Kisaakye Esther

BSc (MUK), MPH (MUK), Field Epidemiology Fellow (PHFP)
Tel: +256775191093, +256703380228
Email: estherkisaakye@musph.ac.ug and esie678@yahoo.com

Host Site: Reproductive Health Division, Ministry of Health

Host Mentors: Dr. Dinah Nakiganda and Dr. Livingstone Makanga

ABOUT THE FELLOW

Esther Kisaakye holds a Master of Public Health and a Bachelor of Science in Nursing, both from Makerere University Kampala, Uganda. Esther has had training in health systems research at Makerere University and has worked in several projects in areas of research, programs and clinical work. Before joining the fellowship program, Esther worked as Project Coordinator, Safe Motherhood and Childhood Disability project at Mildmay Uganda, Lweza, Entebbe. While on the fellowship program, Esther has been hosted at the Reproductive Health Division, Ministry of Health where she has gained skills/experience in implementing reproductive health, maternal, new born and adolescent care programs/services at all levels. The fellowship program has enabled Esther to gain expertise in outbreak detection, investigations and response, development and evaluation of public health surveillance systems, proposal/concept/project development and implementation, leadership, management, support supervision/mentoring, effective communication, scientific writing and results dissemination skills.

  Achievements at the Host Site

While at the host site, Esther was involved in several activities that included:

1. Development, implementation, supervision, monitoring and evaluation of different reproductive health, maternal, new born and adolescent care programs/ activities at national level.
2. Extraction and analysis of DHIS2 data on key reproductive health, maternal, new born and adolescent care indicators and recommended ways to ensure improved service delivery, data reporting and data usage.
3. Assessment of the current data reporting and surveillance tools for reproductive health, maternal, newborn and adolescent health services offered at health facility levels, district and national levels and recommendations to improve on the tools.
4. Provision of technical support to the Maternal and perinatal mortality surveillance and response (MPDSR) section of the Reproductive Health Division by engaging in support supervisions, compilation of the quarterly and annual MPDSR reports.
5. MPDSR training Bududa District.
6. Conducting AFP/Polio surveillance and integrated support supervision for vaccine preventable diseases in high risk districts of Zombo, Jinja, Mayuge, Kyenjojo, Hoima, Wakiso, Lwengo and Iganga.
7. Participating in quarterly data quality validation exercises organized by the department and identified gaps for data quality improvement at both facility and district levels.

Fellowship program specific achievements

Descriptive analysis
Analysis of Surveillance data to determine the spatial and temporal distribution of maternal sepsis admissions in Uganda, 2013 -2017. Results demonstrated a gradual increase in admissions due to maternal sepsis in all four regions of Uganda over the study years. However, the cumulative
incidence in maternal sepsis admissions over the five years was highest in the northern region (199/10000 live births) and lowest in the central region (146/10000 live births). The aggregated data from DHIS2 system does not give a leeway to study modifiable risk factors for the high maternal
sepsis admissions in northern Uganda, yet this would provide valuable information to inform planning of obstetric care aimed at reducing maternal morbidity and mortality due to post-partum sepsis in Uganda. This led to the epi-study that I conducted to assess for the risk factors of post-partum
sepsis among women in Lango sub region, Northern Uganda, August, 2019.

Outbreak investigations
Lead investigator:

• Outbreak of Cutaneous and Gastrointestinal Anthrax Associated with Handling and Eating Meat from a Cow that Died of Anthrax: Kween District, Uganda, April 2018
• Suspected black water fever among children in Manafwa District, May to June 2018.

Co-Investigator:

• Investigation of Cholera outbreak in Hoima, District, April, 2018
• Investigation of human anthrax in Makutano village, Kween District, May 2019
• Investigation of anthrax outbreak among animals in Kiruhura District, Uganda, 23rd to 28th October 2018
• Investigation of anthrax among animals in Kween District, Uganda, 5th to 15th December 2018
• Investigation of anthrax in animals in Arua District, Uganda, July 2018
• Investigation of Cholera outbreak in Kampala, January 2019
• Risk factors of CCHF outbreaks in western Uganda, January 2019
• Investigation of CCHF outbreak in Isingiro District, Uganda, July-August, 2018
• Investigation of RVF outbreaks in Western Uganda, August, 2018
• Investigation of suspected Food Poisoning at Katuulo Village, Lwengo District, September 2018
• Investigation of Ebola outbreak in Kasese District, June-July 2019

Bulletin articles

• Analysis of Surveillance data to determine the spatial and temporal distribution of maternal sepsis admissions in Uganda, 2013 -2017
• Outbreak of Cutaneous and Gastrointestinal Anthrax Associated with Handling and Eating Meat from a Cow that Died of Anthrax: Kween District, Uganda, April 2018
• Suspected black water fever among children in Manafwa District, May to June 2018

Quality improvement project
“Improving prevention, early diagnosis and management of postpartum hemorrhage through risk screening and active Management of third stage of labour at Mityana Hospital, Mityana District, Uganda”.

