Phoebe Nabunya

BHUN (MaK); MPH (MaK)
Email: pnabunya@musph.ac.ug
Telephone: +256-789681757

Host Site: National Malaria Control Program (NMCP)

Host Mentor: Dr. Damian Rutazaana, Dr.Daniel Kyabayinze and Dr.Denis Rubahika

ABOUT THE FELLOW

Phoebe Nabunya is an epidemiologist with a special interest in disease outbreak investigations. She holds a Master‟s Degree in Public Health from Makerere University, School Of Public Health and has a background in Human Nutrition.
During her time as a Field Epidemiology Fellow, she has been attached to the National Malaria Control Division (NMCD), Ministry of Health. While in this position, she has led the investigation of four outbreaks and participated in three other outbreak investigations. She has also undergone a number of short courses in data analysis, scientific writing, and surveillance.
The short courses have improved her skills in data analysis using statistical packages including R, Stata, Epi-info, QGIS; manuscript writing, and writing of bulletins, which she used in supporting the Division to publish their routine (weekly and quarterly) malaria bulletins.

  Achievements at the Host Site

The fellow led a malaria outbreak investigation and response in Kyotera district in 2019 where she was in charge a team of epidemiologists and entomologists. The team conducted line listing from the health facility, environmental assessments, and community assessments to determine the factors associated with the observed increase in cases.

• Led the investigation of a malaria outbreak in Bugweri district in 2020 where she studied the spatial distribution of cases in the district and evaluated factors associated with the observed increase in malaria cases.
• Led the writing and publication of weekly, monthly, and quarterly bulletins at the National Malaria Control Division which are used as information sources and a basis for decision making at national and subnational levels as well as by malaria partners.
• Supported routine analysis of malaria data as reported in the DHIS 2 and shared weekly malaria status of districts with the staff in NMCD.
• Developed and updated a weekly report on the malaria status of districts which was shared with all staff and key malaria partners to inform early intervention in case of malaria upsurges
• Part of the Malaria Surveillance Monitoring, Evaluation and Operational Research technical working group which discussed and shared experiences in the fight against malaria from different malaria partners. As part of the team, she championed the analysis of routine surveillance data from DHIS 2 and updating the team on the malaria status in the country.
• Participated in drafting the malaria Annual Report 2019/2020
• Participated in the Malaria Program Review (MPR) and subsequent strategic planning for the years 2020-2025.
• Conducted a trend analysis of malaria cases in Uganda between 2014 and 2018. This study was conducted to determine the trend and distribution of uncomplicated, severe, and malaria related deaths over the years. We anticipated that this study would inform the targeting of malaria interventions to areas where they are most needed.
• Lead editor for 4 quarterly malaria bulletins that were widely disseminated to malaria stakeholders in the country. The bulletin is based on data routinely collected from health facilities through the DHIS 2 platform. It gives highlights on malaria incidence, test positivity rate, mortality, malaria in pregnancy and other key malaria indicators at national level and district level.
• Participated in building capacity of districts in malaria surveillance, detection of malaria outbreaks using malaria normal channels, and coordination of responses to detected outbreaks.
• Carried out support supervision for districts in iCCM, and malaria surveillance activities
• Participated in training of health workers in the updated Malaria in Pregnancy guidelines in Hoima region.
• Participated in organizing the World Malaria Day Celebrations which were held in Alebtong District in 2019.
• Conducted a quality improvement project on use of malaria channels to detect malaria outbreaks at health facility level in Kyotera District. This was informed by the challenges identified form the outbreak investigation done in 2019, where the health workers were not aware of the outbreak due to lack of skills to monitor their cases using the malaria channels.
• Participated in building capacity of district staff in COVID-19 surveillance between January and April 2020.

Fellowship program specific achievements

Descriptive analysis
Described the distribution and trends of uncomplicated malaria, severe malaria, and malaria-related deaths in Uganda from 2014-2018. Findings revealed that malaria and malaria-related deaths in Uganda decreased between 2014 and 2018. It also showed that children under five, regions including west Nile, Karamoja, Lango and Busoga were the most affected. We recommended sustained efforts with a continuous focus on children <5 and particular attention to most affected areas such as to help the country achieve the targets on the malaria indicators as stipulated in the Uganda Malaria Reduction strategic plan of 2020-2025.

