Job Morukileng

Advanced Field Epidemiology (UPHFP), MPH
(Mak), BSHSM (IUIU)
Email: morukileng@musph.ac.ug / morujob.mj@gmail.com
Telephone: +256782611585

Host Site:Ministry of Health
Reproductive Health Division

Host Mentor: Dr. Mutumba Robert

ABOUT THE FELLOW

Job holds a Master of Public Health Degree from Makerere University College of Health Sciences, School of Public Health. Before joining the fellowship programme, he worked with International Rescue Committee (IRC) and Baylor College of Medicine Children’s Foundation where he managed and implemented public health projects focusing on improving maternal and child health (MCH), HIV and malaria in Teso and conflict affected Karamoja region in Uganda. During his involvement in public health project management and implementation, he realized gaps in his capacity to investigate and provide evidence-based recommendations to the public health problems that significantly affected the communities he was serving (such as outbreaks, side effects of MCH project services like family planning and immunization). To address this gap, he joined the Public Health Fellowship Programme (PHFP). During the two years of the fellowship, Job has appreciated the role of several statistical methods and research designs in field epidemiology and public health. He has gained skills in managing research projects, developing policy briefs, collecting data, managing and analyzing data (Epi info, STATA, SPSS), mapping (QGIS), scientific writing, and report writing. He has written manuscripts, published bulletin articles, led outbreak investigations and implemented a quality of care improvement project

  Achievements at the Host Site

The Reproductive Health Division (RHD) is one of the divisions under the Maternal and Child Health (MCH) department of Ministry of Health, Uganda. RHD covers antenatal care, family planning, emergency obstetric care, neonatal care and cancer of the cervix. The mandate of RHD is to guide planning, standardization, implementation, monitoring and evaluation of RH services provided by the government, nongovernmental organizations (NGOs), faith-based organizations (FBOs), community-based organizations (CBOs), private for-profit sectors and communities in Uganda. Several policies and legal frameworks obligate the Government of Uganda to enhance the Reproductive Health (RH) status of all Ugandans by increasing equitable access to RH services and by improving the quality, efficiency and effectiveness of the services at all levels. To support the role of the reproductive health division, I was involved in the following:

• I joined the RH division at the time COVID-19 response was not integrated in the routine delivery of RH services, one of the initial activities I participated in, was the development and review of guidelines for the management of pregnant, breastfeeding women and infants in the context of COVID-19 in May 2020
• Following interruption of planned activities in the RH division due to restricted movements (COVID-19 measure), there was need to review and adjust the division plans and budgets. I participated in the review process in July-September 2020 quarter.
• One of my main areas of interest in the RH division was integration of health care services. Integration of health care services is one of the most cost effective, efficient and the most recommended approaches for service delivery. I was involved in many activities in this area. Initially, I participated in the assessment (including development of ODK assessment tools) of integration of sexual reproductive health and rights (SRHR), HIV and sexual gender-based violence (SGBV) services in Amudat, Bududa, Isingiro, Gulu, Kampala, Katakwi, Namayingo and Yumbe Districts. The assessment identified some gaps in the implementation of integration strategy. To address these gaps, I participated in the direct mentorship of 20 health care workers in Katakwi District on integration of SRHR, HIV and SGBV services (December 2020 and August 2021). In addition, I supervised six clinical mentors from Soroti Regional Referral Hospital (SRRH) during integration of SRHR, HIV and SGBV clinical mentorship of health workers in Usuk H/C II, Toroma H/C IV and Katakwi Hospital. Following the above mentorship, I compiled and submitted facility clinical mentorship reports to the implementing partner on behalf of the MoH. As part of the RH division secretariat, I participated in organizing the first virtual and physical SRHR, HIV and GBV conference held from 4 to 5 Feb 2021. Prior to the conference, I reviewed and provided feedback for five abstracts submitted for presentation during the conference. During the conference, I led a team of six rapporteurs and compiled and submitted the conference report. Our assessment of integration of services further revealed gaps in collection of forensic evidence for SGBV. To address this gap, I and several other staff were trained as national trainers for collection forensic evidence for SGBV. We further reviewed and adjusted the national training manual for collection of forensic evidence for SGBV.
• The other area of interest to me at RH division was maternal and perinatal death surveillance and response (MPDSR). The MPDSR strategy emphasises identifying and reviewing all maternal and perinatal deaths, deriving lessons from the reviews and suggesting appropriate strategies to reduce avoidable maternal and perinatal deaths from the identified causes. To contribute to the MPDSR strategy, I participated in writing the MPDSR annual report for 2020 and in organizing a conference for the dissemination of the MPDSR report findings for the year 2020. This MPDSR report revealed that postpartum hemorrhage (PPH) was the cause of about 50% of all maternal deaths in Consequently, we developed and launched an activity framework for reducing maternal deaths due to PPH in Uganda in March 2021. This activity framework for reducing maternal deaths due to PPH inspired one of my newspaper article, titled ‘Ministry of Health renews commitment to reduce deaths due to PPH; a major single cause of maternal death in Uganda’ (Published by the New Vision Newspaper on April 2, 2021). As part of monitoring progress towards improving MPDSR, I attended weekly virtual meetings for reviewing maternal and perinatal death surveillance and response (MPDSR) progress in Uganda. In addition, I participated in the development of the national training manual for MPDSR and led in the designing and formatting of the manual in April 2021. To support planning at the division, I led the development of the national MPDSR costed workplan for 2021 to 2025
• Additional engagements at the division included participating in the review and update of the Maternal and Child Health (MCH) passport/Mothers passport to align with new Health Management information system (HMIS) tool and user guide for the MCH passport, participating in the results-based financing (RBF) health facility verification in Bwindi community hospital, Kikagati Hospital, St. Karoli Lwanga Hospital, Bishop Comboni Hospital, Kissizi Hospital and Kambuga Hospital.

