Host Site: Viral Hemorrhagic Fever Surveillance Program – Uganda Virus Research Institute (UVRI)
Host Mentors: Dr. Julius J. Lutwama, Dr. Luke Nyakarahuka and Mr. Stephen Balinandi
ABOUT THE FELLOW
Mirembe Bernadette Basuta is an Epidemiologist with special interest in the One Health initiative. She has a Bachelor of Environmental Health Science and Master of Veterinary Preventive Medicine from Makerere University. She was attached to UVRI where she has supported the institution through leading multiple outbreak investigations associated with her host site among other projects. She played a crucial role in establishing an alert desk during the Ebola outbreak response in 2019 in Kasese District. She led 13 Crimean-Congo Hemorrhagic Fever (CCHF) outbreak investigations that span over 7 months in 2018-2019 gathering vast expertise in the topic. She has vast knowledge on Viral Hemorrhagic Fevers (VHF) and has been at the frontline of such outbreaks multiple times. She has successfully estimated the cost of treating Rift Valley Fever (RVF) patients, which can improve planning for future outbreaks. She has disseminated her work and knowledge in various forums and hopes to further her expertise in the area.
Achievements at the Host Site
Participated in Ebola outbreak response where she was inharge of setting up the alert lines and protocols to be followed in case of an alert.
Led investigations of sporadic CCHF outbreaks in over 14 districts for seven months. Tick contact was the exposure determined to be associated with transmission as in previous studies. Visiting patients both in hospital and community further led to understanding challenges to individuals, community and health facilities during these outbreaks.
Led investigations of imported Dengue outbreak of Indian origin where she had to trace movements of a religious missionary who had been in the country for over 29 days. He arrived in Entebbe and travelled preaching in several districts. He was intercepted in Yumbe District and luckily none of his companions acquired the disease.
Led investigations of suspected O‟nyong nyong fever in Kampala District. Two suspected case-patients were line-listed of which one was confirmed with O‟nyong nyong fever at UVRI. Case-patient had travel history to Kitgum District during the effective exposure period.
Updated the VHF surveillance system on a daily basis for four months after attachment. This involved making calls to health workers to clarify information on suspect VHF samples sent and also following up if necessary.
Described the VHF surveillance system hosted at UVRI. The findings showed that increase in samples received through sentinel sites led to increase in number of outbreaks detected. This showed importance of improving suspicion index of health workers so as to sustain transfer of samples to the VHF lab.
Entered, analysed and developed a report for the customer review survey assessing acceptability and functionality of the VHF surveillance system as perceived by health workers. About 60% of health workers were satisfied with the VHF surveillance system.
Submitted an article to the UVRI newsletter about the Viral Haemorrhagic Fever surveillance program where successes of the program was described.
Formulated and implemented an archiving system of surveillance case investigation forms since 2010 for easy retrieval. The system was adopted and has greatly simplified the retrieval process of forms.
Participated in opening of five new sentinel surveillance sites for the surveillance program and trained hospital staff on completion of the VHF case investigation forms.
Participated in an ecological study in the caves in Kween District where presence of rossettus bats was established using smell and sound. Rossetus bats are known reservoirs for Marburg virus and it was reported that the index case during the 2017 Marburg outbreak had visited these caves.
Collated and analysed data on Crimean- Congo Haemorrhagic Fever since 2013 in the VHF surveillance system. The aim was to create a case-control dataset within the surveillance system to see whether exposures differed. Analysis was however not fruitful because of incompleteness of previous entries due to missing information in case investigation forms.
Developed two concepts for longitudinal studies on immune response of VHF survivors and frontline healthcare workers vaccinated during the Ebola preparedness and response
Fellowship program specific achievements
Emergency response and outbreak investigation
Lead Investigator;
Cholera outbreak at Sebagoro Landing site in Hoima District that was epidemiologically linked to the massive outbreak in Kyangwali Refugee Settlement, February – May 2018
Imported case of Dengue Fever from India identified after spending one month in Uganda and travelling to Yumbe District, October 2018
Sporadic Crimean-Congo Hemorrhagic Fever outbreaks in Central and Western Uganda, June 2018 – January 2019
O‟nyong nyong fever outbreak detected at a hospital in Kampala District suspected to originate from Kitgum District, February 2019
CCHF outbreak investigation in Lyantonde District, August 2019
Co-Investigator;
Cholera outbreak in Kyangwali Refugee Settlement in Hoima District, February – May 2018
Anthrax outbreak in Kiruhura District, May 2018
Black Water Fever in Manafwa District, May – June 2018
Rift Valley Fever (RVF) in Western Uganda, June – October 2018
Plague outbreak in Zombo District, March 2019
Scientific communication and writing
Conference Presentations;
International Federation of Environmental Health (IFEH) that took place from 9 – 11 April 2019. „Cholera Outbreak propagated by Heavy Rainfall at Sebagoro Landing site, Hoima District, Uganda, Feb-May 2018’ and ‘Epidemiology of Typhoid fever in Kasese District, Uganda’
MakCHS 15th JASH Conference that took place on 6th – 8th November 2019 at Hotel Africana. ‘Predictors for Mortality among Multidrug– Resistant Tuberculosis and HIV Co-Infected Patients in Uganda, 2013-2016’.
5th National Field Epidemiology Conference (NFEC) that took place on 24 October 2019. „Sporadic Crimean-Congo Haemorrhagic Fever outbreaks associated with Tick Exposures: Western and Central Uganda, 2018 – 2019’ and ‘Predictors for Mortality among Multidrug–Resistant Tuberculosis and HIV Co-Infected Patients in Uganda, 2013-2016’.
