Dr. Carol Nanziri

MBChB (MUK), MPH (MUK), Field Epidemiology Fellowship (PHFP)
Email: cnaanziri@musph.ac.ug
Tel: +256759800634

Host Site: National Tuberculosis and Leprosy Program (NTLP), Ministry of Health

Host Mentors: Dr. Stavia Turyahabwe and Dr. Robert Majwala

ABOUT THE FELLOW

Carol has a Bachelor of Medicine and Bachelor of Surgery, and a Master of Public Health from Makerere University. Before joining the fellowship, Carol worked in the field of HIV and TB for a good time. She has extensive knowledge in HIV/AIDS and Tuberculosis patient care including prevention care and treatment, capacity building and health systems strengthening. She successfully built capacity of both public and private health care workers in TB and HIV patient centered care through on site mentorships programs to improve quality of patient care and retention. These included practical trainings in clinical care, quality improvement projects, recording and reporting. Through this experience, she developed planning, budgeting, mentorship, report writing and leadership skills. During the fellowship, she gained competences in investigating disease outbreaks including Ebola Virus disease preparedness, proposal writing, data management and analysis, report, abstract, manuscript writing, presentation and publishing skills for articles in the local newspapers, national bulletins and international journals. She has a successful track record of employing evidence base findings, resilience and determination to achieve required outputs.

  Achievements at the Host Site

• Developed the 2018/19 community TB Annual Operational Plan which enabled advocacy for financing and implementation on of national community based activities.
• Drafted the Community TB Guidelines in 2018 which was approved in 2019 and is used to enhance implementation of TB activities at community level by all Implementing Partners and Civil Society Organizations.
• Developed community section of the MoH participants‟ manual for the in-service course on integrated and comprehensive TB and Leprosy management and control in 2018. This has been used in district level trainings to improve implementation of community TB activities such as TB case finding through contact tracing.
• Investigated and reported on the suspected TB outbreak in Butabika Hospital in 2018 that led to routine TB screening and early treatment of TB among psychiatric patients in Butabika Hospital.
• Conducted a descriptive analysis and presented a report on TB in Karamoja Region to NTLP. This contributed to advocacy for support to TB patient follow up and treatment activities in Karamoja Region by donor agencies such as Doctors with Africa under Italian non-Government organization for University Colleagues, Aspirants and Medical Missionaries CUAMM).
• Participated in the revision of the Tuberculosis Health Information Management Systems (TB-HIMS) tools which led to the incorporation of TB community activities in the national surveillance and reporting system.
• Carried out data quality assessment in Amudat District in 2019 which led to improved accuracy of reporting in Karamoja Region.
• Conducted support supervision in Kamwenge District in 2019 to enhance TB case finding and better TB treatment outcomes.
• Conducted a Quality Improvement project on improving TB screening among HIV patients in Kotido Health Center IV. This led to increased proportion of HIV patients screened for TB at Kotido Health Center IV from a mere 38% to 85% and the number of presumptive TB patients also increased by 50%.
• Published two NTLP quarterly bulletins of October-December 2018 (Vol 2 Issue 4) and January-March 2019 (Vol 3 Issue 1) in which the following articles were published: TB Outbreak in Butabika Hospital, the 2019 World TB day celebrations and dissemination of TB operations research by UPHFP fellows.
• Published a newspaper article on the role of the public in ending TB in Uganda and compiled the Ministerial press statement for World TB Day celebrations, 24th /Mar/2019.
• Represented NTLP in Quarterly TB performance review meetings in Mbale District.

Fellowship program specific achievements

Disease outbreak investigations
Lead investigator:

• A suspected intussusception outbreak in Kampala which led to the development of a concept and budget for the intussusception national baseline survey submitted for funding to WHO Country Office in March 2018. Crimean Congo Haemorrhagic Fever outbreak investigation in Kakumiro and Mubende Districts in May 2018. Our findings revealed that the outbreak was caused by CCHFV-infected tick bite with an epidemiological link to tick infested livestock from Kyankwanzi District. We recommended spraying of livestock with acaricides, disinfection of livestock owners‟ homes and quarantine on livestock movement from CCHF affected districts to stop the transmission of CCHFV in Kakumiro District. This investigation contributed to advocacy for Government interventions to support use of acaricides by farmers to spray their animals.
• TB outbreak in Butabika National psychiatric Hospital, Kampala District,Uganda, December, 2018. We concluded that the outbreak may have been caused by ward congestion and inadequate infection control measures in place. We recommended reduction of ward congestion by implementing the recommended inter-bed spacing of at least 2.5 meters, routine in patient TB screening for early identification, isolation of TB patients and initiation of TB treatment.
• Ebola Virus Disease preparedness assessment and risk mapping in Kabarole and Bunyangabu Districts in August 2018. These findings were used to develop the district and national contingency plans that enabled facilitation and resource mobilisation for preparedness and prevention of importation of Ebola into the districts and country.

