MAKERERE UNIVERSITY PREVALENCE AND FACTORS ASSOCIATED WITH ERYSIPELOTHRIX RHUSIOPATHIAE INFECTION AMONG RAW PORK HANDLERS IN KAMULI DISTRICT, EASTERN UGANDA By Musewa Angella, BLT (Mak) SUPERVISORS Prof Joseph Erume (BVM, MSc, PhD) Dr. Kristina Roesel (DVM, PhD.) Assoc. Prof Nakanjako Damalie (MBChB, M.Med, PhD) A DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF MASTER OF SCIENCE IN CLINICAL EPIDEMIOLOGY AND BIOSTATISTICS, MAKERERE UNIVERSITY SEPTEMBER 2016 i Declaration I Angella Musewa declare that all the work in this dissertation is original and has never been submitted for any other academic award at any other institution of higher learning. Signature_______________ __________ Angella Musewa (Principal Investigator) Date This dissertation has been submitted for examination with approval of the following supervisors 1. Prof Joseph Erume ________________________ Date__________________ 2 Kristina Roesel _________________________ Date_________________ 3 Assoc. Prof Damalie Nakanjako ___________________________ Date_____________________ ii Dedication This book is dedicated to all those people who are earning a living by engaging themselves in the pig industry and all organizations/bodies that have come together to support them. iii Acknowledgements It is with utmost gratitude that I wish to appreciate the persons mentioned hereunder for the invaluable support they rendered to me technically, morally, financially, socially, spiritually, physically or otherwise made this project a success. Firstly, I acknowledge my mother Miss Angella Nantale and family for the strong academic foundation they gave me and the good upbringing. The value of your investment in my life is so instrumental that no one can ever break it. To my supervisors, Prof Joseph Erume, Kristina Roesel and Assoc. Prof Damalie Nakanjako for their unparalleled input into this project right from concept development to submission of this dissertation. Secondly to my lecturers, Assoc Prof Joan Kalyango and Assoc Prof Charles Karamagi for their tireless efforts right from development of the concept to write up of this dissertation. To the non-teaching staff of the Clinical Epidemiology Unit for support throughout this academic programme thank you so much. To James Luswata for the technical support, spiritual and moral and the field team, Robert Isabirye and Milly Nanyolo for the mobilization, Michel Dione, Joyce Akol and Joseph Kungu for piloting the blood draw from pigs for the preliminary study. To all my class mates CEB cohort 2014 thank you for the supporting me throughout this programme I am so grateful. The study was supported by Safe Food, Fair Food project led by the International Livestock Research Institute and carried out with the financial support of the Federal Ministry for Economic Cooperation and Development, Germany, and the CGIAR Research Program on Agriculture for Nutrition and Health, led by the International Food Policy Research Institute. iv Table of contents Declaration ....................................................................................................................................... i Acknowledgements ........................................................................................................................ iii Table of contents ............................................................................................................................ iv List of figures ................................................................................................................................. vi List of tables .................................................................................................................................. vii List of appendices ........................................................................................................................ viii List of acronyms ............................................................................................................................ ix Operational definitions.................................................................................................................... x Abstract .......................................................................................................................................... xi CHAPTER ONE ........................................................................................................................... 1 1.0 Background .............................................................................. 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Bookmark not defined. 1.1 Problem statement ..................................................................................................................... 2 1.2 Justification ............................................................................................................................... 3 1.3 The conceptual frame work ...................................................................................................... 4 1.3.1 Conceptual framework and scope of the study ...................................................................... 5 1.4 Research questions .................................................................................................................... 6 1.5 Objectives ................................................................................................................................. 6 CHAPTER TWO ............................................................................................................................ 7 Literature review ............................................................................................................................. 7 2.1 Introduction ............................................................................................................................... 7 2.2 Etiology of E. rhusiopathiae infection in humans (erysipeloid).............................................. 8 2.4 Clinical description of the human infection ............................. 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Bookmark not defined. 2.9 Prevention and control of E. rhusiopathiae infection in humans .......................................... 12 CHAPTER THREE .................................................................................................................... 14 3.0 Materials and methods ............................................................................................................ 14 3.1 Study design ............................................................................................................................ 14 3.2 Study setting............................................................................................................................ 14 Population ..................................................................................................................................... 14 v 3.4 Selection criteria ..................................................................................................................... 15 3.5 Sample size estimation ............................................................................................................ 17 3.6 Sampling ................................................................................................................................. 19 3.7 Variables and measurement .................................................................................................... 20 3.8 Data collection ........................................................................................................................ 21 3.8.2 Microbiological cultures ...................................................................................................... 23 3.8.6 Biochemical tests for confirmation of E. rhusiopathiae infection ....................................... 25 3.9 Qualitative methods of data collection ................................................................................... 30 3.10 Statistical analysis .................................................................. 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Bookmark not defined. 3.10.1 Data management............................................................................................................... 28 3.10.2 Data analysis ...................................................................................................................... 29 3.11 Quality control ...................................................................................................................... 32 3.12 Ethics..................................................................................................................................... 33 CHAPTER FOUR ....................................................................................................................... 34 4.0 Results ..................................................................................................................................... 34 4.1 Description of study population .............................................................................................. 34 4.2 Socio-demographic characteristics .......................................... Error! Bookmark not defined. 4.3 Individual factors .................................................................................................................... 36 4.4 Health related factors .............................................................................................................. 38 4.8 Results of the Qualitative assessments. .................................................................................. 52 4.8.1 Focus group discussions and key informant interviews ...................................................... 52 Discussion. ..................................................................................... Error! Bookmark not defined. 5.0 CHAPTER FIVE .................................................................................................................. 60 5.1 Prevalence of E. rhusiopathiae infection ................................................................................ 60 5.2 Strengths of the study.............................................................................................................. 66 5.3 Limitations of the study .......................................................................................................... 67 6.0 Conclusions and recommendations......................................................................................... 69 References ..................................................................................................................................... 71 vi List of figures Figure 1: Conceptual framework of the factors associated with Erysipelothrix rhusiopathiae infection among raw pork handlers and its consequential outcomes ........................................................................... 4 Figure 2: The possible transmission routes of Erysipelothrix rhusiopathiae to animals, birds, rodents and Erysipelothrix rhusiopathiae infection to humans ......................................... 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Figure 3: Diagnosis of Erysipelothrix rhusiopathiae infection in humans ................................................. 28 Figure 4: Age distribution of 302 participants in Kamuli district, Eastern Uganda. ................................... 34 Figure 5: Sub counties in Kamuli district, (adapted from the Natural population and housing census, 2007). ......................................................................................................................................................... viii vii List of tables Table 1: Socio-demographic characteristics of the 302 study participants in Kamuli District Eastern Uganda ............................................................................................................................. 35 Table 2: Individual characteristics of raw pork handlers in Kamuli district, Eastern Uganda .. 37 Table 3: Overall prevalence of E. rhusiopathiae infection among raw pork handlers in Kamuli district, Eastern Uganda ................................................................................................................ 39 Table 4: Prevalence of E. rhusiopathiae infection among raw pork handlers within the socio demographic characteristics in Kamuli district, Eastern Uganda ................................................. 41 Table 5: Prevalence of E.rhusiopathiae infection among raw pork handlers among within the individual factors in Kamuli district, Eastern Uganda .................................................................. 43 Table 6: Frequency of E. rhusiopathiae infection among raw pork handlers who reported skin related infection in Kamuli district, Eastern Uganda .................................................................... 44 Table 7: Bivariate analysis of the association between socio demographic factors and E. rhusiopathiae infection among raw pork handlers in Kamuli district, Eastern Uganda ............... 46 Table 8: Bivariate analysis of the association between individual factors and E. rhusiopathiae infection among raw pork handlers in Kamuli district, Eastern Uganda ...................................... 48 Table 9: Results of multivariate analysis for Erysipelothrix rhusiopathiae infection among raw pork handlers in Kamuli district, Eastern Uganda ........................................................................ 51 Table 10: Participants screening log for Erysipelothrix rhusiopathiae infection among raw pork handlers in Kamuli district, Eastern Uganda ................................................................................ vii viii List of appendices Appendix 1: Questionnaire for butchers and abattoir workers in Kamuli district, Eastern Uganda. ........... ix Appendix 2: Lusoga translated questionnaire for butchers and abattoir workers in Kamuli district, Eastern Uganda. ....................................................................................................................................................... xii Appendix 3: Questionnaire for cooks/household raw pork handlers in Kamuli district, Eastern Uganda, 2016. ........................................................................................................................................................... xv Appendix 4: Lusoga translated questionnaire for cooks/household raw pork handlers in Kamuli district, Eastern Uganda ......................................................................................................................................... xviii Appendix 5: Informed consent form for the prevalence and factors associated with E.rhusiopathiae infection among raw pork handlers in Kamuli district, Eastern Uganda. ................................................... xxi Appendix 6: Translated informed consent form for prevalence and factors associated with E.rhusiopathiae infection among raw pork handlers in Kamuli district, Eastern Uganda. ..................... xxvi Appendix 7: Oral consent form for the Focus Group Discussions ........................................................... xxxi Appendix 8: Translated oral consent form for the participants ............................................................... xxxiv Appendix 9: Focus Group Discussion topic guide ................................................................................. xxxvii Appendix 10: Translated Focus Group Discussion guide ....................................................................... xxxix Appendix 11: Key Informant Interview guide ............................................................................................xlii Appendix 12: Translated key informant interview guide .......................................................................... xliii ix List of acronyms BHFB Brain Heart Infusion Broth EDTA Ethylene Diamine Tetra Acetic acid ER Erysipelothrix rhusiopathiae ESM Erysipelothrix Selective Media FGDs Focus Group Discussions ILRI International Livestock Research Institute KII Key Informant Interview MDA Modified Blood Agar MoH Ministry of Health PCR Polymerase Chain Reaction SPVCD Small Holder Pig Value Chain Development Project SSA Sub-Saharan Africa TSA Trypticase Soya Agar UBOS Uganda National Bureau of Standards WHO World Health Organization x Operational definitions Raw pork- This is pig meat with or without fat that is not cooked/ processed into sausages or bacons or ready for consumption. Raw pork handlers These were defined as adults >18 years (males or females) who were in contact with raw pork; they included butchers, abattoir workers, slaughter men or cooks. Infection: The invasion and multiplication of microorganisms such as bacteria, viruses, and parasites those are not normally present within the body. An abattoir This is a facility where animals are killed and processed into meat products, ( FAOSTAT, 2011). Abattoir workers These were adults > 18years (males or females) who were working in pig abattoirs/ pig slaughter houses during the study period. Their work involved handling live pigs, slaughtering pigs in the three study sub counties. Butchers These were adults > 18 years (males or females) with retail butcheries in Namwendwa, Kitayunjwa and Bugulumbya sub counties. Consumers/pork buyers - These are adults >18 years (males or females) who bought raw pork from butchers and abattoirs during the study period or prepared pork for consumption at the different butcheries or eating places where the study was conducted. xi Abstract Introduction: Erysipelothrix rhusiopathiae (ER) is a zoonotic, ubiquitous gram-positive bacterium, which causes erysipelas in swine, mammals, birds and erysipeloid in humans. The study was conducted in Kamuli district because farmers had reported signs of disease in their pigs which was reported at a prevalence of 67%. Therefore this study determined the prevalence and factors associated with ER infection among raw pork handlers in Kamuli district, Eastern Uganda. Methods: A cross-sectional community based study was done which employed quantitative and qualitative methods for data collection between January and March 2016. The study was conducted in Namwendwa, Bugulumbya and Kitayunjwa sub counties in Kamuli District because the farmers reported signs of the disease in their pigs. A total of 302 participants (butchers, abattoir workers and cooks) were enrolled consecutively for quantitative data collection. Participants for qualitative data collection were sampled purposively. E. rhusiopathiae infection among the handlers was determined by collecting whole blood which was used for culture and isolating the bacteria. The infection was confirmed the infection using biochemical tests and gram staining of the resulting isolates. Results: The prevalence of E.rhusiopathiae infection was 9.9 % (95% CI: 7.35 -12.52). Type of raw pork handler and alcohol consumption increased the risk of acquiring the infection. Working in the abattoir and butchery increased the risk of the infection at (aOR= 26.13 95% CI: 5.29- 129.10) and (aOR= 8.37 95%CI: 1.79 -39.10) respectively. Alcohol consumption was associated with E.rhusiopathiae infection (aOR= 4.02 95%CI: 1.07 -15.03). xii Conclusion: The overall prevalence of E. rhusiopathiae infection was low compared to those from previous studies. Abattoir worker and butchers were highly infected with E. rhusiopathiae. Alcohol consumption, working in the abattoir and being male increased the risk of acquiring the infection. The main causes of E. rhusiopathiae were poor hygiene of the personnel especially the abattoir workers and butchers. Increased alcohol consumption among participant was associated developing the infection. Recommendations: Abattoir workers, butchers and cooks/pork buyers should be sensitized on the risk of being infected with E.rhusiopathiae infection and how to prevent it while carrying on with their duties. Raw pork handlers should avoid working under the influence of alcohol as this would impair their sense for judgment and increase their exposure to E. rhusiopathiae infection. 