Public Health Fellowship Program – Field Epidemiology Tra ck p Achie ievemen ments ts My Fellowshi hip Dr.Fred Nsubuga, MBChB, B, MPH Fellow, Cohort rt 2015
Host Site-UNEPI NEPI Goal – Ensure that every child and high-risk k grou oup is fully vacci cinated with high quality and effect ctive vacci cines 2 My Fellowship Achievements
Public health surve veillance ce Measle les surveil illan lance data a analy lysis is ; 2012-2015 Traine ned DHTs on surveil illa lanc nce during ng implementatio ntation n of hous use to house polio io campaig ign Evaluatio uation n of AFP surveil illan lance syste tem in Ugand nda 3 My Fellowship Achievements
Response to public c health emergence ce Outbr break ak investig tigatio ations ns – Measles outbreak k in Kamwenge district ct, Western Uganda, 2015 – Typhoi oid verifica cation on exerci cise in Bukwo – Outbreak investigation that assessed “Risk factors for measles death: Kyegegwa District, Western Uganda” – Rapid assessment of a suspect cted measles outbreak k at Rwamwanja primary schoo ool 4 My Fellowship Achievements
Response to public c health emergence ce Outbr break ak investig tigatio ations ns – measles outbreak k investigation on in Rwamwanja refugee settlement – Typhoi oid verifica cation on in Pallisa District ct – Outbreak k of typhoi oid fever in Kampala in 2015 5 My Fellowship Achievements
Epidemiologica cal study Conduc ucte ted d study that t compar ared the proportio tion n of childr dren n reache hed d durin ing stati tic and outreac ach h immuni nizatio ation strate ategies, , Ugand nda Conduc ucte ted d a study dy to assess factors that affect t immuni nizatio ation data a quali lity ty in Kabarole le distr tric ict 6 My Fellowship Achievements
Scientific c communica cation Manus uscript ipt title led: d: Facto tors contr tributin ibuting to measles transmis issio ion n in Kamweng nge Distric ict t – BMC Public ic Health th Co Co-autho uthor in a publi licatio ation n on measle les death in Kyegegwa 2016 – BMC Infectio tious us Health th Journal nal Co Co-autho uthor in a publi licatio ation n on a large typhoid id outbr break ak in Kampala ala – BMC Public ic Health th Co Co-autho uthor in a publi licatio ation n facto tors affectin ting virolo logic ical al non suppr pressio ion among HIV patie ients nts on ART in Uganda da – BMC Infectio tious us diseas ase 7 My Fellowship Achievements
Scientific c communica cation Presente nted d at AFENET Conferenc nce and got an award d as 2 nd nd run-up up Presente nted d at 2 natio iona nal l conferenc nces: : Regional al HIV Conferenc nce and National nal Epide demio iolo logy Conferenc nce Publis ishe hed d 1 artic icle le in MOH quarte terly epidemio iolo logy bulletin tin 1 newspape paper artic icle le in New Visio ion 8 My Fellowship Achievements
Leadership and Management Facili litat tated d a sessio ion on the management nt of measle les outbreak ak for medical al stude dents nts at the College of Health th Sciences, , Makerere University ty Member of TWG that t update ated d Immuniz izatio ation n in Practic tice Manual ual for Uganda da Traine ned Gulu u regional nal teams on polio io end game to prepar are for IPV introduc uctio tion, n, switc tch h and SIAs 9 My Fellowship Achievements
Leadership and Management Natio ional al supervis isor/tr train ainer durin ing the Sub Natio ional nal Immuni nizatio ation n Days for polio io in Lamwo Distric ict Led and coordin dinate ted d the writin ing of natio iona nal l report t on sub-na natio tiona nal l immuni nizatio ation n days, , 2016 Member of the NTF 10 My Fellowship Achievements
End of Fellows wship Achieve vements Director TEPHINET 11 My Fellowship Achievements
Public Health Fellowship Program – Field Epidemiology Tra ck Large ge Outbr break ak of Typho hoid Fever r in Kampa pala, a, Uganda; nda; Januar uary – June 2015 Dr.Fred Nsubuga, MBChB, MPH On behalf of Cohort 2015 Fellows of the Uganda Public Health Fellowship Program – Field Epidemiology Track
Strange disease reported in Kampala Feb 2015 Death of index patient Feb 2nd 3rd 4th 5th 6th 7th 8th 9th 10th Start of investigation Index patient hospitalised Symptoms: • Abdominal pain Reported to city authority • Prolonged fever and MoH • Jaundice 13 Typhoid outbreak
