My Fellowshi hip p Achievement nts Christine Kihembo, MBChB, MIPH - PowerPoint PPT Presentation

Public Health Fellowship Program – Field Epidemiology Tra ck My Fellowshi hip p Achievement nts Christine Kihembo, MBChB, MIPH Fellow, Cohort 2015

Host Site - Epidemiology y & Surve veillance ce Divi vision (ESD), MoH  ESD Mandate Robust, sustainable systems for forecasting, early detection, response to public health events and improve disease prevention & response through IDSR 2 Fellowship Achievements

Response to Public c Health Emergence ces  Large Typhoid outbreak in Kampala – Desk review on strategies to deal with Antibiotic Resistance (ABR) – ABR Patterns Study in Kampala.  Typhoid Verification in Central districts – Use of Standard Case Definitions – Strengthening Laboratory Surveillance 3 Fellowship Achievements

Outbreak k Investigations & Rapid Response  Podoconiosis, Neglected Tropical Disease in Kamwenge  Cholera Outbreak in Mutufu, Sironko  Suspected Hereditary Spastic Paraplegia in Ibanda  Rapid Assessment Avian Flu in Kalangala  Malaria Upsurge in Northern Uganda, Measles in Kiruhura , Carbamate poisoning in Kagadi 4 Fellowship Achievements

Surve veillance ce System Analysis and Evaluation  National Typhoid Surveillance System Analysis – Disaggregation of data – Typhoid thresholds review  Re-vitalised IDSR/IHR evaluation  2016 yellow fever outbreak preparedness and response evaluation. 5 Fellowship Achievements

Leadership and management  National Taskforce , Rapid Response Team Member  Technical Assistance to Emergency Operation Centre on Event Based Surveillance  TWGs: – AMR Taskforce, – Hepatitis B, Podoconiosis 6 Fellowship Achievements

Deve velopment and Revi view of National Policy cy Guidelines  Antibiotic Resistance Surveillance Plan  Multi-hazard Preparedness and Response Plan  Curricula & SOPs: – VHFs case management, – Frontline FETP – Rapid Response Teams  2017 Cholera Prevention and Control Guidelines 7 Fellowship Achievements

Led generation of epidemiological info for public c health action 8 Fellowship Achievements

Training on Epidemic c Preparedness and Response.  IDSR/IHR Training and Support Supervision in 3 districts  Establishment of Podoconiosis Training: care, treatment and surveillance  National Rapid Response Teams Training  Frontline Training roll out and mentorship 9 Fellowship Achievements

Scientific c Communica cation  Risk factors for Podoconiosis : EIS, NFEC, CDC science series  Significant Intermediate Ciprofloxacin Resistance: JASH  ABR patterns in Kampala  ABR of Salmonella species from scepticaemic patients in Kampala 10 Fellowship Achievements

Sci cientific c Communica cation  Uganda to rethink infant Hep B vaccination schedule  Articles in NIPH epi-bulletin  Co-author: BMC public health – Large Typhoid Outbreak in Kampala – Risk Factors for ART Non-suppression  Kihembo et al., Risk factors for Podoconiosis in Kamwenge , AJTMH 11 Fellowship Achievements

Public Health Fellowship Program – Field Epidemiology Tra ck

Public Health Fellowship Program – Field Epidemiology Tra ck Anti-bacterial Resistance Patterns and Trends among Scepticaemic Patients, Kampala 2010-2015

ABR strains health system and economy  Anti-bacterial resistance (ABR): organism not responsive to anti-bacterial drug previously effective  ABR implications: Longer hospital stay, high cost, more toxic agents, poorer patient outcomes  ABR is a priority area on GHSA 14 ABR patterns in Kampala, 2010-2015

Limited non-mycobacterial ABR info: Fragmented surveillance in Uganda  No national active surveillance for ABR  Bacterial infections: – 20% of all hospital deaths – 25% of deaths among children <5years  Published ABR info is a decade old  ABR data from private sector not utilized 15 ABR patterns in Kampala, 2010-2015

Objectives  Describe bacterial (non-mycobacterial) etiologies for blood sepsis in Kampala  Characterize ABR patterns among most identified bacteria 16 ABR patterns in Kampala, 2010-2015

Data source  Reviewed all blood culture records: 9 labs (Public and Private) in Kampala  ABR testing according to Clinical and Laboratory Standards Institute (CLSI) standards  Standardized data abstraction form  Collected demographics, organism isolated  Data analyzed over 6 year period 17 ABR patterns in Kampala, 2010-2015

Case definitions  Species resistant to a drug annually – High ABR ≥50%; Moderate ABR 10 -49%; Low ABR <10%  Multi-drug resistant (MDR) salmonella: resistant to Cotrimoxazole (COTRIM), Chloramphenicol (CAF) and Ampicillin (AMP)  MRSA: Staph species resistant to Oxacillin or Cefoxitin 18 ABR patterns in Kampala, 2010-2015

