Dr. Fred Monje

Dr. Fred Monje:

BVM (MUK); MVPM (MUK); Cert. Risk Analysis (USA)
Email: fredmonje@musph.ac.ug
Tel: +256775640304

Host Site: National Animal Disease Diagnostic Epidemiology Centre (NADDEC) and Arua attached to Infectious Disease Institute

Host Mentors: Dr. Deo Birungi Ndumu, Assistant, Commissioner Diagnostics & Epidemiology, Dr. Joseph Sserugga-Data Manager and Mr. Martin Esau, Laboratory Technician

ABOUT THE FELLOW

Dr. Fred Monje holds a Master of Veterinary Preventive Medicine and a Bachelor of Veterinary Medicine from Makerere University, Kampala, Uganda. Fred is a former FETP-V awardee of a 2-year AFENET Scholarship that led to his Master‟s degree in Veterinary Preventive Medicine of Makerere University. Prior to joining the fellowship program, Fred was a Senior Veterinary Inspector and One Health Focal Person for the Ministry of Agriculture, Animal Industry and Fisheries where he played a key role in the establishment of the National One Health Platform in Uganda. Fred joined the Uganda Public Health Fellowship Program in January, 2018 and was hosted at the National Animal Disease Diagnostics and Epidemiology Centre (NADDEC), Entebbe, Uganda and Arua District (attached to Infectious Diseases Institute) for the 2-year period. While at the host site, Fred was part of the National Rapid Response Team that strives to build capacity, prevent, and control infectious diseases especially of animal origin (zoonoses) in Uganda. With his passion for a safer and healthier world for all, Fred proactively participated and gained skills in epidemiology including: investigation and mitigation of disease outbreaks, preparedness, response to public health emergencies, description and evaluation of disease surveillance systems, implementation of quality improvement projects, designing and implementation of operational research, scientific writing, communication and leadership.

Achievements at the Host Site

Studied the trends and spatial distribution of animal bites and vaccination status among victims and the animal population, Uganda: 2013- 2017. We found out that there was low reporting of animal bites in the veterinary surveillance system and low vaccination of the pets against rabies. So, we designed and implemented a quality improvement project in one of the non-reporting districts in Uganda (i.e. Sironko District) from April 2019 to September, 2019 to improve reporting of animal bites. The animal bites reporting improved from 0% in April 2019 to 100% in September, 2019. In addition, we came up with a policy brief advocating for compulsory vaccination of pets against rabies in the country.
Analyzed NADDEC data for the Trends and spatio-temporal distribution of brucellosis in animals in Uganda, 2014- 2018. Brucellosis being one of the 7 priority zoonoses in Uganda, targeted for control, we established the hotspot districts with bovine brucellosis in Uganda. Information on hotspots districts generated will guide NADDEC and National One Health Platform on trade (for NADDEC) and targeted interventions (for the country). The findings may also be used as a support tool for test and slaughter policy of infected animals in the affected districts.
Studied the Trends and spatio-temporal distribution of bovine tuberculosis in animals in Uganda, 2014-2018. We established the hotspot districts of bovine tuberculosis in Uganda. Findings informed NADDEC and the National Tuberculosis and Leprosy Programme in the Ministry of Health on the hotspots of bovine TB in Uganda. Information on hot spot districts of bovine TB in Uganda will guide prioritized interventions in the affected districts, using a One Health approach as Uganda strives to END TB deaths by 2030, including bovine TB.
Evaluated the Animal Disease Surveillance System in Arua District, 2019. We found that the animal disease surveillance system was useful. To improve upon the functionality of animal disease surveillance system, we recommended improvement in data quality through use of standard case definitions for livestock diseases, standard reporting format, improving completeness of forms and reporting rates. There is an urgent need for an increment in dedicated quarterly allocations to surveillance activities to improve stability and hence functionality of animal disease surveillance system. We shared the findings with District Veterinary officer and Infectious disease institute, Arua office for action.
Sensitisation of communities in Kyotera District about rabies prevention and control, September 2018. Participated in awareness creation of rabies during the World Rabies Day commemoration in Kiryadongo District in September 2019. These were follow-up activities that arose from our descriptive for rabies/animal bites at NADDEC where one of our recommendations was to sensitize the public about the consequences of animal bites and need for urgent health care.
Following animal anthrax outbreak investigation in the country, I organised an anthrax symposium that led to the formation of an anthrax prevention and control technical working group for the country to spearhead control of anthrax
To support animal disease surveillance activities at NADDEC (Country) and the region, we engaged in the following activities:
Trained data entrants on usage of Epiinfo at NADDEC to improve data quality at NADDEC
Facilitated One Health Training in Ntoroko District, 23rd to 27th, April, 2018 as part of support to animal disease surveillance activities in Uganda
Facilitated a stakeholders meeting to operationalize National Rabies Control Strategy in Uganda, 2019-2023
Trained District Surveillance Veterinary focal persons on early disease reporting, disease detection, and outbreak response using One Health approach in Buyende District and Mid-Western Uganda. This was support to animal disease surveillance activities
Trained District Surveillance focal persons on early reporting, and outbreak investigation and response from selected disease hot spot districts in August 2019
Participated in Joint Risk Assessment (JRA) training for assessing health risks at the interphase between animals and humans, Jinja, 2019
Trained Rubirizi, Kamwenge and Kabarole district top leadership (RDC, CAO, DHO, DVO‟s, Game wardens etc.) on Hazard analysis and Disaster risk management
Represented Uganda in development of a manual guiding countries globally in establishment of Animal Health Emergence Operation centre (AH-EOC) in Rome, Italy, in December, 2018; March 2019 and October, 2019
Facilitated One Health Trainings in surveillance and infectious Disease Management at Micelle, Jimma and Addis Ababa Universities, Ethiopia, 2018. This was support to disease surveillance activities in the region
Trained IOWA state university students on how One Health Approach has been applied in Disease detection and Outbreak responses of Zoonotic Diseases at NADDEC, 2019. This was part of sharing the success stories of One health in Uganda
National trainer for Joint Risk Assessment tool (A tool used to prioritise risks at the interphase between animals and humans)