Fellowship program specific achievements

Achievements

7. Descriptive analysis

• The first activity I did after joining the RH division (host site) was to perform a descriptive analysis of preterm birth data from the District Health Information System (DHIS) to determine the trend of preterm birth admissions in Uganda from 2015- Finding showed that nationally, annual incidence of preterm births admissions/1,000 Live Births (LB) has significantly been increasing (OR=1.3, CI=1.32-1.33) with the mean annual incidence of 10/1,000 LB. The annual incidence similarly increased significantly in all the four regions (central OR=1.5, CI=1.5-1.5; eastern OR=1.3, CI=1.2-1.3; western OR=1.2, CI=1.2-1.2 and Southern OR=1.2, CI=1.2-1.3). The mean annual incidence was highest in central 12/1,000 LB and lowest in the east (7/1,000 LB). We observed minimal clustering in the distribution of annual incidence at district level. We concluded that the incidence of preterm birth admissions is increasing nationally and regionally. There is need to plan for and prepare health facilities to manage preterm births. Equipping health facilities and building capacity of health workers to manage preterm labour should be prioritized.
• The descriptive analysis of preterm data resulted in written products and a QI project as described below
• A report -submitted to the UNIPH.
• Poster presentation, titled ‘Incidence of Preterm Birth Admissions in Uganda, 2015-2019’ presented during the 8th East African Health and Scientific Conference, November 2021
• Manuscript, titled ‘Incidence of Preterm Birth Admissions in Uganda, 2015-2019. Authors: Job Morukileng, Wilberforce Mugwanya, Robert Mutumba, Maureen Katusiime, Aggrey Byaruhanga, Doreen N. Gonahasa, Bob Omoda Amodan, Steven Kabwama, Daniel Kadobera, Lilian Bulage, Alex Riolexus Ario. Under journal review
• Epi-bulletin, titled ‘Incidence of preterm births admissions on the rise in Uganda, 2015-2019, published in the UNIPH Epi-bulletin Volume 6| Issue 2| April – June 2021
• Quality Improvement (QI) project The above descriptive analysis of preterm data inspired the design of my quality improvement After the descriptive analysis revealed that the annual incidence of preterm births admissions has been increasing in the past five years, there was need to ensure that the quality of care for the preterm babies is optimized. I designed a QI project that aimed to improve the proportion of new born babies who are assessed and classified for prematurity in Kawempe Referral Hospital in Uganda. The summary of the QI project is below. Kawempe Referral Hospital has one of the highest incidences of preterm birth admissions in Uganda. For preterm babies to receive quality care, all babies need to be identified through adequate assessment at birth. However, in Kawempe referral Hospital, only 72% of new-born babies where adequately assessed for prematurity and classified as preterm or at term as per the guidelines on the maternity register. This QI project aimed to increase the proportion of babies who are adequately assessed and classified as term or preterm from the current 72% to 95% between July 2021 to September 2021.
• Midwives were mentored on how to assess new-born for prematurity using the gestation age during weekly QI meetings. In addition, documentation of the assessment on the maternity register was regularly reviewed and the gaps/errors discussed and correct.
• This QI project was successful and the proportion of the babies who are adequately assessed and classified as term or preterm increased from 72% to 96.6% between July 2021 to September 2021.

