Lilian Bulage

Bsc. (Technology – Biology) (KYU), MHSR (Mak),+256 782623624
lbulage@musph.ac.ug, lbulage@uniph.go.ug

Host mentors

Mr. Steven Aisu
Executive Director, Central Public Health Laboratories
Mr. Isaac Ssewanyana
Laboratory Manager, Central Public Health Laboratories.
Mr. Atek Kagirita
Central Public Health Laboratories

Academic Mentor

Dr. Victoria Nankabirwa
Lecturer Makerere University School of Public Health

About the Fellow

Lilian Bulage has a biological science background from Kyambogo University and a Master of Health Services Research from Makerere University. Prior to joining PHFP-FET, Lilian worked at the National Tuberculosis and Leprosy Program (NTLP) specifically at the National Tuberculosis Reference Laboratory (NTRL); a South African National Accreditation System (SANAS) accredited and WHO Supra-National Reference Laboratory. At NTRL, Lilian worked as a Laboratory Scientist in-charge of External Quality Assurance (EQA) activities for the South Eastern TB Zone.

In-addition, she worked as a secretary in-charge of the NTLP Tuberculosis Research and Innovations Forum. She had publications about Tuberculosis, titled, “The Quality of Tuberculosis Services in Health Care Centres in a Rural District in Uganda: The Providers’ and Clients’ Perspective, and Quality of Sputum Specimen Samples Submitted for Culture and Drug Susceptibility Testing at the National Tuberculosis Reference Laboratory-Uganda, July-October 2013” as lead author.

Outside NTLP, Lilian was a member of the WHO National Stop transmission of Polio (NSTOP) where she actively participated in conducting active surveillance activities. She joined the PHFP-FET in January 2015 and was based at the Central Public Health Laboratories (CPHL), Ministry of Health for her field placement.

Achievements at host institution While at CPHL

1. Lilian evaluated the laboratory response to the 2015 typhoid outbreak in Kampala. The Laboratory played its roles successfully, however there were gaps in logistic supply, limited human resource (both in number and specialized staff such as microbiologists) and overall coordination of the response.

2. She also conducted a descriptive analysis of viral load surveillance data (August 2014-July 2015). The analysis revealed that second time testers (non-suppressed on first time testing and underwent intensified adherence support for 6 months) registered the highest non-suppression rate. Young age, poor adherence and having active TB increased the risk of virological non-suppression.

3. Lilian conducted a follow up study titled, “Factors Affecting Quality of Care for Virologically Non-suppressed HIV Positive Patients in Jinja, Buikwe and Iganga Districts: A Baseline Assessment” to understand some of the findings revealed in the descriptive analysis.

4. She also played a key role in coming up with draft 1 of the CPHL/UNHLS 2015-2020 draft strategic plan and later on participated in its subsequent write ups and reviews by different stakeholders.

5. She spearheaded the write up of the 2015 Microbiology Laboratory Annual Report. Lilian participated in many other activities at CPHL including; development of the bio-safety and bio-risk training curriculum and manual, bio-safety and bio-risk health facility baseline assessment tools, review of the National Health Laboratory Test Menu, development of the operational plan for shifting of CPHL from Buganda road to its state of the ART Structures in Butabika, Writing of monthly and quarterly monitoring and evaluation reports for viral load and early infant diagnosis.

Program specific achievements At the PHFP-FET, Lilian;

1. Led an epidemiological study titled, “Risk factors associated with typhoid intestinal perforations during a large outbreak of typhoid, Kampala Uganda, 2015”.

2. Led investigations in a complex setting titled, “Investigation of a measles outbreak in a refugee population: Rwamwanja Refugee Settlement-Kamwenge District, July 2015”, “Rapid Health Assessment of Newly Arriving Refugees at Rwamwanja Refugee Settlement, and Rapid Assessment of a Suspected Measles Outbreak at wamwanja Primary School”. Given the complex setting Lilian was dealing with, she was given an opportunity to be mentored by the overall CDC director, Dr.
Thomas Frieden.

3. Led an investigation titled, “Cholera Outbreak Caused by Drinking Contaminated River Water, Bulambuli, Uganda, March 2016”.

4. Participated in a measles outbreak investigation in Kamwenge district, Western Uganda.

5. Participated in a typhoid verification activity in Lyantonde and Rakai Districts

6. Participated in an investigation titled, “A Large and Persistent Outbreak of Typhoid Fever Caused by Consuming Contaminated Water and Street-vended Beverages: Kampala, Uganda, January – June 2015”.