Outbreak investigations
Lead Investigator:

• Malaria in Kyotera. The late detection of the malaria outbreak in the Kyotera informed her quality improvement project which focused equipping health workers with skills in constructing updating and interpreting malaria channels.
• Investigation of and response to an outbreak of Crimean-Congo Hemorrhagic Fever in Kagadi District, January 2020.
• Spatial distribution of cases in Bugweri district, during a malaria outbreak June 2020
• Investigated COVID clusters in Kampala and Wakiso district.
• Pilot Project to assess the feasibility and acceptability of the COVID-19 case report form in Gulu, Mulago and Entebbe Regional referral Hospitals
• Investigation of the sudden deaths in Ntoroko District, November 2019. Our findings reveled that there was no epidemiological link between the deaths. They were likely linked to chemical poisoning.

Co-Investigator

• Investigation of leprosy outbreak in Lira and Alebtong, 2019. Lira district had reported 38 Leprosy cases in the last quarter of 2018, and investigations into this revealed that most of the cases identified had lived in IDP camps where they were likely exposed.
• Assessment of Health facility readiness to handle infectious pathogen, Kampala and Wakiso, March 2020
• Malaria Outbreak associated with increased human activity in swamps and road construction, Butambala district, March 2019
• Screening of travellers for COVID-19 at Entebbe International airport between March-June 2020
• COVID-19 Case investigations in Ankole region, Wakiso and Kampala Districts
• COVID-19 in East Africa and Democratic Republic of Congo: A Comparison of the Outbreaks, and Interventions in the First Four Months

HIV project

• The fellow analysed secondary data from the Dreams project with the aim of assessing the layering of HIV interventions given to adolescent girls and young women in the DREAMS project in Uganda. We found that giving a higher number of interventions to AGYWS on the DREAMS program was associated with a higher risk of sero-conversion likely because of the program design where AGYWS with a higher perceived risk for sero-conversion received more interventions. We also found that most commonly offered services were social protection services for AGYW & their families followed by the Targeting male partner and Adolescent friendly health services while strengthening communities Interventions were the least offered. We recommended that the program revise the way interventions are given to emphasize the need for AGYWs to understand the purpose of each intervention given and how it can prevent them from acquiring HIV.

Quality Improvement

• Following the investigation of a malaria outbreak in Kyotera District, the investigation team noted that the outbreak was detected 6 months late due to lack of data analysis at health facility level.
• We implemented a continuous improvement project in Kyotera district to identify the root cause for the late detection of malaria outbreaks.
• We found that health workers at health facility level did not have knowledge and skills of constructing malaria channels which are used to detect malaria outbreaks.
• We therefore, conducted training and onsite mentorship of records officers on how to construct malaria normal channels and updating them at 4 high volume facilities in the district between June 2020 and October 2020.
• The project demonstrated an improvement in the use of malaria channels by the 4 health facilities. This was attributed to equipping the health workers especially the records persons with skills in constructing the malaria normal channels, supporting them to print out the channel for updating and sending them weekly reminders to update and report the channels to the district through the district biostatistician.
• We recommended that the trained health workers in Kyotera, cascade the training to other health workers not involved in the QI project.

Scientific writing
Articles in the MOH surveillance or Epidemiology Bulletin

• A policy brief titled “Using malaria channels based on percentiles to detect malaria epidemics in Uganda”.
• Malaria situation update following a country wide malaria outbreak, January 2020
• Uganda FETP at the 10th TEPHINET Global Scientific Conference in Atlanta
• Commemorating the world malaria day in Alebtong, 2019
• Is Elimination of malaria in Uganda only a dream?

Newspaper articles
The following articles were published in the new vision

• Men can support breastfeeding by using pumped breast milk
• How to protect yourself and your family from Malaria this rainy season
• Maintain the Nutritional benefits that come with Ramadhan

Written Manuscripts

• Malaria Outbreak due to Increased Breeding Sites and Rainfall, Kyotera District, Uganda, January-July 2019
• Malaria Data Quality Assessment Conducted in Selected Health Facilities in 15 Districts, Uganda, March 2020
• Improving the use of malaria channels to detect malaria upsurges at health facilities in Kyotera District, Uganda, 2020 Co-authored manuscripts:
• Malaria Outbreak associated with increased human activity in swamps and road construction, Butambala district, March 2019
• Assessment of Health facility readiness to handle infectious pathogen, Kampala and Wakiso, March 2020
• Food Poisoning Outbreak Caused by Consumption of Contaminated Food with Jimson Weed Lamwo District, Uganda, August 2019.
• Investigation of leprosy outbreak in Lira and Alebtong, 2019