Co-Investigator:

• A prolonged Cholera outbreak in Kyangwali Refugee Settlement in Hoima District conducted in March 2018. This was a propagated outbreak caused by drinking contaminated stream water in the settlement.
• A suspected Typhoid intestinal perforation outbreak in Kabarole District conducted in July 2018. This was a case of misdiagnosis because of lack of confirmation by blood culture.
• An anthrax outbreak in Kiruhura District conducted in September 2018. Handling and butchering infected dead animals led to the disease outbreak.
• A malaria outbreak in Kyotera District conducted in July 2019. The findings revealed that the sustained stagnant water due to a prolonged rainy season increased mosquito breeding sites in addition to lack of functional mosquito nets which led to the outbreak.

Analysis of Surveillance data

• Conducted a descriptive analysis of surveillance data of TB in Karamoja Region. It was the most affected region with TB and the major finding was that TB mostly affected the elderly above 60 years of age. This led to additional support for TB care and treatment in the region from international agencies like CUAMM.
• Studied the characteristics and treatment outcomes of Multi-Drug Resistant Tuberculosis (MDR-TB) and Rifampicin Mono-Resistant Tuberculosis (RMR TB) patients in Uganda 2012-2017. The major finding was that MDR-TB and RMR-TB patients had similar demographic and clinical characteristics but poor treatment outcomes were associated with HIV positive MDR-TB compared to HIV positive RMR-TB
  patients
• Characterized Non-Occupational Post Exposure Prophylaxis for HIV in 5 Urban Health Centres of Kampala, Uganda: January 2016 – June 2019. We found that attendance at follow-up visits for HIV testing was poor and recommended exploration of the causes to improve service completeness, and integration of PEP with other HIV prevention services.

HIV study

• Using secondary data analysis from Ministry of Health Post Exposure Prophylaxis registers, we characterized Non-Occupational Post Exposure Prophylaxis for HIV (NPEP) in 5 Urban Health Centers of Kampala, Uganda: January 2016 – June 2019.
• The major finding was that sexual exposure is the main indication for NPEP in Kampala. Attendance at follow-up visits for HIV testing was poor and was associated with PEP receipt 24-72 hours after exposure and knowing the HIV status of the exposure source. We recommended exploration of causes of poor follow-up after PEP to improve adherence and explore opportunities for linkage to additional services.

Epidemiological study on TB/HIV

• Using secondary data from the 2017 Ministry of Health TB/HIV policy evalution study, I studied the Predictors of Mortality among TB/HIV co-infected patients before and after implementation of the TB/HIV Collaborative Policy in Uganda, 2012 and 2016. The major finding was that
  mortality of TB/HIV co-infected patients slightly increased after implementation of the revised TB/HIV policy. Clinically diagnosed and extra pulmonary TB predicted mortality, while ART was modestly protective. We recommend further studies to establish the cause of increased mortality after policy initiation.

Conference Presentations

• “Ebola preparedness assessment in Uganda August –September 2018” at the 10th TEPHINET Global Scientific Conference in Atlanta Georgia USA,  October 2019 and 4th National Field Epidemiology Conference in November 2018
• “Predictors of Mortality among TB/HIV co-infected patients before and after implementation of the TB/HIV Collaborative Policy in Uganda, 2012 and 2016” at the 5th National Field Epidemiology Conference in October 2019 and 15th MAKCHS Joint Annual Scientific and Health Conference(JASH) & 4th Grande Doctors’ Conference in November 2019.

Manuscripts

• Ebola Virus Disease Preparedness and Risk Mapping: Uganda, August- September 2018” submitted to the Health Security Journal.
• Uganda‟s experience in the Ebola Virus Disease Outbreak preparedness, 2019 under peer review.
• Predictors of Mortality among TB/HIV co-infected patients before and after implementation of the TB/HIV Collaborative Policy in Uganda, 2012 and 2016, under peer review.
• Characteristics and treatment outcomes of MDR and RMR TB patients in Uganda 2012-2017, under peer review.
• Characterizing Non-Occupational Post Exposure Prophylaxis for HIV in Five Urban Health Centers of Kampala, Uganda: January 2016 – June 2019, under peer review.