Initial inve vestigation indicated typhoid Docto tor: : Index patie ient nt had severe abdomin inal al pain n and (+) Widal al Test A A hospital pitalise ised patie ient nt had simil ilar ar sympto toms – Many of her colleagues sicke ckened; some died – Her husband had similar symptom oms, took antibiot otics cs and got better Communi nity ty intervie iews and observatio tions ns identif tifie ied d other people le with simila lar sympto toms 14 Typhoid outbreak
Case definition Suspecte ted d case: – Onset of fever ≥5 days since 1/1/2015, not respon onding to antimalarial treatment, in a p person on worki king or living in Kampala – Plus ≥2 of the following: abdominal pain; diarrhea; headach che; nausea/vom omiting; or altered mental state Probabl able case: : Suspe pecte ted d case plus TUBEX X test (+) Confirmed d case: : Suspecte ted case plus Salmone nella Typhi hi (+) from blood d cultur ure 15 Typhoid outbreak
Case finding Active ve case finding in areas where outbreak k had been reported Setting up free treatment centers throughout the city Media outreach ch 16 Typhoid outbreak
Case count 30-Mar-2015 2015 3817 Suspected cases 1033 Probable cases 46 Confirmed cases 17 Typhoid outbreak
1623 cases have been found (as of 12 Mar); Cases Reported throughout Kampala 18 Typhoid outbreak
Demographic c info (as of March ch 30th) Age Mean = 26 (years) Range = 1-79 Sex Male 55.0% Female 45.0% 19 Typhoid outbreak
Epi Curve ve, Suspect ct Typhoid Feve ver Cases meeting the case definition – Kampala, 2014-2015, n = 4,139* 2014 450 400 Death of index patient Number of cases 350 300 250 200 Investigation began 150 100 50 0 20 Date of illness onset *for whom date of illness Typhoid outbreak onset is available
Food-borne or water-borne? Case distr tribut buted d throug ugho hout ut Kampala ala Cases reporte ted d buying ng unbott ttled drink nks at unreas asona nably bly low price Hypoth thesis-gene nerating ating intervie iews: : Patients ts more likely ly to get drinking ing water from workpl plac ace Strong g suspicion of water er-borne e outbrea eak 21 Typhoid outbreak
Case-co control study 33 cases 78 controls Frequency cy-match ched by sex x and place ce of work Info on water and food intake ke 22 Typhoid outbreak
Consuming loca cally made drinks and water associ ciated with disease Usually drank… OR M-H (95% CI) Kaveera water (Y/N) 8.9 (1.6-49) Butunda (Y/N) 4.6 (1.9-11) Obushera (Y/N) 2.8 (0.76-10) Munanansi (Y/N) 2.0 (0.74-5.2) Bottled water and food items were not associated with disease 23 Typhoid outbreak
Butunda Kaveera water 24 Obushera Typhoid outbreak Munanansi
Dose-response # of types of locally made % cases % controls OR (95%CI)* drinks (n=33) (n=78) 0 36 64 1 (Ref) 1 27 26 1.9 (0.68-5.1) 2 15 9 3.0 (0.80-11) 3-4 21 1 29 (3.2-260) *Chi-square test for linear trend: Chi-square =14.65, p = 0.00013 25 Typhoid outbreak
1 2 26 3 4 Typhoid outbreak
Butunda - passion fruit juice 27 Typhoid outbreak
Laboratory y inve vestigation 9 th th April 46 blood d sample les (+) for Salmonella typhi hi by cultur ure All drinks and water heavily contam aminate nated d with faecal al matte ter – 9/9 juice ce samples – 18/20 water samples 28 Typhoid outbreak
Concl clusions Large outbreak ak of typhoid id fever Caused d by consumin ing locall lly made drink nks, , made with h contam tamin inate ated d underground nd water 29 Typhoid outbreak
Public health actions take ken Provide ided d safe water to most heavily ly affecte ted areas Closed d off underground und water sources Health th educatio ation – Drink k only boiled water – Avoid drinki king unclean water and juice ce from marke kets 30 Typhoid outbreak
Public Health Fellowship Program – Field Epidemiology Tra ck Ackn know owledge gements KCCA MOH CPHL EOC - MoH Makere rere re College ge of Health Sciences Micro robiology gy Labora ratory ry MoH-MAKSPH-CDC PHFP-FET Mark rket committee members rs Health work rkers rs at the are rea HCs
BACK UP SLIDE DES: 32 Typhoid outbreak
Typhoid feve ver Salmonella typhi Major signs/symptoms – Prolonged fever – Abdominal pain – Vomiting Transmission – fecal oral – Waterborne – Foodborne Incubation period – Most common: 8-14 days – Range: 3-60 days Humans are the only host 33 Typhoid outbreak
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