Written communication
Bulletin articles
Investigation of an imported case of Dengue fever, Uganda, November 2018 – UNIPH Volume 3 Issue 2 October – December 2018
Multiple sporadic Crimean-Congo Haemorrhagic Fever Outbreaks, Uganda, July 2018-January 2019 – UNIPH Volume 4 Issue 1 January – March 2019
Investigation of suspected O‟nyong nyong fever Outbreak in Kampala District, Uganda, February 2019 – UNIPH Volume 4 Issue 2 April – June 2019
Newspaper articles
‘Beware of animal diseases this season’ published in New Vision as letter of the day on 28 December 2018. The intention was to inform the public about zoonotic diseases that had been rampant in 2018 and linked to handling raw meat.
Manuscripts
Multiple sporadic Crimean-Congo Haemorrhagic Fever Outbreaks, Uganda, July 2018-January 2019 Predictors of Mortality among MDR-TB/HIV co-infected patients in Uganda, 2013 – 2016
Cost Analysis Project
Conducted a cost analysis study for management of patients at Mbarara Regional Referral Hospital during the 2018 RVF outbreak in Western Uganda. The estimated cost of managing a critical RVF patient was UGX 55,520/$15 and UGX 2,406/$0.66 daily in recovery phase for patients that survive. Average time spent in critical condition was 7 days and in recovery was 11 days. Patients that died cost on average UGX 127,154/$35 and spent approximately two days in isolation unit. Estimated welfare costs for RVF patient with one attendant was UGX 27,000/$7.4.
Epidemiological Study
Predictors of mortality among MDR-TB/HIV co-infected patients in Uganda, 2013 – 2016. MDR-TB/HIV co-infected persons that had been treated before for TB had higher risk of death compared to new cases as well as those in whom sputum conversion had failed during treatment.
Waste management practices in selected laboratories around Uganda. About 54% of them were found to uphold good waste management practices.
Summary of Epidemiological Study:
Title:Risk factors for Active Tuberculosis among HIV-Positive Male Prisoners on Antiretroviral Therapy, at Luzira Maximum Security Prison, Uganda, 2013-2017
Background: Crimean-Congo Haemorrhagic Fever (CCHF) is a severe tickborne, zoonotic viral disease. Despite having ten confirmed outbreaks between 2013 and 2017, all within or along the „cattle corridor‟, no national tick control program exists in Uganda. During a seven-month-period from July 2018-January 2019, the Ministry of Health confirmed multiple isolated CCHF outbreaks. We investigated to identify risk factors to prevent future outbreaks.
Methods: We defined a confirmed case as sudden onset of fever with ≥4 of the following: anorexia, vomiting, diarrhoea, headache, abdominal pain, joint pain, sudden onset of unexplained bleeding and tested positive for CCHF by RT-PCR assay or IgM serology between 1 July 2018 and 30 January 2019 in a resident of the 11 affected districts. We identified cases by record review at Uganda Virus Research Institute and active community case-finding. In a case-control study, we compared the exposures of cases with neighbourhood matched controls (1:4). We assessed risk factors using Mantel-Haenszel odds ratios derived by stratification analysis of case control sets.
Results: Of We identified 14 confirmed case patients, with 5 deaths (case-fatality rate=36%) from July 2018–January 2019. Case-patients came from 11 districts in Western and Central region; 78% of case patients resided within the cattle corridor of Uganda. Males (AR 4.4/1,000,000) were more affected than females (AR2.4/1000000). Case-patients ranged in age from 6-36 years, with persons aged 20-44 years more affected (AR:7.2/1,000,000) than persons ≤19 years (2.02/1,000,000). Most (93%) case-patients had contact with livestock ≤2 weeks before symptom onset. Ten (71%) of 14 case-patients found ticks attached to their bodies ≤2 weeks before symptom onset, compared to 15 (27%) of 56 control-persons (ORM-H=9.3, 95%CI=1.9-46).
Conclusion; Isolated CCHF outbreaks occurred sporadically during 2018-2019 within and outside „cattle corridor‟ districts of Uganda. Most outbreaks were associated with tick exposure. The Ministry of Health partnering with Ministry of Agriculture, Animal Industry and Fisheries should consider a One Health approach towards tick control by developing joint nationwide tick-control programs and strategies
Key Skills and Competencies acquired.
I understood and appreciated epidemiology theories and concepts through fieldwork and its challenges. I appreciated terms such as confounding, effect modification and bias as well as the art of understanding epidemic curves and their role in epidemiology. I appreciated outbreak investigations
and its challenges.
I learned how the Uganda Health System works. I had the opportunity to join the National Stop Transmission of Polio (NSTOP) team and I gained vast experience in vaccine management.
I have acquired new skills such as using software for example QGIS, ODK and GoData. I learned how to draw maps, malaria channels and conduct contact tracing among others. I also benefited from various trainings for example TB Operations Research, Evidence-based Public Health Interventions and Preparedness and Response on Ebola Virus Disease.
I learned the art of disseminating results through presentations, reports and manuscript writing at a more vigorous and effective level.
Most of all, I expanded my professional network through working with different key stakeholders and institutions in the health system of Uganda as well as health personnel at districts and communities at large. This was the biggest achievement of all as it grounds me in my career path.
Next Steps
Further my career in Public Health as an Epidemiologist with passion in the One Health Initiative. Serve and support Ministry of Health towards improving lives of Ugandans.
Bernadette picking coordinates from a household during the response to an outbreak of CCHF in Rakai District