My Fellowship Achievements My Fellowship Achievements Scientific Communication-Manuscripts 2nd author; –A large and persistent outbreak of typhoid fever caused by consuming contaminated

Public Health Fellowship Program – Field Epidemiology Track

My Fellowship Achievements

Lilian Bulage, BSTB, MHSR

Fellow, Cohort 2015

2


Host Site: Central Public Health Laboratories

Mandated

– Provide stewardship for the National Health Laboratory Network

– Technical focal point for laboratory Services in Ministry of Health

3


Public Health Emergency Investigations Led

Cholera Outbreak investigation, Bwihkonge, Bulambuli,

2016

Measles outbreak in a refugee population: Rwamwanja

Refugee Settlement, 2015

Rapid Health Assessment of Newly Arriving Refugees at

Rwamwanja Settlement, 2015

Rapid Assessment of Suspected Measles Outbreak at

Rwamwanja Primary School, 2015

4


Mentored by CDC Director-Dr Thomas Frieden

https://www.cdc.gov/globa

lhealth/healthprotection/fe

tp/stories/uganda-fetp-

mentoring-bulage.html

5


Public Health Emergency Investigations Participated in

Measles outbreak investigation, Kamwenge, 2015

Typhoid Fever outbreak investigation in Kampala, 2015

6


Epidemiological Studies: Lead Investigator

Risk factors associated with typhoid intestinal perforations

during a large outbreak of typhoid fever, Kampala Uganda,

2015

7


Public Health Surveillance

Typhoid outbreak verification, Lyantonde and Rakai Districts,

2015

Evaluated the laboratory response to the 2015 typhoid

outbreak in Kampala

Descriptive analysis of viral load surveillance data (August

2014-July 2015)

Conducted a follow up study;

– Factors Affecting Quality of Care for Virologically Non-suppressed

HIV+ Patients, Jinja, Buikwe and Iganga Districts

8


Scientific Communication-Conference Presentations

Factors Associated with Virological Non-suppression among

HIV+ Patients on ART , Uganda, Aug 2014-Jul 2015

– National Field Epidemiological Conference (NFEC) 2015

– 6th AFENET Scientific Conference, Abuja, Nigeria

Rapid Assessment of Health Status of Newly Arriving

Refugees at Rwamwanja -JASH 2015

9


Scientific Communication-Conference Presentations

Factors Affecting Quality of Care for Virologically Non-

suppressed HIV+ patients, Jinja, Buikwe and Iganga

Districts- 2nd NFEC

Modifiable Risk Factors for Typhoid Intestinal Perforations

During a Large Outbreak of Typhoid Fever -10th International

Conference on Typhoid and Other Invasive Salmonelloses

10


Scientific Communication-Manuscripts

First author;

– Factors Associated with Virological non- Suppression among HIV

Patients on ART, Uganda, Aug 2014-Jul 2015-Submitted to BMC

Infectious Diseases

– Modifiable Risk Factors for Typhoid Intestinal Perforations During a

Large Outbreak of Typhoid Fever, Kampala Uganda, 2015-

Submitted to BMC Infectious Diseases

11


Scientific Communication-Manuscripts

2nd author;

– 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 Public Health

– Factors contributing to Measles Transmission during an Outbreak in

Kamwenge District, April to August 2015-Submitted to BMC Public

Health

Co-author for the Measles outbreak investigation case study,

Kamwenge district

12


Scientific communication-Newspaper articles

Antimicrobial resistance: One of the greatest challenges to

global public health

Uganda makes more strides in the health laboratory sector

13


Scientific communication-Articles in MoH Quarterly

Epidemiological Bulletin

Overview of the laboratory response to 2015 typhoid

outbreak, Kampala, Uganda

Risk factors associated with typhoid intestinal perforations

during a large outbreak of typhoid, Kampala, Uganda, 2015

HIV Viral Load Sample Delivery Times, Rejection Rates and

Results Dispatch Turnaround Time, Uganda, Aug 2014-Jul

2015

14


Leadership and Management

Member of the team that wrote draft 0 of CPHL/UNHLS

2015-2020 strategic plan

Led the team that wrote 2015 Microbiology Laboratory

Annual Report

Coordinated the writing of monthly, quarterly M and E

reports for viral load and early infant diagnosis units, 2015,

2016

15



Member of the team that developed;

