Uganda takes strides in handling epidemics

Although Uganda has faced many epidemics in which many lives have been lost, the country is finding ways of dealing with current ones and also taking measures to prevent any others that may strike, Chris Kiwawulo reports

At one time or another, in the last 50 years or so, Uganda has faced a number of epidemics namely leprosy, plague, cholera, meningitis, Ebola, Marburg fever, Polio, Hepatitis E and lately the nodding disease, which claimed hundreds of lives. 

But, because the outbreaks were new and the causes unknown, many associated them with witchcraft. Instead of seeking medical help, many opted for traditional healers’ services. 

Medical experts explain that it was this ignorance, absence of cure and lack of facilities to handle these epidemics that allowed easy spread of cholera, plague and leprosy, yet these diseases are preventable and treatable.

Dr. Bildard Baguma, the undersecretary general of the Uganda Red Cross Society (URCS), said they have participated in the handling of cholera, meningitis, Ebola, Marburg fever, Polio and Hepatitis E outbreaks in the country.

He said URCS usually works with the Ministry of Health and hospitals in carrying out mobilisation and sensitisation of the communities, surveillance and early detection to ensure that epidemics are quickly contained.

“Cholera is the commonest outbreak, with at least two to three outbreaks in different parts of the country every year,” Baguma says. He adds that since 1999, they have been providing kits to health personnel to help in treatment of victims.

To contain epidemics, Baguma called for the strengthening of the surveillance network, especially at the community level, and empowering of village health teams as a priority.

But Dr. Asuman Lukwago, the health ministry permanent secretary, says they have a surveillance unit that moves around the country on a daily basis for early detection of any epidemic.

Lukwago also revealed that they have embarked on regular sensitisation of communities since some epidemics such as cholera arise from lifestyles and hygiene, and commonly occur in crowded places with poor sanitation like refugee camps and slums.

“We advise people to maintain hygiene to avoid cholera. When epidemics like Ebola or Marburg fever break out, we advise people to avoid hunting because these diseases are spread through contact with infected animals. 

But because we cannot force people to comply, we usually work with the local leadership to ensure people have toilets for proper disposal of human waste, and with Uganda Wildlife Authority to stop hunting,” he explained.

Lukwago assured Ugandans that they have the capacity to handle any outbreak, adding that; “We usually mobilise resources from our emergency budget and set up camps where we isolate and treat victims. Our only problem is lack of capacity to stop transmission from the source (changing people’s lifestyles).”

He said the health ministry has over time worked with international bodies like the World Health Organisation (WHO) and US Centres for Disease Control (CDC) to coordinate international assistance to respond to the outbreaks.

In June this year, the CDC, together with the Uganda Virus Research Institute, opened up a facility that supports identification of the world’s deadliest pathogens like Ebola and Marburg after renovating it in Entebbe.

The refurbished laboratory now has state-of-the-art equipment for rapid diagnosis of viral diseases associated with haemorrhagic fevers.

CDC has supported numerous outbreak investigations, including Ebola, Marburg fever, Botulism, anthrax, and typhoid, as well as the ongoing investigation into nodding syndrome. “Rapid diagnostic capacity is the foundation of successful disease surveillance programmes. 

A containment laboratory such as this allows CDC to identify the emergence of these dangerous viruses. It also allows them to make appropriate recommendations to the Ministry of Health on how to effectively implement public health programmes to reduce the spread,” a statement issued by the US embassy recently read.

Cholera
According to the international federation of Red Cross and Red Crescent societies, the first cholera epidemic was reported in Uganda in 1979. In the history of the epidemic, 1998 remains the year when the biggest outbreak was recorded, with over 30,000 cases detected in almost all districts of Uganda.

The most recent outbreak was reported in July this year with an influx of refugees from DR Congo to western Uganda, although no death has been recorded yet.

Cholera is an acute infectious disease characterised by watery diarrhoea and vomiting. It largely spreads through eating and drinking foods contaminated with faeces of an infected person.

Polio
Polio is a viral disease that spreads through the oral route and cripples the nervous system permanently. Symptoms of polio include a stiff neck and limbs, fever and vomiting. The polio vaccine is administered orally.

There is no documentation about how many of the seven million Ugandans had polio by independence in 1962. Following the arrival of a study team from the World Health Organisation (WHO) in 1969, the Uganda Virus Research Institute (UVRI) received enhanced status as a fully-fledged virus research laboratory capable of handling viral diseases deemed to be of public health significance like polio.

During subsequent years, extensive and valuable data on entero-andrespiratory viruses and the efficacy of vaccination with oral polio virus vaccine and measles vaccine were accumulated. In 1977, when the East African Community collapsed, UVRI deteriorated as international support was stopped.

The Institute suffered adversely with damaging repercussions in its infrastructure, research policy direction and personnel. Cases of polio were rampant by the time. 