1 CHAPTER ONE 1.0 Background Erysipelothrix rhusiopathiae is a gram-positive, facultative aerobic, non-spore forming, non- acid-fast bacterium which causes erysipelas in swine, mammals, and erysipeloid in humans (Brooke et al., 1999). The organism can survive in soil for a long period of time ranging from fourteen days to six months but can also persist in frozen and chilled meat as well as decaying carcasses (Wabacha et al., 1998). It is also reported to withstand salting, pickling and smoking (Wabacha et al., 1998). Approximately 60% of all human diseases and 75% of all emerging infectious diseases are zoonotic (Taylor et al., 2001), spreading from livestock including pigs, chicken, cattle, goats, sheep and camels (WHO, 2013). Globally this zoonotic infection affects 24-55% (WHO, 2013) in USA, Asia and Europe leading to loss of life. The piggery industries in the USA, Europe and Asia have lost billions of money because of the reduction in trade and carcass burning (WHO, 2013). The most common form of E.rhusiopathiae infection in humans is erysipeloid (Kichloo et al., 2013b) though patients also present with generalized and systemic forms, usually transmitted through skin cuts. The population at risk of this infection includes people handling infected animal tissue. These groups are often exposed due to their occupation and comprise of veterinarians, butchers, abattoir workers and cooks (Joshi et al., 2015; Kichloo et al., 2013b). Nearly, 31% of all erysipeloid cases progress to serious complications requiring surgical debridement, reconstruction surgery, or amputation (Kichloo et al., 2013b). The complications may present in the form of abscesses, septic arthritis, osteomyelitis, and necrotizing fasciitis (Pereira et al., 2010). If not treated, complications can yield more debilitating conditions like 2 septicemia, endocarditis or even death (Kichloo et al., 2013b). This extreme systemic infection of erysipeloid has been reported to occur in 1/3 of all patients with alcohol and drug dependence, immunosuppression, poor hygiene and chronic liver disease (Kichloo et al., 2013b). Penicillin given either parentally or orally depending on the clinical severity is the treatment of choice for erysipeloid (Stevens et al., 2016). This study therefore sought to determine the prevalence and factors associated with E. rhusiopathiae infection among raw pork handlers in Namwendwa, Kitayunjwa and Bugulumbya sub- counties in Kamuli district, Eastern Uganda. 1.1 Problem statement In 2015, a preliminary study done in Namwendwa, Kitayunjwa and Bugulumbya sub counties, Kamuli District reported the prevalence (seroprevalence) of E.rhusiopathiae infection in live pigs at 67% was isolated in 45% of the fresh pork samples sold in the different pork butcheries and from slaughter abattoirs. Erysipelothrix rhusiopathiae is transmitted from infected raw pork and live pigs to humans. If Erysipelothrix rhusiopathiae is prevalent in pigs these groups of pork handlers may be at an increased risk of acquiring Erysipelothrix rhusiopathiae infection (Kichloo et al., 2013b). There is limited awareness of Erysipelothrix rhusiopathiae infection which makes it very hard to diagnose and treat which if recognised early and treated is curable. Nearly 31% of all Erysipeloid cases progress to serious complications which if erysipeloid is not recognized , it can lead to bacteremia and endocarditis, valve replacement, (36%) of the patients (J. Bille, 1999); where mortality is reported at 38% in patients who develop endocarditis (Brooke et al., 1999). 3 1.2 JUSTIFICATION Preliminary study has shown that the seroprevalence of E.rhusiopathiae was at 67% in live pigs and isolated in 45% of fresh pork sample sold. Since E. rhusiopathaie is a zoonotic bacteria and prevalent in pigs thus pork handlers and pig owners are at an increased risk for developing the infection. Infection with E.rhusiopathiae can lead to serious complication which may require surgical debridement, reconstructive surgery or even amputation. Therefore this study seeks to determine the prevalence and factors associated with E.rhusiopathiae infection among raw pork handlers in Kamuli district, Eastern Uganda.The results from this study will help guide policy on pork handling and also create awareness about the burden of E.rhusiopathiae in the community so that the infection is controlled. 4 1.3 The conceptual frame work Figure 1: Conceptual framework of the factors associated with E. rhusiopathiae infection among raw pork handlers and its consequential outcomes Socio demographic  Age  Sex  Ethnic group  Religion  Marital status Socio-economic status  Education level  Housing condition  Occupation  Poverty Erysipelothrix rhusiopathiae infection Socio-cultural factors  Beliefs  Traditional practices  Norms and values  Way of living  Bacteremia and endocarditis  Renal failure Vehicles  Infected fresh pork  Contact with infected pigs  Infected chicken  Infected meat, (beef, mutton, goats meat) Individual factors  Poor hygiene and lack of protective equipment  Poor slaughtering methods  Poor sanitation  Previous traumatic contact with infected animals or their meat  Substance abuse (i.e. alcohol)  Increased chances of morbidity and mortality  Reduced productivity 5 1.3.1 Conceptual framework and scope of the study The conceptual framework, (Figure 1) outlines the predictors of E.rhusiopathiae infection among raw pork handlers in Kamuli district and the possible outcomes. The prevalence of E.rhusiopathiae infection among humans would be reported to be high among those individuals who have been exposed to those vehicles when they are compared to those who are not exposed. Age and sex have also been stated as important factors to be studied in relation to the infection since it is reported that males are likely to be more infected compared to the females due to the occupational nature of the disease. Similarly, age is reported to be an important factor to study since it is reported that the occupation is mainly dominated by subjects who are above 40 years, (Pereira et al., 2010). This study looked at the sociodemographic factors, individual factors and socio cultural factors. 6 1.4 Research questions 1. What is the prevalence of Erysipelothrix rhusiopathiae infection among raw pork handlers in Kamuli district? 2. What factors are associated with Erysipelothrix rhusiopathiae infection among raw pork handlers in Kamuli district? 3. What socio-cultural factors influence Erysipelothrix rhusiopathiae infection among raw pork handlers in Kamuli district? 1.5 Objectives 1.5.1 General objective To determine the prevalence and factors associated with E.rhusiopathiae infection among raw pork handlers in Kamuli district. 1.5.2 Specific objectives 1. To determine the prevalence of E. rhusiopathiae infection among raw pork handlers in Kamuli district. 2. To determine the factors associated with E. rhusiopathiae infection among raw pork handlers in Kamuli district. 3. To explore the socio-cultural factors associated with E. rhusiopathiae infection among raw pork handlers in Kamuli district. 7 CHAPTER TWO Literature review 2.1 Introduction Erysipelothrix rhusiopathiae is a nonsporulating, gram-positive, rod-shaped bacterium which was identified more than 100 years ago as the etiologic agent of swine erysipelas (Reboli and Farrar, 1992). Since then, it has been found to cause infection in several dozen species of mammals and other animals. Humans become infected through exposure to infected or contaminated animals or animal products (Kichloo et al., 2013b). Approximately 50 cases of endocarditis have been reported; all but one recent case have involved native valves. The organism may be isolated from biopsy or blood specimens on standard culture media ( Brooke et al., 1999). It is identified by morphology, lack of motility, and biochemical characteristics; identification may be confirmed by the mouse protection test ( Bender et al., 2010). It is susceptible to penicillin, cephalosporins, erythromycin, and clindamycin, but it is often resistant to many other antibiotics, including vancomycin, a drug frequently used in empiric therapy for infections due to gram-positive bacteria (Reboli and Ferrar, 1989). 8 2.2 Etiology of E. rhusiopathiae infection in humans (erysipeloid) Erysipeloid is an acute, occupational bacterial infection of traumatized skin and other organs, (Bernard, 2008). Direct contact between meat infected with E. rhusiopathiae and traumatized human skin may result in erysipeloid (Krasagakis et al., 2006). Humans acquire erysipeloid after direct contact with infected animals or animal products. Erysipeloid is more common among farmers, butchers, cooks, homemakers, and veterinarians (Bonnetblanc and Bedane, 2003), all groups of people who are more exposed due to their occupation. The risk of infection in humans is based more on opportunistic exposure, and factors such as age, sex, vehicles, race and socio-economic status relate only to this opportunity (Reboli and Ferrar, 1989) (McGinnes et al., 1934). Individuals with close contact to animals, animal products or animal wastes are at greatest risk. Thus, E.rhusiopathiae infection is said to be occupationally related (Kichloo et al., 2013b). 2.3 Prevalence of E.rhusiopathiae infection humans Globally 829 cases of Erysipelothrix rhusiopathiae infection per 100,000 have been reported. However research in humans has not been done for more than a decade without research due to the difficult in diagnosis of the bacteria (Reboli and Farrar, 1992). In sub Saharan Africa there is limited research on the disease with only reports from Kenya and Nigeria that reported Erysipelothrix rhusiopathiae infection pigs (Friendship and Bilkei, 2007). However the prevalence of E.rhusiopathiae infection in humans varies from region to region. A study conducted in Czech Republic on the occupational infectious diseases reported a prevalence of 29% of erysipeloid among agriculturalists, game managers and forestry workers. Among the zoonoses was erysipeloid infection (Brhel and Bartnicka, 2003). Another study conducted by (Amal et al., 2004) on the epidemiology, clinical features, and evolution of 9 erysipeloid in the Marrakech region reported the relapse of E.rhusiopathiae infection in 12 % of the cases studied (Amal et al., 2004). 2.4 Research on E. rhusiopathiae infection in East Africa A systematic review by Ocaido et al., 2013 reported that there is a gap in knowledge and added that no study has been in Uganda to establish the prevalence and factors associated with E. rhusiopathiae infection in pigs and humans. Two outbreaks of swine erysipelas were reported in Kenya (Wabacha et al., 1998) and (Friendship and Bilkei, 2007). In the first outbreak, Wabacha et al reported that ten pigs from a herd of 181 pigs in a medium-scale, semi-closed piggery in Kiambu district, Kenya, contracted the clinical disease in 1997. Friendship and Bilkei (2007) reported a concurrent outbreak of E.rhusiopathiae and Clostridium novyi occurring in a large outdoor pig-breeding unit in Kiambu district in Kenya resulting in high mortality. In 2012/13, during participatory appraisals conducted with pig farmers conducted in Masaka, Mukono and Kamuli district , pig keepers in four villages reported signs of erysipelas (Okumyuka in Lusoga language) to be one of the diseases affecting their pigs (Roesel et al., 2014). 2.5 Epidemiology of Erysipelothrix rhusiopathiae infection E. rhusiopathiae is a gram-positive bacillus and has for long been an important pathogen in veterinary medicine as well as a cause of serious disease in humans (Wang, 2004). As stated, E. rhusiopathiae is an occupational illness with 89% of the cases linked to high-risk epidemiological situations (Kichloo et al., 2013b). It is reported to affect birds, mammals, animals and humans. Study findings by Nakazawa (1998) reported a prevalence of 30% E. rhusiopathiae in chicken samples collected from an abattoir in Nagano Prefecture, Japan. In soil 10 it may live long enough to cause infections, for two weeks to six months after initial contamination (Nicoleta et al., 2010). People with the highest risk of exposure include butchers, abattoir workers, veterinarians, farmers, fishermen, fish-handlers and housewives, (Reboli and Ferrar 1989). The principal reservoir of E. rhusiopathiae infection seems to be swine, the etiologic agent has been isolated from the tonsils of up to 30% of apparently healthy swine world (WHO, 2013). In a study carried out in Chile, the agent was isolated from tonsil samples of 53.5% of 400 swine in a slaughterhouse, (Skoknic, 1981). E.rhusiopathiae was isolated from 25.6% of soil samples where pigs live and from their feces (Wood et al., 1981). It can survive a long time outside the animal organism, both in the environment and in animal products, which contributes to its perpetuation (WHO, 2013). 2.6 Factors associated with E. rhusiopathiae infection among raw pork handlers 2.6.1 Hygiene of the slaughter house Slaughter hygiene has been documented to be one of the major predictors of erysipelas and erysipeloid infection in pigs and humans. Pigs acquire the infection through feeding on contaminated feeds, water and housing. Humans acquire the infection through handling infected pork without protective gears (Kichloo et al., 2013a). 2.6.2 Occupational exposure Individuals involved in occupations or recreations with contact with animals, animal products or animal wastes are at greatest risk. Thus E. rhusiopathiae infection is said to be occupationally related (Brooke et al., 1999). It follows that those in occupations with most frequent animal contact, such as butchers, abattoir workers, veterinarians, farmers, fishermen, fish-handlers and housewives are the most commonly infected (Brooke et al., 1999). 11 2.6.3 Alcoholism This is also a known risk factor for erysipeloid in humans in a case study since it compromises the immunity of the personal. Therefore when the bacteria invade the person it multiplies easily in the body and hence weaken him/her leading into severe infection (Kichloo et al., 2013a). A case study on E.rhusiopathiae endocarditis and presumed osteomyelitis in a 67 year old woman reported that the patient had a history of drinking hard liquor that reduced her immunity thus developing endocarditis, (Romney et al .,2001) 2.6.4 Environmental factors The bacteria have the ability of surviving in the environment and marine locations. Because of its resilience it has the ability to affect others, especially the farmers. While it has been suggested that the incidence of human infection could be declining because of technological advances in animal industries, like processing (transforming pork into other roducts like sausages) infection still occurs in specific environments (Brooke et al., 1999). 2.6.5 Age of the raw pork handler A study conducted by Pereira and others found that age was an important risk factor for erysipeloid. They concluded that participants who were greater than 45 years of age were at increased risk of acquiring the infection with a population of 428 patients (Pereira et al., 2010). 