2998 Positive Blood Cultures Abstracted 19 ABR patterns in Kampala, 2010-2015

Staphyl yloco cocc ccus predominant gram positive ve Non specified 0.1 Others 0.6 Bacillus 0.7 Corynbacteria 1.2 Enterococcus 3.6 Streptococcus 7.9 Staphylococcus 85.9 0 20 40 60 80 100 20 ABR patterns in Kampala, 2010-2015

Staph aureus most predominant among Staph speci cies Staphylococcus species Staph saprophyticus 1 Others 1.1 Staph hominis 2.5 Staph spp 3.5 Staph haemolyticus 4.8 Staph epidermidis 5.3 Coagulase negative Staph 11.2 Staph Aureus 70.7 0 10 20 30 40 50 60 70 80 Frequency (%) 21 ABR patterns in Kampala, 2010-2015

Children<5 and elderly y more affected by Staph infections Incidence /100,000 250 Incidence of Staph spp by Age-group 200 150 100 50 0 0 20 40 60 80 100 Age ( years) 22 ABR patterns in Kampala, 2010-2015

Salmonella predominant gram neg eg Gram Neg Others 3.04 Non Specified 2.97 Citrobacter 3.1 Enterobacter 4.3 Pseudomonas 4.8 Acinetobacter 6.1 E. coli 12.5 Klebsiella 12.7 Salmonella 20.6 Coliforms 28.4 0 5 10 15 20 25 30 Frequency (%) 23 ABR patterns in Kampala, 2010-2015

Typhoidal speci cies predominant among Salmonella organism Salmonella specie Salmonella choleraesuis 0.4 Salmonella B 1.2 Salmonella enterica 2 Salmonella D 4.5 Salmonella paratyphi 5.3 Non- Salmonella spp specified 35.2 Salmonella typhi 51.4 0 10 20 30 40 50 60 Frequency (%) 24 ABR patterns in Kampala, 2010-2015

Children 0-5, young adults and elderly more affected by Salmonella 18 Incidence Incidence of Salmonella spp by Age-group /100,000 15 12 9 6 3 0 0 20 40 60 80 100 Age ( years) 25 ABR patterns in Kampala, 2010-2015

Staph: Moderate to high ABR to common drugs COTRIM 100 ERTH % Resistance 80 TETRA 60 40 CAF 20 0 2010 2011 2012 2013 2014 2015 Year 26 ABR patterns in Kampala, 2010-2015

Increasing trend of Methici cillin Resistant Staph % 90 Resistance OXA 80 CIPR MRSA 70 60 50 40 CEFTR 30 20 10 0 2010 2011 2012 2013 2014 2015 Year 27 ABR patterns in Kampala, 2010-2015

Reduct ction in 1st line drug ABR for Salmonella % COTRIM Resistance 90 AMP 75 60 45 CAF 30 MDR 15 0 2010 2011 2012 2013 2014 2015 Year 28 ABR patterns in Kampala, 2010-2015

Rapidly increasing intermediate resistance ce to Ciprofloxaci cin % Resistance 50 40 30 20 10 0 2010 2011 2012 2013 2014 2015 Year 29 ABR patterns in Kampala, 2010-2015

Increasing Resistance ce to Ceftriaxo xone 25 20 15 X 2 =6.5 p=0.01 10 5 0 2010 2011 2012 2013 2014 2015 30 ABR patterns in Kampala, 2010-2015

No Ciprofloxa xaci cin, Ceftriaxo xone susce ceptibility testing in >20% Salmonella isolates % Tested Ciprofloxacin 78 (Fluroquinolone) Ceftriaxone (Cephalosporin) 79 31 ABR patterns in Kampala, 2010-2015

Limitations and Strengths Strength  Relatively large sample for ABR studies  Routine data collected from registered health units Limitations  Incomplete and missing data 32 ABR patterns in Kampala, 2010-2015

Concl clusion  Salmonella and Staphylococcus most common cause of scepticaemia  High level Methicillin Resistant Staph  Rapid increase in ABR to Ciprofloxacin among Salmonella spp.  Susceptibility to traditional first line antibiotics for Salmonella has gradually returned 33 ABR patterns in Kampala, 2010-2015

Reco commendations  Adherence to ABR testing standards  Rational use of antibiotics guided by ABR patterns to address the changing ABR picture. 34 ABR patterns in Kampala, 2010-2015

Public Health Fellowship Program – Field Epidemiology Tra ck Acknowledgment  Mulago, Mengo, Rubaga, Nsambya Hospitals, Nakasero, Ebenezer Makerere University Medical Microbiology Lab, LMK, ABI, UNHLS  PHFP Secretariat  Epidemiology & Surveillance Division, MOH  CDC