Fellowship program specific achievements

Outbreak investigations
Lead investigator:

Cholera outbreak investigation in Hoima District, 2018. We found that drinking water from the stream was associated with the outbreak. We recommended boiling drinking water to the communities, increasing latrine coverage and safe water access by the District and UNHCR. The outbreak was contained.
Animal anthrax outbreak investigation in districts of Arua, Kiruhura and Kween, 2018. In these outbreak investigations, we found that in districts where human outbreaks occurred, animal outbreaks occurred, which were associated with butchering suspected anthrax-infected livestock and improper carcass disposal. We recommended vaccination of domestic ruminants for anthrax, proper carcass disposal, and sensitization of communities, game reserve wardens, animal and medical health workers about anthrax control.
Ebola Virus Disease Preparedness in the districts of Bundibugyo and Ntoroko, 2018. We found that readiness and preparedness for EVD response in the Bundibugyo and Ntoroko Districts was wanting. We recommended immediate actions on the identified gaps in the EVD preparedness core capacities in the high-risk districts of Bundibugyo and Ntoroko.
Ebola Virus Disease Preparedness in Kagadi and Rubirizi Districts, 2018. We found that readiness and preparedness for EVD response in the Kagadi and Rubirizi Districts was very low. We recommended immediate actions on the identified gaps in the EVD preparedness in all the core capacities in the high-risk districts of Kagadi and Rubirizi.Ebola Virus Disease Preparedness in Kagadi and Rubirizi Districts, 2018. We found that readiness and preparedness for EVD response in the Kagadi and Rubirizi Districts was very low. We recommended immediate actions on the identified gaps in the EVD preparedness in all the core capacities in the high-risk districts of Kagadi and Rubirizi.

Co-investigator:

Investigation of anthrax outbreak investigation in Kiruhura District in humans, 2018. We found that cutaneous Anthrax outbreak in humans was caused by skinning and cleaning of waste from dead animals. The team implemented the following immediate control measures in the infected villages, Engari Sub-county: provision of Post Exposure Prophylaxis to community members, sensitized the community on the dangers of consuming meat from dead animals, and participated in safe disposal of dead animals in Engari Subcounty. We recommended vaccination of all animals in affected sub county and safe disposal of dead animals.
Investigation of malaria outbreak investigation in Gomba District, 2019. We found that two sub-counties were affected by malaria. Transmission of malaria was exacerbated by presence of water logging around households. We recommended drainage of the waterlogged areas around households.
Investigation of malaria outbreak investigation in Mbale District, 2019. We found that presence of erosion control pits was significantly associated with the occurrence of malaria outbreak. Lack of awareness on malaria transmission and control highlighted by the belief that mosquito nets brought bedbugs also created laxity on preventive measures. We recommended removal of potential mosquito breeding sites and draining of erosion pits regularly. Community awareness on malaria prevention and control mechanisms should be done.