Epidemiological Bulletin Articles

The MoH-UNIPH Quarterly Epidemiological Bulletin, Volume 3, Issue 3 (July – September 2018) in which I published the technical highlights on the Ministry of Health-Uganda Public Health Fellowship Program (MOH/PHFP) scientific work at the 14th Joint Annual Scientific Health (JASH 2018) conference in Kampala, and the Ebola Virus Disease (EVD) Preparedness in Western Uganda, 2018.

Epidemiological articles in the MoHUNIPH

• Quarterly Epidemiological Bulletin, Volume 3, Issue 2 (April – June 2018); One on the suspected intussusception outbreak in Kampala
• District and the other on the Crimean Congo Hemorrhagic fever outbreak in Kakumiro District.

Newspaper Articles

• Newspaper article on the dangers of Crimean Congo Hemorrhagic Fever, April 2018.
• Newspaper article on the role of the public in ending TB in Uganda, March

Summary of Epidemiological Study: 

 Title: Predictors of Mortality among TB/HIV co-infected patients before and after implementation of the TB/HIV Collaborative Policy in Uganda, 2012 and 2016

Background: Tuberculosis (TB) remains the leading cause of mortality among HIV patients in Uganda. In 2013, Uganda implemented the revised TB/HIV Collaborative Policy to include co-located TB/HIV services and early initiation of antiretroviral therapy (ART) to reduce mortality among TB/HIV co-infected patients. We examined predictors of mortality among TB/HIV co-infected patients before and after policy implementation.

Methods: We abstracted data from TB Unit registers for co-infected patients who were treated for TB before (July 2012-June 2013) and after (July 2015-June 2016) policy implementation. Patients were categorized into “pre-policy” and “post-policy” cohorts.We used logistic regression to identify
predictors of mortality.

Results: We examined 15,971 records of coinfectedpatients. Of these, 8,641 (56%) were  in the pre-policy and 7,330 (44%) in the post-policy cohort. Mean age was 34 years in both cohorts. In pre-policy cohort, 956 (11%) patients died compared to 1,018 (13%) in post-policy cohort (OR=1.11; 95%
CI, 1.16-1.40, p=0.04) with mean time to death in both of 4.2 months. The mortality rate was higher in post-policy vs pre-policy cohort (5.9 vs. 5.4/100,000, p=0.03). Compared to bacteriologically-confirmed TB, clinically-diagnosed TB had significantly increased odds of mortality in both prepolicy cohort (aOR=1.41; 95% CI, 1.22-1.67) and post-policy cohort (aOR=1.85; 95% CI, 1.59-2.16). Extra-pulmonary TB increased the odds of mortality, compared to bacteriologically-confirmed TB, in pre-policy (aOR=1.57; 95% CI, 1.30-1.90) and post policy cohorts (aOR=2.42; 95% CI, 2.00-2.93). ART was protective against mortality in post-policy (aOR=0.84; 95% CI, 0.74-0.96) but not pre-policy cohort (aOR = 0.96; 95% CI, 0.87-1.06).

Conclusion: Mortality of TB/HIV co-infected patients increased slightly after implementation of the revised TB/HIV policy. Clinically-diagnosed and extra pulmonary TB predicted mortality, while ART was modestly protective. We recommend further studies to establish the cause of increased mortality after policy initiation. Strategies to ensure early initiation and adherence to ART should be investigated and implemented.

Key lessons learnt during the fellowship

The PHFP has been a wonderful opportunity for hands on learning experience in field epidemiology and public health leadership. The skills and competencies acquired from this practical experience and mentorship with supervision from technical experts in the Ministry of Health and the fellowship program are invaluable. These include;

• Evaluation and analysis of MoH surveillance systems to generate information for action to improve program implementation strategies and
  policy formulation for better patient care and disease control interventions across MOH programs.
• National disease outbreak investigations and response as part of the MoH National rapid Response Team (NRRT) and the National Task Force (NTF) to establish causes of outbreaks and inform early prevention and control interventions to prevent further spread and save lives.
• Operational research through proposal development, secondary data analysis, to generate information to evaluate progress, outputs and impact of MoH program interventions
• Writing and publishing of scientific papers (Manuscripts), reports, policy briefs, and newspaper and Epi-Bulletins articles to inform the public, National and Global health actions for control and elimination of disease epidemics.
• Leadership skills in rapid response and control of disease outbreaks, analysis and evaluation of national surveillance systems, quality improvement and program implementation.

Next Steps

As I leave PHFP, I look forward to working as an epidemiologist with the Ministry of Health, National and international agencies to contribute towards prevention and control of disease epidemics in Uganda and elsewhere in the world.

Pictorial and narrative