Dr. Yasiini NuwamanyaMBChB (MUK), MPH (MUST), PGD Clinical Trials Host Site: Uganda National Expanded Program on Immunization (UNEPI), Ministry of Health
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ABOUT THE FELLOWNow a polished field epidemiologist, I hold a Master of Public Health degree, a postgraduate Diploma in Clinical Trials, and a Bachelor of Medicine and Bachelor of Surgery degree with a strong background in the public health sector. I have a particular interest in infectious disease epidemiology, vaccines, and immunization. During the fellowship I was hosted at the Uganda National Expanded Program on Immunization (UNEPI); recently rebranded into the Vaccines and Immunization Division of the Ministry of Health. The vision of UNEPI is a Ugandan population that is free of vaccine-preventable diseases with a mission to reduce morbidity, mortality, and disability due to vaccine-preventable diseases in Uganda. The major goal is to ensure that every child and high-risk group is fully vaccinated with high-quality and effective vaccines against the target diseases in line with the recommended strategies. Achievements at the Host SiteAt UNEPI, I supported the data and surveillance subcommittee, participating in various projects and activities such as outbreak investigation and response, evaluation of the routine immunization program performance, support supervision and mentorship, development of policy documents, I authored three articles and co-authored several in the UNEPI quarterly bulletin including: – Effect of PCV10 on Trends of Pneumococcal Meningitis in Children Under Five Years, Uganda, 2003–2022 – Performance of the National Expanded Programme on Immunization by Antigen – Persistent gaps in immunization coverage: closing the gaps using Quality Improvement Approaches – Integrated Child Health Days (ICHDs) postponed to November 2024: Fast-tracking the Big Catch-Up Vaccination Exercise – Updated Routine Immunization Schedule: Key Messages for stakeholders
I contributed to the development of an operational plan for the nationwide ‘Big Catch-Up’ vaccination exercise that aimed to ensure that 90% of the eligible population were up-to-date with their routine immunization. Subsequently, I supervised the implementation of the Big Catch-up in Mubende District in North Central Uganda, overseeing a successful exercise. I led measles outbreak investigations in Budaka, Butebo, Terego, and Sembabule districts; determining outbreak magnitude and risk factors. The findings informed subsequent mass vaccination campaigns and interventions to strengthen routine immunization in the districts. After the measles outbreak investigations, I oversaw the mass measles-rubella vaccination campaigns across all four districts, excelling at the national target of 95% coverage and successfully controlling outbreaks. I took part in developing the operational plan for phase 2 of Uganda’s Yellow Fever Preventive Mass Vaccination Campaign. Specifically, I served as an editor for the accompanying field guide and talking points tailored for various stakeholders, including district health teams and implementing partners. Additionally, I compiled the technical package for national supervisors, which became a key reference for training and implementation of the YFPMVC at the district level. I led a readiness assessment for the second phase of the national Yellow fever mass vaccination campaign across three districts in western Uganda—Bushenyi, Mitooma, and Rubirizi— supporting their preparations for a successful vaccination campaign. During the implementation, I served as the national supervisor for Kyotera District, which emerged among the eighth best performing districts, achieving 83% coverage compared to the national average of 75%. I participated in the revision of the national EPI Health Management Information Systems (HMIS) tools. Specifically, I recommend a birth cohort based child health register for better longitudinal data capture which was adopted in the new EPI HMIS tools. I co-led the monitoring and evaluation of the effectiveness of the Tickler Box innovation in Luwero District and Smart Paper Technology in Masindi District in reducing immunization dropout rates. I contributed to an article in the Ministry of Health report to H.E. the president of Uganda, on the performance of routine immunization programs. Specifically, my article highlighted the pneumococcal conjugate vaccine’s impact on bacterial meningitis trends in children under five. I analyzed the spatial distribution of suspected measles outbreaks in Uganda to inform targeted and proactive interventions by the Uganda National Expanded Program on Immunization including the development of the national measles preparedness and response plan, 2024. I contributed to the Health System Strengthening III GAVI grant application, which was successfully awarded. Specifically, I participated in responding to reviewers’ comments and refining the document. I served as the deputy team lead for the Hoima health region during the WHO-led Post Introduction Evaluation (PIE) of new vaccines introduced in Uganda’s routine immunization system for children under 2 years in 2022, focusing on Masindi and Kiryandongo districts. I contributed to data collection tool review, report writing, and findings dissemination to national immunization stakeholders. I attended and actively participated in majority of the scheduled UNEPI and subcommittee meetings during which I made several presentations of my work on data and surveillance and