My Fellows wshi hip Achi hievem evements nts Benon n Kwesiga - - PowerPoint PPT Presentation

Public Health Fellowship Program – Field Epidemiology Track

My Fellows wshi hip Achi hievem evements nts

Benon n Kwesiga a MBChB, MPH PHFP Fellow Cohort t 2015

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My Fellow

• wshi

hip Achi hievement nts

• Mandate

– To provide ide quality ity and timely ly health-relate lated d informatio ation n to all stakeho hold lders – To enable le performan ance based d decisio ion n making ng at all levels of the health h sector

Host Site: MoH - Divi vision of Health Information

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My Fellow

• wshi

hip Achi hievement nts

Public Health Surve veillance ce

• Weekly

ly analysis is of Integrate ated d Diseas ase Surveil illan lance and Respo ponse (IDSR) data

– HMIS timeliness and completeness of District cts – Cases and deaths of prior

• rity IDSR diseases

– Data cleaning

• Descriptiv

iptive analysis of Uganda’s eMTCT surveillance data a in DHIS2 (2012-2015)

– Great improv

• vement in eMTCT indica

cator

• rs

– Consistently low male involvement in eMTCT

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My Fellow

• wshi

hip Achi hievement nts

Response to Public c Health Emergenci cies

• Led outbreak

k responses

– Communi nity ty - wide Cholera outbr break ak in Kasese – Organo nopho phosph phate ate poisoni ning ng after eating ng chapati in Tororo

• Partici

cipated in other outbreak k responses

– Typhoid id in Kampal ala – Typhoid id verific icatio ation n in Rakai ai & Lyanto tonde nde – Cholera a – In Kasese and Sironk nko – Yellow fever in various us distric icts ts

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My Fellow

• wshi

hip Achi hievement nts

Epidemiologica cal study

• VHT functio

tional nality ty and adherenc nce to requirements nts of Communi nity ty Based d Surveil illa lanc nce (CBS) in Kasese – VHTs do not adequa uate tely ly follo low CBS guideli line nes – VHTs are not properly ly recruite ited, , traine ned or supervise ised – CBS improves when VHTs are properly ly suppo porte ted d by Development nt Partne ners

• Findings were disseminated to Kasese DHT

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My Fellow

• wshi

hip Achi hievement nts

Scientific c Communica cation

• Presente

nted d at AFENET Conferenc nce in Abuja, a, 2016

– Organop

• phos
• sphate poison
• ning after eating chapati
• Presente

nted d at JASH/Natio ational nal Field d Epidemio iolo logy Conferenc nces

– Community-wide cholera outbreak, k, Kasese

• 3

3 article les in MoH UNIPH quarte terly ly Epibu bull lletin tin

• Newspape

paper artic icle le – Role of safe water provisio ision n in preventing ting diarrho hoeal al diseas ase outbreak aks

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My Fellow

• wshi

hip Achi hievement nts

Publications

• Main

n autho hor

– A A Prolon

• nged, Community-Wide Cholera Outbreak

k Assoc

• ciated with Drinki

king Water Contaminated by Sewage in Kasese, Uganda, 2015

• Co

Co-autho uthor

– Cholera Outbreak k Caused by Drinki king Contaminated Water from a Lakeshor

• re Water-Col
• llect

ction

• n Site, Kasese

– Case study - Cholera Outbreak k in a Fishing Village in Uganda – Typhoi

• id outbreak

k in Kampala

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My Fellow

• wshi

hip Achi hievement nts

Leadership and Management

• Upon

n being traine ned, d, I train ined d Distr tric ict t level health h workers in:

– District ct Health Infor

• rmation
• n System 2

– IDSR

• Ensur

ured d routine tine and timely analy lysis is of weekly IDSR data a and train ined d other fellows

• Traine

ned Cohort t 2016 fellows on analysis of surveil illan lance data a

• Traine

ned health th workers on yellow fever surveil illan lance

Public Health Fellowship Program – Field Epidemiology Track

Food Poisoni ning ng after er Eating ng Chapatti Contam aminat nated d with Orga gano nopho phosphat hate, Uganda anda, Octobe ber r 2015

• Dr. Benon Kwesiga, MBChB, MPH

Fellow

• w, Cohor
• rt 2015

10

Food Poi

• isoni
• ning

ng after eat ating ng chap hapat ati

Location of affecte cted area – Mukuju Sub-Co County

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Food Poi

• isoni
• ning

ng after eat ating ng chap hapat ati

Organophosphate Poisoning in Uganda

• Common

n occur urrenc nce

• Cases are usuall

lly suicidal idal/ho homic icid idal al

• Easy access to organo

nopho phospha phate tes from animal l drug shops ps

• Uses

– Pestici cides in most homes – Indoo

• or Residual Spraying against mosquitoe
• es

– Agricu cultural farms

12

Food Poi

• isoni
• ning

ng after eat ating ng chap hapat ati

Initial alert 3 students reported dead in a few w hours

• 3

3 stude dents nts became severely ly ill and died after eating ng chapatti

• Other peopl

ple also fell ill

• n the same day
• They had eaten

n chapatt tti from the same food-sta tand nd

Chapat atti

1

2

13

Food Poi

• isoni
• ning

ng after eat ating ng chap hapat ati

Objecti ctive ves

• To ascertain

tain the cause of illness and death

• To guide contr

trol & preventio tion n measures

14

Food Poi

• isoni
• ning

ng after eat ating ng chap hapat ati

Case definition

• Suspecte

ted d case

– Onset of confusion, vomiting, excessive sweating in a resident of Mukuju from 24-30/October/2015

• Probable

able case

– Onset of foaming of saliva or low blood pressure or loss of consciousness or constricted pupils