Epi-bulletin Articles

Cholera outbreak in Kyangwali Refugee Settlement in Hoima, Uganda, 2018. We found that stream water was associated with cholera outbreak. We recommended increased access to safe water in all affected communities.
Prolonged Animal Anthrax outbreak amplified by slaughtering infected carcasses on the pastureland in Arua District, Uganda, 2016 – 2018. Animal anthrax infection in Arua District was associated with butchering of anthrax infected animals on the pastureland, and grazing animals near the river bank. We recommended vaccination of domestic ruminants at risk against Anthrax and enhanced sensitization of all the key stakeholders about anthrax control.
Animal Anthrax outbreak caused by slaughtering infected carcasses on and or near the pastureland, Kiruhura District, Uganda, May-October 2018. Butchering anthrax infected carcasses on and or near the pastureland and improper disposal of infected carcasses were associated with anthrax infection in animals. We recommended vaccination of domestic ruminants at risk against anthrax and enhanced sensitization of the key stakeholders about anthrax control.
Animal Anthrax outbreak triggered by butchering infected carcasses on and or near the pastureland, Kween District, Uganda: January – December 2018. Animal anthrax infection in Kween District was associated with improper disposal of infected carcasses and butchering anthrax infected carcasses on or near the pastureland were the main exposures. We recommended vaccination of domestic ruminants at risk against anthrax and improved sensitization of the communities; animal health workers and medical health workers about anthrax control.
Trends and Treatment Outcomes of Pediatric Tuberculosis, Mbale Regional Referral Hospital, Uganda, 2013-2017. We found out that TB treatment completion rate was below the WHO recommendation of 85%. Better TB completion rate was associated with TB patients residing ≤ 20km from the Hospital. To improve completion of TB treatment, MRRH should consider designing a means of follow up of TB patients who transfer out due to long distance to ensure they complete TB treatment in the scheduled period. Ministry of Health should consider
educating communities on the importance of completing TB treatment.
Animal bite patterns and delays in initiating Post Exposure Prophylaxis (PEP) caused by Vaccine stock- outs at Arua Regional Referral Hospital, Arua District, Uganda: 2014-2018. We found that there was low timely initiation of PEP among animal bite victims in Arua District associated with stock-outs of rabies vaccine at ARRH. We recommended increasing availability of rabies vaccine at ARRH guided by animal bites data from the veterinary department; and sensitization of the public about PEP usage to minimize the dangers of animal bites/rabies in humans.

Policy Brief

“Adopt compulsory vaccination of pets against rabies to prevent human rabies”. In this policy brief, we emphasized that rabies can be controlled in pets and prevent spillage to human population. The government of Uganda through the Ministry of Agriculture, Animal Industry and Fisheries (MAAIF), Ministry of Health (MoH), Uganda Wildlife Authority (UWA) needs to design and strengthen collaborative strategies that enable compulsory vaccination of pets against rabies to ensure elimination of dog mediated human rabies by 2030.

Newspaper Articles

Embrace Animal Anthrax Vaccination to save lives- Daily Monitor, 26th April, 2019
Beware of animal-to-human diseases-Daily Monitor, 9th Aug, 2019: Featured as letter of the day
Rabies vaccination- Uganda‟s New Vision, 25th September 2019
Embrace compulsory vaccination of pets against rabies to prevent human rabies, New Vision, 28th September, 2019
Rabies vaccine stock-outs in health care facilities delays uptake among animal bite victims, New Vision, 28th September, 2019

