Sudan virus disease super-spreading, Uganda, 2022
Authors: Komakech Allan , Whitmer Shannon , Izudi Jonathan , Kizito Charles , Ninsiima Mackline , Ahirirwe Sherry R. , Kabami Zainah , Ario Alex R. , Kadobera Daniel , Kwesiga Benon , Gidudu Samuel , Migisha Richard , Makumbi Issa , Eurien Daniel , Kayiwa Joshua , Bulage Lilian , Gonahasa Doreen N. , Kyamwine Irene , Okello Paul E. , Nansikombi Hildah T. , Atuhaire Immaculate , Asio Alice , Elayeete Sarah , Nsubuga Edirisa J. , Masanja Veronica , Migamba Stella M. , Mwine Patience , Nakamya Petranilla , Nampeera Rose , Kwiringira Andrew , Akunzirwe Rebecca , Naiga Helen Nelly , Namubiru Saudah K. , Agaba Brian , Zalwango Jane Frances , Zalwango Marie Gorreti , King Patrick , Simbwa Brenda Nakafeero , Zavuga Robert , Wanyana Mercy Wendy , Kiggundu Thomas , Oonyu Lawrence , Ndyabakira Alex , Komugisha Mariam , Kibwika Brian , Ssemanda Innocent , Nuwamanya Yasin , Kamukama Adams , Aanyu Dorothy , Kizza Dominic , Ayen Daniel Okello , Mulei Sophia , Balinandi Stephen , Nyakarahuka Luke , Baluku Jimmy , Kyondo Jackson , Tumusiime Alex , Aliddeki Dativa , Masiira Ben , Muwanguzi Esther , Kimuli Ivan , Bulwadda Daniel , Isabirye Herbert , Aujo Deborah , Kasambula Arthur , Okware Solome , Ochien Emmanuel , Komakech Innocent , Okot Charles , Choi Mary , Cossaboom Caitlin M. , Eggers Carrie , Klena John D. , Osinubi Modupe O. , Sadigh Katrin S. , Worrell Mary C. , Boore Amy L. , Shoemaker Trevor , Montgomery Joel M. , Nabadda Susan N. , Mwanga Michael , Muruta Allan N. , Harris Julie R. 
Published: May 2024

Abstract
Background
On 20 September 2022, Uganda declared its fifth Sudan virus disease (SVD) outbreak, culminating in 142 confirmed and 22 probable cases. The reproductive rate (R) of this outbreak was 1.25. We described persons who were exposed to the virus, became infected, and they led to the infection of an unusually high number of cases during the outbreak.

Methods
In this descriptive cross-sectional study, we defined a super-spreader person (SSP) as any person with real-time polymerase chain reaction (RT-PCR) confirmed SVD linked to the infection of ≥ 13 other persons (10-fold the outbreak R). We reviewed illness narratives for SSPs collected through interviews. Whole-genome sequencing was used to support epidemiologic linkages between cases.

Results
Two SSPs (Patient A, a 33-year-old male, and Patient B, a 26-year-old male) were identified, and linked to the infection of one probable and 50 confirmed secondary cases. Both SSPs lived in the same parish and were likely infected by a single ill healthcare worker in early October while receiving healthcare. Both sought treatment at multiple health facilities, but neither was ever isolated at an Ebola Treatment Unit (ETU). In total, 18 secondary cases (17 confirmed, one probable), including three deaths (17%), were linked to Patient A; 33 secondary cases (all confirmed), including 14 (42%) deaths, were linked to Patient B. Secondary cases linked to Patient A included family members, neighbours, and contacts at health facilities, including healthcare workers. Those linked to Patient B included healthcare workers, friends, and family members who interacted with him throughout his illness, prayed over him while he was nearing death, or exhumed his body. Intensive community engagement and awareness-building were initiated based on narratives collected about patients A and B; 49 (96%) of the secondary cases were isolated in an ETU, a median of three days after onset. Only nine tertiary cases were linked to the 51 secondary cases. Sequencing suggested plausible direct transmission from the SSPs to 37 of 39 secondary cases with sequence data.

Conclusion
Extended time in the community while ill, social interactions, cross-district travel for treatment, and religious practices contributed to SVD super-spreading. Intensive community engagement and awareness may have reduced the number of tertiary infections. Intensive follow-up of contacts of case-patients may help reduce the impact of super-spreading events.