Christine Kihembo MBChB, MIPH,Epidemiology and Surveillance Division, Ministry of Health Host MentorDr. Monica Musenero, Assistant Commissioner, Epidemiology and Surveillance Ministry of Health, Uganda. Dr. Issa Makumbi, Head, Public Health Emergency Operations Centre Ministry of Health, Uganda Academic MentorDr. Frank Kaharuza |
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ABOUT THE FELLOWChristine Kihembo holds a master’s degree in international Public Health from the University of Sydney, Australia and Bachelor of Medicine and Bachelor of surgery from, Makerere University, Uganda. Prior to joining the fellowship program, Christine had worked at the Infectious Diseases Institute (IDI) in various capacities; including provision of clinical care to over 10,000 patients living with HIV AIDS; lead medical officer for the Anti-retrovirals for AIDS related Kaposis’ Sarcoma clinical trial. While working as the learning Innovations manager at the AIDS Treatment Information Centre- IDI, Christine spearheaded the establishment of several training programs including the East African clinician training in Especially Dangerous Pathogens (EDPS). It is this work on EDPS that ignited her interest in field epidemiology Christine joined the Uganda Public Health fellowship Program in January 2015 and was hosted at the Epidemiology and Surveillance (ESD) Division Ministry of Health for the two year apprenticeship. Christine was part of the team that strives at having robust and sustainable systems for forecasting, early detection and response to epidemics, emergencies and other priority diseases so as to improve disease prevention and public health response at all levels. She led the weekly analysis and dissemination of the national public health surveillance data for prompt public health action. While at ESD, Christine led and participated in the rapid response and investigation of various disease outbreaks, led and supported various capacity building initiatives and participated in the development of several national policy guidelines/documents. She evaluated the Uganda national typhoid surveillance system, 2012-2014 as reported in HMIS/DHIS2 and was part of the team that evaluated the re-vitalised IDSR implementation in Uganda to inform future IDSR direction in the country. Christine also spearheaded the establishment of the quarterly epidemiological bulletin of National Institute of Public Health (NIPH) that showcases epidemiological evidence for policy and decision making and highlights epidemiological data of importance nationally and globally. She conducted a study to determine the trends of Anti-microbial resistance patterns in Kampala whose results will inform the global health security implementation in Uganda. Achievements at the host siteWas as a team member of the rapid response team in case of outbreaks and public health events – outbreak investigation, contact tracing and incident team leadership. After spending only two weeks on the fellowship program, Christine and her colleagues found themselves on the streets of Kampala investigating a mysterious acute febrile illness that had killed one person and sickened scores. Christine was part of the Ministry of health (MoH) rapid response team (RRT) that investigated and responded to call that turned out to be a large typhoid outbreak in the city. The outbreak was driven by consumption of contaminated water and locally made and vended drinks. The MoH RRT working in collaboration with key partners and stakeholders like KCCA, National water and sewerage cooperation, WHO, UNICEF and the US CDC managed to control the outbreak before it could spread else where.Consequently, she conducted a literature review on strategies to deal with antibiotic resistance during typhoid outbreaks in developing settings. The information helped in the implementation of the enhanced laboratory surveillance during this outbreak. Subsequently, Christine took the lead in several rapid response and outbreak investigations including;
She also participated in the rapid response and investigation of the Malaria outbreak in northern Uganda, Measles outbreak in Kiruhura district, Mysterious crippling illness in Ibanda district, Carbamate Poisoning in Kagadi districts among others From Dec 2015 to Dec 2016, Christine was responsible for the production and dissemination of the MoH national weekly epidemiological bulletin. The bulletin highlights key epidemiological events from national IDSR priority public health events and conditions as reported from districts via the sms bases mtrack health management information (hmis) system to key stakeholders for prompt public health action. The bulletin also acts as a feedback mechanism to the districts. She also provided technical support to the public health emergency operations centre team in verifying and responding event based public health alerts to complement the indicator based public health surveillance system. Christine participated in the delivery and follow-up support of the training of district health teams on Integrated Disease Surveillance and Response (IDSR) and International Health Regulation (IHR) and other capacity building initiatives. As a national trainer, Christine led the delivery of several district based trainings on IDSR/IHR and subsequently led support supervision of IDSR/ IHR implementation and health management information system (hmis) in the country. She supported the development and roll-out of RRT training in the country and in collaboration with Malaria consortium Uganda, she supported the development and roll out of training materials for the surveillance and clinical management of Podoconiosis, one of the neglected tropical diseases in the country. Christine also supported the roll-out of the district based Frontline Epidemiology training in the country right from curriculum adaptation, technical facilitation, mentorship and field support supervision of mentees. Surveillance System analysis and EvaluationChristine conducted an analysis of the national typhoid surveillance system 2012-2015 via DHIS2 and recommended disaggregation of the surveillance data to more informative age groups, and review of typhoid surveillance thresholds among others. In collaboration with the WHO and CDC, she was also part of the team that designed and conducted re-vitalised IDSR/IHR evaluation in the country to guide future program implementation in the country; an activity. The evaluation identified best practices and key achievements made thus far. Some gaps in funding for IDSR mainstreaming, inadequate human resource for health for implementation at different levels and lack of onsite tools and supplies among others and made recommendations accordingly. Christine also participated in the 2016 yellow fever outbreak preparedness and response evaluation to inform future responses. Participate in preparation and dissemination of new policies on disease prevention and control. Christine was a member of the National Task Force on Antimicrobial Resistance that is working towards developing the National Antimicrobial resistance Action Plan. She also participated in the development and review of the following national guidelines/policy documents;
Other achievements:Christine is a member of the following; Podoconiois Technical Working Group, Hepatitis B-Surveillance Technical Working group, the National Antimicrobial Resistance Task Force. Communication, Presentations, Publications and Awards.Christine wrote and published the following;
Conference presentationsChristine made the following presentations:Christine Kihembo, Ben Masiira et al., “Risk factors for Podoconiosis: Kamwenge District, Western Uganda.”An oral Presentation at the first national epidemiology conference in Kampala, Uganda, 12th Dec 2015. The same paper was presented at the CDC Science series held at MOH, Kampala Uganda.