Conference Presentations

Prolonged cholera outbreak in Kyangwali refugee settlement caused by drinking contaminated water from the stream, Hoima, Uganda, 2018, Time: 15:00-15:15 hours, 26th September, 2018 (AFENET Conference, Maputo, Mozambique, 12-16, November, 2018 & JASH Conference, 26-28 September, 2018 & 4th National Field Epidemiology Conference, 30th September, 2018)
Anthrax Outbreaks among Domestic Ruminants Associated with Butchering Infected Livestock and Improper Carcass Disposal: Three Districts, Uganda, 2016-2018, Time:9:10am-9:20am (10th TEPHINET Global Scientific Conference, Atlanta, USA, 28th October-01st November, 2019 &5th National Field Epidemiology Conference, 24th October, 2019)
Trends and spatial distribution of animal bites and vaccination status among victims and the pet population, Uganda: A veterinary surveillance system analysis, 2013 – 2017, Time: 4:10pm-4:20pm (5th National Field Epidemiology Conference, 24th October, 2019)
Rabies Vaccine stock-outs delays uptake among animal bite victims at Arua Regional Referral Hospital, Uganda: 2014-2018. Time: 9:50am-10:00am on 7th November, 2019 (JASH-GDC-AMR Conference, 6-8, November, 2019)
Trends and Treatment Outcomes of Pediatric Tuberculosis at Mbale, 6th November, 2019 (JASH-GDC-AMR Conference, 6-8, November, 2019)
One Health Champion, 12:10pm- 12:20pm 24th, July 2019 (3rd OHCEA International Conference, 24-26, July 2019)
Correlates of Early Retention among newly initiated persons on HIV treatment in Kampala and Wakiso Districts, Uganda: 2018 (PEPFAR Science Summit, 13-14, Jan, 2020) HIV project
Correlates of Early (3-6 months) Retention among newly initiated persons on HIV treatment in Kampala and Wakiso Districts, Uganda: 2018. We found out that the sub group of young adults (aged 20-30) in cohort January-March 2018 had a lower early retention. Early retention was associated with increasing residential distance from the Urban Health facility and decreasing distance from rural health facility. May be due to Urban stigma and rural transportation costs. We recommended that the District Health Office and Ministry of Health should conduct
regular refresher training of health workers and community sensitization against stigma of ART patients. QI project.
Improving the reporting rates of animal bites through quality improvement approaches in Sironko District, Uganda, 2019. This led to 100% improvement in animal bites reporting. Improved animal bites reporting was associated with teamwork, adoption of appropriate data
collection tools and sensitization.

TB Operations Research

Trends and Treatment Outcomes of Pediatric Tuberculosis at Mbale Regional Referral Hospital, Uganda, 2013-2017. We established that TB treatment completion rate was below the WHO recommendation of 85%. Better TB completion rate was associated with TB patients being HIV- negative. To improve completion of TB treatment, MRRH should strengthen HIV treatment services among childhood TB patients who are HIV-positive through involving community linkage facilitators.

Epidemiologic Study

Animal bite patterns and delays in initiating Post Exposure Prophylaxis for rabies prevention among animal bite victims at Arua Regional Referral Hospital, Arua District, Uganda: 2014- 2018. We established that delayed rPEP initiation was associated with stock-outs of rabies vaccine at ARRH. We recommended increasing availability of rabies vaccine at ARRH guided by animal bites data from veterinary department; and sensitization of the public about rPEP to minimize the consequences of animal bites.

Manuscripts

Trends and spatial distribution of animal bites and vaccination status among victims and the animal population, Uganda: A veterinary surveillance system analysis, 2013 – 2017- Submitted to PLOS one Journal.
Prolonged Cholera Outbreak Caused by Drinking Contaminated Water from a Stream, Kyangwali Refugee Settlement, Hoima District, Western Uganda: February-May 2018- Submitted to BMC Infectious Diseases journal
Anthrax Outbreaks among Domestic Ruminants Associated with Butchering Infected Livestock and Improper Carcass Disposal in Three Districts of Uganda, 2016-2018- Submitted to BMC One Health Outlook journal
Trends and Treatment Outcomes of Pediatric Tuberculosis at Mbale Regional Referral Hospital, Uganda, 2013-2017- Under peer review
Animal bite patterns and delays in initiating Post Exposure Prophylaxis for rabies prevention among animal bite victims at Arua Regional Referral Hospital, Arua District, Uganda: 2014-2018- Under peer review
Evaluation of Animal Disease Surveillance System: Arua District, 2019 – Under peer review
Improving the reporting rates of animal bites through quality improvement approaches in Sironko District, Uganda, 2019 – Under peer review
Correlates of Early (3-6 months) Retention among newly initiated persons on HIV treatment in Kampala and Wakiso Districts, Uganda: 2018 – Under peer review
Trends and spatio-temporal distribution of brucellosis in animals in Uganda, 2014-2018 – Under peer review
Trends and spatio-temporal distribution of bovine tuberculosis in animals in Uganda, 2014-2018 – Under peer review Editorial work
Editor for the UNIPH bulletin Volume 3, Issue 3, July-Sept 2018 Special presentations during high level visits in 2018 and 2019
Anthrax presentation during US CDC Director‟s visit to Uganda, 2018
Anthrax presentation during US Secretary of Health and Human Services visit in Uganda, 2019 Mini Grants
Awarded a mini grant from Infectious disease institute to evaluate animal disease surveillance system in Arua District, 2019.
Awarded a mini grant from Food and Agriculture Organization to organize a national anthrax symposium that led to the formation of National Anthrax Prevention and Control Technical Working Group (NAPCTWG) for Uganda, 2019.