But President Yoweri Museveni launched a campaign with mass mobilisation and immunisation to kick polio out of Uganda. He was supported by WHO, United Nations’ Children’s Fund (UNICEF) and the United States Agency for International Development.

Although the campaign met some resistance with politicians branding it as a ploy to kill Ugandan children, it later turned out successful. By 1996, Uganda had been declared polio-free until the 2009 outbreak, where eight cases were reported. In August 2010, Uganda was again declared polio-free.

But in October 2010, a polio case was detected in the Bugiri district, according to the Ministry of Health, WHO and UNICEF. The case led to a countrywide immunisation campaign drive against the viral infection.

The exercise was specifically targeting over two million children up to the age of five in 48 high risk districts in east, north eastern and northern Uganda.

Marburg and Ebola fevers
The two are viral haemorrhagic fevers. In 2007, Marburg was confirmed in a 29-year-old man who was working at Kitaka gold mine in western Uganda. He died 10 days after admission. Marburg was confirmed by laboratory diagnosis on July 30 and 40 people were confirmed infected.

Marburg is a fast-spreading haemorrhagic fever like Ebola. According to WHO, Marburg was first identified in 1967 in Marburg and Frankfurt in Germany. It was also identified in Belgrade in the former Yugoslavia from importation of infected monkeys from Uganda.

Ebola, on the other hand, was first reported in Gulu, Masindi and Mbarara districts of Uganda in 2000, and by 2001 at least 425 people were infected. Many health workers in Gulu, including Dr.Matthew Lukwiya, of St. Mary’s Hospital Lacor in Gulu, succumbed to Ebola, which they contracted in the course of their duty.

Ebola was again reported in Bundibugyo in 2007 and in Luwero in 2011, where the deaths tested positive to the epidemic. Marburg and Ebola are severe and highlyfatal diseases caused by a virus from the same family. These viruses are among the most virulent pathogens known to infect humans. 

Both diseases are rare, but have a capacity to cause dramatic outbreaks with high fatality rate. Transmission occurs by contact with infected wild animals (monkeys, fruit bats) or people. The predominant treatment is general supportive therapy.

How health inspectors helped
Phillipo Rwabuganzi, an elder in Bushenyi district, says in the 1960s, the community, administrative and health systems were alive and active. There were vigilant health inspectors in all villages and parishes countrywide who oversaw sanitation, educated communities and ensured that hygiene was strictly observed. 

The inspectors and local chiefs moved around monitoring all homesteads in the areas of jurisdiction, educating people on the importance of hygiene.

Every homestead was mandated to have a clean latrine, clean compound, a granary, well-ventilated house and a rack to dry their cooking utensils. The communities were also mandated to have well-maintained water sources and every month a day was designated for cleaning the village well. 

Every member had to take part in the cleaning exercise and everybody had to comply. Defaulters were arrested and heavily fined and forced to put in place the facilities they lacked.

Rwabuganzi says it was a big shame for a family head to be tied with ropes and taken to the Muruka headquarters for not having a latrine, so everyone endeavoured to put all these things in place. This system, however, collapsed during the political upheavals of the 1970s, through the 1980s, to-date, giving rise to frequent outbreaks of cholera.

The population increase, from about seven million in the 1960s to the current 34 million has also resulted in rural-urban migration, overcrowding in towns and the emergence of slums, which has made the situation worse, thus the rampant cholera outbreaks.

Leprosy
In the early days, leprosy control was a domain of church-based organisations, who took it as a humanitarian Christian mission. 

Leprosy was first reported around Lake Bunyonyi (now Kabale) in southwestern Uganda as early as 1921 when English missionary Dr.Leonard Sharp came to this part of Uganda. In 1931 he established a leprosy treatment centre on the then uninhabited Bwama island.

Establishing the centre on the island was to isolate the victims and reduce infections in the communities. Other missionaries joined the fight against leprosy.

In 1934, St. Francis Hospital, Buluba, now belonging to the Catholic Diocese of Jinja, was established by Mother Kevin of the Franciscan Missionary Sisters for Africa as a centre to care for leprosy patients. But with time, the Ugandan government joined the fight and a combined programme for tuberculosis and leprosy was conceived in 1988 and it started in 1990.

According to a report done in eastern Uganda in December 2005 under the National Tuberculosis and Leprosy Programme, 46 of the 56 districts continued to report new leprosy cases by 2004. But with increased intervention, the numbers have since dropped significantly as many who had leprosy got treated by 2010.

Nodding disease
The nodding disease outbreak has up to now eluded scientists on the actual cause, so no treatment has been prescribed. The disease has claimed hundreds of lives, especially children in northern Uganda.

Although scientists first described the nodding disease about 40 years ago, the illness can be traced to the 1980s in Uganda. It came into the limelight around 2009/2010 when deaths were reported in hundreds.

Since September 2009, several teams of medics, including those from the African Field Epidemiology Network, Mulago and Butabika hospitals and abroad have carried out studies but the cause remains unknown.