7. Presented at both national and international conferences.

8. Submitted manuscripts titled, “Factors Affecting Virological non Suppression among HIV Patients on Antiretroviral Therapy in Uganda, August 2014-July 2015”, and “Modifiable Risk Factors for Typhoid Intestinal Perforations during a Large Outbreak of Typhoid Fever, Kampala Uganda, 2015” to peer reviewed journals. Published new paper articles titled, Uganda makes more strides in the health laboratory sector”, and “Antimicrobial resistance: One of the greatest challenges to global public health”. Published articles in the UNIPH Quarterly Epidemiological Bulletin titled, “An overview of the laboratory response to the 2015 typhoid outbreak in Kampala, Uganda,” “Risk factors associated with typhoid intestinal perforations during a large outbreak of typhoid, Kampala Uganda, 2015,” “HIV Viral Load Sample Delivery Times, Rejection Rates and Results Dispatch Turnaround Time, August 2014-July 2015, Uganda”.

Other achievements

9. Participated in the training and mentorship of the Frontline FETP trainees.

10. Played a key role in revamping the ministry of health epidemiological bulletin currently known as the Uganda National Institute of Public Health Epidemiological Bulletin as part of the editorial team.

Summary of planned study: Factors Affecting Quality of Care for Virologically Non-suppressed HIV Positive Patients in Jinja, Buikwe and Iganga Districts: A Baseline Assessment

Introduction: Viral load (VL) testing improves monitoring of patients’ response to HIV therapy. According to the World Health Organization (WHO), more than 70% of non-suppressed clients should re-suppress after 6 months intensified adherence support (IAS). However, only 50% re-suppressed on 2nd time testing at 6 months of follow up.

We established whether virologically non-suppressed patients underwent IAS for 6months, identified structural and process issues affecting service delivery for non-suppressed clients, estimated outcomes at end of 6 months period of IAS, and assessed patient and provider perspectives on what else is needed for effective provision of IAS.

Methods: Data collection was based on Donabedian model of quality of health care that evaluates structures, processes and outcomes of
health care. We extracted data from clients’ files, ART card and, CD4 and VL daily activity register. We interviewed clients who had received their 1st VL result between Aug 2014 and Dec 2015 (427) at 10 health facilities. We interviewed ART clinic in-charges, expert clients and laboratory staff (33).

In-addition, we used a checklist and an observation guide to obtain additional data. Primary outcome in the study was % virological suppression status at 6months. The secondary outcomes were % that underwent IAS (monthly visits to health facility), % that submitted 6months follow up sample and % of eligible clients switched to 2nd line ART.

Results: Of the 282 clients interviewed, 20% (57/282) had high, 28% (79/282) had moderate, and 48% (139/282) had low knowledge about VL and VL testing services. of the 378 clients, only 39% (137/378) underwent IAS for the recommended 6months, 28% (106/378) 4-5 times, 17% (63/378) 1-3 times and 16% (59/378) not conducted, and 1% (3/378) LTFU/Died. 42% (162/379) did not submit FU sample at 6months, 43% (90/207 tested successfully) non-suppressed on 2nd time testing, 62% (56/90 non suppressed) not switched to 2nd line, 38% (13/34) switched immediately after 1st VL result, and 56% (65/117) of suppressed clients had been switched immediately after 1st VL result. 14/31 health workers (HW) did not know standard results turnaround time (TAT). Clients, dislikes about VL testing services were, that knowing VL results causes; stress, worry, scares, discourages and increases stigma. Health workers disliked IAS being recommended without counselors at health facilities, IAS period is short, mis-allocation of results and VL testing services being very far from clients. Some of the reasons for not switching clients were, client given second chance on IAS, patient feels well, patient unreliably adherent to 1st line therapy and patient is concerned about 2nd line therapy side effects.

Conclusion: Non-adherence to guidelines for monitoring response to ART using VL and limited knowledge about VL among both non-suppressed clients and health workers was observed. We recommended that the AIDS Control Programme and CPHL come up with performance indicators for monitoring response using VL. The info gathered in this study could guide formulation of clients’ IEC materials.

Lessons learned, key skills/competences acquired and next steps

Lilian says, the fellowship program has re-emphasized the importance of team work, leadership, good managerial skills and the uniqueness of each health problem that are key in results achievement. As evidenced by the achievements listed above, Lilian gained/strengthened her skills in field outbreak investigations, field outbreak investigations report writing, data analysis including analysis of public health surveillance data, manuscript writing, communication and leadership. “My decision to join the PHFP-FETP has made me a disease detective competent in surveillance, outbreak detection, investigation and response in all kinds of situations including in emergency and complex settings, CPHL has greatly improved my knowledge and skills in laboratory based health systems” she says. Lilian intends to focus on Health Laboratory Surveillance/Epidemiology and Infectious diseases Surveillance/Epidemiology including HIV and Tuberculosis.