– Bio-safety and bio-risk training curriculum and manual

– Bio-safety and bio-risk health facility baseline assessment tools

– Review of the National Health Laboratory Test Menu

– Operational plan for shifting of CPHL to Butabika

16



Mentor and trainer for the Frontline FETP

Member of the National Rapid Response Team

17


Sub-Editor-Uganda National Quarterly Epidemiological

Bulletin

Public Health Fellowship Program – Field Epidemiology Track

Modifiable Risk Factors for Typhoid Intestinal

Perforations During a Large Outbreak of Typhoid

Fever: Kampala, Uganda, 2015

Lilian Bulage, BSTB, MHSR

Fellow, Cohort 2015

19


Increase in number of intestinal perforations

(IPs) during the 2015 Typhoid Outbreak

0

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

Increase in IPs

noted by surgeons

Typhoid cases

Date of onset

20


Objectives

Ascertain if there was an increase in intestinal perforations

Identify modifiable risk factors for Typhoid Intestinal Perforations (TIPs)

during the outbreak

To inform prevention and control measures

21


Definitions

Non-traumatic IP: Onset of physician-diagnosed perforation

in any part of the intestine of a patient who did not have a

recent trauma or injury that could explain the perforation

TIP case: Onset of non-traumatic IP in the terminal ileum of a

physician-diagnosed typhoid patient

Perforation in

terminal ileum

22


Definitions

Other perforations: Onset of non-traumatic IP that occurred in

regions other than the terminal ileum or otherwise did not

meet the definition of a TIP

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

the outbreak but without IP

23


Extracted data from theatre registers and case

files, 2013-2015

Conducted at 5 major hospitals within Kampala:

– Mulago NRH, Naguru RRH, Nsambya, Mengo, and

Rubaga Hospitals

Extracted data from theatre registers and case files

to identify IPs, TIPs, and other IPs, 2013-2015

Variables considered:

– Socio-demographic factors;

– Clinical information

– Knowledge about typhoid fever and 2015 typhoid fever outbreak

24


Individually matched case-control study

Matched by age (±5 years), sex and Division (County) of

residence

Case-control ratio: 1 : 3

Performed face to face and phone interviews

Conditional logistic regression used to cater for study design

25


Intestinal perforations sharply increased,

Jan - Mar 2015

0

5

10

15

20

25

30

0

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 cases

Intestinal perforations

26


Risk for developing TIP was 6.6/1000 infections

Outbreak resulted into 10,230 typhoid cases

68 cases of TIPs identified during outbreak period

70 cases of other IPs identified during outbreak period

Risk for developing TIP was 6.6 (68/10,230) per 1000

infections

27


Case fatality rate was 10%

7/68 TIP cases died

Case fatality rate 10%

28


Socio-demographic and clinical characteristics

of cases and controls

Characteristic % TIP cases

(N=50)

%Controls

(N=145)

P-Value

Gender

Male 86 87 0.87

Female 14 13

Mean age(±SD) 28(±8.4) 28(9.0) 0.96

No. of clinics visited before

0 32 26 0.51

1 50 57

2 13 14

3 3 3

4 3 0

29


Significant modifiable risk factors for TIPs

Variable % of TIP cases

(N=45)

% of controls

(N=137)

ORadj

(95% CI)

Days before seeking treatment

0-3

4-9

10+

29

42

29

63

32

5.1

Ref

2.2(0.83-5.8)

11(1.9-61)

Heard of typhoid outbreak in

Kampala

Yes

No

41

59

75

25

Ref

5.2(1.8-15)

Got treatment before

No

Yes

45

96

77

23

Ref

9.0(1.1-78)

30


Limitations

Some of the controls were only TUBEX TF-positive

rather than culture-confirmed

Recall bias

31


Conclusions

Outbreak of intestinal perforations occurred concurrently with

the 2015 typhoid fever outbreak

Delay in seeking care and having got treatment before going

to the treatment centers increased the risk for TIPs

32


Recommendations

Aggressive community case-finding for early and appropriate

treatment

Strengthening health education about typhoid fever and TIPs

and their prevention during future typhoid outbreaks

33


Acknowledgement

MoHealth, Uganda

US CDC

Public Health Fellowship Program

Makerere School of Public Health

Mulago, Naguru, Mengo, Rubaga and

Nsambya Hospitals

Iganga, Buikwe, and Jinja districts

Mentors: Aisu Stephen, Isaac Ssewanyana,

Charles Kiyaga, Atek Kagirita, Dr. Henry

Kajumbula &

Dr. Victoria Nankabirwa

My Fellowship Achievements My Fellowship Achievements Scientific Communication-Manuscripts 2nd author; –A large and persistent outbreak of typhoid fever caused by consuming contaminated

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