2.7.6 Sex of the raw pork handlers 12 Sex was reported as an important risk factor for E. rhusiopathiae infection in a study of 428 patients. Males have been reported to have a high prevalence of the disease compared to the females. One reason may be that a greater percentage of males work in the food industry compared to females, however both are infected with the bacteria, (Pereira et al., 2010). 2.7 Prevention and control of Erysipelothrix rhusiopathiae infection in humans Containment and control of E. rhusiopathiae are the most effective means of preventing the spread of infection in man and animals (Brooke et al., 1999). An awareness of the infection is essential for individuals in occupations which put them at risk. Suggested preventive measures include but are not limited to wearing of gloves or other protective hand wear, good hygiene especially frequent hand washing with disinfectant soap and the prompt treatment of any small injuries (Conklin and Steele, 1979). Good general health is considered an important factor in prevention, as any condition suppressing the immune system, including chronic alcoholism, may predispose to the serious forms of infection. Control of animal disease by sound husbandry, herd management, good sanitation and immunization is recommended if practitioners are made aware of the infection, signs and symptoms,(Nicoleta et al., 2010). 2.7.1 Disinfection Erysipelothrix spp. can be inactivated by commonly available disinfectants (Conklin and Steele, 1979) and several commercially available home disinfectants have been found to be highly effective; however, structurally complex equipment which contained organic matter was more difficult to disinfect especially without prior mechanical cleaning of surfaces with hot water and soap (Fidalgo, 2002). Due to the inability of disinfectants to fully remove the organism from the 13 environment, a multifaceted approach composed of sound husbandry, herd management, sanitation, and immunization has been recommended,(R. L. Wood, 1999) 14 CHAPTER THREE 3.0 Materials and methods 3.1 Study design A cross-sectional community based study was done which employed quantitative and qualitative methods for data collection between January to March 2016. 3.2 Study setting The study was conducted in Kamuli district in Eastern Uganda. This district forms part of the Busoga sub region. It is multi-ethnic and multi-cultural region with Basoga forming 76% of the population, while Iteso make up 3.8%, Banyoro and Bantu make up 1.8% (Local Government Kamuli district, 2009). It is bordered by Buyende district in the North, Luuka district in the East, Jinja district in the South and Kayunga district in the West. It has an estimated population of 662, 407 and 55,998 pigs (Local Government Kamuli district, 2009). The district was selected in a participatory manner for a research for development program to improve the performance smallholder pig value chains in Uganda, led by the International Livestock Research Institute (Ochola, 2012). The study was based in three sub counties of this district including Namwendwa, Kitayunjwa and Bugulumbya which had reports of swine erysipelas in 2013 (Roesel et al., 2014). The setting has three abattoirs, one in each of the sub counties. 15 3.3 Population 3.3.1 Target population Adult raw pork handlers in Kamuli district, Eastern Uganda. 3.3.2 Accessible population Abattoir workers, butchers, farmers, veterinarians and cooks in eating places and homes, resident in the three selected sub counties. 3.3.3 Study population Adult healthy raw pork handlers (abattoir workers, butchers, and cooks who buy raw pork from the butcheries) in Namwendwa, Kitayunjwa and Bugulumbya sub counties. 3.4 Selection criteria 3.4 1 Inclusion criteria Adult healthy raw pork handlers (abattoir workers, butchers, and cooks who buy raw pork from the butcheries) in Namwendwa, Kitayunjwa and Bugulumbya sub counties during the study period, and who gave written informed consent. 3.4.2 Exclusion criteria All those participants who wouldn’t comprehend Lusoga, luganda and English were excluded from the study. 16 3.4.2 Withdrawals Participants who did not adhere to the procedures of the study proposal e.g. refusal to draw blood for the E. rhusiopathiae test were considered as withdrawal. 17 3.5 Sample size estimation 3.5.1 Sample size for objective 1, prevalence of Erysipelothrix rhusiopathiae infection among raw pork handlers in Kamuli District. The sample size was calculated using the Kish Leslie formula, (Kish Leslie., 1965) Where p is the proportion of ER in humans. However, in animals p= 0.67 in Uganda (Musewa et al., 2015-forth coming) assuming the transmission rate to humans is 50%, therefore p =0.50 d is the precision, usually 5%, (0.05) Zα/2 is the critical value at 95% level of confidence, =1.96. This gives a sample size of 385. 2 2/ 2 )1( d ppZ N    18 3.5.2 Sample size for factors associated with E. rhusiopathiae infection among raw pork handlers in Kamuli District. This was adopted from a text book of designing clinical research by (Cumming, 2013). Where p1 is the proportion of participants greater than 50 years with E. rhusiopathiae infection, p2 is the proportion of participants less than 50 years with E. rhusiopathiae infection, N is the required sample size, q1 is proportion of subjects with >50 years, q2 is proportion of subjects with ≤ 50 years. Zα is standard normal value corresponding to level of significance, 1.96, Zβ is standard normal value corresponding to power of the study at 80% corresponds to a value of 0.84. A study by Pereira reported a prevalence of E. rhusiopathiae infection was 60% among participants >50 years .Therefore p1=0.6, considering a clinical significance of 30%, the difference in proportions in those above and below 50 years E.rhusiopathiae is 0.3*0.6 = 0.18. The proportion (p2) = (0.6-0.18) =0.42. Estimating the ratio of 50 years and above, below 50 years being 2:1, the proportion of those with E.rhusiopathiae below 50 years = 1/3=0.333, (q1) and proportion of those with E.rhusiopathiae above 50 years = 2/3=0.667 (q2). Therefore, P= (p1*q1+p2*q2), P= (0.6*0.667) + (0.42*0.333) = 0.5006. 2 21 2 2 22 1 11 21 2/ )( ]1)1(1)1()11)(1([ pp q pp q ppZ qq ppZ N     19 Substituting the above proportions in formula above gave a sample size of 269 participants. However since this is smaller the sample size for objective one, the two objectives were answered with the sample size for the first objective. 3.5 Sampling 3.5.1 Sample population The sample population included all raw pork handlers (abattoir workers, butchers and consumers) in Namwendwa, Kitayunjwa and Bugulumbya sub counties. 3.5.2 Sampling unit Abattoir workers, butchers and cooks residing and sourcing pork from the sub counties under study were sampled for this study. 3.5.3 Sampling procedure for quantitative data collection Since the sampling was done in three sub counties with Namwendwa subcounty having the highest numbers of bucthers and consumers, participants were sampled depending on the number of butchers available in the subcounty. However all abattoir workers (38 from the three sub counties) and 59 butchers were included in the study. Cooks who fulfilled the selection criteria were sampled consecutively as they came to the butcheries to buy raw pork. All cooks were sampled from the butcheries. This was because there was no clear population of cooks who buy pork though there were daily customers at different pork joints. However some cooks felt shy to be interviewed from the joint/butchery and asked us to go to their homes. This was done to see us raise the sample size required for this study and for confidentiality purposes of the study participants. 20 3.6 Variables and measurement 3.6.1 Dependent variable E.rhusiopathiae infection was the outcome variable. 3.6.2 Independent variables 3.6.2.1 Demographic factors Age of the RPH, sex, ethnic group, religion, marital status 3.6.2.2 Socio-economic factors Education level, housing, occupational exposure, duration on job 3.6.2.3 Socio-cultural factors Traditional beliefs, traditional practices, norms and values, way of living 3.6.2.4 Individual factors Personal hygiene, poor slaughtering methods, eating undercooked pork, no personal protective wear when handling raw pork 3.6.2.5 Vehicles: Infected fresh pork, contact with infected pigs, infected chicken, infected meat, (beef, mutton, goat’s meat). 3.7.2.6 Socio-cultural factors The socio-cultural factors were explored during the focus group discussions (FGDs) and key informant interviews (KIIs). The FGDs were conducted separately for each group in each subcounty at the subcounty headquarters. The participants were categorized as; butchers, abattoir 21 workers and cooks. Males who dominated the butchers and abattoir workers were in different focus groups and also the cooks, (where females were selected were separated from the males) during the focus group discussions. Nine participants were included in each FGD, and KIIs were conducted with nursing officer and a health assistant and Veterinarian in each of the sub counties. Question guides were designed for the FGDs and KIIs, (Appendix 9 and 10). The FGD guide was translated to Lusoga while that of the KIIs were not translated, (Appendix 11 and 12). 3.7 Data collection Both qualitative and quantitative methods of data collection were used. The principal investigator directly observed data collection. 3.7.1 Quantitative methods of data collection Participants were asked to give a written consent after the study had been explained to them,(Appendix 6) Questionnaires were administered to the participants by the research assistant (Lusoga native speakers). A tourniquet was tied on the upper arm and vein was observed. An alcohol swab was used to clean the area of blood draw. Blood was drawn from the participants by the principal investigator. Before the participant left, the questionnaire was cross checked to ensure that all the gaps and the necessary information was obtained. Data from all butchers and abattoir workers was collected at their places of work and data from cooks was collected from the butcheries and abattoirs where they bought the raw pork whereas others told the research team to follow them home for safety and privacy issues. Whole blood, (EDTA) was collected from the participants. A sterile syringe and new needle were used for each participant to draw 4ml of fresh blood. The syringe and needle were disposed 22 into a hazardous waste bin and the blood was kept on ice in a cool box then transported to Kamuli district regional referral hospital deep freezer until when it was transported to the microbiology laboratory, College of Veterinary Medicine, Animal Resources and Biosecurity at Makerere University in Kampala for analysis. 3.8 Laboratory diagnosis Different laboratory diagnostic approaches have been reported for isolation and identification of Erysipelothrix rhusiopathiae infection in animals and humans. 3.8.1 Growth conditions and requirements Erysipelothrix rhusiopathiae is a facultative anaerobe organism (Reboli and Ferrar, 1989). Newly isolated strains are micro-aerophilic, but laboratory adapted cultures grow both aerobically and anaerobically, with some strains being favored by incubation in C02 5% or 10%. The organism can grow at temperatures between 5oC-44°C, optimally between 30oC- 37°C. Best growth is favoured by an alkaline pH (Conklin and Steele, 1979), and the limits of growth as 6.7- 9.2 (Sneath et al., 1951). Growth is enhanced by the inclusion of serum 5- l0%, blood, glucose 0.1 -0.5%, protein hydrolysates, or surfactants such as Tween 80 in media (Ewald, 1970). The exact nutritional requirements of the organism are not known, but riboflavin, small amounts of oleic acid and several amino acids, particularly tryptophan and arginine are needed for growth (Ewald, 1970). 2.8.2 S- and R-shape (indicator for virulence) On blood agar E.rhusiopathiae is alpha-hemolytic with green hemolysis often reported but is never beta hemolytic. After growing for 24 h at 37°C, colonies are small, circular, and transparent, with a smooth glistening surface and edge. These are smooth or S forms. Larger 23 flatter colonies with a matter surface and fimbriated edge are R-form or rough colonies. Forms, (R and S shape) are usually light blue in color or sometimes green. Intermediate forms are also seen. S-form colonies dissociate to give rise to intermediate and R-form colonies. R-form colonies also give rise to S forms. In broth, S-form organisms cause a slight turbidity and a powdery deposit; R forms have a tangled hair like appearance. Microscopically, S-form organisms are 0.3 to 0.6 by 0.8 to 2.5 ,um, while R-form organisms form long non branching filaments which can be >60 ,um in length ,(Reboli and Farrar, 1992) 3.8.3 Microbiological cultures Whole blood from humans was cultured in order to isolate E.rhusiopathiae from EDTA blood (figure 3). The dependent outcome was measured by culturing EDTA blood on trypticase soya agar, brain heart infusion broth, modified blood agar and gram staining. Erysipelothrix selective broth, (this was made in the laboratory with the available reagents) and confirmed using biochemical tests like catalase, gelatine test and aesculin test and gram staining. 3.8.4 Principle and preparation of the test– Selective culture media Selective media allows growth of certain type of organisms and inhibit growth of other organisms. Some organisms have the ability to utilize a given sugar and are screened easily by making that particular sugar e.g. glucose, the only carbon source in the medium for the growth of the microorganism. Selective inhibition of some types of microorganisms can be studied by adding certain dyes, antibiotics such as kanamycin and neomycin, salts or specific inhibitors that will affect the metabolism or enzymatic systems of the organisms (Wang et al., 2010). 24 Twenty five grams (25g) of infusion broth was dissolved in 1 litre of 0.1 phosphate buffer solution (12.02g) of Na2HPO4 (12.02g) and KH2PO4 (2.09g) per liter of distilled water and then autoclaved for 1hour and 15mins. Sterile fetal bovine serum (5%), kanamycin (400mg/ml) and neomycin (50mg) was added to the broth and specimens were cultured on Erysipelothrix species- selective agar (Bender et al., 2010). 3.8.5 Preparation of modified blood agar Forty grams of horse heart infusion agar was dissolved with 0.4g of sodium azide in 1000ml of distilled H2O. The media was sterilized at 121 oC for 1hour and 15minutes. It was cooled to room temperature and 20ml of defibrinated bovine blood and 50ml of horse serum were added aseptically (Harrington et al., 1971). 3.8.6 Preparation of trypticase soya agar Twenty five grams of trypticase soya were dissolved in 1000 ml of distilled water. The solution was left to stand for 15 minutes until all the powder was dissolved. Four grams of European agar were added and mixed gently. The dissolution was autoclaved at 121oc for 1 hour and 15minutes, the medium was cooled to room temperature and sterile blood was added (Shimoji et al., 1998). 25 3.8.7 Biochemical tests for confirmation of E.rhusiopathiae infection 3.8.7.1 Biochemistry The genus Erysipelothrix is relatively inactive and gives negative results for catalase, oxidase, methyl red, indole and Voges-Proskauer reactions (Cottral, 1978). Andrade's agar with horse serum 10% is the recommended medium for biochemical tests, (Brooke et al., 1999). The majority of strains produce H2S gas, but again the extent of this production varies with the culture medium. The best reaction is demonstrated on triple sugar iron agar. 3.8.7.2 Catalase test This was done to confirm the presence of E. rhusiopathiae and distinguish it from the microorganisms with similar characteristics. Using a wire loop, a bacteria colony was picked from the culture plate and placed into a test tube. Three millilitres of hydrogen peroxide were added and for positive test , bubbles were formed while for a negative test , no bubbles were formed (Forbes et al., 2007). 3.8.7.3 Aesculin hydrolysis Aesculin was used in a microbiology laboratory to aid in the identification of E. rhusiopathiae infection. E. rhusiopathiae is group D Streptococci which hydrolyzes æsculin in 40% bile. Aesculin was incorporated into agar with ferric citrate and bile salts (bile aesculin agar).When aesculin was hydrolyzed it formed aesculetin and glucose. The aesculetin formed dark brown or black complexes with ferric citrate. The bile aesculin agar was streaked and incubated at 37°C for 24 hours. The absence of a dark brown or black halo indicated that the test was negative ( Forbes et al., 2007). 26 3.8.7.3 Gelatin test Nutrient gelatin was a differential medium that tested the ability of an organism to produce an exoenzyme, called gelatinase that hydrolyzes gelatin. A wire loop was used to pick colonies and put them in a test tube. Nutrient gelatinase was added. Breakdown of proteins was read upon formation of bubbles and no bubble formation indicated a negative test . 