8. Outbreak investigations Lead Investigator

• I led the Covid19 risk mapping and population movement study along Uganda-Rwanda borders and Uganda-Tanzania borders, May 2020.
• This investigation resulted into written products such as;
• Report, the investigation report was written and sub-mitted to UNIPH and IDI
• Epi-bulletin, titled ‘Covid19 risk mapping and population movement study along Uganda-Rwanda borders and Uganda-Tanzania borders, May 2020’ published in the UNIPH bulletin Volume 5| Issue 3| July – September 2020
• Manuscript, titled ‘Covid19 risk mapping and population movement study along Uganda-Rwanda borders and Uganda-Tanzania borders, May 2020’ authors: Job Morukileng, Geoffrey Amanya, Bob Omoda, Alex Ndyabakira, Lilian Bulage, Danniel Kadobera, Ario Alex Riolexus.: Under PHFP review Conference presentation titled ‘Covid19 risk mapping and population movement study along Uganda-Rwanda borders and Uganda-Tanzania borders, May 2020’ presented during the 6th Uganda Annual National Field Epidemiology Conference, November 4, 2020
• Second conference presentation titled ‘Covid19 risk mapping and population movement study along Uganda-Rwanda borders and Uganda- Tanzania borders, May 2020’ presented during the East African FETPs Conference on COVID-19 Response, November 18-19, 2020 Led an investigation of anthrax outbreak associated handling and consuming meat from a cow -Kapchorwa District, May 2021. The following products resulted from this investigation;
• An investigation report: submitted to UNIPH and Kapchorwa District
• Manuscript, titled ‘Anthrax outbreak associated handling and consuming meat from a cow -Kapchorwa District May 2021’authors: Job Morukileng, Josephine Namayanja, Fred Monje, Nelson Chelangat, Alfred Mwanga, Martin Obenyo, Fred Makasu, Joshua Buule, Joshua Kayiwa, Herbert Isabirye, Musa Sekamatte, Daniel Kadobera, Lilian Bulage, Alex Riolexus Ario, Julie R. Harris. Under CDC review
• Conference presentation titled ‘Anthrax outbreak associated handling and consuming meat from a cow -Kapchorwa District May 2021’ presented during the 7th Uganda Annual National Field Epidemiology Conference November 4, 202
• Follow-on study. There were questions that were not answered by the anthrax outbreak This resulted in the design of a follow-on study to understand the knowledge, attitudes and practices of the community regarding anthrax. We conducted this in November-December 2021
• COVID-19 case investigation in Bombo and Moroto region. This resulted in a written report submitted to UNIPH secretariat

Co-investigated the following outbreaks

• Measles outbreak in Nakivaale refugee settlement in Isingiro district in February 2020• Measles outbreak in Nakaseke District September 2021
• COVID-19 cluster outbreak investigation in Moroto Prison, October 2020• COVID-19 deaths investigations in Kampala metropolitan area, Feb 2021

Other epidemiological studies and response activities

• I led thed team that trained the District Health Teams (DHT) in five districts of Lango region (Dokolo, Apac, Kole, Alebotong and Oyam) on developing malaria normal channels to enhance early detection of malaria outbreaks. This activity targeted districts that experienced malaria outbreaks during 2019. This activity resulted in:A written report -submitted to the UNIPHEpi-bulleting, titled ‘The Uganda Public Health Fellowship Program Trains District Health Teams in five Districts of Lango on Early Detection of Malaria Outbreaks, September 2020’ published in the UNIPH bulletin Volume 6| Issue 1| January – March 2021
• Conducted contact tracing for COVID-19, established quarantine centers and activated district task forces in Rakia, Arua, Kiryadongo (refugee camp) and Kyotera. The contact tracing exercise and risk mapping in Isingiro (Nakivale refugee settlement) triggered the need to assess the knowledge, attitudes and practices regarding COVID-19 among refugees. Consequently, I designed an epidemiological study to assess the knowledge, attitudes and practices regarding COVID-19 among refugees as summarized below.

Summary of Epidemiological Study: 

 Title: The Epidemiological study was titled ‘Knowledge, Attitudes, and Practices of Adult Refugees towards COVID-19, Nakivale Refugee Settlement, Uganda, July 2020’ was inspired by the COVID-19 contact tracing, quarantine and risk mapping activities that I participated in during the initial phase of COVID-19 outbreak. The abstract of the study is summarised below.

Background: Nakivale Refugee Settlement (NRS) in Uganda is home to >130,000 refugees from several countries in the surrounding region. Beyond living in settings with high risk of outbreaks due to crowding and poor living conditions, refugees have limited access to health information given competing priorities and language barriers. On 20 April 2020, the first COVID-19 case in NRS was reported. We assessed knowledge, attitudes, and practices about COVID-19 among refugees in NRS to inform appropriate control interventions.

Methods: From 20 July–1 August 2020, we conducted a cross-sectional survey among refugees from randomly-selected households in NRS. We adapted a pre-existing questionnaire and administered it to adults ≥18 years of age. We asked participants about their knowledge of COVID-19 symptoms, transmission and prevention, their attitudes about specific preventive measures, and their protective practices. We calculated percentage scores and used Bloom’s cutoff of ≥80% to categorize and generate composite variables for knowledge, attitudes, and practices. Scores <80% were categorized as ‘inadequate knowledge’, ‘inadequate practices,’ and ‘negative attitudes. We performed weighted Complex Sample Design Analysis in Epi Info to identify factors associated with adequate knowledge and adequate practices.

