveillance data from their respective districts, as well as the team managing the DHIS2 platform; your hard work enabled the availability of data we used for this analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRZ: participated in the conception, design, analysis, interpretation of the study and wrote the draft manuscript; MWW, GZ, PK, RM, DK, BK, PEO, RM, LB and FLA reviewed the report, reviewed the drafts of the manuscript for intellectual content and made multiple edits to the draft manuscript; RM, DK, FLA, BK, LB, JK, IM and ARA reviewed the manuscript to ensure intellectual content and scientific integrity. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe project was supported by the President\u0026rsquo;s Emergency Plan for AIDS (PEPFAR) through the United States Centers for Disease Control and Prevention Cooperative Agreement number GH001353-01 through Makerere University School of Public Health to the Uganda Public Health Fellowship Program, Ministry of Health. The contents of this manuscript are solely the responsibility of the authors and do not necessarily represent the official views of the US Centers for Diseases Control and Prevention, the Department of Health and Human Services, Makerere University School of Public Health, or the Ministry of Health.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe funders had no role in the study design, data collection, data analysis and decision to publish\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eor preparation of the manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets upon which our findings are based belong to the Uganda Public Health Fellowship Program. For confidentiality reasons, the datasets are not publicly available. The datasets can be availed upon reasonable request from the corresponding author with permission from the Uganda Public Health Fellowship Program.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBecause our study used routinely collected surveillance data reported by health facilities in the DHIS2 which were also aggregated with no individual patient identifiers, we did not seek for ethical approval. However, we sought permission to use the data from the Uganda MoH. The US Centers for Disease Control and Prevention (CDC) also provided the non-research determination (NRD) for non-human subjects which is equivalent to a waiver. Data were only accessed by the study team.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKushwaha M, Verma S, Chatterjee S: \u003cstrong\u003eProfenofos, an Acetylcholinesterase\u003c/strong\u003e\u003cstrong\u003e‐\u003c/strong\u003e\u003cstrong\u003eInhibiting Organophosphorus Pesticide: A Short Review of Its Usage, Toxicity, and Biodegradation\u003c/strong\u003e. \u003cem\u003eJournal of environmental quality \u003c/em\u003e2016, \u003cstrong\u003e45\u003c/strong\u003e(5):1478-1489.\u003c/li\u003e\n\u003cli\u003eGunnell D, Eddleston M, Phillips M, Konradsen F: \u003cstrong\u003eWorldwide patterns of fatal pesticide 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Makerere University; 2019.\u003c/li\u003e\n\u003cli\u003eNamazzi G, Waiswa P, Nakakeeto M, Nakibuuka VK, Namutamba S, Najjemba M, Namusaabi R, Tagoola A, Nakate G, Ajeani J: \u003cstrong\u003eStrengthening health facilities for maternal and newborn care: experiences from rural eastern Uganda\u003c/strong\u003e. \u003cem\u003eGlobal health action \u003c/em\u003e2015, \u003cstrong\u003e8\u003c/strong\u003e(1):24271.\u003c/li\u003e\n\u003cli\u003eNingwa A, Muni K, Oporia F, Kalanzi J, Zziwa EB, Biribawa C, Kobusingye O: \u003cstrong\u003eThe state of emergency medical services and acute health facility care in Uganda: findings from a National Cross-Sectional Survey\u003c/strong\u003e. \u003cem\u003eBMC Health Services Research \u003c/em\u003e2020, \u003cstrong\u003e20\u003c/strong\u003e(1):1-10.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Uganda Public Health Fellowship Program, Uganda National Institute of Public Health, Kampala, Uganda ","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Organophosphate poisoning, pesticides, Uganda","lastPublishedDoi":"10.21203/rs.3.rs-3903010/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3903010/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eOrganophosphates (OP) are toxic chemical agents used as agricultural pesticides and insecticides and are one of the commonest agents of poisoning worldwide, responsible for \u0026gt;\u0026thinsp;3,000,000 poisonings and 300,000 deaths globally per year. As a country with an agriculture-based economy, Uganda has widespread use of pesticides, creating an elevated risk for OP poisoning. We assessed the distribution and temporal and spatial trends of OP poisoning admissions in Uganda during 2017─2022 to guide control and prevention interventions.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe analysed OP poisoning surveillance data from the District Health Information System version 2 (DHIS2). As per DHIS2, OP poisoning admissions were defined as a hospital stay due to suspected OP poisoning while deaths were defined as inpatient deaths with OP poisoning listed as the cause of death. We calculated annual incidence of OP poisoning admissions per 100,000 population and case-fatality rates per patient admitted with OP at national, regional, and health facility levels. We used the Mann-Kendall (MK) test to determine the strength and direction of the trend.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 37,883 (average: 6,314 per year) OP admissions and 1,599 (average: 267 per year) deaths were reported (case-fatality rate [CFR]\u0026thinsp;=\u0026thinsp;4.2%) during 2017─2020. Males (incidence\u0026thinsp;=\u0026thinsp;18/100,000), children\u0026thinsp;\u0026lt;\u0026thinsp;5 years (incidence\u0026thinsp;=\u0026thinsp;20/100,000), and residents of Ankole Region (incidence\u0026thinsp;=\u0026thinsp;26/100,000) were the most affected. CFRs increased with the increasing healthcare level of the admitting health facility. The incidence of OP declined by over 3-fold over the study period (MK=-13, p\u0026thinsp;=\u0026thinsp;0.02). Kiruhura and Bukwo Districts had consistently high incidences (\u0026gt;\u0026thinsp;50/100,000) throughout the study period.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThere was a significant reduction in incidence of OP poisoning in Uganda during 2017─2020. Males, children\u0026thinsp;\u0026lt;\u0026thinsp;5 years, and residents in Ankole Region were the most affected. Strengthening sensitization among agricultural and livestock farming communities about the risks of pesticide poisoning and building capacity of health workers and equipping lower-level health facilities to effectively manage medical emergencies including OP poisoning could reduce the OP burden and mortality in Uganda.\u003c/p\u003e","manuscriptTitle":"Organophosphate poisoning temporal trends and spatial distribution, Uganda, 2017─2022","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-30 16:59:47","doi":"10.21203/rs.3.rs-3903010/v1","editorialEvents":[{"type":"communityComments","content":1}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5c32b936-9974-47d5-8e3a-7dd3972f4c12","owner":[],"postedDate":"January 30th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":28406743,"name":"Toxicology"}],"tags":[],"updatedAt":"2025-06-13T15:23:27+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-30 16:59:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3903010","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3903010","identity":"rs-3903010","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}