Atypical hyperendemicity of Rift Valley fever in Southwestern Uganda associated with the rapidly evolving lineage C viruses

Introduction. Recent Rift Valley fever (RVF) epidemiology in eastern Africa region is characterized by widening geographic range and increasing frequency of small disease clusters. Here we conducted studies in southwestern (SW) Uganda region that has since 2016 reported increasing RVF activities. Methods. A 22-month long hospital-based study in three districts of SW Uganda targeting patients with acute febrile illness (AFI) or unexplained bleeding was followed by a cross-sectional population-based human-animal survey. We then estimated RVFV force of infection (FOI) and yearly cases using the age-structured seroprevalence data and conducted genomic phylodynamic modelling of RVFV isolates. Results. Overall RVF prevalence was 10.5% (205 of 1,968) among febrile or hemorrhagic cases, including 5% with acute (PCR or IgM positive) infection, averaging 5 cases per month. Community-based serosurvey recorded prevalence of 11.8% (88 of 743) among humans and 14.6% (347 of 2,383) in livestock. Expected yearly human RVF cases were 314-2,111 per 1,369 km2 in SW Uganda versus 0-711 in comparable regions of Kenya and Tanzania. Viral genomic studies identified RVFV lineage C, sub-clade C.2.2, as the circulating strain in SW Uganda since 2019. Lineage C strain has undergone recent rapid evolution and clonal expansion resulting in four sub-clades, C.1.1, C.1.2, C.2.1, and C.2.2, that are more adept at establishing endemicity in new territories. Conclusions. We demonstrate an atypical RVF hyperendemic region in SW Uganda characterized by sustained human clinical RVF cases, unusually high population prevalence, and high number of expected yearly human cases, associated in part with emergence of new RVFV sub-lineages.