1 Introduction

In recent years, there has been an increase in the frequency of outbreaks, epidemics, and pandemics globally [1]. This has been attributed to an increase in human mobility, particularly in international travel, that has facilitated the global spread of disease [2,3,4]. Previous epidemics, such as the 2014–2016 West Africa Ebola epidemic, and more recently the mpox and COVID-19 pandemics, have demonstrated the importance of having the capacity to detect and respond to disease at Points of Entry (PoE) [5, 6]. In response, countries including Uganda have prioritised developing their capacities for prevention, early detection and effective response to infectious disease threats through various global commitments and agreements. These include the Global Health Security Agenda, which focuses on protecting the world from global health threats caused by infectious agents, and the 2005 World Health Organisation (WHO) International Health Regulations (IHR) which aim to prevent, protect, control, and provide a public health response to public health events with minimal interruption to trade and travel [7, 8].

To achieve these outcomes, the WHO IHR require countries to build capacities in coordination and communication, surveillance, response, preparedness, risk communication, human resources, and access to appropriate medical services and diagnostics at IHR priority PoEs. Additionally, PoEs are expected to have specific disease prevention and control core capacities including providing access to medical services and diagnostic facilities, ways to transport ill persons to medical facilities, trained staff and appropriate equipment, a safe environment for travellers with food and sanitation services, and a vector and reservoir control program at or near the PoE at all times [9]. In response to PHEs, POEs are expected to be able to conduct both primary and secondary screening to identify ill travellers, isolate suspected ill travellers and animals and quarantine exposed travellers and animals. Primary screening involves observing travellers for obvious signs of illness, measuring their temperature, and collecting information on experienced symptoms, exposure history, and travel details. Secondary screening involves further medical examination of suspected ill travellers, including symptom monitoring and laboratory testing, if necessary.

Previous assessments in Uganda [10, 11], including the 2017 WHO Joint External Evaluation [12], indicated that most PoEs in the country were lacking in most of these areas. In 2020, the Ministry of Health and partners made efforts to build capacities of various PoEs in screening, testing, isolation, and quarantine of exposed travellers. We conducted a new assessment in 2022 to document changes and identify areas for further improvement. We assessed capacity and performance in detection, reporting, and responding to public health emergencies at PoEs in Uganda.

2 Methods

2.1 Study setting

We assessed 53 PoEs officially recognized by the Government of Uganda PoEs (airports/airfields, ground crossings, and in-land ports). These included 12 designated PoEs that are internationally recognised by the World Health Organisation and 41 PoEs that are not (Fig. 1).

Fig. 1
figure 1

Points of entry assessed for capacity in detection, reporting and responding to public health events of international concern, Uganda, July–October 2022

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2.2 Study design

To assess capacities detection of public health events, reporting, and responding to PHEs at PoEs in Uganda, we conducted a cross-sectional assessment using an adapted standardised assessment tool for core capacity requirements at designated airports, inland ports, and ground crossings developed by the WHO in 2009 [9]. This tool enables member states to identify existing capacities and potential gaps in IHR core capacities. We physically assessed all 53 PoEs from June 27 to September 12, 2022.Due to the sizeable distances between PoEs, the assessment was completed with 3 months.

We abstracted from the national PoE reporting database hosted with the national surveillance system database District Health Information System version 2 (DHIS2), to assess performance in detecting public health events, reporting, and responding to PHEs at PoEs in Uganda.

2.3 Study variables and data collection

We assessed PoE capacities to communicate pertinent information for detection of public health events, prevention, and control of PHEs and coordinate detection, prevention and control activities at sub-national, national, and international levels. For ‘expected capacities at all times’, we assessed the capacity to: (a) provide access to appropriate medical services, trained medical personnel, and equipment for prompt assessment and care of ill travellers, (b) provide access to equipment and personnel for the transport of ill travellers to an appropriate medical facility, (c) provide trained personnel for inspection of conveyances, (d) ensure a safe environment for travellers with potable water supplies, hygienic eating establishments and flight catering facilities, public washrooms; appropriate solid and liquid waste disposal services and (e) provide, as far as practicable, a programme and trained personnel for the control of vector and reservoirs in and near PoEs.