3.8.7.4 Gram staining Using a sterile wire loop, a drop of normal saline was added on the slide. A colony was picked from the culture plate and added to the normal saline. A thick smear was air dried then fixed on heat. The smear was placed on a staining rack to cool. The slide was fold with crystal violet stain for 1minute. The stain was washed off with tap water. Iodine solution was added much enough to cover the smear. The Iodine stayed for 1minute. The Iodine was washed off using tap water. Acid acetone, (50%) was added as a decolorizer to wash off the excess stain. The smear was counter stained with carbol fuchsin for 1 minute. Tap water was used to wash off the stain from the slide. The slide was left to dry off and excess stain was wiped off using clean cotton wool. The slides were left to stand until dry prior to examination. Using a light microscope with an objective lens of X100, the slide was loaded on the microscope and adjustments were made, until a fine focus was made for the examination of E. rhusiopathiae. E.rhusiopathiae is a gram positive organism. Positive gram stained E. rhusiopathiae isolates had a purple/ bluish background, with purplish curved rods. 27 3.8.8 Sample preparation Whole blood, (EDTA) was put on a working bench to thaw. After thawing all bottles were sterilized before picking an inoculum. A sterile wire loop was used to pick an inoculum from the sample and then added to appropriate media for culture. 3.8.9 Sample culture Trypticase soy agar and brain heart infusion was poured on sterile culture plates and left to cool. Using a wire loop, blood from the resultant procedure above was strake on the plate and incubated for 24-48 hours in an incubator at room temperature. The plates were read after incubation. Colonies with morphological characteristics of Erysipelothrix rhusiopathiae were subculture on modified blood agar, Erysipelothrix selective media and on trypticase soy agar. This was incubated for 24 hours and bacterial colonies on the plates were sub cultured on the Erysipelothrix selective media. The colonies that grew on the media were biochemically confirmed using the catalase, aesculin test and the gelatin test and gram staining. 28 Subculture ER from the above culture plates colonies onto and incubate for 24hours Subculture ER colonies onto and incubate for 24hours to obtain pure colonies Confirmatory tests for ER NB: Gram staining and any one of the above stated biochemical tests can be used in confirmation of E.rhusiopathiae infection. Figure 2: Diagnosis of Erysipelothrix rhusiopathiae infection in humans 3.9 Data management Data was checked for completeness daily, edited, coded and double entered using EPI Data version 3.00. Daily backups were done in drop box and using google drive. When data was Trypticase soy agar, culture on EDTA blood and incubate for 48hours Brain heart infusion broth, culture EDTA blood and incubate for 48hours Erysipelothrix selective media Modified blood agar Erysipelothrix selective media yields ER colonies Catalase test - Gelatin hydrolysis - Aesculin test - Gram staining 29 checked for completeness and consistency it was exported to STATA version 12.0 for cleaning and then analysed. 3.9.1 Data analysis 3.9.1.1 Univariate analysis Descriptive statistics were used to summarize baseline characteristics of the study participants. The prevalence of E. rhusiopathiae infection among raw pork handlers was reported in percentages with its 95% confidence interval when clustering was considered. The numerator comprised of all subjects who confirmed positive with E. rhusiopathiae infection and the denominator comprised of all the participants in the study. Continuous independent variables were summarised into, medians, range, standard deviations; and histograms were displayed for age. 3.9.1.2 Bivariate Analysis This was one to determine the association between E. rhusiopathiae with each of the categorical independent variable using the binary logistic regression. Continuous variables were categorized and the chi-square test was used to get the factors associated with E. rhusiopathiae infection. All variables with P=<0.20 were considered for multivariate analysis. 30 3.9.1.3 Multivariate analysis To determine the factors that are independently associated with E. rhusiopathiae, all independent variables with P <0.20 at bivariate analyses were entered into multiple logistic regression models. Multivariate logistic regression was used because the outcome was rare to identify the predictor variables with E. rhusiopathiae, among raw pork handlers in Kamuli. Interaction was assessed using the chunk test. This was done using the stepwise regression method, the significantly independent factors associated with E. rhusiopathiae among raw pork handlers, in Kamuli district that stayed in my final model were used to form interaction terms which were tested for significance. Product terms were formed with the predictor and other independent variables and the difference in the (-2LL) log likelihood of the reduced and the full model was calculated. Confounding was determined by calculating the difference in crude and adjusted odds ratios. A 10% difference will be taken as significant. All variables which had a difference greater than 10% were retained in the model thereby controlling for confounding. 3.10 Qualitative methods of data collection To explore the socio cultural factors influencing E. rhusiopathiae infection among raw pork handlers in the three sub counties, Six (6) FGDs were conducted with butchers, abattoir workers and cooks with six participants in FGDs that were included in the butchers and abattoir workers. Since there were many cooks in the study, three FGDs with nine cooks/pork buyers in each FGD at the respective sub counties. The FGDs was moderated by a Lusoga Natives speaker and information was tape recorded by the Lusoga speakers as the principal investigator was tape 31 recording and watching how the FGDs were conducted. A FGD guide was used during the focus group discussions, (Appendix 9), to elicit dialogue and ensure that they are no responses obtained from the guide but from the participant’s view regarding the theme being discussed. The FGD guide was translated from English to Lusoga because the all participants in the FGD were conversant with Lusoga language. Key informant interviews were conducted using a question guide, however it was not translated to Lusoga the respondents were literate. The FGDs conducted until the circulation point, where no new inform was coming out of the responses regarding each sub theme discussed. 3.10.1 Analysis of qualitative data Tape recorded information and notes taken during the conduction of FGDs were transcribed and translated from Lusoga to English and then typed into word. This was also applied for the key informant interviews; they were taped into word after transcription. The investigator was immersed into the data to generate content from it and then thematic analysis was used for analysis in line with major themes used during data collection. 32 3.11 Quality control The following procedures were undertaken by the principal investigator to ensure quality control: All questionnaires were translated to Lusoga and back translated by qualified and competent persons (native speakers) for ease of the interviews and to give chance to the participants to go through the questionnaire and all research assistants were trained before they conducted the interviews. In the laboratory, cultures were done in duplicates to avoid any misdiagnosis/ wrong diagnosis in culture, identification and isolation of E. rhusiopathiae. Isolates were kept in the fridge until the work is published. All reagents were prepared according to the manufacturer’s instructions and technical support was sought from the laboratory staff. Data was cleaned, edited and double entered to minimise errors and all the filled questionnaires will be kept under lock and key. Data was protected with security codes and backed up in different locations to avoid loss of information. Comparison of tape recorded and written records from FGDs for qualitative data was obtained and safely stored until the study findings have been published. 33 3.12 Ethics Permission to conduct this study was sought from the Clinical Epidemiology Unit, Kamuli district commissioner and ethical approval was obtained from the School Of Medicine, Research and Ethics committee, (SOMREC) and the International livestock Research institute, Institutional Research and Ethics committee, (ILRI-IREC2014-07). Participants gave written (informed) consent. Oral informed consent was obtained from the FGD respondents and confidentiality was ensured through keeping all records under lock and key and confidentiality of the blood culture results. However, before participants provided the written and oral consent the principal investigator briefed them about the study, study purpose, procedures, risks and benefits, why they are selected/ considered for this study, issue about confidentiality, costs and compensations, reimbursement and voluntariness. Participants were given time to ask questions pertaining to the study, questions about their rights and their own will to join the study or withdraw from the study at any time without penalty. Those who agreed to join the study gave informed written or/ oral consent. 34 CHAPTER FOUR 4.0 Results for the quantitative study 4.1 Description of study population The study was conducted between January and March 2016 in Namwendwa, Kitayunjwa and Bugulumbya sub counties in Kamuli district, Eastern Uganda. A total of 302 participants were enrolled into the study to determine the prevalence and factors associated with E. rhusiopathiae infection among raw pork handlers in Kamuli District. Three KII were done, (a nursing officer, veterinarian and a health assistant each). Six FGD were conducted with 18 butchers/ abattoir workers and 26 consumers. 4.1.2 Graph showing the age of the study participants The median age was 39 years, interquartile range, 18-47 (figure 4). 0 10 20 30 40 Frequency 20 40 60 80 Age of the participant Figure 3: Age distribution of 302 participants in Kamuli district, Eastern Uganda. 35 4.1.3 Socio demographic characteristics of the study participants From (Table 1), majority (154/302, 50.99%) of the participants were from Namwendwa subcounty. Most of the participants were males (155/302, 51.3%) and majority of the participants were Anglicans (157/302, 52%). The married participants dominated the study with (219/302, 72.5%), with primary education being the highest level of education (158/302, 52.3. The consumers studied were (205/302, 67.9%). Table1: Socio demographic characteristics of the 302 study participants in Kamuli District Eastern Uganda, 2016 *other religions included Pentecostals, 7.9%, 1% born again and 1.7% Muslims Variable Frequency ( N=302) Percent Sub county Namwendwa 154 51 Kitayunjwa 99 32.8 Bugulumbya 49 16.2 Sex Males 155 51.3 Females 147 48.7 Religion Catholic 113 37.4 Anglican 157 52 Others* 32 10.6 Education level Never 78 25.8 Primary 158 52.3 Secondary 54 17.9 Tertiary 12 4 Raw pork handler Butcher 59 19.5 Abattoir worker 38 12.6 consumers/pork buyers 205 67.9 Marital status single 47 15.6 Married 219 72.5 Divorced 22 7.3 Widowed 14 4.6 36 4.1.4 Individual factors of the study participants From (Table 2) 93.7% of the participants reported that were had no training prior to handling raw pork. Participants who reported receiving training from NGOs like volunteer efforts for development, Entebbe veterinary training school and other training skills from veterinary officers in the different Sub counties. Majority of the cooks reported that they buy their raw pork from butchers (62.0%). The type of pork bought by the consumers was raw pork (93.7%). Alcohol consumption was reported by majority of the participants (54.6%). 37 Table 2: Individual characteristics of raw pork handlers in Kamuli district Eastern Uganda, 2016 Variable Frequency (N=302) Percent Participant's training prior to handling raw pork Yes 19 6.3 No 283 93.7 Source of pork for consumers and butchers* Abattoirs 100 43.5 Butchers 130 56.2 Source of pigs slaughtered for butchers and abattoir workers* Pig farmers 51 70.8 Pig traders 14 19.5 Market 7 9.7 Type of pork bought by the consumers# Raw 192 93.7 Roasted/cooked pork 13 6.3 Alcohol consumption Yes 165 54.6 No 137 45.4 Participant's duration on exposure to raw pork Below 10 years 261 86.4 Above 10 years 41 13.6 Engagement in other pig related activities Yes 144 47.7 No 158 52.3 Frequency of handling raw pork Daily 99 32.8 Weekly 113 37.4 Others** 90 29.8 *source of pork for consumers and butchers while the source of pigs slaughtered was studied for butchers and abattoir workers; #The type of pork bought was studied for consumers since the butchers and abattoir workers usually handled raw pork; **Frequency of handling raw pork, other frequency included monthly and yearly handling of raw pork. 38 4.2 Health related factors 4.2.1 Medical checkup of the respondents Majority of the respondents (249/302, 82.5%) reported that they had never gone for a medical checkup ever since they started handling raw pork or consuming pork since they added that it rather improved their lives especially the HIV/AIDS infected people who supported that pork added nutrients to their body and would give them more energy. 4.2.2 Period when they last suffered from a skin infection Two hundred and seventy four participants (274/302, 90.7%) reported that they have never suffered any skin related infection during the past year. 4.2.3 Previous use of antibiotics Majority of the respondents reported that the last time they fall sick, they went to hospital and were given medicine (8.0%). 4.2.5 Taking on the intervention in case results are positive All respondents reported that they would allow the intervention (medicine) which will be given to them in case their results turn positive for the infection. . 39 4.3 E. rhusiopathiae infection among raw pork handlers in Kamuli district, 2016 The overall prevalence of E.rhusiopathaie infection among raw pork handlers was (9.9%, 30/302) with a CI 7.35-12.52 after adjusting for clustering as shown in the table below (Table 3). Table 3: Overall prevalence of Erysipelothrix rhusiopathiae infection among raw pork handlers in Kamuli district Eastern Uganda, 2016 Blood result Frequency Percent 95% CI Positive 30 9.9 7.35-12.52 Negative 272 90.1 86.67-93.46 #This blood result was for both biochemistry and gram staining 40 4.4 Prevalence of E. rhusiopathiae infection among raw pork handlers within the social demographic characteristics in Kamuli district Eastern Uganda, 2016 The prevalence of E.rhusiopathiae infection was highest among participants from Kitayunjwa (11.1%); males (13.5%), catholic participants (11.5%), those who have never gone to school (12.8%) and among abattoir workers (36.8%) as shown in (Table 4). 41 Table 4: Prevalence of E.rhusiopathiae infection among raw pork handlers within the socio demographic characteristics in Kamuli district Eastern Uganda, 2016 Variable Number (N=302) ER infection positive Prevalence (%) 95% CI Sub county Namwendwa 154 15 9.7 5.02-14.46 Kitayunjwa 99 11 11.1 4.86-17.36 Bugulumbya 49 4 8.1 0.39-15.94 Sex Males 155 21 13.5 8.12-18.98 Females 147 9 6.1 2.21-10.03 Religion Catholic 113 13 11.5 3.02-17.44 Anglican 157 14 8.9 2.28-13.40 Others* 32 3 9.4 0.93-19.68 Education level Never 78 10 12.8 3.81-20.32 Primary 158 18 11.4 2.54-16.38 Secondary 54 2 3.7 2.59-8.81 Tertiary 12 0 0 Type of raw pork handler Butcher 59 9 15.3 5.90-24.54 Abattoir worker 38 14 36.8 21.1-52.44 Consumers 205 7 3.4 0.90-5.92 Marital status Single 47 5 10.6 1.69-19.58 Married 219 21 9.6 5.66-21.44 Divorced 22 2 9.1 3.25-21.44 Widowed 14 2 14.3 4.81-33.38 *Other religions studied include born-again Christians, Pentecostals and Muslims. 42 4.5 Prevalence of E. rhusiopathiae infection among raw pork handlers within the individual characteristics in Kamuli district Eastern Uganda, 2016 From (Table 5) Respondents who had no training prior to handling raw pork reported a higher prevalence of E.5rhusiopathiae infection (10.2%, 29/283) while bucthers and abattoir workers who bought pigs for slaughtering from pig farmers also reported a high prevalence (18/51, 35.3%). Consumers who reported to buy processed pork had a high prevalence compared to those who bought raw pork (23.1%, 3/13). Participants who reported handling raw pork on a daily basis had a high prevalence (13/99, 13.1%) while those who reported engagement in other pig related had a prevalence of (12%, 19/158) and for those who reported alcohol consumption had a prevalence of (16.4%, 27/165). 43 Table 5: Prevalence of E. rhusiopathiae infection among raw pork handlers within the individual factors in Kamuli district, Eastern Uganda, 2016 Variable Frequency (N=302) ER positive infection prevalence 95%CI Participant's training prior to handling raw pork Yes 19 1 5.3 5.1-15.62 No 283 29 10.2 6.79-13.8 Source of pork for cooks and butchers* Abattoirs 100 5 5 1.32- 9.88 Butchers 130 2 1.5 0.09- 3.45 Source of pigs slaughtered for butchers and abattoir workers* Pig farmers 51 18 35.3 15.34- 40.44 Pig traders 14 4 28.6 12.31- 33.70 Market 7 1 14.3 5.23- 19.36 Type of pork bought by the consumers* Raw 192 4 2.1 0.87- 4.24 Processed 13 3 23.1 11.74- 29.99 Alcohol consumption Yes 165 27 16.4 No 137 3 2.2 Engagement in other pig related activities Yes 144 11 7.6 3.27-12.01 No 158 19 12.03 6.92-17.13 Frequency of handling raw pork Daily 99 13 13.1 6.42-19.85 Weekly 113 12 10.6 4.89-16.34 Others* 90 5 5.6 0.78-10.33 *Other times of pork preparation are monthly and yearly. 44 4.6 Frequency of E. rhusiopathiae infection and skin infection The study reported that (2/26, 7.1%) of the respondents who had ever skin infection before were positive for E. rhusiopathiae infection among the raw pork handlers. Respondents were asked about the signs they experienced, (2/11, 18.2%) who had burning signs were culture positive, (1/5, 20%) who had wounds were culture positive and (27/274, 9.9%) who reported no sign tested culture positive (Table 6). Table 6: Frequency of Erysipelothrix rhusiopathiae infection among raw pork handlers who reported skin related infection in Kamuli district Eastern Uganda, 2016 Variable ER infection Positive percent Total Skin related infection Yes 2 7.1 28 No 28 10.2 274 Signs Burning 2 18.2 11 Skin rash 0 0 12 Wounds 1 20 5 None 27 9.9 274 When participants were asked about previous medical complications (160/302, 53%) reported to have had experienced complications like malaria, syphilis, kidney problems, gonorrhea, diarrhoeal and headache. The study reported 14/160, 8.8% of those who reported medical complications were positive for E. rhusiopathiae. 