contributed to discussions on other topics. In recognition of my expertise and contributions to the immunization program, I was nominated to the National Certification Committee on Polio Eradication (NCC) for Uganda, which consists of independent experts responsible for assessing and verifying national documentation on polio-free status and reporting to WHO regional certification committee with improvement recommendations. Fellowship program specific achievementsIn addition to leading three measles outbreak investigations under the host site, I led three others as part of my assignments during the fellowship. – Food poisoning at a funeral in Buyengo Town Council, Jinja District, February 2024 – Anthrax outbreaks in Western Uganda District, April 2023, during which I investigated the role of illegal meat dealers in spreading human anthrax infections – Measles outbreak in Sembabule District, July August 2024 Participated in six other outbreak investigations: – Anthrax outbreak in Ibanda District, April 2024, during which I led the investigation of illegal meat dealers in spreading anthrax infections – Measles outbreak in Bundibugyo District, 2023 – Cholera outbreak in Kayunga District, 2023 – Measles outbreak in Terego District, 2024 – Multi-Drug Resistant TB outbreak in Kayunga District, 2024 – Mpox outbreak in Kampala Metropolitan area (Kampala, Wakiso and Mukono districts), 2024 Analyzed pediatric bacterial meningitis sentinel surveillance data and assessed the effect of 10-valent pneumococcal conjugate vaccine on the trends of pneumococcal meningitis among children under 5 in Uganda from 2003─2022, to generate evidence of the effectiveness of the PCV10 routine immunization program. Presented at six local conferences during 2023-2024 – Anthrax outbreaks in Western Uganda: the role of illegal meat dealers in spreading the infection at the 9th National Field Epidemiology Conference, November 2023, and the National Quality Improvement Conference, March 2024. – Effect of 10-valent pneumococcal conjugate vaccine on the trends of pneumococcal meningitis among children under five years in Uganda, at the 23rd conference of the Uganda Society of Health Scientists, August 2024, and National Health Promotion Conference, October 2024. – Food poisoning outbreak caused by Aeromonas bacteria at a funeral in Jinja District, at the 18th Joint Annual Scientific Health Conference, October 2024, and the 10th National Field Epidemiology and 2nd Laboratory Leadership Conference, November 2024. I led the protocol development for the national immunization coverage mini-survey to evaluate the routine immunization program and determine factors associated with the uptake of immunization services in Uganda. Subsequently, I won a grant of 85,000 USD from the US CDC in partnership with IDI for the Uganda National Institute of Public Health (UNIPH) to conduct the survey. I successfully coordinated the survey in all the fifteen designated health regions of Uganda, during August-September 2024. Presented to two international audiences – Anthrax outbreaks in Western Uganda: the role of illegal meat dealers in spreading the infection, to the Global Health Center (GHC), US Centers for Disease Control and Prevention (CDC) Web and Content Development Team in CDC Atlanta. The presentation was incorporated into a documentary showcasing work done with funding from the US government for presentation to the US congress, in July 2024. – Cost-effectiveness of preventive strategies for human anthrax infections in Uganda, during the international Data-to-Policy technical exchange session organized by Vital Strategies in collaboration with CDC foundation, November 2024. Excellence awards – Best abstract at the 23rd conference of the Uganda Society of Health Scientists, August 2024 – Best poster presentation at the 18th Joint Annual Scientific Health Conference, October 2024 Mentor for the fifth cohort of the Intermediate Field Epidemiology Training Program. Wrote and published two newspaper articles in the New vision – Prevent liver cancer; get vaccinated against Hepatitis B! – Save your child from brain dysfunction; vaccinate against meningitis now! Editor for Issue 1 of volume 9 of the quarterly Uganda Public Health Bulletin; a public health communication channel ran by the Uganda National Institute of Public Health. I am a lead author of five articles in the Uganda Public Health Bulletin; a national public health communications channel run by UNIPH. These included: – Anthrax outbreak in Western Uganda: the role of illegal meat dealers in spreading infection, August 2022─April 2023 – Food poisoning caused by Aeromonas bacteria at a funeral in Buyengo Town Council Jinja District, February 2024 – Uganda switches from Rotarix rotavirus vaccine to Rotasiil: Introducing a 3-dose Rotavirus vaccine schedule into the routine immunization program, March 2024 – Uganda Yellow Fever Preventive Mass Vaccination Campaign Phase 2, April 2-8, 2024 – World Health Awareness Days, and International Health Days, for April-June 2024: International Cesarean Awareness Month, April 1-30, World Hemophilia Day, April 17, World Malaria Day, April 25, World Immunization week April 1-30, World Asthma Day, May 7, World Hypertension Day, May 17, World Preeclampsia Day, May 22, World Blood Donor Day, June 9, and World Sickle Cell Day, June 19. Implemented a Quality Improvement Project on reducing the dropout between the first and second doses of measles-rubella vaccine, among children aged 18-59 months at Masaka Regional Referral