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Public Health Fellowship Program – Field Epidemiology Track
My Fellowship Achievements
Lilian Bulage, BSTB, MHSR
Fellow, Cohort 2015
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My Fellowship Achievements
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
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My Fellowship Achievements
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
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My Fellowship Achievements
Mentored by CDC Director-Dr Thomas Frieden
https://www.cdc.gov/globa
lhealth/healthprotection/fe
tp/stories/uganda-fetp-
mentoring-bulage.html
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My Fellowship Achievements
Public Health Emergency Investigations Participated in
Measles outbreak investigation, Kamwenge, 2015
Typhoid Fever outbreak investigation in Kampala, 2015
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My Fellowship Achievements
Epidemiological Studies: Lead Investigator
Risk factors associated with typhoid intestinal perforations
during a large outbreak of typhoid fever, Kampala Uganda,
2015
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My Fellowship Achievements
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
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My Fellowship Achievements
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
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My Fellowship Achievements
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
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My Fellowship Achievements
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
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My Fellowship Achievements
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
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My Fellowship Achievements
Scientific communication-Newspaper articles
Antimicrobial resistance: One of the greatest challenges to
global public health
Uganda makes more strides in the health laboratory sector
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My Fellowship Achievements
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
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My Fellowship Achievements
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
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My Fellowship Achievements
Leadership and Management
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
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My Fellowship Achievements
Leadership and Management
Mentor and trainer for the Frontline FETP
Member of the National Rapid Response Team
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
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My Fellowship Achievements
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
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My Fellowship Achievements
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
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My Fellowship Achievements
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
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My Fellowship Achievements
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
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My Fellowship Achievements
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
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My Fellowship Achievements
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
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My Fellowship Achievements
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
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My Fellowship Achievements
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
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My Fellowship Achievements
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
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My Fellowship Achievements
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+
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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)
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My Fellowship Achievements
Limitations
Some of the controls were only TUBEX TF-positive
rather than culture-confirmed
Recall bias
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My Fellowship Achievements
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
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My Fellowship Achievements
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
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My Fellowship Achievements
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