45 4.7 Bivariate analysis of the socio demographic characteristics among raw pork handlers in Kamuli district Eastern Uganda From (Table7) the study reported that working in the abattoir was associated with E. rhusiopathiae infection (OR=16.5, 95% CI: 6.06-44.91). Similarly, working in the butcher was associated with E. rhusiopathiae infection, (OR= 5.09, 95%CI: 1.8-14.33). Sex of the participant was associated with E. rhusiopathiae infection. Males were more likely to develop the infection compared to females (OR=2.4, 95%CI: 1.04-5.44). 46 Table 7: Bivariate analysis of the association between socio demographic factors and Erysipelothrix rhusiopathiae infection among raw pork handlers in Kamuli district Eastern Uganda, 2016 Variable ER infection positive ER infection negative Odds ratio 95% CI P value Raw pork handler Consumers 7(3.4) 198(96.6) 1 Butchers 9(15.3) 50(84.8) 5.09 1.80-14.33 0.002 Abattoir workers 14(36.8) 24(63.2) 16.5 6.06-44.91 <0.001 Subcounty . . Namwendwa 15(9.7) 139(90.3) 1 Kitayunjwa 11(11.1) 88(88.9) 1.2 0.51-2.64 0.726 Bugulumbya 4(8.2) 45(91.8) 0.82 0.26-2.61 0.742 Sex Females 9(6.1) 1.38(93.9) 1 Males 21(13.6) 134(86.5) 2.4 1.06-5.44 0.035 Religion Others** 13(11.5) 100(88.5) 1 Catholic 14(8.9) 143(91.1) 0.75 0.34-1.70 0.49 Anglican 3(9.4) 29(90.6) 1.10 0.21-2.98 0.74 Marital status Single 5(10.6) 42(89.4) 1 Married 21(9.6) 198(90.4) 0.82 0.32-2.50 0.83 Divorced 2(14.3) 12(85.7) 0.84 0.15-4.71 0.84 Widowed 2(14.3) 12(85.7) 1.5 0.24-8.14 0.71 Education level Never 10(12.8) 68(87.2) 1 1 Primary 18(11.4) 140(88.6) 1.4 0.24-8.14 0.75 Secondary 2(3.7) 52(96.3) 0.87 0.38-2.00 0.092 Tertiary 0 12(100) **Other religions that were studied include Born-again Christians, Pentecostals and Muslims. 47 4.8 Bivariate analysis of individual factors among raw pork handlers in Kamuli district Eastern Uganda, 2016 From (Table 8) respondents who had no training prior to handling were more likely to develop E. rhusiopathiae infection (OR=2.06, 95% CI: 0.26-16.0). The type of pork bought by the cooks and butchers, (roasted/ fried) was associated with E. rhusiopathiae infection (OR= 2.56, 95% CI: 1.09-5.99). Buying pork from butchers was associated with developing E. rhusiopathiae infection (OR=2.24, 95% CI: 1.04-4.79). Consumption of alcohol was also associated with E. rhusiopathiae infection (OR= 8.74, 95% CI: 2.59-29.49). 48 Table 8: Bivariate analysis of the association between individual factors and Erysipelothrix rhusiopathiae infection among raw pork handlers in Kamuli district Eastern Uganda, 2016 Variable ER infection positive ER infection negative OR 95%CI pvalue Participant's training prior to handling raw pork Yes 1(5.3) 18(94.7) 1 No 29(10.2) 254(89.8) 2.06 0.26-16.0 0.483 Source of pork for consumers and butchers*** Abattoirs 5(5) 95(95) 1 Butchers 2(1.5) 128(98.5) 2.24 1.04-4.79 0.038 Source of pigs slaughtered for butchers and abattoir workers* Pig farmers 18(35.3) 33(64.7) 1 Pig traders 4(28.6) 10(71.4) 1.24 0.38-4.01 0.716 Market 1(14.3) 6(85.7) 0.36 0.15-0.89 0.026 Type of pork bought by the consumers** Raw 4(2.1) 188(97.9) 1 fried/Roasted 3(23.1) 10(76.9) 2.56 1.09-5.99 0.03 Alcohol consumption No 3(2.2) 134(97.8) 1 Yes 27(16.4) 138(83.6) 8.74 2.59-29.49 <0.001 Engagement in other pig related activities# Yes 11(36.7) 133(48.9) 1 No 19(63.3) 139(51.1) 0.56 0.173-1.81 0.326. Frequency of handling raw pork . Others## 5(16.7) 85(31.3) 1 Daily 13(43.3) 86(31.6) 0.39 0.13-1.20 0.077 Weekly 12(40) 101(37.1) 0.786 0.34-1.82 0.573 ***consumers and butchers while;* butchers and abattoir workers; **consumers alone; # pig farming and trading; ##monthly and yearly. 49 50 4.9 Multivariate analysis After bivariate analysis, variables that had p- values less than 0.2 were considered for multivariate analysis. The variables retained as independent predictors of E. rhusiopathiae infection were alcohol consumption, type of raw pork handler and sex of the participant and frequency of handling raw pork. There was no interaction in the multivariate model (Table 9). 4.9.1 Multivariate analysis for the factors associated with Erysipelothrix rhusiopathiae Type of raw pork handler was associated with E.rhusiopathiae infection. The study reported that abattoir workers were 26.13 times more likely to develop E. rhusiopathiae infection when compared to the consumers (OR=26.13, 95%CI: 5.29-129.10). The butchers were 8.37 times more likely to develop E. rhusiopathiae infection compared to the consumers, (OR= 8.37, 95% CI: 1.79-39.10). Alcohol consumption was associated with E. rhusiopathiae infection. Participants who reported alcohol consumption were 4.02 times more likely to develop E. rhusiopathiae infection compared to those who reported no alcohol consumption, (OR=4.02, 95%CI: 1.07-15.03). Sex of the participants was retained in the model because it was confounding the association between type of raw pork handler and E. rhusiopathiae infection. 51 Table 9: Results of multivariate analysis for E.rhusiopathiae infection among raw pork handlers in Kamuli district Eastern Uganda, 2016 Variable OR 95% CI Pvalue Type of raw pork handler Consumers 1 Butcher 8.37 1.79-39.10 0.007 Abattoir worker 26.13 5.29-129.10 <0.0001 Alcohol No 1 Yes 4.02 1.07-15.03 0.038 Confounder Sex Females 1 Males 3.85 0.91-16.23 0.067 52 4.10 RESULTS OF THE QAULITATIVE ASSESSMENTS. 4.10.1 Focus Group Discussions and Key Informant Interviews Overall, FGD and KII revealed gaps in knowledge about ER infection among raw pork handlers. 4.10.1.1 Participant’s perception on the causes of E.rhusiopathiae infection among raw pork handlers Provision of animal/ veterinary services Participants in the FGDs, (five of the six FGDs) reported that they offer veterinary services like assisting their pigs during delivery and administration of treatment to the pigs when they are sick since they have very few veterinary officers. “We have very few veterinary officers who ask for money to treat our animals yet we cannot afford the costs charged at times. A veterinary officer can charge you a cost when he is going to treat a very small pig. Since we cannot afford we buy the medicine (obhulezi) and we treat them ourselves. We don’t have enough skills but we do it because we need our pigs alive. A participant added that one day, at night I heard my pig scream, when I went out I saw it was giving birth I had to give it a hand in the process to reduce the pain, however I had no protective clothing”( male FGD, Namwendwa). High poverty levels in the district Participants reported that the poverty levels are very high to the extent that some families have just three meals in a week. They cannot afford buying food, firewood and even clothing for themselves. Some have decided to start working in the pig abattoirs and butchers to get some money survive with their families. 53 “Young, youth and the elderly have decided to start working in the abattoir, they lack adequate materials to start the work like gum boots as a safety measure which would protect them from acquiring the infection. The abattoir and butchers have bones that can easily pierce them thereby developing an infection in case they get pierced” (KII Nam). Lack of knowledge on rearing animals and their associated infections It was perceived that people who work in butchers, abattoir or handle raw pork have never gone school. All FGDs reported that the levels of education are very low in their communities. The highest level of education that was attained among participants that they reported, (majority) was senior one. “We didn’t go school because our parents didn’t have money to take us to school. Our children wanted to go to school but they all failed because of poverty. We are so ignorant to the extent that our chairmen (pork slaughter organization) have also not been to school. We lack knowledge on rearing pigs and slaughtering them. We like pigs like our own because they are source of income. However we cannot tell which one is sick and which one is not. They continue spreading diseases to us whether live or not which we cannot tell” (FGDs, Kamuli). Share of utensils with pigs Participants in the qualitative study also reported that they are very free with their animals. For their animals to live well and healthy like human beings, they need to be treated well. They need to feed and also have shelter like humans though most of them couldn’t afford them ..”Ehhhh I cook feeds for my animals (pigs) from the saucepans we also use. This is a sign of treating them fairly equal as living things. We feed them cooked feeds. After we have cooked 54 them we serve them from bathing basins which we also use. May be this might cause some infections but since they are animals they need to be treated fairly. Another participant reported that when it rains my pigs have a section on my house where they sleep. The rain affects my animals in that they can develop other diseases that may require me a lot of treating” (FGD, Kitayunjwa). Bestiality Participants reported that bestiality is increasing in their communities. Some men have decided rape animals sexually. This was reported that men who are possessed with demons or those who have been bewitched are raping pigs. This may eventually results into spread of zoonotic infections from the pig to the man and vice versa. “FGDs reported that on several occasions they hear their pigs making noise while the pigs have left to feed away from home. At first I thought maybe someone is stealing my pig to take it and sell if off, however I was shocked I found a man behind the pig. He decided to run away. I was so annoyed we ran after the man, he got him and tied him ropes, called a veterinarian to examine the pig only to confirm that the pig was raped. These people who rape pigs transmit infections to pigs and pigs also transmit infections to humans and the transmission cycle continues like that” (KII and FGDs, Kamuli). Increased alcohol consumption Key informants and participants during the FGD reported that alcohol consumption is high in their communities. In every kilo meter there is a small drinking bar selling local brew and other alcoholic drinks. Alcohol consumption is reported to suppress the immunity of the individual hence being easily invaded with all kinds of infection. 55 “Ohh we need a solution to see this end.” Our men drink from morning to morning, most drinking points sell pork, if there are many drunkards at the point, and the person serves half cooked pork which is at times coming from dead animals. People here have a tendency of slaughtering pigs which are reported to have swine fevers, diarrhoeal diseases and pigs that have died abruptly. This has continued to spread such infections” (KII and female FGDs Kamuli). 4.10.1.2 Participant’s perceptions on lifestyle that predispose them to ER infection Lack of proper waste disposal It was noted that homes with no toilets are many in their communities today. People use the bush to solve their stomach problems and the pigs that freely roam end up feeding on the fecal matter. If they get infected they will keep the infection in their bodies that will be carried to the human being when the pig is slaughtered. “Most people in the village lack toilets. Since we lack toilets, we use the bush and dispose of waste. When pigs are feeding, especially the free roaming pigs, they look for food and eventually feed on the waste that was disposed of by humans. So if the human fecal disposed was carrying any worms or any diseases the pigs will be pick the microorganisms and keep them in the body ad continue to transmit the infection to other human being” (KII, Kamuli). Poor hygiene Most participants reported that body hygiene is very poor especially for the men working in abattoirs and butchers. Men can spend nearly seven days with changing their clothes or bathing even after they have come back from the activities. They claim soap is expensive that even when they change they will still be made dirty with the blood from the pigs when they slaughter the 56 following day. However this was reported to increase the chances of acquiring ER in they stay in dirty clothes where the bacteria can stay multiplying and eventually catches the handler. “Men don’t want bath.” When he puts on a shirt he will have it for a whole week. Even when we provide them with clean clothes they still refuse putting them on thinking. If they have slaughtered a pig which has been infected with a disease transmissible to humans will stay on the body for some time. It will multiply and by the time he bathes the disease has already manifested its self in that human being” (KII and female FGDs Kamuli). Handling infected raw pork and roasted/ fried pork Participants noted that many bucthers want to work alone because of the limited capital they have in their business. They perform more than one activity at the butchery. They handle that raw pork when cutting to sell off to the cooks and when an order comes to roast or fry pork, the same person will prepare. You find that they may contaminate the roasted or fried meat with the fresh pork since it is one person involved. “You can hardly find butchery with more than two people working in them. You can find someone with blood on his fingers when you ask him to prepare for you pork, he will just cut and put on fire without washing off the blood. Since we like the pork we shall sit and wait for the preparation, however they keep crossing form cooking to cutting fresh pork for the orders being made, this contaminates our meat and we get ER infection” (female FGD, Bugulumbya). Poor storage methods of pork Participants reported that the ER infection might be as result of the storage methods that they are employing when meat stays over the next day. 57 “We lack deep freezers and fridges where we can keep our meat. We normally keep our meat in cut jerry cans or on the cutting boards. Microorganisms can easily multiply with in the meat and the next time we cut it we are exposed to infections” (male FGD, Kitayunjwa) 58 4.10.1.3 Cultural beliefs, norms or practices associated with Erysipelothrix rhusiopathiae infection Tying bones around the waist cures measles Measles is a disease that affects the young and old. We have seen our elders treat themselves with pig sauce and tying bones around the waist of the person being infected. “It is believed that measles is a cultural disease. Therefore when people develop it they don’t look for medicine immediately because they perceive it is originating in wind and is spread in wind. “We don’t immediately buy medicine for those infected with measles, we go to butcheries and abattoir and look for pig bones which can tie around the waist or neck and can cure the measles. We also use these bones to scare away demons in the houses” (FGDs Kamuli). Consumption of ofals believed to cure diseases It was reported that since pigs have two stomachs, the digestion that takes place is not very rigorous as the one in ruminants with four stomachs. Since that is the case we think the intestines are still nutritious for human consumption and it believed that they cure diseases originating from witchcraft. “Those days’ ofals were taboos. However we had discovered how nutritious ofals are. However we might be picking some infection when we are handling them, because whatever pigs feed on goes through one stomach and it isn’t digested very well. Therefore in the end when we are separating them to cook we handle dirty things but the good thing is they cure serious diseases like HIV/AIDS and keep our immunity strong” (FGDs Kamuli). 59 Smearing pig blood on house walls brings blessings Participants reported that they living in an era of haters. People hate them and can do anything to them if they are successful. However if you pig blood in your house the demon can’t cross borders and also the house will receive blessings in the end. “Animal blood is a blessing.” People go to shrines to look for blessings, however, we believe that our own pigs can bring blessings of children, knowledge and wealth creation. When a healthy pig is cut, we can collect its blood and smear it on the wall, in that process, you can ask for what you want from God because God blessed these animals”(FGDs Kamuli). 