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
PENAPH First Technical Workshop; Chiang
Mai, Thailand, 11-13 December 2012
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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
PENAPH First Technical Workshop; Chiang
Mai, Thailand, 11-13 December 2012
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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
PENAPH First Technical Workshop; Chiang
Mai, Thailand, 11-13 December 2012
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PENAPH First Technical Workshop; Chiang
Mai, Thailand, 11-13 December 2012
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METHODS – 2
• Analysis:
– Summary into themes and quotes
– Priority tabulations using ranks
– Summary scores using Mean, median and Range
PENAPH First Technical Workshop; Chiang
Mai, Thailand, 11-13 December 2012
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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
Mai, Thailand, 11-13 December 2012
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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)
PENAPH First Technical Workshop; Chiang
Mai, Thailand, 11-13 December 2012
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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
Mai, Thailand, 11-13 December 2012
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RESULTS – 5
• SEASONALITY: occured in the dry and rainy
seasons (months)
PENAPH First Technical Workshop; Chiang
Mai, Thailand, 11-13 December 2012
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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
PENAPH First Technical Workshop; Chiang
Mai, Thailand, 11-13 December 2012
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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
PENAPH First Technical Workshop; Chiang
Mai, Thailand, 11-13 December 2012
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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
Mai, Thailand, 11-13 December 2012
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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
PENAPH First Technical Workshop; Chiang
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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
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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
PENAPH First Technical Workshop; Chiang
Mai, Thailand, 11-13 December 2012
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REFERENCES
• www.who.org/int
• www.ci.vbi.edu
• Kasese District HMIS
PENAPH First Technical Workshop; Chiang
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