Conference presentations 

• Oral presentation on Malaria Outbreak due to Increased Breeding Sites and Rainfall, Kyotera District, Uganda, January-July 2019 at the National Field Epidemiology Conference, Kampala, 2019
• Poster presentation on Malaria Outbreak due to Increased Breeding Sites and Rainfall, Kyotera District, Uganda, January-July 2019 at the JASH conference , 2019
• Poster presentation on Malaria Outbreak due to Increased Breeding Sites and Rainfall, Kyotera District, Uganda, January-July 2019 at the ICRED conference , 2019
• Oral presentation on the distribution and trends of malaria in Uganda, 2014-2018 at the National Field Epidemiology Conference, Kampala, 2020

Summary of Epidemiological Study: 

 Title: Spatial distribution of cases in Bugweri district, during a malaria outbreak June 2020

Background: Bugweri District was one of the 34 districts reporting a malaria outbreak in 2020. The outbreak, which started in January 2020, persisted for over 5 months with Buyanga sub-county being the most affected. Buyanga reported the highest increase in cases between January–June 2020, having 32,663 cases compared with 20,000 in the same time frame in 2019. Investigations into the previous malaria outbreaks in the country have been linked to environmental risk factors such as rainfall and presence of breeding sites around households created by nature or human activity. However, the spatial distribution of these cases in relation to known environmental risk factors for malaria has not been done. This study aimed to investigate the malaria outbreak in Buyanga to assess the magnitude and the associated factors using a case control study as well as identify the hotspots for malaria transmission during the outbreak using a Bayesian model to document the spatial distribution of malaria cases in Buyanga Sub-county, Bugweri District. The identification of malaria transmission hotspots through the useof spatial statistics is important to guide the targeting of interventions as residual malaria transmission is likely to persist in hotspots even after overall reduction of malaria in an area.

Methods: We developed a line list of malaria cases reported in the sub-county from the health facility data. We then took a random sample of these cases and took the Geographic Positioning System coordinates of their residence. We also conducted a case control study to study the associations between identified exposures and disease status for a sample of the cases. This was done by selecting a proportion of the cases and interviewing them using a structured questionnaire with a proportion of the cases to collect information on their demographic and malaria risk factors for malaria transmission. We conducted matched pair analysis to measure the association between exposure variables and disease status.

Results: Similar to other malaria outbreaks in the country, we found that females and children under 5 years had higher attack rates compared to males and older persons. The factors associated with the outbreak were living in close proximity to swamps, living near road ditches and using damaged nets. The fine-scale spatial maps were created to visualize the risk distribution of malaria in Buyanga sub-county at a resolution of 250m by 250m showed that most cases were concentrated in urban areas and along the roads which were being worked on since the end of 2019.

Conclusion: There was increased transmission of malaria in Buyanga sub-county between January and June, 2020, likely propagated by the presence of favorable breeding sites near people‟s homes created by the road construction activities coupled with use of torn mosquito nets that promoted exposure. We recommended use of larvicides to control mosquito breeding from identified breeding sites created by human activities such as road construction.

Key lessons learnt during the fellowship

• Outbreak detection, Investigation, response and control
• Scientific writing; concepts, proposals, manuscripts, abstracts, policy briefs, bulletin articles and Newspaper articles
• Editorial skills for scientific articles including weekly, monthly, quarterly e bulletins, and epidemiological bulletins
• Data analysis using Epi info, STATA, SPSS, R, and QGIS and interpretation of results
• Development of surveillance systems
• Leadership and management skills acquired from the various projects led and assignments
• Designing and implementation of Quality Improvement Projects
• Conducting Data Quality assessment
• Evaluating a surveillance system
• Communication skills including presentation, written and negotiation skills
• Networking skills

Next Steps

With the skills Phoebe has acquired throughout the period of the fellowship, she hopes to further her career in the field of Epidemiology through service in an organization that will leverage on her knowledge, experiences, skills, and networks.
Phoebe plans continue with writing abstracts, manuscripts and publishing all the work done during the fellowship period as well as the work she will do post the fellowship period.

Pictorial