60 5.0 CHAPTER FIVE DISCUSSION 5.1 Prevalence of Erysipelothrix rhusiopathiae infection The overall prevalence of E. rhusiopathiae infection among raw pork handlers in Kamuli District was 9.9%. The reported prevalence was low compared to that in Sweden that was reported at 14.5% among abattoir workers (Molin et al., 1989). However comparison of the prevalence is difficult since few studied have done similar work in a similar setting like the one where the study was conducted. In the East African region this is the first paper to report the infection among raw pork handler. Erysipelothrix rhusiopathiae infection was reported at 67% in pig sera, 45% in fresh pork in Kamuli district (Musewa et al., 2015). The study reported the prevalence in humans at 9.9% which is lower than the one reported in animals. The prevalence was human African trypanosomiasis was reported at a prevalence of 2.4% in a previous study which is lower than ER infection in humans in Kamuli district, Eastern Uganda. A study by Brhel and Bartnicka (2003) studying occupational infectious diseases in Czech Republic reported a prevalence of 29% of E.rhusiopathiae infection, (erysipeloid) among agriculturalists, forestry workers and game park managers (Brhel and Bartnicka., 2003). The prevalence was higher than the one that was found in this study. This could probably be explained by the fact that the population studied included game park managers, agriculturalists and forestry worker who could be exposed to more than one strain of the bacterium because of the different animals they encounter apart from mammals. The increased incidence of diseases was mostly due to epidemics in the general population, (non-game park managers and 61 agriculturalists) and its spread was attributed to a low hygiene and social standards, overcrowding, increased migration that created a higher risk for the elderly, mentally retarded and immunocomprised subjects (Brhel and Bartnicka 2003). A study by Molin et al (1989) reported an occurrence of 14.5%. This prevalence was reported among abattoir workers in Sweden. Although the prevalence of the infection among abattoir workers was 36.8% is higher than the one reported in Sweden and Czech Republic, the overall prevalence was 9.9% was lower compared to the two studied. This could probably be explained by the involvement of cooks in the study which deflated the prevalence that would have been reported in bucthers and abattoir workers were the only study participants and increased use of antibiotics. A study by Golota (1970), studied E.rhusiopathiae infection in pigs and abattoir workers, reported that 797/1000 abattoir workers were infected with E.rhusiopathiae infection between (1962-1970) in Russia. The incidence of the infection was reported at 25% annually. This study reported a higher prevalence of 79.7% among abattoir workers in the earlier years in Russia because the population of pigs in Russia was high (up to 10 million) pigs, (Golota, 1962). This attracted business for people to work in slaughter houses and abattoirs which activity they conducted without strict regulations pertaining the economic activity. Very many abattoir workers were exposed to the infection because there was no use on protective clothing which would have helped in reducing the spread of the infection. In Uganda literature and systematic reviews (site) show no studies of E. rhusiopathiae infection. This study was done in a setting where the population of pigs is growing with a population of people working in the pig industry growing along the consumers. The prevalence of E. 62 rhusiopathiae infection reported in this study might be an underestimate because of the era of wide use of antibiotics, issues with diagnosis, difficult in isolating the bacteria, because at times it’s mistaken as a contamination on the culture plates and the nature of samples, (blood rather than skin scraps). This would have depicted the true picture of E.rhusiopathiae infection among raw pork handlers. Given that the prevalence of erysipelas in pigs was 67% and 45% infection in fresh pork this would have given an estimated high prevalence in line with the findings in the from the preliminary study. The poor pig rearing methods, poor slaughter abattoirs, lack of protective equipment and poor disposal of waste could be some of the factors that could lead to existence of E.rhusiopathiae infection in the community. This was justified in the key informant interviews and focus group discussions that were held. There are no clear guidelines governing handling raw pork, no trainings established by the government prior to this exposure. Therefore very many people especially the rural people, (un educated), have gone far to slaughter pigs in from any source to sell off to the community due to the increased consumption and demand of pork hence increasing the exposure to the infection to the people in the community. Because of this reason many people have opted to join the butchery business pork hence increasing the exposure to the infection to the people in the community. Therefore it is important to inform the ministries concerned like , (Ministry of Health, Ministry of Agriculture and animal fisheries) and non-government organizations concerned in research in animals and zoonotic infections among populations in contact with animal products and animal waste on how to regulate pig slaughtering at the different slaughter abattoirs and proper handling of animal waste (Government of Uganda, 63 2009). Awareness of Erysipelothrix rhusiopathiae infection in both humans and animals should be done to the Veterinarians, Clinicians and Laboratory personnel to make them familiar with the disease, how it is diagnosed and its natural history. 5.2 Factors associated with E. rhusiopathiae infection among raw pork handlers The type of handler and consumption of alcohol increased the risk of E. rhusiopathiae infection among raw pork handlers in Kamuli district Eastern Uganda. Abattoir workers were 26.13 times more likely to develop the infection while butchers were 8.37 times more likely to develop the infection compared to the consumers. Respondents who reported to consume alcohol were 4.02 times more likely to develop the infection compared to the non-consumers. This could be associated with the increased pork consumption among the alcoholic and the continued exposure to raw pork among the abattoir workers and butchers. These factors have been reported in studies that have done similar work and those that have conducted research on E. rhusiopathiae infection (Upapan, 2015). Infection in man is occupationally related occurring principally as a result of contact with animals, their wastes products , the infection is occupationally related (Upapan, 2015). Risk of human infection is due to factors such as age, sex, race and socio-economic status all relate to this infection (Reboli and Farrar, 1992). It has been reported that 89% of E.rhusiopathiae infection in humans is strongly occupationally among individuals working in animal sourced foods and the highest categories at risk are, veterinarians, housewives, butchers, abattoir workers and animal farm workers (Tomaszuk-Kazberuk et al., 2011). Kichloo reported that alcohol abuse is an important risk factor for E.rhusiopathiae infection (Kichloo et al., 2013b). 64 The study found that males were more likely to develop the E.rhusiopathiae infection compared to females. This was probably due to the occupation nature of the infection. These findings were in line with those that Brooke and Riley (1999) who reported that males were twice as likely to develop E.rhusiopathiae infection and added that this was due to occupational nature of the job (Brooke et al., 1999). Alcohol consumption was reported to be at 55% in Kamuli District among the respondents. The study also found out that men consumed more alcohol (105/155, 67.7%) when you compare them to the women who reported to consume alcohol (60/147, 40.8%). This could probably be explained by the fact that men have social drinking points every evening before and after work. This is in line with the qualitative findings where participants reported men always drink at any time of day as long as they have company. Alcohol is believed to impair some sense of judgment and so the handlers may not use protective wear even when it’s available. This finding is in line with findings from other case studies like Kichloo et al (2013) who reported that the patient under study was a abusing alcohol consumption, that by Romney et al (2001) who reported that alcohol consumption leads to immune compression hence the body can easily be invaded with the bacteria (Romney et al., 2001). The type of raw pork handler was associated with the infection. As the prevalence in the sub groups indicated, the prevalence was 36.8%, 15.3% and 3.4% among abattoir workers, butchers and consumers. Comparing the odds ratio, the study reported that the abattoir workers were 26.13 times likely to develop the infection compared to the consumers while the butchers were 8.37 times likely to develop the infection compared to the consumers. This could be explained by the continous exposure to raw pork, the poor working environment, lack of protective clothing 65 and alcohol consumption that was reported among the participants that is known to weaken the immune system. Sex was reported to confound the relationship between type of handler and E. rhusiopathaie infection. No study has reported sex as a confounder but several studies have reported sex to be associated with E.rhusiopathiae infection due to the nature of the occupation. A study by Pereira et al (2010) reported that the males were highly infected with erysipeloid in his study. He added that males were twice infected compared to the females. He reported that the occupational nature of the infection may have led to that prevalence (Pereira de Godoy et al., 2010). The men are reported to be in close contact with animals compared to the females. Brooke et al (1999) reported that the kind of life style men live predisposes them to this infection. The pork handling (without any protective clothing, no hand washing after handling) practices predispose them to the infection (Brooke et al., 1999). In this study, we found that males who were raw pork handlers were 3.85 times more likely to develop E.rhusiopathiae infection when they are compared to females who are raw pork handlers. Previous studies that have done similar work reported that men are twice more likely to develop the infection when you compare them to the females (Kichloo et al., 2013b). 66 5.2 Strengths of the study The study was done in a rural setting that was mapped and selected due to high population of pigs and high poverty levels (measured by the economic activities conducted in the area and the housing structure) among the population of people rearing pigs and working with other pig related activities like pig agribusinesses and trading. The setting where the study was conducted had the infection confirmed in live pigs (pig sera) and fresh pork that was sampled during the preliminary study in 2014 hence selection bias was minimised Data was collected by trained research assistants who had skills in Lusoga therefore communication was adequate using pretested data collection tools. Phlebotomy was done by a skilled person who had skills in drawing blood. The blood collected was stored in the appropriate anticoagulant tube to prevent it from clotting. The samples were transported appropriate to avoid lysis of cells. While in the laboratory, all reagents were prepared according to the manufacturer’s instructions and stored at the required temperature. As a practice in microbiology to ensure sterility of the equipment the reagents were sterilized at 121oc for 1hour and 15 minutes before use. Calibration was done to the microscope before examining the gram stained slides which was done by a qualified person hence information bias was minimized. Confounding was controlled for at the point of analysis and all confounders were retained in the final model. 67 5.3 Limitations of the study Random Error: This could have been introduced by the sampling procedure. Consecutive sampling was used because there was no sampling frame for pork buyers (consumers) that would have been used for random sampling. Consumers were enrolled consecutively as they came to the butcheries or abattoirs to buy pork of which this was the most appropriate sampling procedure for this study. Random error would also have been come up by the sample size which was used. The calculated sample size was not achieved but the. However the study had enough power to generalize the findings. However I would conclude that random error was minimal. Selection bias: in this study, there was no equal chance of being selected since a non-probability sampling method was used. However a census for butchers and abattoir workers in the three study sub counties was done and consumers were selected demanding on who came to buy pork However this was minimal because the consumers were representative of the community since the butchers and abattoir had different cooks (who bought pork) hence selection bias was minimized. Information bias: This would have been introduced by the data collection tool, (questionnaire) that required participants to address issues that they had to recall for some time which would have introduced recall bias. However this was minimized in the way that the tool was retested on seventeen raw pork handlers in Kampala District and all discrepancies were collected. In the laboratory there was no information bias originating from the instruments used in the laboratory since they were calibrated e.g. microscope. A trained and qualified person observed the bacteria under the study. All reagents used were prepared with working manual and sterilized prior to use. 68 Confounding: the true association of E.rhusiopathiae infection and type of handler was confounded by sex. However this was overcome by controlling for it and reported them in the final model. 69 CHAPTER SIX 6.0 Conclusions and recommendations 6.1 Conclusions The overall prevalence of E. rhusiopathiae infection was low compared to those from previous studies. Abattoir worker and butchers were highly infected with E. rhusiopathiae. Alcohol consumption, working in the abattoir and being male increased the risk of acquiring the infection. 6.2 Recommendations Abattoir workers, butchers and consumers/pork buyers should be sensitized on the risk of being infected with E.rhusiopathiae infection and how to prevent it while carrying on with their duties. Raw pork handlers should avoid working under the influence of alcohol as this would impair their sense for judgment and increase their exposure to E. rhusiopathiae infection. We recommend for further studies to help determine causation since cross sectional studies do not determine causal relationships. 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Golota. (1962). Swine erysipelas and its control in Ukraine. Russia: "Kiev: Gosud. izdatelstvo sel'skokhoz. literatury Ukrainskoi SSR". Government of Uganda, Kamuli district reports. (2009). HIGHER LOCAL GOVERNMENT STATISTICAL ABSTRACT Harrington, R., Jr., & Hulse, D. C. (1971). Comparison of two plating media for the isolation of Erysipelothrix rhusiopathiae from enrichment broth culture. Appl Microbiol, 22(1), 141-142. J. Bille, J. Racourt, and B. Swaminathan. (1999). Listeria, erysipelothrix and kurthia. in Manual of Clinical Microbiology,, 7th edition(American Society for Microbiology Press, Washington, DC, USA), 346–356. Joshi, Suman Kumarl, Singh, Manish Kr, & Sathapathy, Srinivas. (2015). Text book on zoonotic diseases 72 Kichloo, Asim Ahmed, Hallac, Alexander, Mousavi, Ben, & Hirekhan, Omkar. (2013a). Nonspecific Erysipelothrix rhusiopathiae Bacteremia in a Patient with Subclinical Alcoholic Liver Disease. Case Reports in Infectious Diseases, 2013, 474593. doi: 10.1155/2013/474593 Kichloo, Asim Ahmed, Hallac, Alexander, Mousavi, Ben, & Hirekhan, Omkar. (2013b). Nonspecific Erysipelothrix rhusiopathiae Bacteremia in a Patient with Subclinical Alcoholic Liver Disease. Case Reports in Infectious Diseases, 2013, 3. doi: 10.1155/2013/474593 Kish Leslie. (1965). survey sampling. New york: John Wiley and Sons, Inc. Krasagakis, K., Samonis, G., Maniatakis, P., Georgala, S., & Tosca, A. (2006). Bullous erysipelas: clinical presentation, staphylococcal involvement and methicillin resistance. Dermatology, 212(1), 31- 35. doi: 10.1159/000089019 McGinnes, G. F., & Spindle, F. (1934). Erysipeloid Condition Among Workers in a Bone Button Factory Due to the Bacillus of Swine Erysipelas. Am J Public Health Nations Health, 24(1), 32-35. Molin, G., Soderlind, O., Ursing, J., Norrung, V., Ternstrom, A., & Lowenhielm, C. (1989). Occurrence of Erysipelothrix rhusiopathiae on pork and in pig slurry, and the distribution of specific antibodies in abattoir workers. J Appl Bacteriol, 67(4), 347-352. Erysipelothrix rhusiopathiae Bacteremia with Rare Manifestation of Diffused Cutaneous Skin Lesions. J Infect Dis Antimicrob Agents, 28, 59-62. Nicoleta Negrut1, Sonia Draghici1, Mirela Indries1, & GeorgetaCalinescu2. (2010). Erysipeloid- A rare zonoones. Ochola, W.O. 2012. (2012). Report of outcome mapping/site selection workshop,Smallholder Pig Value Chains Development (SPVCD) in Uganda Project. Pereira de Godoy, J. M., Galacini Massari, P., Yoshino Rosinha, M., Marinelli Brandao, R., & Foroni Casas, A. L. (2010). Epidemiological data and comorbidities of 428 patients hospitalized with erysipelas. Angiology, 61(5), 492-494. doi: 10.1177/0003319709351257 Reboli and Farrar, W.E. (1992). The genus Erysipelothrix. In The Prokaryotes: a Handbook on the Biology of Bacteria: Ecophysiology, Isolation, Identification, Application a Handbook on the Biology of Bacteria: (1992), 1629–1642. . Reboli, A C, & Farrar, W E. (1989). Erysipelothrix rhusiopathiae: an occupational pathogen. Clinical Microbiology Reviews, 2(4), 354-359. doi: 10.1128/cmr.2.4.354 Roesel, K., Ouma, E.A., Dione, M.M., Pezo, D., Grace, D. 2014. (2014). Smallholder pig producers and their pork consumption practices in three districts in Uganda. Paper presented at the 6th All Africa Conference on Animal Agriculture, Nairobi, Kenya,. Romney, Marc, Cheung, Stephen, & Montessori, Valentina. (2001). Erysipelothrix rhusiopathiae endocarditis and presumed osteomyelitis. The Canadian Journal of Infectious Diseases, 12(4), 254-256. Shimoji, Yoshihiro, Mori, Yasuyuki, Hyakutake, Koji, Sekizaki, Tsutomu, & Yokomizo, Yuichi. (1998). Use of an Enrichment Broth Cultivation-PCR Combination Assay for Rapid Diagnosis of Swine Erysipelas. Journal of Clinical Microbiology, 