Summary of Epidemiological Study:

Title: Risk Anthrax Outbreaks amongDomestic Ruminants Associated with Butchering Livestock and Improper Carcass Disposal: Three Districts, Uganda, 2016-2018

Introduction: In 2017 and 2018, human anthrax outbreaks occurred in Arua, Kween and Kiruhura districts, Uganda. Investigations indicated eating and handling meat from domestic ruminants that died suddenly caused these outbreaks. We investigated to determine the existence and extent of anthrax in domestic ruminants, identify exposures, and recommend control measures.

Methods: We defined a suspected case animal as sudden death with unclotted blood oozing from body orifices in a domestic ruminant during 2016–2018 in the above-mentioned districts. A probable case animal was a suspected case-animal with a positive rapid diagnostic test (RDT) for Bacillus anthracis and/or identification of Gram-positive rods from a specimen. A case-kraal was one with a suspected caseanimal. A kraal meant “an enclosure for cattle or sheep” in this study. We reviewed district veterinary records and conducted active case-finding for case-animals. We conducted case-control studies in the three affected districts separately to compare exposures among case-kraals and controlkraals (with no suspected case-animals during the same time period), frequency matched by village, with ratios of 1:1 in Arua, 1:4 in Kiruhura and 1:2 in Kween. We estimated the overall associations using pooled analysis.

Results: We identified 1971 case-animals during 2016–2018 (attack rate[AR]=1.4/1000); 229 of 31500 kraals (7.3/1000) were affected. Cattle (AR=2.3/1000), goats (AR/1000=0.39/1000) and sheep (AR=0.094/1000) were all affected. Arua (AR=14/1000) was the most affected district, followed by Kween (AR=2.5/1000) and Kiruhura (AR=0.095/1000). The epidemic curve indicated continuous outbreaks in Arua and Kween districts. Human outbreaks were reported during or after the onset of livestock outbreaks in all three districts. Butchering suspected anthrax-infected livestock (OR=8.0; 95%CI=5.2-12) and improper carcass disposal on/near pastureland (OR=1.7, 95%CI=1.1-2.4) were significant exposures. Of 21 animal carcasses tested, 14 (67%) were positive for B. anthracis by both RDT and gram stain.

Conclusion and Recommendation: Ugandan districts with human anthrax outbreaks had concurrent livestock anthrax outbreaks associated with nearby butchering and improper carcass disposal of livestock with suspected anthrax. We recommended anthrax vaccination for domestic ruminants, proper carcass disposal, increased surveillance for sudden livestock deaths, increased capacity for laboratory confirmation, and sensitization to livestock-keepers about anthrax control.

Key words: Anthrax, animal; Disease outbreaks; pooled-analysis; Global Health Security; Uganda, Bacillus anthracis, Rapid diagnostic test

Key lessons learnt during the fellowship

Outbreak investigation and response skills
Scientific Writing and communication skills: abstract and manuscript writing in peer reviewed journals, presentations, policy briefs,
newspaper articles, bulletin articles, trainings, dissemination meetings.
Leadership skills: Anthrax symposium, Class president, implementation of QI and Operational research
Evaluation of disease surveillance systems
Epidemiological data presentation using QGIS and EPI info
Team work through outbreak investigations

Next Steps

With the epidemiological skills and competencies gained coupled with hard work, commitment, discipline and teamwork, Fred hopes to have a great career in epidemiology especially in building capacity and systems for preparedness, early detection, and response to public health threats. As a public health leader, Fred hopes to write and win grants to create a difference in the society through epidemiological work for a safer and healthier world for all.