My Fellowshi owship p Achievements nts Lilian Bulag age, BSTB, - - PowerPoint PPT Presentation

Public Health Fellowship Program – Field Epidemiology Track

My Fellowshi

• wship

p Achievements nts

Lilian Bulag age, BSTB, MHSR Fellow

• w, Cohor

hort 2015 15

2

My Fellowship Achievements

Host st Site: e: Central Public Health Laboratories es

• Mandate

ated

– Provide stewa wardship for the National Health Laboratory Netwo work – Technical focal point for laboratory Services in Ministry of Health

3

My Fellowship Achievements

Public Health Emerge gency Invest estigat gations s Led

• Cholera

ra Outb tbre reak ak investi tigati ation,

• n, Bwihk

hkong

• nge,

, Bulam ambul uli, , 2016 2016

• Measles outbre

reak ak in a refugee popul ulat ation:

• n: Rwam

amwanj anja Refugee Settl tlement, nt, 2015

• Rapid Health

th Assessment nt of Newly Arriving ng Refug ugees at Rwamwanj anja Settl tlement nt, 2015 15

• Rapid Assessment

nt of Suspecte ted Measles Outb tbre reak ak at Rwamwanj anja Primary ary Schoo hool, 2015 15

4

My Fellowship Achievements

Mentored ed by CDC Direc ector-Dr Thoma mas Fried eden en

https://www.cdc.gov

• v/glob
• ba

lhealth/ h/he heal althp thprote

• tecti

tion/

• n/fe

tp/stor tories/ug ugand anda-fetp tp- mentor

• ring

ng-bul ulag age.htm html

5

My Fellowship Achievements

Public Health Emerge gency Invest estigat gations s Participated ed in

• Measles outbre

reak ak investigati tion,

• n, Kamwenge, 2015

15

• Typhoi

hoid Fever r outb tbre reak ak investi tigati ation

• n in Kampal

ala, a, 2015

6

My Fellowship Achievements

Epidemi emiologi gical Studies: es: Lead Invest estiga gator

• Risk factors
• rs assoc
• ciate

ated with th typhoi hoid intesti tinal al perfora

• rati

tions

• ns

during a large outb tbre reak ak of typhoi hoid fever, r, Kampal ala a Ugand nda, 2015 2015

7

My Fellowship Achievements

Public Health Survei eillance

• Typhoi

hoid outb tbre reak ak verificati ation,

• n, Lyanto

ntond nde and Rakai ai Distr tricts ts, 2015 2015

• Evaluat

uated the labora

• ratory
• ry respons

nse to the 2015 5 typhoi hoid

• utbre

reak ak in Kampal ala

• Descripti

tive analysis of viral load ad surv rveillan ance data a (Augus ust t 2014 2014-Jul uly 2015 15)

• Conduc

ucte ted a follow

• w up stud

udy;

– Factors Affecting Quality of Care for Virologically Non-suppressed HIV+ Patients, Jinja, , Buikwe we and Iganga Districts

8

My Fellowship Achievements

Scien entifi fic Comm mmunication-Confer feren ence e Presen sentations

• Facto

tors Assoc

• ciat

ated with th Virol

• log
• gical

al Non-sup uppre ression

• n among

ng HIV+ + Patients nts on ART , Uganda, a, Aug 201 014-Jul 201 015

– National Field Epidemiological Conference (NF NFEC) C) 2015 – 6th

th AFENE

NET T Scientific Conference, Abuja, Nigeria

• Rapid Assessment

nt of Health h Statu atus of Newly Arriving ng Refug ugees at Rwamwanj anja -JASH SH 2015 15

9

My Fellowship Achievements

Scien entifi fic Comm mmunication-Confer feren ence e Presen sentations

• Facto

tors Affecti ting Qual ality ty of Care re for Virol

• log
• gical

ally Non- suppressed HIV+ V+ pati tients nts, Jinja, , Buikwe and Igang nga Distr tricts ts- 2nd

nd NFEC

EC

• Modifiab

able Risk Fac actor tors for Typho hoid Inte testi tinal nal Perfor

• rati

ations ns During ng a Large Outb tbre reak ak of Typho hoid Fever r -10t 0th h Inte ternat national nal Confere renc nce on Typhoi hoid and Othe her r Invas asive Salmone

• nellos
• ses

10

My Fellowship Achievements

Scien entifi fic Comm mmunication-Manusc scripts

• First

t author hor;

– Factors Associated with Virological non- Suppression among HIV Patients on ART RT, Uganda, Aug 2014-Jul 2015-Submitted to BMC C Infectious Diseases – Modifiable Risk Factors for Ty Typhoid Intestinal Perforations During a Large Outbreak of Ty Typhoid Fever, Kampala Uganda, 2015- Submitted to BMC C Infectious Diseases