36(1), 86-89. Skoknic, A., I. Díaz, S. Urcelay, R. Duarte, O. González. (1981). Estudio de la erisipela en Chile. Arch Med Vet, 13, 13–16. Sneath, P. H., Abbott, J. D., & Cunliffe, A. C. (1951). The bacteriology of erysipeloid. Br Med J, 2(4739), 1063-1066. Taylor, L. H., Latham, S. M., & Woolhouse, M. E. (2001). Risk factors for human disease emergence. Philos Trans R Soc Lond B Biol Sci, 356(1411), 983-989. doi: 10.1098/rstb.2001.0888 73 Tomaszuk-Kazberuk, A., Kaminska, M., Sobkowicz, B., Hirnle, T., Prokop, J., Lewczuk, A., . . . Musial, W. (2011). Infective endocarditis caused by Erysipelothrix rhusiopathiae involving three native valves. Kardiol Pol, 69(8), 827-829. Upapan, P. (2015). Human Erysipelothrix rhusiopathiae Infection: Unsolved Issues and Possible Solutions. J Med Assoc Thai, 98 Suppl 9, S170-176. Wabacha, J. K., Gitau, G. K., Nduhiu, J. M., Thaiya, A. G., Mbithi, P. M., & Munyua, S. J. (1998). An outbreak of urticarial form of swine erysipelas in a medium-scale piggery in Kiambu District, Kenya. J S Afr Vet Assoc, 69(2), 61-63. Wang, Q. (2004). Erysipelothrix rhusiopathiae: epidemiology, virulence factors and neuraminidase studies. PhD Thesis(The University of Western Australia.s). Wang, Q., Chang, B. J., & Riley, T. V. (2010). Erysipelothrix rhusiopathiae. Vet Microbiol, 140(3-4), 405- 417. doi: 10.1016/j.vetmic.2009.08.012 WHO. (2013). Zonooses and communicable diseases common to man and animals. scientific and technical publication. No 580, vol.1(Bacterioses and mycoses), 27-31. Wood, R. L. (1999). Erysipelas. In: Straw, B. E., D ’Allaire S., Mengeling, W. L., and Taylor, D. J. (ed.). Diseases of Swine, Ames, Iowa,(Iowa State University Press), 419-430. Wood, R.L., R. Harrington, D.R. Hubrich. (1981). Serotypes of previously unclassified isolates of Erysipelothrix rhusiopathiae from swine in the United States and Puerto Rico. Am J Vet Res, 42, 1248– 1250. vii Table 10: Participants screening log for Erysipelothrix rhusiopathiae infection among raw pork handlers in Kamuli district Eastern Uganda, 2016. P a rt ic ip a n t ID D a te P A R T IC IP A N T C O D E INCLUSION CRETERIA EXCLUSION CRETERIA E L IG IB L E ( Y E S o r N O ) IN T E R V IE W E R A d u lt R a w p o rk h a n d le rs A d u lt ra w p o rk h a n d le rs (a b a tt o ir w o rk er s, b u tc h er s, a n d co o k s w h o b u y r a w p o r k f ro m t h e b u tc h er ie s) i n N a m w en d w a , K it a y u n jw a a n d B u g u lu m b y a su b co u n ti es d u ri n g th e st u d y p er io d , a n d w h o g iv e w ri tt en i n fo rm ed c o n se n t P a rt ic ip a n ts w h o c o u ld n o t co m p re h en d E n g li sh , L u g a n d a o r L u so g a w er e ex cl u d ed f ro m t h e st u d y . viii Figure 4: A map showing the 18 sub counties in Kamuli district, adapted from the Natural population and housing census, 2007. ix Appendix 1: Questionnaire for butchers and abattoir workers in Kamuli district, Eastern Uganda, 2016. PREVALENCE AND FACTORS ASSOCIATED WITH ERYSIPELOTHRIX RHUSIOPATHIAE AMONG RAW PORK HANDLERS IN KAMULI DISTRICT, EASTERN UGANDA. Questionnaire No: Participant ID: Date of interview:.__/___/___ Sub country: ______________ Parish: _____________ Village: ____________ General instruction: Indicate the response by ticking the box corresponding to the respondent’s response and where there are no boxes; write clearly the response as stated by the respondent SECTION A: SOCIAL DEMOGRAPHIC CHARACTERISTICS Q1. Name of the participant____________ Q2. Age of the participant _____________ Q3. What is your date of birth? __________ Q4. Sex of the respondent (Observe) 1: Male 2: Female Q5. What is your religion? 1: Catholic 2: Anglican 3: Born again 4: Pentecostal 5: Other, (specify) x Q6. What is your marital status? 1: Single 2: Married 4: Separated/Divorced 5: Widowed Q7. What is the highest level of education attained? 1: Never 2: Primary 3: Secondary 4: Tertiary 5: University. SECTION B: EMPLOYMENT HISTORY Q8. For how long have you been on this job, (exposed to raw pork)? __/___/____ Q9. Did you get any training before you started working? 1: Yes 2: No Q10. Where do you get the pigs you slaughter from? 1: Pig farmers 2: Pig traders 3: slaughter abattoir 4: Other, (specify) Q11. Do you engage yourself in any pig related activities? 1: Pig farmer 2: Pig trader 3: Other, (specify) Q12. How many customers do you handle in a day? ________ Q13. Are they mostly females or males (state percentages)? ________ Q14. Do you buy raw/processed pork? __________ Q15. How many people do you work with? __________ Q16. Do you go for any medical check-up?_____________ Q17 Do you wear any protective gears when handling/cutting the pork? 1: Yes 2:No xi Q18. If yes mention them________ 1: gloves 2: gum boots 3: polythene bags 4: Other, (specify) ___ SECTION C: HEALTH SECTION. Q20. When did you last suffer from a skin infection/skin related infection? __/___/____ (dd/mm/yy). Q21. Which signs did you have? 1: Burning 2: Skin rash 3: Wounds 4: Other, (specify) _____ Q22. Did you visit a medical doctor? 1: Yes 2: No Q23. Were you given treatment? 1: Yes 2: No Q24. If yes which treatment were you given? 1: Antibiotics 2: Skin tube 3: Other, (Specify) ___________________ Q25. How far was a medical doctor from your joint? (In km) _______ Q26. Have you ever had any other complications/ sickness? 1: Yes 2: No Q27. If yes mention them_____________ Q28 Do you consume alcohol 1: yes-------------2: No--------------------- Q29. In case your blood results are out would you like to know them? 1: Yes 2: No Q30 In case they are positive will allow taking the intervention given to you.1: Yes 2: No xii Appendix 2: Lusoga translated questionnaire for butchers and abattoir workers in Kamuli district, Eastern Uganda, 2016. PREVALENCE AND FACTORS ASSOCIATED WITH ERYSIPELOTHRIX RHUSIOPATHIAE AMONG RAW PORK HANDLERS IN KAMULI DISTRICT, EASTERN UGANDA. Einamba yolupapula. Endagamuntu. enaku dhomwezi __/___/___ Eigombolola______________ Omuluka_____________ Ekyalo ____________ Iramu ebibuzo ebikubuzibwa nga otakhu katika era nawazira kabbokisi, wandkha ayenga owandi mungeri etegerekakha EKITUNDU EKIGEMA KUKIKULA KYOMUNTU Q1. Amayinago____________ Q2. Emyakha olina emekha?_____________ Q3. Wazalibwa mwakha kii? __________ Q4. Butondhe 1: Male 2: Female Q5. Oli waidiini ki? 1: Mukatuliki 2: Mukulisitayo 3: Musilamu 4: Mulokole 5: Eidhilyonalyona nga otweleku getwogeleku xiii Q6. Olimufumbo? 1:Timufumbo 2: Mufumbo 3:Twayawukana 4:Nnamwandu/ssemwandu Q7. Wasomaku pakha kyakumeka? 1:Tyajakumusomero 2:Mubibina ebyawansi 3: Muhaya 4:Mutendekero elyemikono 5:Mutendekero lyawagulu. EKITUNDU EKIGEMAGANA NE BYAFAYOBYOKUKOLA Q8. Ibanga ki lyomaze mumulimo guno ogwembiidhi? __/___/____ Q9. Wafunaku okutendhekebwa kwona kwona nga okaali kutandiika okukola?)1: Yii Bee Q10. Embiidi dhoosala odhitoola wa? Q11.Nga otweireku okusala embiidi, elina emirimu egyindi gyewenigiramu egyekuusa kumbiidi? 1: Olimwayi wembidhi 2:Olimutunzi wambidhi 3: Bwobanga toyaya ate nga era totunda, waliyo omulimo gwonagwona ogwekulusanya kumbidhi gwokola Q12. Abaguzi balinga bameka bootera okuguza buli lunaku? Q13. Abasinga bakazi oba basaadha? Q14. Otera okugula enyama nga emaze okulongosebwa? xiv Q15. Ennambha yesimu:______________ Q16. Okola naabantu bameka? Q17 .Otera okugyaku yomusawo oba mukalwaliro okukeberebwaku? Q18. Olina kyoyambala kyona kyoona nga olikusala enyama yembiidi?)1: Yii 2: Bee Q19. Bwekiba nga kituufu, biiki ebyo? EKITUNDU EKIGEMAGANA NEBYOBULAMU Q20. Li lwewasembayo okulwala obulwaire bwolususu?__/___/____ (dd/mm/yy). Q21. Buboneroki bwewalina kulususu? 1:Okukyebhwa 2:okubutuka 3: Amabhwa 4:Other, specify Q22. Wagyaku yomusawo yenayeena oba muilwaliro lyonalyoona? 1:Yii 2:Bee Q23. Wawebwa obwidandhabi? 1: Yii 2: Bee Q24. Bwidandhabi ki bwewawebwa? Q25. Buwanvu ki obwaaliwo okuva wokolera okutuuka awaali omusawo? Q26. Waali ofunyeku embeera eyindi eyobutewulira bulungi oba obulwaire obundi bwona bwoona? 1:Yii 2:Bee Q27. Mbeeraki eyo oba bulwaireki obwo? Q28. Singa ebiviire mukukebera omusaayi biba nga bifuluime, walyenze okubitegeera? 1:Yii 2: Bee xv Appendix 3: Questionnaire for cooks/household raw pork handlers in Kamuli district Eastern Uganda, 2016. . PREVALENCE AND FACTORS ASSOCIATED WITH ERYSIPELOTHRIX RHUSIOPATHIAE AMONG RAW PORK HANDLERS IN KAMULI DISTRICT, EASTERN UGANDA. Questionnaire No Participant ID Date of interview __/___/___ Sub county ___________ Parish____________ Village____________ General instruction: Indicate the response by ticking the box corresponding to the respondent’s response and where there are no boxes; write clearly the response as stated by the respondent. SECTION A: SOCIO-DEMOGRAPHIC CHARACTERISTICS Q1. What is your name? ____________ Q2. How old are you/? _____________ Q3. What is your date of birth? ____/___/___ (dd/mm/yy) Q4. Gender (observe). 1: Male 2: Female Q5What is your religion? 1: Catholic 2: Anglican 3: Muslim 4: Born Again 5: Other, (specify) ______________ Q6. What is your highest level of education? 1: Never 2: Primary xvi 3: Secondary 4: Tertiary 5: University Q7. How many children do you have? ___________ Q8. Are you responsible for buying pork for the home? . 1: Yes 2: No Q9. If no who else prepares the raw pork? (Specify) ___________ Q10. How many times do you prepare raw pork at home? 1: Daily 2: Weekly 3: Monthly 4: Other, (specify)._________ Q11. Do you put on any protective gears when handling the raw pork? 1: Yes 2:No Q12. If yes mention, 1: Gloves 2: Polythene bags 3: Other, (specify) SECTION B: HEALTH SECTION Q13. Do you keep pigs? 1: Yes 2: No Q14 Have you suffered from any skin infection before? 1: Yes 2: No Q15 Which signs did it have? 1: Burning 2: Skin rashes 3: Wounds 4: Other, (specify)_______ Q16. Did you visit a doctor? 1: Yes 2: No Q17. Were you given any medication? 1: Yes 2: No Q18. Which medication were you given? 1: Antibiotics 2: Skin tube 3: Other, (specify)_____________ xvii Q19. How far is the medical personal from your place of residence? (Km) ______ Q20 Do you consume alcohol: 1: yes--------- 2:------------ Q21. In case the test results are out would you like to know them? 1: Yes 2: No Q22. If found positive would you accept the intervention given to you? 1: Yes 2:No Contact number: _____________________ xviii Appendix 4: Lusoga translated questionnaire for cooks/household raw pork handlers in Kamuli district, Eastern Uganda, 2016. PREVALENCE AND FACTORS ASSOCIATED WITH ERYSIPELOTHRIX RHUSIOPATHIAE AMONG RAW PORK HANDLERS IN KAMULI DISTRICT, EASTERN UGANDA. Enamba yolupapula endagamuntu Enaku dhomwezi __/___/___ Eigombolola___________ Omulukha)____________ ekyalo____________ Iramu ebibuzo ebikubuzibwa nga otakhu katika era nawazira kabbokisi, wandkha ayenga owandi mungeri etegerekakha EKITUNDU EKIGEMA KUKIKULA KYOMUNTU Q1. Eliinalyo niwe aani?___________________ Q2. Olina emyaka emeka?__________________ Q3. Wazalibwaalibwaddi ____/___/___ (dd/mm/yy) Q4. Ekikula 1: Mukyala 2: Musadha Q5. Oli waidini ki 1:Mukatulikki 2: Mukulisitayo 3:Mulokole 4:Ediini eyindi Q6. Wasomaku kyenkana ki? 1: Tyasomako 2: Mubibina ebyawansi 3: Muhaya 4:Mutendereko elyemikono 5: Munivasite xix Q7. Olina abaana bameka? Q8 .Niwe avunanizibwaaku okugula enyama yenbiidhi wano waka? 1:Yii / 2:Bee Q9. Bwekiba nga tiniiwe, ani afumba enyama eyo embisi? Q10. Milundi emeka gyofumba enyama yembiidhi waka wano? 1: Bulilunaku 2: Buliwikhi 3: Bulimhwezi 4: Kiseraki ekindi Q11. Olina byoyambala ogolikutekateka nokufumba eyama yembiidhi? Q12. Bwekiba nga kituufu, biki ebyo byoyambala? KITUNDU EKYOGERA KUBULAMU BWEMMILO Q13. Olunda embiidi? 1:Yii / 2:Bee Q14. Olina byoyambala nga olikutemateema enyama yembiidi? 1:Yii 2: Bee Q15. Bwekiba nga kituufu, biki ebyo byoyambala? Q16. Wali olwaileku obulwaile bwolususu bwonabwona? 1:Yii 2:Bee Q17. Buboneroki obwaali kulususu lwo? 1: Okwokyelela kwolususu 2: Amagondyo 3: Amabwa 4: Ekhindhi nga otweleku ebyo byetwgeileki Q18. Wagyaku yomusawo yenayeena oba mukalwaliro koonakoona? 1:Yii / 2: Bee Q19. Wawebwaku obwidhandhabi bwona bwoona? 1:Yii 2: Bee xx Q20. Bwidhandhabi ki bwewaweebwa? ___________________ Q21. Waliwo buwanvu ki okuva wano waka okutuuka awali omusawo oba akalwalilo? ______ Q22. Singa ebiviire mukukeberebwa biba nga bifulwiime, walyenze okubimanha? 1:Yii 2:Bee Q23. Singa oyaganibwa nga olina akawuuka, waaliikiriza obuyambi obukuweebwa? 1: Yii 2:Bee Enambha yesimu _____________________ xxi Appendix 5: Informed consent form for the prevalence and factors associated with ER infection among raw pork handlers in Kamuli district, Eastern Uganda. MAKERERE UNIVERSITY COLLEGE OF HEALTH SCIENCES Title: PREVALENCE AND FACTORS ASSOCIATED WITH ERYSIPELOTHRIX RHUSIOPATHIAE AMONG RAW PORK HANDLERS IN KAMULI DISTRICT, EASTERN UGANDA. PRINCIPAL INVESTIGATOR Musewa Angella. BBLT, Makerere University, Kampala Uganda Telephone: +256-702-422-679 BACKGROUND AND RATIONALE FOR THE STUDY As part of our research under the “Safe food fair food project” coordinated by the International Livestock Research Institute (ILRI), we are planning to conduct research on Erysipelothrix rhusiopathiae infection among raw pork handlers. The infection was reported by pig farmers, Diamond skin disease, (Okumyuka) Namwendwa, Kitayunjwa and Bugulumbya sub counties. Pigs, (450) were sampled and 100 fresh pork samples and preliminary results showed a prevalence of 67% of Erysipelothrix rhusiopathiae in pigs and the bacteria was isolated in 45 of the 100 pork samples. STUDY PURPOSE xxii We are interested in finding out whether the infection exists among raw pork handlers (butchers, cooks, abattoir workers and veterinarians). This study is aiming at identifying the prevalence and factors associated with Erysipelothrix rhusiopathiae among raw pork handlers in Kamuli District. Therefore you are requested to be part of the study because you are a raw pork handler hence at an increased risk of acquiring the infection. The study will involve collection of blood from the vein, taking it to the laboratory and culturing the blood to isolate and identify the bacteria. PROCEDURES On agreeing to participate in the study, venous blood (3ml) will be collected using a new sterile needle and syringe, the procedure isn’t painful and won’t cause and infections. The blood will be kept in Kamuli hospital during the data collection time, and then transported to the College of Veterinary Medicine Animal Resources and Biosecurity, Microbiology laboratory for analysis. You are required to answer a few questions and provide a blood sample. The interviews will focus on work history of the participant, pork eating habits, pig related activities, health concerns, economic status and demographic factors of the participants. All the information will be every confidential. The results from this blood will be reported confidentially to you, all those who will be found positive with the disease will be assisted to seek treatment immediately the results are out. PARTICIPANTS The participants will include all butchers and abattoir workers in Namwendwa, Kitayunjwa and Bugulumbya sub counties. Cooks who buy raw pork from the butcheries will be included. Six xxiii participants from each of the butcheries will be included. A total of sixty seven butchers and abattoir workers will be studied and 300 cooks. The questionnaire will take 15 minutes and the blood collection will take 5 minutes. Therefore each participant will spend 20 minutes actively in the study. RISKS AND BENEFITS No advance risks will be posed to your life if i take off the blood sample because the procedure isn’t painful and all the equipment used will be new. After sample analysis every participant will know his/her status on E. rhusiopathiae infection. All butchers and abattoir workers will be provided with protective gears like gumboots, gloves, Jik, soap, jerry can to be used to improve, the other participants will receive gloves, Jik and a bar of soap. The research will benefit the scientific community on publication of the finding in a peer reviewed journal and the knowledge gained from the study finding will be used to inform policy about the infection and develop possible interventions to control the infection. CONFIDENTIALITY The results of this study will be kept strictly confidential and used only for research purposes. The identity will be concealed in as far as the law allows. Your name may appear on the forms for purposes of tracing the results but won’t be used in reporting and discussing results. Paper and computer records will be kept under the lock and key with password protection respectively. COSTS AND COMPENSATION OF PARTICIPANTS IN THE STUDY The costs of the procedure and the culture of the bacteria will be met by the Safe food fair food project. The medical bills for the participants who will be found infected with Erysipelothrix xxiv Rhusiopathiae will also be covered by the research project. There will be no direct compensation to the participants. REIMBURSEMENT All the costs for transport will be met by the project. The participants will be interviewed and sampled from their place of work/ as they come in to buy raw pork. QUESTIONS Participants who have study related questions will contact the investigators or the veterinary and community health care workers. QUESTIONS ABOUT PARTICIPANT’S RIGHTS All research participants have equal rights to ask about the ask and the investigator will address them. STATEMENT OF VOLUNTARINESS Participation in the proposed study is voluntary and participants may join on their own free will. Participants also have a right to withdraw from the study at any time without penalty. The interviewer has discussed all the above information with me and offered to answer my questions. For any questions regarding the study, contact Musewa Angella, on Tel: +256702- 422-679. STATEMENT OF CONSENT xxv I have been briefed about the study and i know what is going to be done, i know that the blood will only be used to check for organisms that affect humans from pigs. The process isn’t painful and will take a very short time. The study will benefit me in knowing my status regarding swine erysipelas. After this i will trained on the hygienic practices and look after myself while handling raw pork. I have had an opportunity to ask the ILRI field worker who explained the study to me and answers to any questions that i had about the study. I agree to join the study. Name_________________________ Signature_______________ ID______________ Village name______________ Sub county____________ District__________ Tel (if available) ________________ Witnessed by________________ Title_____________ I______________ Confirm that I have explained the nature of the study to__________ as set out in the study protocols, that s/he understood what I said and had an opportunity to ask questions and freely gave his/her consent for him/her to join the study. Name of the field worker __________________ Signature ________________________ Date _____________________ xxvi Appendix 6: Translated informed consent form for prevalence and factors associated with ER infection among RPH in Kamuli district, Eastern Uganda. PREVALENCE AND FACTORS ASSOCIATED WITH AMONG RAW PORK HANDLERS IN KAMULI DISTRICT, EASTERN UGANDA. SCHOOL OF MEDICINE, COLLEGE OF HEALTH SCIENCES OMUTWE Prevalence and factors associated with Erysipelothrix rhusiopathiae among raw pork handlers in Kamuli District, Eastern Uganda. OMUNONEREZZA OMUKULU Musewa Angella. BBLT, Makerere University, Kampala Telephone: +256-702-422-679 EKINUSI KYOMUSOMO OBA ENSONGA OKUNONONKEREZA Bamukagwa ensonga lwaki tulikola okunononenkera kudwaile yo kumyuka ,twendha tumane oba ekosa abantu abakola emirimu egyekusa mukulabirira ensolo dhaiffe magulu mampi.