Involve those, who are managing these outbreaks Identifying barriers and facilitators to the implementation of clinical management guidelines for High-Consequence Infectious Diseases in Uganda

Prior research highlighting the complexity of clinical management guidelines (CMG) implementation, has suggested that limited access to treatments and equipment and substantial issues regarding availability, inclusivity, quality, and applicability hinder the implementation of CMGs in Low and Middle Income Countries (LMICs). This in depth case study of Uganda coincidentally occurring during the 2022 Sudan Virus Disease outbreak aimed to explore contextual and supplementary factors which hinder or facilitate CMG development and implementation. Using thematic network analysis the research describes five thematic topics, that emerged from interviews with 43 healthcare personnel, as barriers to the implementation of CMGs in Uganda, namely: (1) deficient content and slow updates of CMGs; (2) limited pandemic preparedness and response infrastructure; (3) slow dissemination and lack of training; (4) scarce resources and healthcare disparities and (5) patient outcomes. The study displays how insufficient training, patchy dissemination and slow updating exacerbate many of the underlying difficulties in LMIC contexts, by illustrating how these issues are related to resource constraints, healthcare disparities, and limited surveillance and referral infrastructure. Key recommendations to enhance CMG implementation are provided, underscoring the necessity of integrating local stakeholders to ensure guidelines are reflective of the reality of the local health system, applicable and inclusive of resource constrained settings, available as living guidance that is disseminated widely and supported by cascading hands-on training. Findings offer valuable insights for LMICs to improve high consequence infectious disease outbreak responses and for organizations involved in guideline development and funding. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement Funding for this work was provided by the Wellcome Trust [215091/Z/18/Z]. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Makerere School of Public Health Research and Ethics Committee (SPH-2022-265), Uganda National Council for Science and Technology (SS1320ES) and the University of Oxford (# 568-21) approved the study. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The datasets generated and analysed for this study can be found at https://osf.io/djv52/?view_only=e8139fa28c404285829b56c638bf7f47