For capacities in response to events that may constitute PHEs, we assessed: (a) presence of a public health emergency contingency plan, (b) capacity to provide assessment of and care for affected travellers or animals by establishing arrangements with local medical and veterinary facilities for their isolation, treatment and other support services that may be required; (c) presence of appropriate space, separate from other travellers, to interview ill or apparently ill persons, (d) capacity to provide for the assessment and, if required, quarantine of suspect travellers, preferably in facilities away from the point of entry, (e) the presence of recommended measures to disinfect, derat, decontaminate, or otherwise treat baggage, cargo, containers, conveyances, goods or postal parcels at locations designated and equipped for this purpose, (f) entry or exit controls for arriving and departing travellers, and (g) access to specially designated equipment, and trained personnel with appropriate personal protection, for the transfer of travellers who may carry infection or contamination.

For the performance of PoEs, we assessed (1) completeness of reporting defined as the proportion of PoEs reporting to the national surveillance database DHIS2 divided by the number of expected reports from the PoEs, (2) the proportion of travellers screened at PoEs and 3) Proportion of identified suspected cases isolated.

For each capacity area, we obtained responses (yes, no, or partial) from port health staff and PoE stakeholders (immigration, customs, and security) present at the PoE at the time of the assessment. Additionally, we reviewed port health inventory records to assess equipment capacities, guidelines, and plans, including Public Health Emergency Contingency Plans to assess capacity to respond to PHEs and made observations to assess capacity in providing a safe environment for travellers.

We uploaded the data collection tool to Open Data Kit (ODK) software and used Android smartphones for data collection.

2.4 Data management and analysis

We downloaded and cleaned data in Microsoft Excel and analysed using Epi info 7 software. We used descriptive statistics including percentages to summarise capacities and performance under the various areas.

3 Results

3.1 Characteristics of PoEs assessed for capacity in detection of public health events, reporting and responding to PHEs, Uganda, July–October 2022

Of the 53 PoEs included in the assessment, eight were designated by the Ministry of Health and submitted to the World Health Organisation as being required to have the minimum capacity to minimize public health risks caused by the spread of diseases through international traffic. Thirty-five (66%) PoEs had formal building structures with a separate port health unit and 25 (47%) received more than 50 travellers per day. However, only 12 (23%) had a permanent infrastructure for port health services (Table 1).

Table 1 Characteristics of PoEs assessed for capacity in detection of public health events, reporting and responding to PHEs, Uganda, July–October 2022 (N = 53)
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3.2 Capacity in detection of public health events, reporting, and responding to PHEs at PoEs, Uganda, June 27-September 12, 2022

3.2.1 Coordination and communication

Twenty-one (39%) PoEs had the required international communication links with legally delegated authorities at other international PoEs. All PoEs that reported having international communication links had a list of contacts at other PoEs who were in charge of international communication. Forty-one (81%) PoEs with international communication links received lists of suspected cases of diseases of international concern from authorities at other PoEs when there were suspected cases identified. Twenty-one (39%) PoEs had the required port health supervisor overseeing prevention, detection, and response to public health emergencies (Fig. 2).

Fig. 2
figure 2

Coordination and communication capacities among PoEs assessed for capacity in detection public health events, reporting, and responding to PHEs, Uganda, July–October 2022

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3.2.2 Expected capacities at all times

Eight (15%) designated PoEs had laboratory equipment and supplies available for sample collection from ill travellers, while 19 (36%) had mechanisms for the transportation of collected samples from travellers, usually through the laboratory hub system in Uganda. Thirty-seven (70%) had at least one medical personnel or trained health personnel at the PoE. Although no PoEs had an onsite health facility, all PoEs had arrangements with the nearest health facility where travellers accessed medical care, located an average of 5.4 km (range: 1–29 km) from the health facility (Table 2).