(nga banaiffe abalokola mubukya,maama abalabirira embidhi dhaffe,ababazi,na basawo abebisoro).Era nga ebinaba biviyile mukunononkereza kuno,tudha bitwalira abasawo abekitongole ekikola kubyobulamu,bigye nimumalwaliro gano agayiffe agabulido nibanayiffe abandhi betukola naboo omulimo guna tusobole okusalalira walala amagegezi engeri gyetusobola okwetangire endwaire eno.obwoniawo,tulete emisomo egyogera kungeri gyokuba xxvii nemere enkalamu era etagemebwa bulwayi,tubasomese obuyondo,tubagabire gilavu okusobola okwerinda endyaiye eno.era bino byakugabibwa eli’abantu abanaba benigire mumusomo guno. ENGERI OMUSOMO GYEGUJA OKUKOLEBWAMU Eri abo abanaba bayikiriza okwegayita omusomo guno,tugyabatolaku omusayi nga tukozesa empiso era nga empiso eno teluma atenga buli muntu adha kuba nempiso ye.omusayi ongunaba gubatoleyibwaku gwidhasokha gutelekhebwe mwidwaliro ekamuli era eyogyegunava gutwalibwe e Makerere okwongera okwekebedhebwa.omusayi guno bwegunabanga gumaze okwekebedhebwa,twidakwira tubakobele ebinabanga biviyiremu mumusayi ayenga bino bidha kubabyakyama era abantu betunayaganamu bobuwlayire O’ bwo kumyuka, twidha kubalagirira gyebanasobola okuyambibwa mungeri yobwidhandhabi.Iffe abayikiriza okwegayita omumusomo guno,tugyakubuzibwayo obubuzo buto obugemagana kungeri,kumpisa edhabantu nga balya embidhi,mirimoki gyemukola egyekayita mukulabilila embidhi,ebwobulamu,ebyenfuna byaffe enebindhi.Era tubasubiza era nga tweyama nti bulikyetunayogeraku,kigyakumibwa nga kyama. EMIGANULWO Emilundi egiisinga tutera okubuza nti yetugyaffunira wa,no kyo kibuzo,twayindgye ngatulibetegefu okukiramu tuti,iffe abagya okwetaba omusomo guno,tugya kutegera engiri obulamu bwaffe bwebwemerire mungeri yakawukano aka Erysipelothrix rhusiopathiae,tugyakubagabilayo,kubintu nga,butusi,gilavu,jiki,sabuni no budomola okwongera okutumbula ebyobuyondho era muli-muntu,agyakuvawano neyituu OKWEKENGERA xxviii Wazira kabenje konako akagye okutuka obantu abanaba batoleyibwaku omusayi xxix IDHEMBE OKWIKIRIZA OBA OBUTAYIKIRIZA Iffe twenatwena abaliwano,tulina idhembe lyo kwikiriza okwetababa omumusomo guno oba obutayikiriza EKYAMA EKIKUSIKUFU Tusubiza nti ebinavu omukononenkereza kuno,biligya kukumibwa nga bwakyama,era amayina gayimwe,tigagya kubonekera kuwantuntuwonawona,okutolaku kumpapula detugya okwiduuza nimwe okusobola okwawula singa wanabawo alina obulwayire buno. Empapula,kabwidhibwidhi,nebintu ebindhi byetugya okukozesa togye bikumila mubiffobyetwekakasa nti ezira agyakubitukaku. Era bisingawo,musobola okwogera ni Musewa Angella, nga mubita kunamba eno Tel: +256702- 422-679. OBUKAKAFU NTI OKHIRIZA OKUKOLA NIFFE Ndikiriza nti nsomesebwa,kubigegagana no musomo guno,era ntegere ekigya mumayiso,era nti nomusayi ogugya okuntolebwaku gwakukebera obuwuka obukosa embidi era nabantu.ntegere nti okutolaku omusayi tibiluma era nga kitwala akasera katono.Era nga maze okutolebwaku omusayi,ngya kusomesebwa kungeri gyokukumamu obuyondo era nengeri gyesobala okwelabirira nga ngemaku mamba yembidhi. Ndi mwetegefu okwegayita mumusomo Nkiziraku buzibu omunonenkereza okukobera abantu amayina gange) Tyendha omunonenkereza kwogera mayina gange eri abantu) xxx Emperrebwa omukisa okubuza omunonenkereza ebigemagana nomusomo guna era yandiramu nebibuzo byonabyona byembayire nabyo) Ndhi kiriza okwegayita on omusomo/okunonenkereza kuno. Amayina_________________ Ekinkumu_______________ Endhaga muntu______________ Ekyalo______________ Eigombolola____________ Disitukuti__________ E’namba yesimu________________ Abailewo________________ Title_____________ Nze______________ nkakasa nti ninongoile bulungi kubigemagana nokunonenkereza kwetuligya okola __________ mumitendara emitufu,era nga omwami/omukyala o’no ategheire ekinusi kyokunonenkereza kuno,era yambuza nebibuzo era nabiramu,nti era omwami/omukyala akiriza nga tawalirizabwa okwegaita okunononkereza. kuno. Amayina gomukubiriza__________________ Ekinkumu________________________ Enakudho mwezii_____________________ xxxi Appendix 7: Oral consent form for the focus group discussions INTRODUCTION The consent form is to be administered by an interviewer on the research team. Only those participants who consent to participate in the study will be included. TITLE OF THE STUDY Prevalence and factors associated with Erysipelothrix rhusiopathiae among raw pork handlers in Kamuli District, Eastern Uganda. Principal investigator: Musewa Angella, BBLT Makerere University Kampala, postgraduate student, College of Health sciences. PURPOSE OF THE STUDY The study is aim of this focus group discussion is to describe the social cultural factors influencing Erysipelothrix rhusiopathiae infection among raw pork handlers in Kamuli District. STUDY PROCEDURE You as the participant will take part in the focus group discussion. RISKS AND BENEFITS There are no direct risks the study results to promote best bet interventions for this zoonotic disease and best preventive methods. xxxii COSTS AND COMPENSATION There was no direct payment for you to participate in the study. A drink and a snack were provided to FGD participants and a transport refund of 5000. CONFIDENTIALITY Whoever accepted to join the study, all records were kept confidential. Your name will not appear on the study documents transcribed from the tapes even on the tapes. Your name will not appear anywhere in the publications. ALTERNATIVES TO THE PARTICIPATION If you have never a focus group discussion before you can be excused, some of the questions may make you feel shy but feel free if you can’t respond to them. Cultural affiliation will be discussed most here feel free to participate or not to participate; you have a right not to answer questions you do not want. You may decide not to be part of the study and there will be no problem. PROBLEMS AND QUESTIONS If you have any questions you can contact the principal investigator Musewa Angella on phone +256702-422-679, or the international livestock research institute on +256 392 081154 or the Clinical epidemiology unit - Makerere University on +25641530022/3. Further information about the research participant’s right you can contact School of Medicine, research and ethics committee. xxxiii PARTICIPANT’S CONSENT I have understood all that has been explained to me about this study and accept to participate in this study. I voluntarily agree to be part/ participate in the study. A copy of this consent will be provided to me _______________________ ______________ __________________ Name of the participant/thumb print signature Date _________________________ _____________________ ___________________ Name of moderator signature Date and time xxxiv Appendix 8: Translated oral consent form for the participants ENANJULA Ebaaluwa eno elaga nti okhiriza okubuzibwa,ejakwidhulizibwa nomu kubantu abava kutimu yaffe. OMUTWE GWOMUSOMO Twendha okumanya obulyayile buno busasane buwanvuki era nsonga kii edhivaku obulwayire buno okugema abantu abagema kunyama yembidhi embissi. Okulembeyire ekunsukino ekyokunonereza nomukyala, Musewa Angella, omuyizi mu Makerere University Kampala,mutendekero lyabasawo.eranga anonerezaku kawuka akareta okumyukamu bakolamumbiddi. Omunonerezza omukulu: Musewa Angella, BLT Makerere University Kampala. EBIGENDELELWA BYOKUNONENKEREZA Okunonenkereza kuno,kugendele okulingirira nsongaki edhivireku obulwayire bwo kumyuka era kino tuligya kukilkola nga tuta abantu mububinja obwendhalwo kitusobozese okukuba ebilowozo ebyawalala nga twogera kubulombolombo byaffe,emisoso byaffe,byetwikiriza nga basoga era nebyo byetutayikiilizamu. ENGIRI OKUNONENKELENZA BWEKUJA OKUKOLEBWAMU Imwe abatebye on kunonenkereza kuno,ojyatebwa omgulupu edhendhawolo tusobole okukubagannya ebilowozo kunsonga ghetwogeyireku waigulu. xxxv OKWEKENGERA OBA AMIGANOLWO Wazila buzibu bwonabwo obujja okututukaku, wabula okunonenkereza ogendelerwamu, kkungeriki gyetusobola okutangira okumalawo, obulwaire obuema abantu ne bisoloera nga wano,tulikwogera kumbighi ENSANSANYA Tituligya kubasasula,aye tulinayo akokulya na kokunnya ketuligya okubawayo era nga bwetunabanga tumaliriza,tujyabawa entambula ebaiyayo e’wakka. EKYAMA EKIKUSIKUFU Tusubiza nti ebinavu omukononenkereza kuno,biligya kukumibwa nga bwakyama,era amayina gayimwe,tigagya kubonekera kuwantuntuwonawona,okutolaku kumpapula detugya okwiduuza nimwe okusobola okwawula singa wanabawo alina obulwayire buno. Empapula,kabwidhibwidhi,nebintu ebindhi byetugya okukozesa togye bikumila mubiffobyetwekakasa nti ezira agyakubitukaku. ENGERI GYOKUKUBAGANYAMU EBILOWOZO Tuligya kwogera kumisoso gyaiffe,okubulombolombo,era nga tubasaba nti muwulile emirembe ngatukubagannya ebilowozo.Bwobanga nga toidhi kyakwiramu obanga toyendha kwramu.osobala okusirika.ayenga kyetusinga okwendha,kyakubanga bulimuntu kwiffe abakunikyayogera. xxxvi Ebibuzo oba omutawana gwonagwona Bwewabanga waliwo ebibuzo byonabyona,osobala okukubia omukyala Musewa Angella ku nambha eno +256702-422-679,oba wagya okukitongole kya International Livestock Resaerch Institute oba e’mulago gyebakola kunsonga dokunonereza. Bwoba nekibuzo ekigemagana nomusomo guno buzza. Musewa Angella ku+256702-422-679, or Etendekerolyabasawo ku……………. Ndikiiriza nga tibankase Nze ntegeyire ebininongolebwa kubigemagana onukunonenkereza kuno,era ndikiiriza okukwetabamu nga tikakhibwa wabula nga nkyeyendgele. _______________ ______________ __________________ Amayinago Ekinkumu Enakuo dhomwezi _________________________ _____________________ ___________________ Amayina ogomukubiriza Ekinkumu Enaku dhomwezi xxxvii Appendix 9: Focus group discussion topic guide Date__/___/____ Moderator____________________ Recorder_____________________ Language____________________ Time: Start _________________ End ______________ Good morning/afternoon You are welcome to my discussion. My name is__________________________ and my colleague (recorder) is______________________ Our team is from Medical school, Makerere University and we would like to discuss the social cultural factors influencing Erysipelothrix rhusiopathiae infection among raw pork handlers in Kamuli District, Eastern Uganda. We want to collect information from you about our study of the diamond skin disease among raw pork handlers among abattoir workers, butchers and house wives. I also have a tape a recorder to help us remember about what we shall have discussed about. May I use it? (Moderator asks consent). Thank you very much In order to discuss easily, allow me pin your name on your shirts, I will also do the same (one name only). 1. Studies conducted show that 67% of the pigs in Kamuli carry swine erysipelas and 45% of the fresh pork samples are also carrying the bacteria. Do you think there are some factors associated with this? xxxviii 2. Are there any factors/ reasons why this particular disease was reported in only your sub county? 3. Do you raw pork handlers have a way of living (life) that they practice that predisposes them to the infection? 4. Most of us are Basoga, (biggest percentage) are there cultural beliefs, norms or practices that may predispose us to the infection we get when we handle raw pork. xxxix Appendix 10: Translated focus group discussion guide Enaku dhomwezzi __/___/___ Omukubiriza________________ Agema amalobozi_______________ Olulimi______________ Sawa dhotandikireku _________________ Sawa dhomalileku ______________ Bassebo/banyabo mwasuze mutya oba musibye mutya Tubaniriza mumusomo guno ogwalelo gwetuligye okukubaganizamu ebilowozo Amayina ………………………………………….era nga ndiwano nimunange ono…………… Iffe tuli basawo okuva Makerere university era nga twindye wano olwalelo okukubaganiza walala ebilowo kunsonga edigemagana nekikula ekyomuntu edhileta obulwayire bwo bwokumyuka eri abantu abatera okugema kumamba yembidhi mukamuli mu.iffe tituva mubitongole ebivunanizibwa kumbidhi mu-uganda nti tulikwendha kubatolaku bilowozo byamwe tusobole okuwaandika obutabo obatikyindhi bizinense dhamwe okwigala lwo.aya ekilubilwa kyaffe nikyetwayogeraku.Wano wendi,ninawo,kano akabanzungu akagema amalobozi okusobala okunambako okwidhukira bulikye tujja okwogeraku.nga era byenabakobye mukusoka. Mwebale okumpuliriza. Mbayire nsaba nti amayina gamwe kanga timbe kutisati kitusobozese okumanagana bwetunaba tutandise okukubaganya ebilowozo era nga tugyakozesa amayina gayiffe agendini. xl Mukunonenkereza okwakolebwa,kilaga nti 67% embidhi dhe Kamuli dhilina swine erysipelas and 45% emamba yembidhi gye twatolanga nga kubukya erimu akawuka kano.imwe mukulowoza kwaimwe mulowza nti eriyo ensonga edhekusa kunsonga eno? Imwe mulowaza nti eriyo ensonga lwaki a kawuka kano kazulibwa mwigombolola lyamwe? Mulowaza nti banayiffe bano abatema enyama balina obupisa oba ebintu byebakola ebisobola okubaviraku okufuna obuwuka buno? Abasing kwiffe tuli basoga,tibwekili bana,aye bwe mulingirira obulombolo byayiffe era ne misoso gyeiffe imwe mulowoza nti,eriyo ebintu byetukola etuviraku of kuna obuwuka buno mungeri gyetugemamu enyayembidhi embissi. Bassebo/banyabo mwasuze mutya oba musibye mutya Tubaniriza mu kuteesakuno. Nze __________________________ Nagema amalobozi ye ______________________. Iffe tuli basawo okuva Makerere university era nga twindye wano olwalelo okukubaganiza walala ebilowozo kunsonga edigemagana nubulwaile bwembiddi, (Okumyuka) mubakolamumbiddi, (abatinjaji, abatemi nabafumba embiddi) mu Kamuli District. Mwebaleyino Mukutessa kuno tugenda kwewndikako elina limu kituyambe mukumanagana. 1.Okunonere okwakorebwa kwasanga obulwaire bwokumyukka mumbi (67%) mu Kamuli ne mumamba yembindi (45%) . Mulowozza waliwo ensonga ezigemagana nakino. 1.Mulowoza waliwo ensonga lwaki obulwaire obuvamundi bulimugombola yamwe. xli 3. Mulowozza abantu abagema kunyamayembiddi balina obulamu obwendamulo obubalobera okufuna obulwaire okuvamumbiddi. 4.Abasinga muffe tuli Basoga. Tiniko. Muwolozza waliwo obulombolombo nenono ebigemagana nokufuna akawuka bwetukwata munyayembiddi embissi. xlii Appendix 11: Key informant interview guide INTRODUCTION My name is Angella Musewa from Medical School, Makerere University. Together with my team, we are determining the prevalence and factors associated with Erysipelothrix rhusiopathiae among raw pork handlers in Kamuli District, Eastern Uganda. Results from this study will be treated as confidential and only used for research purposes. 1. What is your profession? 2. For how long have you been on this job and in this sub county? 3. Have you ever had of Erysipelothrix rhusiopathiae infection in humans, (diamond skin disease)? 4. Could there be any factors related to culture that influence infection transmitted from pigs to humans. 5. Why are infections from pigs to humans are rising? 6. How do you prevent these infections? 7. Are there any mechanisms put forward to protect humans from acquiring these infection, if yes which ones have been put. 8. If not what can be done. xliii Appendix 12: Translated key informant interview guide ENANJULA Amayina gange ninze musewa okuva e’makerere university medical school,nze nibange twendha okumanna ngeri ne ensonga edivaku okusansanya obulwayire obuno obwo kumyuka eri abantu ebagema kumamba ye mbidhi embissi mukamuli disutikiti,mubuvanduba bwa Uganda.era ebinava mukunonenkereza kuno,bigyakumibwa nga byakyama. 1. Wakuguka mukhi? 2. Omaze ibanga khi nga okola obulimo guno mwi gombolola lino? 3. Wali owulileku kubulwayire bwo kumyuka obugema abantu oba okumyuka 4. Olowoza nti waliwo ensonga edho buwangwa edhivilileku obulwayire buno okuva mumbidhi okwilakubantu 5. Iwe olowoza kwaki obulwayle buno bweyongere okuvu mumbidhi mukugema abantu? 6. Olowoza nti tusobola tutya okwewala obulyayile buno? 7. Waliwo amagezi oba engeri yonayona etelebwawo okusobala okutangira abantu obutafuna ndwayileno,era bwewabaga wali,engeri khi’edho? 8. Bwewabanga wazila,iwe olowoza khikii ekhiba kikolebwa?