This was a successfully implemented QI project. The percentage of midwives/nurses who; take and documents a full history of mother on admission for labour increased from 16% to 92%, assesses the mother for risk of obstetric hemorrhage using a risk checklist tool on admission for labour increased from 0% to 75%, categorize mothers by their risk of post-partum haemorrhage (PPH) before preparation for labour increased from 25% to 83% and those continues to monitor the uterus for 2h after birth increased from 0% to 67%. The overall ratio of PPH cases with in the hospital per 1000 live births reduced from 7/1000 live births before project implementation to (5.8/1000 live births) after the implementation of the Quality Improvement (QI) project. Oxytocin injection use increased after the implementation of the QI project. We recommended that the quality improvement project should be scaled up in other health units with high numbers of PPH cases with in the facility to reduce on the burden of PPH in Uganda.

Conference Presentations

• Outbreak of Cutaneous and Gastrointestinal Anthrax Associated with Handling and Eating Meat from a Cow that Died of Anthrax: Kween District,
• Uganda, April 2018, EIS Conference International Night, 2019 and 4th Uganda National Field Epidemiology Conference
• Spatial and temporal distribution of maternal sepsis admissions in Uganda in Uganda, 2013 -2017, JASH Conference 2019
• Presumptive Tuberculosis among Newly-diagnosed HIV Patients at Naguru Regional Referral Hospital in Kampala, Uganda, January 2016 – June 2018, JASH Conference 2019
• Anthrax in Makutano Village, Kween District, May 2018, The Uganda Society of Health Sciences,19th annual scientific conference 23-24 May 2019
• Mental Illnesses Among Prisoners Who Sought Care At Murchison Bay Prison Hospital, Uganda: 2015 – 2017, The Uganda Society of Health Sciences, 19th annual scientific conference 23-24 May 2019
• Suspected black water fever among children in Manafwa, May 2018, the World Malaria Day Scientific Conference held in Uganda April 2019

Policy brief
“Improve availability and provision of quality postpartum care services at both facility and community levels to reduce occurrence of post-partum maternal and neonatal infections in Uganda”.

HIV project
“Validation of a computer based HIV risk scoring tool for predicting HIV positivity among key populations in Uganda”. Of the 13,787 clients enrolled, 71% (9801/13787) were males, 92% (12628/13787) were aged from 18 to 49 years and 58% (8029/13787) were doing manual work. 27% (3658/13787) of respondents were clients of sexual workers. The prevalence of HIV was highest 27% (209/781) among the female sexual workers. 95% (13071/13787) of enrolled clients reported that it was easy for them to do the ACASI interview. 42% (5823/13796) preferred the ACASI interview with a computer. The rate of HIV positivity was highest (10%, 13/124) among clients who were categorized as high risk by the computer based HIV risk scoring tool compared to other risk categories. The computer based HIV risk scoring tool has a high specificity of 99%. The tool could be useful in low resource settings in discriminating people with almost no risk of HIV infection, and thus excluding them to HIV tested. It could also improve early detection of new HIV infections among key populations.

TB Operations Research
“Presumptive Tuberculosis among Newlydiagnosed HIV Patients at Naguru Regional Referral Hospital in Kampala, Uganda, January 2016 – June 2018”. Of the 3314 patients enrolled into HIV care, 91 (2.7%) were already on TB treatment, 64 (1.9%) were not screened, and 3159 (95%) were screened for presumptive TB. Of 3159 patients screened, 172 (5.4%) had presumptive TB. Of the 172 HIV patients enrolled into HIV care with presumptive TB, 44 (26%) were confirmed to have TB. Factors associated with presumptive TB included: being male (AOR 2.3, 95%CI=1.7-3.2),
having a WHO clinical stage 2 (AOR=2.9; 95% CI=1.8-4.6), having an advanced WHO clinical stage 3 or 4 at enrollment into HIV care (AOR=4.5; 95% CI=2.9-7.1), and not having viral load records at baseline (AOR=1.8; 95% CI=1.3-2.6). We recommended intensified TB case-finding and treatment among PLHIV, strengthening administration of Isoniazid preventive therapy (IPT) to newly-diagnosed HIV patients without TB, and timely treatment of active TB cases among newly-diagnosed HIV patients.