Table 2 Expected capacities at all times at PoEs, Uganda, July–October 2022 (N = 53)
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3.2.3 Responding to events that may constitute public health emergencies

More than half of PoEs reported that they lacked the capacity to respond to PHEs in 7 of the 9 areas assessed. The assessment area in which the highest proportion (44; 83%) had capacity was the assessment of suspected ill travellers and control of entry and departing travellers. All the 8 designated PoEs had approved public health emergency contingency plans; an additional 8 PoEs had drafted public health contingency plans as part of the District Public Health Emergency Plans that were pending approval. The fewest PoEs had capacities to assess affected animals (4; 8%) or quarantine and isolate animals (1; 2%). Thirty-nine (74%) PoEs screened all incoming travellers for at least one disease of international concern, including COVID-19 (53; 100%), Ebola virus disease (24; 45%), tuberculosis (22; 42%), yellow fever (6; 11%), poliovirus (3; 6%) and Mpox (2; 3%). No PoE is routinely assessed for biological, chemical, or radiological hazards (Table 3).

Table 3 Capacities in responding to events that may constitute public health emergencies Uganda, July–October 2022 (N = 53)
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3.3 Performance of Points of Entry in reporting, detection of public health events, reporting and response to PHEs at PoEs in Uganda

During the review period, the overall completeness of PoE daily reporting to the national surveillance system was 88%, with a range of 78–94%. Slightly more than half of the travellers (56%; range 51–62%) passing through the PoEs were screened. Suspected diseases and conditions identified among travellers included measles, polio, viral haemorrhagic fever, polio, and COVID-19. Of the suspected cases detected, 23% (range 15–33%) were isolated, investigated, and referred to a health facility if necessary.

Indicator

%

Reporting

 

 Completeness of PoE Reporting to the national level

88

Detection

 

 Proportion of travellers screened

56

Response

 

 Proportion of suspected travellers isolated, investigated, and referred for further care if necessary

23

4 Discussion

We assessed the capacity and performance of 53 official PoEs in detection of public health events, reporting, and responding to PHEs. Most PoEs reported assessing travellers for key diseases of international concern through primary screening but only assessed half of the travellers passing through the PoE. PoEs had low capacity in personnel, medical, and diagnostic facilities. No PoE was routinely assessed for biological, chemical, or radiological hazards. Most PoEs communicated and coordinated with national and sub-national health authorities with optimal timeliness of PoE reports. Some PoEs communicated with other international PoEs about public health events and PHEs. Few PoEs had public health emergency contingency plans, appropriate facilities to assess, isolate, and quarantine both humans and animals, trained personnel with personal protective equipment, or the ability to decontaminate/ disinfect PoE premises. Less than a third of suspected travellers were isolated, investigated and referred for further care if necessary.

Most PoEs reported routinely conducting primary screening of travellers for illness and assessing the vaccination status of travellers for at least some key reportable diseases. Screening facilitates the identification of suspected ill travellers at PoEs, reducing the risk of disease transmission to travel destination communities/countries [13]. Border screening in Uganda has proven useful on more than one occasion in recent years. During the H1N1 pandemic in 2009, the first case was identified through screening at the international airport, which initiated enhanced surveillance and response for H1N1 in Uganda [14]. During the COVID-19 pandemic, screening at the international airport identified the first confirmed COVID-19 case in the country and led to initiation of response measures, including contact tracing and quarantine of travellers as well as a closure of the international airport for six months [15]. Nevertheless, we observed gaps in the ability to conduct screening, including a lack of equipment for medical examinations during secondary screening and personal protective equipment. These gaps may undermine the actual ability to conduct primary and secondary screening among travellers, some of whom may be infected and subsequently infect persons at their destination communities [16]. We also noted lack of medical personnel, with fewer than one trained medical staff person at each PoE on average. This may limit the capacities of PoEs to conduct secondary screening [17]. Secondary screening supports the identification of travellers who may need laboratory testing, symptom monitoring, isolation, or quarantine [18]. Given these gaps it is not surprising that only half the travellers at the PoEs were screened. This may hinder effective detection of potential PHEs.

As seen in other African countries, few PoEs had the capacity to isolate ill travellers with suspected notifiable illnesses [13, 19]. This presents a risk of disease transmission between travellers at PoEs and eventual disease importation or exportation, even in the presence of screening [13]. Beyond the inability to conduct secondary screening or isolate persons, we identified low access to medical and diagnostic facilities at PoEs, with only 30% having SARS-COV2 rapid diagnostic kits. This may hinder the timely detection of cases and lead to spread at the PoEs themselves. During the COVID-19 pandemic, lack of testing capacity and shortages of sample-taking supplies at PoEs led to delays in case confirmation, as samples needed to be transported to the laboratories far away (over 50 km) from the PoE [20]. We further noted that most PoEs lacked equipment to transport suspect or ill travellers to the nearest health facility. This may delay the prompt clinical management of ill travellers and safe and hygienic transportation of ill travellers [21]. As a result of these gaps, less than a third of suspected travellers are isolated, investigated, and referred for further care if necessary.