• Confirmed

d case

– Any suspected/Probable case with confirmed toxicological or post-mortem results of organophosphate poisoning

15

Food Poi

• isoni
• ning

ng after eat ating ng chap hapat ati

Case finding

• Medical

al records ds reviewed

• Conduc

ucte ted d communi nity ty intervie iews among

– Survivor

• rs

– Health worke kers – School

• l Administrator
• rs

– Police Offic ficers

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Food Poi

• isoni
• ning

ng after eat ating ng chap hapat ati

Clinica cal, , laboratory y and autopsy inve vestigations

• Patient

nt records ds - clinic ical l investig tigatio ation/ n/mana anagement nt

– To aid in verifying the diagnos

• sis

– To classify the cases

• Autopsy results

ts follo lowed d up with h Polic ice

– To identify cause of death

• Environm

nmental tal sample les collecte ted & tested

– To identify the implica cated chemica cal(s) in the chapatti

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Food Poi

• isoni
• ning

ng after eat ating ng chap hapat ati

7 people were affecte cted

Level of case definition Case count Suspected 7 Probable 5 Confirmed by autopsy 3

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Food Poi

• isoni
• ning

ng after eat ating ng chap hapat ati

Characte cteristics of cases (N=7)

Characteristic Frequency % Sex Male 6/7 86 86 Female 1/7 14 14 Residing in Mukuju village 7/7 100 Hospitalised (admitted) 4/7 57 57 Case Fatality Rate 3/7 43 43 Age: Mean = 24 years (20-32)

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Food Poi

• isoni
• ning

ng after eat ating ng chap hapat ati

Clinica cal signs/sym ymptoms consistent with

• rganophosphate poisoning (N=7)

7 7 4 3 3 3 3 2 4 6 8 10 Profuse sweating Confusion Diarrhea Constricted pupils Frothing of saliva Low blood pressure Vomitting blood Cases Symptoms

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Food Poi

• isoni
• ning

ng after eat ating ng chap hapat ati

Flow w of events 30th

th Oct 2015

Chapattis sold with no problem ems Studen ents referre erred to Mukuju HC IV but worsen ened ed

12 hrs 13 14 15 16 17 18 19 20 21 22 23 24

4 studen ents ate chapattis & developed ed symptoms immediatel ely. 1 ate only part of chapatti Refer erred red to Tororo ro Hospital 3 die within 24 hours post hospitalisation Studen ent who ate e part of chapatti recovered ered

4 hours

21

Food Poi

• isoni
• ning

ng after eat ating ng chap hapat ati

Cases clustered around the chapatti vending point

Chapatti point Mukuju HC IV ≈2km Cases Mukuju Primary Teacher’s

0.25 0.5 1.0km

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Food Poi

• isoni
• ning

ng after eat ating ng chap hapat ati

Autopsy findings consistent with

• rganophosphate poisoning
• Gross gastroin

inte testina tinal l infla lammatio ation n

– Suggested ingestion

• n as primary route of expos
• sure

– Stron

• ng organop
• phos
• sphate smell in gut contents
• Evidenc

nce of multiple iple organ n failur lure

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Food Poi

• isoni
• ning

ng after eat ating ng chap hapat ati

Samples of chap apatt atti and wheat flour contained

• rganophosphate
• Sample

les of chapatt atti and flour ur collecte ted d

• Sent to Ugand

nda a Analytic tical al Lab ab

• Testin

ing confir irmed organo nopho phospha phate te contam tamin inatio ation

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Food Poi

• isoni
• ning

ng after eat ating ng chap hapat ati

Further Police ce inquiry y reve vealed intentional contamination

• Sometim

times people le would ld bring ng their own flour ur to the vendor to make for them chapatti

• One person

n broug ught t flour ur laced d with h OP to make chapatis for a specif ific family ly (Domesti tic conflic icts ts)

• Chapatti vendor unkno

nowing ngly ly mixed up the chapatti

• Poisone

ned d chapatti ended up being eaten by random people le

• Culprit

t arreste ted d and currentl ntly in prison

25

Food Poi

• isoni
• ning

ng after eat ating ng chap hapat ati

Summary y of key y findings

• Chapatti were contam

tamin inate ated d with organo nopho phosph phate ate

– Community interviews – Clinica cal investigation

• ns

– Autopsy findings – Testing of environ

• nmental samples
• We demonst

nstrate ated a dose response relatio tionshi nship p

– Did not eat chapatti - No symptom

• ms

– Ate part of chapatti - Mild symptom

• ms

– Ate whole chapa patti i - More severe symptom

• ms (died)

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Food Poi

• isoni
• ning

ng after eat ating ng chap hapat ati

Concl clusions

• Illne

ness was caused d by eating ng chapatti contam tamin inate ated d with h organo anopho hosphate phate

• Flour

ur was intentio ntionall ally contam tamin inate ated

• Delay at the lower level facili

lity ty worsene ned progno nosis is

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Food Poi

• isoni
• ning

ng after eat ating ng chap hapat ati

Public c health actions take ken & policy y implications

– Chapatti vending point shut down immediately – Retrained health worke kers on early diagnos

• sis & referral

– We recom

• mmended more stringent control
• l measures on

pestici cides access and storage

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Food Poi

• isoni
• ning

ng after eat ating ng chap hapat ati

Ackn knowl wledgements

• Host Mentor
• rs: Dr Eddie Mukoo
• oyo,

, John Kisa, Carol

• l Kyozira
• Academic

c Mentor

• r: Assoc
• c. Prof.

Nazarius M M Tumwesigye

• MoH
• US CDC
• PHFP Secretariat
• Toror
• ro
• DHT & police

ce

• Mukuju community members
• Other 2015 Fellow
• ws

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Food Poi

• isoni
• ning

ng after eat ating ng chap hapat ati

Thank you