Hospital, Uganda, July–December 2024. Conducted an epidemiological study on predictors of Mortality among Children <5 years Admitted with Bacterial Meningitis at Pediatric Bacterial Meningitis Sentinel Surveillance Sites, Uganda, 2003–2022. Led a TB/HIV epidemiological study on Interval from TB diagnosis and treatment initiation, and factors associated with treatment outcomes among TB patients in high-volume health facilities in North-Central Uganda, 2018-2022. Research supervisor for the household survey on excess mortality due to COVID-19 in Uganda, March-April 2023. Wrote two policy briefs – Reducing Mortality from Snakebite Envenoming in Uganda, A policy brief – Cost effectiveness of prevention strategies for human anthrax in Uganda Publications in peer-reviewed journals – Lead author of an article titled “Effect of 10-valent pneumococcal conjugate vaccine on trends of pneumococcal meningitis among children under five years in Uganda, 2003-2022”, that was published in the BMC infectious diseases Journal. – Co-authored a manuscript titled “Ebola disease outbreak caused by the Sudan virus in Uganda, 2022: a descriptive epidemiological study” that was published in the Lancet journal. – Lead author for a manuscript titled “Food poisoning outbreak caused by Aeromonas bacteria at a funeral in Buyengo Town Council Jinja District, February 2024”, currently under peer-review in the BMC infectious diseases Journal. – Lead author for two other manuscripts titled ‘predictors of Mortality among Children <5 years Admitted with Bacterial Meningitis at Pediatric Bacterial Meningitis Sentinel Surveillance Sites, Uganda, 2003–2022’ and “Anthrax outbreaks in Western Uganda: the role of illegal meat dealers in spreading the infection” are under internal review. Summary of Epidemiological Study:Title: Effect of 10-valent pneumococcal conjugate vaccine on the trends of pneumococcal meningitis among children under five years in Uganda Background: Pneumococcal meningitis, a vaccine-preventable disease caused by Streptococcus pneumoniae (Spn) is the leading bacterial meningitis in Under Five children. In April 2014, Uganda introduced routine immunization with 10-valent Pneumococcal Conjugate Vaccine (PCV10) for infants. The target coverage for herd immunity is ≥90% with three doses (PCV10-dose 3). We assessed the effect of PCV10 introduction and coverage on the trends of pneumococcal meningitis in under five children. Methods: We analyzed laboratory-confirmed pediatric bacterial meningitis (PBM) data at two high-volume WHO-accredited sentinel surveillance hospitals in Kampala City and Gulu District, from 2003–2022. We used confirmed cases to estimate the minimum incidence of pneumococcal meningitis in the host districts and calculated annual incidence of pneumococcal meningitis per one million populations, and the proportion of confirmed PBM attributable to Spn. We divided the study period into 2003– 2013 (pre-PCV10) and 2014–2022 (post-PCV10), and conducted interrupted time series analysis using autoregressive integrated moving average models for the effect of PCV10 on trends of pneumococcal meningitis and PBM attributable to Spn. We analyzed reported PCV10 data in DHIS2 from 2014–2022 for annual PCV10-dose 3 coverage. Results: Among the 534 confirmed PBM cases, 331(62%) were pneumococcal meningitis; 227(69%) from Gulu District and 104(31%) from Kampala City. The majority (95%) of the isolates were not serotyped. The majority (57%) were male and unimmunized (98%); median age=14(IQR=6-27) months with most (55%) aged ≥12 months. The case fatality rate was 9%. During Pre-PCV10 period, the overall incidence of pneumococcal meningitis in the host districts increased; slope change=1.0 (95%CI= 0.99999, 1.00001). which declined in post PCV10 period (2014–2022) by 92% from 86 cases /1,000,000 in 2014 to 7/1,000,000 in 2022, slope change= -1.00006 (95%CI=-1.00033, -0.99979). Whereas there was an immediate decline in the proportion of confirmed PBM attributable to Spn in the host districts, level change=- 1.84611(95%CI=-1.98365, -1.70856), an upward trend was recorded from 2016–2022, slope change=1.0 (95%CI=0.99997, 1.00003). During 2015–2022, PCV10-dose 3 coverage was largely>90% for Gulu District and 52-72% for Kampala City. Conclusion: The PCV10 routine immunization program reduced the incidence of pneumococcal meningitis in Kampala City and Gulu District. There was no effect on the confirmed PBM proportionately attributable to Spn. Kampala City persistently recorded PCV10-dose3 coverage<90%. We recommend enhancing serotyping and periodic nasopharyngeal carriage surveys to ascertain the maximum vaccine effectiveness and monitor Spn serotypes, and strengthening routine immunization in Kampala City. Key lessons learnt during the fellowshipDuring the fellowship, I learnt and developed the following skill sets:
Next StepsWorking with the Ministry of Health and/or partner organizations, I hope to use my newly acquired skills and knowledge to advance Uganda’s health security agenda, by strengthening public health surveillance to ensure prompt detection and control of outbreaks at source. I also intend to use my mentorship skills to build capacity of fellow health workers in public health surveillance in Uganda and beyond; with particular emphasis on routine health data use. Above all, I am looking forward to furthering my career as a field epidemiologist for maximum contribution to towards the attainment of Global Health Security. Pictorial
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