Despite these gaps, we noted improvements compared to previous assessments conducted in 2010, 2017 and 2020. In 2010, both primary and secondary screening were not routinely conducted at any PoE; instead, it was only done as part of international response to Public Health Emergencies of International Concern, such as during the outbreak of influenza (H1N1), and not done during national response to PHEs [10]. In 2017, the Joint External Evaluation indicated that no ground crossing or inland port PoE routinely screened travellers for key reportable diseases [22]. According to the IHR States Parties Self-Assessment Annual Reporting Tool, 42% of PoEs had capacity to assess of suspected ill travellers and control of entry and departing travellers in 2020 [23]. Based on our findings this indicated a 41% increase in capacity in this area.The COVID-19 pandemic in 2020 led to the introduction of port health units at most ground crossings and inland port PoEs in Uganda. Such units are the ones that now provide routine screening and vaccination assessments to enhance cross-border surveillance of COVID-19 [24], and some of the improvements since the previous assessments in screening capacity are undoubtedly attributable to these efforts.

Most PoEs reported communication and coordination with international health authorities. This facilitates the timely sharing of relevant information for detection, prevention, and appropriate response [25], which may in turn reduce the risk of disease importation into other countries. An example of this principle in action was experienced during the 2018–2019 EVD outbreak and the 2019 EVD outbreak in Uganda. During these outbreaks, the prompt sharing of information between Uganda and the Democratic Republic of Congo (DRC) during in DRC enabled the rapid identification and isolation of an imported case from DRC to Uganda and contact tracing of other exposed travellers. This resulted in enhanced community-based surveillance and prevented further disease spread [26].

Only a small number of PoEs had approved public health emergency contingency plans. Failure to have agreed-upon public health emergency contingency plans increases the risk of delayed and uncoordinated response at PoEs [27]. We also found that few PoEs assessed animals or provided veterinary facilities for isolation and treatment, despite the risk of importing and exporting zoonotic diseases [28]. In East Africa, this risk is very real: frequent movement of livestock across the border poses a risk of spread of Rift Valley Fever and anthrax [29]. Transmission of transboundary animal diseases such as foot-and-mouth disease along the Uganda-Tanzania border and African Swine Fever across the Kenya-Uganda border have also been documented [30, 31]. There are opportunities to utilize One Health activities at these PoEs [32]. Integrating animal disease screening and response with existing human health border activities at PoEs in Ethiopia along the Ethiopia-South Sudan, Ethiopia-Kenya, and Ethiopia-Somalia borders improved surveillance and capacity to respond to zoonotic diseases, including rabies, anthrax and brucellosis [33]. One Health approaches along the Mali and Côte d'Ivoire border provided an opportunity for testing animal samples at the border for brucellosis where veterinary laboratories were difficult to access [34].

Our findings should be interpreted with consideration of the following limitations. We used a cross-sectional design, and therefore our findings reflect existing capacities at the time of the assessment. These capacities will likely change over time, potentially in either direction. In addition, we excluded unofficial PoEs despite their use by travellers. Uganda like other African countries has porous borders with several unofficial points of entry commonly used by cross-border communities [35]. By October 2022, the ratio of official to unofficial PoEs was 53:91.Such unofficial PoEs are likely to have lower capacities in disease detection, reporting and response and thus may provide opportunities for disease importation and exportation across the border. Strengthening community-based surveillance in these areas to facilitate timely disease detection and response in these areas.

5 Conclusions

In summary, despite some improvements in recent years, major gaps exist in the ability to detect and respond to disease at PoEs in Uganda. As human and animal movement continues to increase across borders, the risk of disease importation and exportation will similarly increase. Targeted efforts are required to strengthen international communication linkages, develop emergency response plans, and establish infrastructure, equipment, and personnel for the assessment, isolation, and quarantine of humans and animals.