Other abstracts submitted
Manuscript:
In her own words, Christine says: “The fellowship has made me realize the critical importance of field epidemiology as in engine in public health. Specifically, I have come to appreciate the critical importance of applying specific timely tailor-made interventions guided by epidemiological evidence in the effective control of outbreaks and public health emergences. The fellowship has not only provided me an opportunity for technical advancement (particularly surveillance, epidemic preparedness, outbreak investigation and response) but also, networking, leadership enhancement and interpersonal growth. I have appreciated the dynamics of working effectively at a national public health setting while harmonizing various stakeholders’ interests amidst the fellowship program’s targets. I am now resilient enough to take up any leadership challenge in the noble cause of public health advancement. My career prospect is to become an infectious disease control expert particularly through education,surveillance and health system strengthening. Summary of Planned study:Risk factors for Podoconiosis: Kamwenge District, Western Uganda.Introduction: In Uganda, bacterial infections are responsible for 20% of all hospital deaths and are a cause of 25% of mortality among children <5years. Rapid Antibiotic Resistance (ABR) emergence has outpaced development of new pharmaceutical agents and ABR is a priority area on global health security agenda. In Uganda, there is no national active ABR surveillance in place with limited published ABR information available. We therefore set out to describe bacterial (non-mycobacterial) etiologies for blood sepsis in Kampala 2010-2015 and characterize ABR patterns among most identified bacteria. Methods: We reviewed all blood culture records from 9 public and private laboratories in Kampala that conduct ABR testing according to Clinical and Laboratory Standards Institute (CLSI) standards. Using a standardized data abstraction form, we collected demographics, organism isolated and ABR susceptibility information over the 6 year period. We defined high ABR as ≥50 %, Moderate ABR 10-49% and low ABR <10%of identified species (spp) resistant to a drug annually. Multi-drug resistant (MDR) salmonella was salmonella resistant to Cotrimaxazole (COTRIM), Chloramphenicol (CAF) and Amipicillin(AMP), Methicillin Resistant Staphylococcus (MRSA) as staph species resistant to Oxacillin or Cefoxitin. Results: 85% (1525/1794) of gram positives were Staphyloccoccus species; 71% of which were S. aureus, affecting mainly children <5years incidence 215/100,000 and the elderly, incidence 104/100,000. Among Staph spp, resistance to commonly used antibiotics (erythromycin, Tetracycline and CAF) remained high and resistance to CAF reduced from high to moderate levels. MRSA increased from 44% to 81% (X2= 4.3, p<0.03). 28% (334/1193) of gram negatives were nonspecified coliforms, 21% (247/1193) were Salmonella spp. From 2010 to 2016 resistance to traditional first-line drugs for Salmonella (COTRIM, AMP, and CAF) reduced from high to moderate levels. Specifically, ABR reduced as follows: Ampicillin, from 87% to 34%; CAF, from 73 to 2%; CTX, from 80% to 31%. The range of MDR salmonella was 0-20%. 18% (49/247) of isolates had intermediate resistance to Ciprofloxacin, a preferred first line alternative drug. Intermediate ABR to Ciprofloxacin increased from 0 in 2010 to 39% in 2015. Overt Ciprofloxacin resistance range was 0-17%; all of which were Nalidixic acid resistant. ABR to Ceftriaxone ranged 0-17%. All species tested susceptible to Cefepime, a 4th generation cephalosporin. Ciprofloxacin and Ceftriaxone susceptibility testing was done in only 79% of Salmonella spp Conclusions and Recommendations: Salmonella and Staphylococcus spp with high level Methicillin Resistant Staph with were most common cause of septicemia in Kampala. There was rapid increase in ABR to Ciprofloxacin and Ceftriaxone among Salmonella spp whereas susceptibility to traditional first line antibiotics for Salmonella has gradually returned. We recommend Adherence of laboratories to ABR testing standards and rational use of antibiotics guided by ABR patterns to address the changing ABR picture. |
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