Factors associated with typhoid fever and gut perforation outbreak in Kasese district, Uganda: Using PE methods

FACTORS ASSOCIATED WITH TYPHOID FEVER

AND GUT PERFORATION OUTBREAK IN

KASESE DISTRICT, UGANDA: USING PE

METHODS

BERNARD LUBWAMA

Makerere University School of Public

Health

PENAPH First Technical Workshop; Chiang

Mai, Thailand, 11-13 December 2012 12/19/2012 1

BACKGROUND

• Typhoid is endemic in Uganda

• Prevalence: National = 700 per 100,000;

Kasese = 8092 per 100,000

• Intestinal perforations occur in 1 – 3% of cases

– 50% occur in children

– Mortality: 10 – 32% of perforation cases

• Outbreak since 2007; response October 2011

• 207 typhoid cases; 147 with perforations



OBJECTIVES

Use PE and PDS techniques to:

• Characterize area disease burden

• Establish risk factors related to outbreak

• Establish community perceptions, behaviors,

knowledge related to the outbreak



METHODS – 1

• PE study conducted

• SAMPLING

– Sub County = sampling unit

– 8 villages from 3 most affected Sub Counties

purposively selected

• DATA COLLECTION

– At least one FGD per village selected

– KII with victims of gut perforations





METHODS – 2

• Analysis:

– Summary into themes and quotes

– Priority tabulations using ranks

– Summary scores using Mean, median and Range



RESULTS – 1

• Cholera, typhoid, malaria were ranked

diseases of highest priority

• Typhoid (22 {10, 63}), Malaria (20.5 {17, 47})

and cholera (15.5 {4, 30}) were scored

diseases of highest burden

• Females were perceived more at risk of

catching typhoid (62%)

• Perceived risk factors were linked to poor

hygiene (56%) and poor sanitation (20%) PENAPH First Technical Workshop; Chiang


RESULTS – 2

• Risky predisposing behaviors included:

– ‘Habitual’ contamination of rivers and wells by:

• Bathing, washing clothes, defecating in water sources

– Poor hand washing and unhygienic practices

“Its normal for people in Maliba town to drink unboiled water; I have

done that since I was a child”

– Delays in seeking care from health facilities

– Misdiagnosing typhoid at lower health units

“Sometimes, by the time you discover it is typhoid, you have already

spent a lot treating it as malaria” (female student, victim of

intestinal perforation from Kigoro village)



RESULTS – 4

• Symptoms of typhoid: stomach pain, vomiting, low

grade fever, constipation and diarrhea.

• Length of hospitalization (gut perforations): - 3 weeks up to 6 months or more

“A person can take three to six months in hospital after the operation

but some have even taken more. I lost 2 terms from school.” (female

student, victim of intestinal perforation in Kigoro village)

• Cost of treatment (gut perforations):

– Cost is $100 – 800

“If they find someone with holes in the intestines, it takes a lot of

money and time. I sold my land to meet the bills. I have to live in my

father’s house which is a shame for a grown man like me” (former

victim in Maliba Town) PENAPH First Technical Workshop; Chiang


RESULTS – 5

• SEASONALITY: occured in the dry and rainy

seasons (months)



RESULTS – 6

• Sources of typhoid

COMMON

SOURCE

COMMUNICABILITY

WATER Drinking un-

boiled water

Drinking

contaminated

water

Drawing water

from dirty wells

HYGIENE Using containers

that are dirty

FOOD Eating raw

unwashed food

Eating fermented

food kept

overnight

Eating food not

well cooked



DISCUSSION: SEASONALITY

• Dry season:

– Competition for scarce water contaminated

animals

– Indiscriminate open defecation in bushes and

gardens (“the feces dry off”)

• Rainy season:

– Feces in bushes washed down to streams and

other communal water sources

– Poorly constructed VIP latrines are flooded



DISCUSSION - 2

• Females scored as the sex more at risk for

catching typhoid (62%) differing from hospital

data (57.1% cases reported were males).

• Barriers to chemical treatment of drinking

water were identified

– “Water treated with chemicals (Waterguard® or

PUR®) smells bad, like hypochlorite” (high school

female discussant)

– “The chemically treated water exacerbates my

ulcers” (health worker in Bwera town) PENAPH First Technical Workshop; Chiang


RECOMMENDATIONS

• Stop people from defecating and bathing in

River Bwera

• Enforce latrine construction and use

• Suggested Control measures: - Free Chemical water treatment

- Enforcing hygiene and sanitation laws by local government

- Sensitization at community gatherings including Religious

gathering, burials, schools and markets



INTERVENTIONS

• Promoted chemical treatment of water

• Free Pur® distributed to every home

• Ongoing 2 year typhoid vaccination campaign

• Intense sensitization on typhoid prevention

• Increased enforcement of public health laws

• Free typhoid treatment in all hospitals in

district



TEAM

• Uganda Ministry of Health: Dr. Fred Mulabya

• CDC – Uganda: Dr. John Lule, Mr. Robert Mubiru

• CDC – Atlanta: Dr. Jannnel Routh and Dr. Maroya

Walters

• CDC – Kenya: Mrs. Caroline Ouma, Dr. Samuel

Kadivane

• Makerere University: Dr. Bernard Lubwama, Dr. David

Mugabi, Dr. Fred Monje, Dr. Calvin Odong

• Kasese District Health Team



REFERENCES

• www.who.org/int

• www.ci.vbi.edu

• Kasese District HMIS



Technology

Factors associated with typhoid fever and gut perforation outbreak in Kasese district, Uganda: Using PE methods