Results: Among 824 refugees, 486 (57%) had inadequate knowledge, 542 (68%) had negative attitudes, and 667 (84%) inadequate practices. Knowledge gaps included not knowing that COVID-19 can present without symptoms (49% did not know and that COVID-19 can be less severe in children (65% did not know this). Refugees expressed a negative attitude towards staying home (56%) and not touching one’s face (66%). For hygiene practices, most did not purchase (83%) or use (78%) hand sanitizer. Receiving COVID-19 related messages via posters [Adjusted Prevalence Ratio (APR)=2.9, CI 1.7-4.8] or mobile loudspeaker [APR=1.9, CI 1.5-2.5] and having attained secondary level of education [APR=1.4, CI 1.1-2.0] were associated with adequate knowledge. Having positive attitudes [APR=1.4, CI 1.1-1.8] was associated with increase in adequate practices.

Conclusion:

About 6 in 10 persons evaluated had inadequate knowledge, 7 in 10 had negative attitudes and 8 in 10 had inadequate practices towards COVID-19. Risk and behavior change communication on COVID-19 prevention measures in NRS may be improved by using popular media channels like posters and mobile loudspeakers to disseminate the messages. The COVID-19 KAP study among refugees resulted in the following products • Conference Presentations, titled ‘Knowledge, Attitudes, and Practices Towards COVID-19 among Adult Refugees, Nakivale Refugee Settlement, Uganda, July 2020’presented during the East African FETPs Conference on COVID-19 Response, November 18-19, 2020

Manuscripts, titled ‘Knowledge, Attitudes, and Practices Towards COVID-19 among Adult Refugees, Nakivale Refugee Settlement, Uganda, July 2020. Authors: Job Morukileng, Immaculate Akusekera, Gerald Okello, Bob Omoda Amodan, Lilian Bulage, Daniel Kadobera, Steven Ndugwa Kabwama, Julie R. Harris, Alex Riolexus Ario, under conflict and health journal review

Newspaper articles

Stigma associated to COVID-19 may jeopardize control efforts (publication not established)

Ministry of Health renews commitment to reduce maternal deaths due Postpartum Haemorrhage (PPH); a major single cause of maternal death in Uganda (Published by the New Vision Newspaper on April 2, 2021)

When did you last check your blood pressure? (Published by the New Vision Newspaper on May 17, 2021)

Policy brief

Participated in developing a policy brief on improving access to malaria community case management services for children under five years of age in Uganda. Currently the integrated community case management of malaria facilitates the Village Health Team (VHTs) members to attend reporting, and drug restocking meetings on quarterly basis. However, this model affects restocking of malaria drugs used by the VHTs to treat children in the community. Up to 62% of the VHT experience stockout of malaria drugs and are not able to treat children at community level. This policy proposes to increase the frequency of VHT reporting and restocking meetings to monthly basis to minimize stockout at VHT level.

9. HIV Project

Title: Determinant of retention in care among HIV exposed infants in Rwenzori region, Western Uganda

Retention of mother-baby pairs in early infant diagnosis (EID) care is high in Rwenzori region at 85%, enabling 73% of the HIV Exposed Infants (HEI) to get the first DNA-PCR test at two and 94% to receive nevirapine prophylaxis within one day month post-delivery and leading to only 3% of HEIs turning positive for HIV at 18 months. In addition, being a mother aged ≥25 years old and attending two or more ANC visits were associated with increased retention in EID care. Having four or more children was associated with reduced retention in EID care. Implementing partners in Rwenzori region and the Ministry of Health should identify and closely follow-up mothers younger than 25 years, those that are not completing their ANC visits and those that have given birth to four or more children to ensure that they are retained in care.

Key lessons learnt during the fellowship

• I have learned to multi-task to be able to execute my fellowship projects as well as host site tasks a midst other competing priorities. This has sharpened my decision-making skills and has helped me to appreciate the importance of planning and priority setting when faced with overwhelming pressure at work.
• Working at the host site improved my leadership and management skills through assignments
• Outbreaks detection, investigation, response, and
• 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
• Development and implementation of Quality Improvement projects

Next Steps

• To identify an appropriate opportunity that will utilize the skills I have gained from the fellowship especially focusing on investigating health events and providing appropriate recommendations
• To continue advancing my knowledge and skills in epidemiological studies and management of public health projects
• To proceed with process of sharing findings of multiple studies conducted during the fellowship through publications, bulletins and presentations
• To participate in any public health response at any level when called upon.

Pictorial