Newspaper articles

1. Why you should and how to protect yourself and your newborn baby from Infections after giving birth (Published in New Vision paper)
2. Back to school time: Is your child vaccinated against measles?
3. Who should get the HPV vaccine in Uganda and why?
4. What it means to have a child with black water fever: lessons learnt from Manafwa district

Manuscripts

• Outbreak of Cutaneous and Gastrointestinal Anthrax Associated with Handling and Eating Meat from a Cow that Died of Anthrax: Kween District,
  Uganda, April 2018 (Submitted to the Emerging Infectious Diseases Journal)
• Factors associated with Presumptive Tuberculosis among Newly-diagnosed HIV Patients at Naguru Regional Referral Hospital in Kampala, Uganda, January 2016 – June 2018 (under peer review)
• An increasing trend of admissions for maternal sepsis in Uganda, 2013 – 2017(under peer review)
• Risk factors of post-partum sepsis among women in Lango sub region, Northern Uganda, August, 2019 (under peer review)
• Validation of a computer based HIV risk scoring tool for predicting HIV positivity among key populations in Uganda (under peer review)

Summary of Epidemiological Study: 

 Title: Risk factors of post-partum sepsisamong women in Lango sub region, Northern Uganda, August, 2019

Introduction: Maternal sepsis is the third most common direct cause of maternal mortality in Uganda. The greatest attention in obstetric care in Uganda has been put on postpartum hemorrhage and hypertensive disorders, the two leading direct causes of maternal mortality however, maternal sepsis, has received less attention and programming. We assessed for the Risk factors of post-partum sepsis among women in Northern Uganda to provide valuable information to inform planning of obstetric care aimed at reducing maternal morbidity and mortality due to post-partum sepsis in Uganda

Methods:  We conducted an unmatched case control study during august 2019 at Lira Regional Referral Hospital (LRRH) that serves the lango sub region of northern Uganda. Sample size was calculated using Fleiss JL formula using a 1:4 case to control ratio. In total we recruited 38 cases and 152 controls. We used a semi structured interviewer administered questionnaire to collect data. Data was analysed using Stata software version 12.0. A logistic regression model was used for multivariate data analysis.

Results: The age of respondents rangedfrom 16 to 43 years with a mean age of  29(SD=5.8) years. The largest proportion 43% (81/190) of the respondents were within age group of >30 years. Factors independently associated with post-partum sepsis included: having a first pregnancy
(prim gravid) (aOR =14, 95%CI=2.0-99), having more than six vaginal examinations during delivery (AOR=4.6; 95% CI=1.0-35), having a cesarean section delivery (AOR=11; 95% CI=3.1-38) and having a vaginal tear during delivery (AOR=10; 95% CI=2.7-38).

Conclusion and Recommendation: Having the first pregnancy, having more than six vaginal examinations during delivery, having a cesarean section delivery and having a vaginal tear during delivery were identified as risk factors for postpartum sepsis. We recommended strengthening of health education programs for post-natal mothers about how to prevent post-partum sepsis with more focus to first time mothers, women who have had a cesarean section and those who have had vaginal tear. We also recommended sensitization of health workers to observe sterility while carrying out vaginal examinations, minimize vaginal examinations and also ensure that they conduct health education about infection prevention talks to mothers attending ANC.

Key lessons learnt during the fellowship

• Outbreaks detection, investigation, response and control.
• Scientific writing (manuscripts, newspaper articles, policy briefs, bulletin articles etc.) and presentation skills at both national and international audiences.
• Analysis, interpretation and evaluation of surveillance data to improve health
• Development of surveillance systems
• Leadership and management skills attained from the different assignments at the host site
• Development and implementation of Quality Improvement projects
• National level programing and coordination of reproductive health, maternal, new born and adolescent care programs

Next Steps

• Using the expertise that I have acquired in field epidemiology, I desire to build a career in infectious disease epidemiology.
• Using the expertise I have acquired in national level leadership, programing and coordination, I intend to contribute towards the movement aiming at improving reproductive, maternal, new born and adolescent health in Uganda.
• I also intend to transfer the knowledge and skills I have gained to upcoming epidemiologists and public health officials.

Pictorial and narrative