11

My Fellowship Achievements

Scientific c Communica cation-Manuscripts

• 2nd

nd author

hor;

– A large and persistent outbreak of typhoid fever caused by consuming contaminated water and street-vended beverages: Kampala, Uganda, Jan – Jun 2015-Published in BMC C Public Health – Factors contributing to Measles Tr Transmission during an Ou Outbreak in Kamwenge District, April to August 2015-Submitted to BMC C Public Health

• Co

Co-aut author hor for r the Measles outb tbre reak ak investi tigati ation n case stud udy, Kamweng nge distr trict

12

My Fellowship Achievements

Scien entifi fic comm mmunication-New ewspaper er articles es

• Antimicrob
• bial

al resistanc ance: One of the greate test challeng nges to global al public health th

• Uganda

a makes more stri rides in the health th labora

• ratory
• ry sector

tor

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My Fellowship Achievements

Scien entifi fic comm mmunication-Articles es in MoH Quarter erly Epidemi emiologi gical Bullet etin

• Overview of the labor
• rato

atory respons

• nse to 201

015 5 typhoi

• id
• utbre

reak ak, Kampal ala, a, Ugand nda

• Risk factor
• rs associat

ated with h typho hoid intesti tinal nal perfor

• rati

ations ns during a large outb tbre reak ak of typhoi hoid, Kampal ala, a, Ugand nda, a, 201 015

• HIV Viral

al Load Sample Delivery Times, Rejecti tion

• n Rate

tes and Results ts Dispatc atch h Turna rnaround

• und Time, Ugand

nda, a, Aug 201 014-Jul ul 201 015

14

My Fellowship Achievements

Leader ersh ship and Manage gement ent

• Member

r of the team that t wrote

• te draf

aft t 0 of CPHL/UNHLS S 2015 2015-202 020 0 strat rategic plan an

• Led the team that

t wrot

• te 2015

5 Microb robiol

• log
• gy Laborat

ratory

• ry

Annual al Report rt

• Coord

rdina nate ted the writing ng of monthl thly, quart arterl rly M and E report rts for r viral al load ad and early infant ant diagnos nosis units ts, 2015 15, 2016 2016

15

My Fellowship Achievements

Leader ersh ship and Manage gement ent

• Member

r of the team that t develop

• ped;

– Bio-safety and bio-risk training curriculum and manual – Bio-safety and bio-risk health facility baseline assessment tools – Review w of the National Health Laboratory Test Menu – Operational plan for shifting of CPHL to Butabika

16

My Fellowship Achievements

Leader ersh ship and Manage gement ent

• Mentor

r and trai aine ner for r the Fron

• ntl

tline FETP

• Member

r of the National

• nal Rap

apid Respons

• nse Team

am

17

My Fellowship Achievements

Sub-Editor-Uga ganda National Quarter erly Epidemi emiologi gical Bullet etin

Public Health Fellowship Program – Field Epidemiology Track

Modif ifiabl iable Risk Factors for Typhoid id Inte testina tinal l Perforatio ations During ng a Large Outbr break ak of Typho hoid d Fever: : Kampala, ala, Uganda da, , 2015

Lilian Bulage, BSTB, MHSR Fellow

• w, Cohor
• rt 2015

19

My Fellowship Achievements

Increase in number of intestinal perforations (IPs) during the 2015 Typhoid Outbreak

100 200 300 400 500 600 700

01-Jan-15 01-Feb-15 01-Mar-15 01-Apr-15 01-May-15 01-Jun-15

Increa ease e in IPs noted ed by surge geons

Ty Typhoid id cases Date of onset

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My Fellowship Achievements

Objecti ctive ves

• Ascertain if there was an increase in intestinal perforations
• Identify modifiable risk factors for Typhoid Intestinal Perforations (TI

TIPs) during the outbreak

• To inform prevention and control measures

21

My Fellowship Achievements

Definitions

• Non-traumatic

c IP: Onset of physici cian-diagnos

• sed perfor
• ration
• n

in any part of the intestine of a patient who did not have a rece cent trauma or injury that could explain the perfor

• ration
• n
• TIP case: Onset of non-traumatic

c IP in the terminal ileum of a physici cian-diagnos

• sed typhoi
• id patient

Perfor

• rat

ation

• n in

termina nal ileum um

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My Fellowship Achievements

Definitions

• Other perforations: Onset of non-traumatic

c IP that occurred in region

• ns other than the terminal ileum or otherwise did not

meet the definition

• n of a T

TIP

• Control: A resident of Kampala City diagnosed with typhoid fever during

the outbreak but without IP

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My Fellowship Achievements

Extracte cted data from theatre registers and case files, 2013-2015 2015

• Conduc

ucte ted d at 5 major hospitals itals withi hin n Kampala ala:

– Mulago

• NRH, Naguru RRH, Nsambya, Mengo,
• , and

Rubaga Hospitals

• Extrac

acte ted d data from theatr tre registe ters and case files to identif tify IPs, , TIPs, , and other IPs, , 2013-2015

• Variab

ables considere red:

– Socio-demographic factors; – Clinical information – Knowl wledge about typhoid fever and 2015 typhoid fever outbreak

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My Fellowship Achievements

Indivi vidually match ched case-co control study y

• Matche

hed by age (±5 years), sex and Division

• n (Count
• unty) of

residenc nce

• Case-cont
• ntrol

rol ratio:

• : 1 : 3
• Performe

rmed face to face and phone

• ne inte

terv rviews

• Conditi

tional

• nal logistic regression
• n used to cater

r for stud udy design

25

My Fellowship Achievements

Intest estinal perfo forations sharply increa eased ed, Jan - Mar 2015 15

5 10 15 20 25 30 1000 2000 3000 4000 5000 6000 7000 Jan-13 Jul-13 Jan-14 Jul-14 Jan-15 Jul-15

TIPs

Other IPs Typhoid cases

Typhoid id cases es

Intestinal nal perfor

• rat

ations

• ns

26

My Fellowship Achievements

Risk sk for devel eloping g TIP was s 6.6/1000 000 infec fections

• Outbre

reak ak resul ulte ted into

• 10,23

230 0 typhoi hoid cases

• 68 cases of TIPs identi

ntified duri ring ng outb tbre reak ak peri riod

• d
• 70 cases of other

r IPs identi ntified duri ring outb tbreak ak period

• d
• Risk for develop
• ping

ng TIP was 6.6 6 (68/10 10,23 230) 0) per 1000 00 infecti tions

• ns

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My Fellowship Achievements

Case fatality rate was 10%

• 7/68 TIP cases died
• Case fatali

ality ty rate 10%

28

My Fellowship Achievements

Soci cio-demographic and clinical characte cteristics

• f cases and controls

Charact cter eris istic ic % TIP cases es (N=50) %Controls ls (N=145) P-Valu lue Gender er Male 86 86 87 87 0.87 Female le 14 14 13 13 Mean age ge(±SD) 28( 28(±8.4) 28(9.0) 0.96

• No. of clin

linics ics vis isit ited ed bef efore 32 32 26 26 0.51 1 50 50 57 57 2 13 13 14 14 3 3 3 4 3

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My Fellowship Achievements

Significant modifiable risk k facto ctors for TIPs

Variable le % of TIP cases es (N=45) % of controls ls (N=137) OR ORadj (95% CI) Days bef efore e see eekin ing g trea eatmen ent 0-3 4-9 10+ 29 42 29 63 32 5.1 Ref 2.2(0.83-5.8) 11(1.9-61) 61) Heard of typhoid id outbrea eak in Kampala la Yes No 41 59 75 25 Ref 5.2(1.8-15) Got trea eatmen ent bef efore No Yes 45 96 77 23 Ref 9.0(1.1-78)

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My Fellowship Achievements

Limitations

• Some of the contr

trols were only TUBEX X TF-po positi itive rather than cultur ure-conf nfir irmed

• Recall

ll bias

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My Fellowship Achievements

Conclusi sions

• Outbre

reak ak of intesti tinal nal perforat rations ns occur urre red concurr urrentl ntly with th the 2015 5 typhoi hoid fever r outbre reak ak

• Delay in seeking

ng care and having ng got treatme atment nt before

• re going

ng to the treatme tment nt cente ters rs incre reas ased the risk for TIPs

32

My Fellowship Achievements

Recommend mendations

• Aggressive communi

nity ty case-find nding ng for early and approp ropriate ate treatme tment nt

• Streng

ngthe thening ng heal alth th educati ation

• n about
• ut typhoi

hoid fever r and TIPs and their r preventi ntion n duri ring ng future ure typhoi hoid outbre reak aks

33

My Fellowship Achievements

Acknowled edge gemen ment

• MoHealth, Uganda
• US CDC
• Public Health Fellows

wship Program

• Makerere School of Public Health
• Mulago, Naguru, Mengo, Rubaga and

Nsambya Hospitals

• Iganga,

, Buikwe we, and Jinja districts

• Mentors: Aisu Stephen, Isaac Ssewa

wanyana, , Charles Kiyaga, , Atek Kagirita, Dr. Henry Kajumbula &

• Dr. Victoria Nankabirwa

wa