Up until this year the largest Ebola
outbreak the world had witnessed occurred towards the end of 2000 in
Uganda, centered around the town of Gulu. By the time the outbreak was
eventually contained, some 425 patients had been infected with the
virus, of whom 224 died (Case Fatality Rate = 53%). Are there lessons
we can draw from the Ugandan experience in this West African outbreak?
How were the Ugandans able to defeat Ebola? What mistakes did they make
and what worked well? How might we make a better effort?
Uganda was fortunate (or, depending on your point of view, sufficiently
vigilant) that the outbreak was for the most part contained in the
district of Gulu, which experienced 93% of the cases. It did spread to
two other areas but was quickly contained there. In Gulu it was more
difficult, and at one point appeared to be out of control. The New York
Times, in one of the
best accounts of the Uganda outbreak ( www.nytimes.com/2001/02/18/magazine/dr-matthew-s-passion.html
) tells the story of Dr Mathew
Lukwiya, who became famous for his handling of the emergency in Gulu;
he is credited with the early diagnosis of Ebola, which was then an
unknown disease in Uganda, and with quick institution of an isolation
ward, thus preventing the spread of the disease to other areas. This
notwithstanding, many of the features of the disease that we see here
in West Africa,
were very much present in Uganda: denial, association with
witchcraft, fear, infection of hospital workers and near
breakdown of the health care system.
How was the disease contained? It's unclear from the accounts whether
any one factor can be credited with ending the outbreak in Gulu.
According to WHO's Epidemiology of Gulu Ebola ( http://www.who.int/docstore/wer/pdf/2001/wer7606.pdf
) contact tracing and
surveillance played a significant. role. During the course of the
outbreak approximately 5,600 contacts were under surveillance for
21-day periods in Gulu district by over 150 trained volunteers. Given
that the West African outbreak is now at least eight times as
large in terms of numbers of cases, a proportionately larger
contact tracing and surveillance effort would require 1,200 trained
volunteers to have placed up to 45,000 contacts under
surveillance at this point. Clearly we have not mounted as extensive a
contact tracing and surveillance effort as the Ugandans did.
One of the other areas in Uganda to which Ebola spread was Masindi
district, with a total of 26 cases. In a well-researched paper, Review
of Ebola Hf in Masindi, Uganda ( www.biomedcentral.com/1471-2334/11/357
the authors credit voluntary
quarantining with contributing to the containment of the disease,
although quarantining (as opposed to isolation of suspect and confirmed
cases) was not used much in Gulu.
How about treatment centers? What role did they play in containing the
outbreak? The evidence here is mixed. WHO says, "...the use of
isolation centers to diminish community transmission of the virus
and reduce the overall burden of EHF in the community
remains the single most effective means of controlling outbreaks of
EHF." However, in the same paper the authors point out that the Case
Fatality Rate, CFR, at around 50% was approximately the same as
it had been in outbreaks of the same strain of Ebola
(Ebola-Sudan) in Sudan in 1976 and 1979, where according to the New
York Times article "medical care was all but non-existent". In other
words the presence of good hospitals in Uganda did not seem to
make much difference to the CFR.
Dr Mathew Lukwiya, for all his heroics at Gulu hospital, was battered
by patient deaths and infections and deaths of his health care workers.
Dr Daniel Bausch was a CDC epidemiologist who managed the Ebola ward of
the government hospital in Gulu (Dr Mathew's was a larger,
private hospital). He is quoted in the New York Times article as
saying, "Ebola is a tough disease. I am not so sure that once someone
is infected that the treatment we offer prevents more people from dying
than would have died anyhow." The Masindi report, based on a small
number of cases, "...can only suggest, based on observations, that
intensive supportive treatment may improve survival."
Transmission of Ebola to health care workers and to non-Ebola patients
in hospitals was a thorny and recurring problem both in Gulu and
Masindi. Health care workers were regularly struck down, despite
wearing all the Personal Protective Equipment. It was unclear exactly
how they were being infected, especially when infections spread even to
nurses not assigned to Ebola wards.
The Masindi report is emphatic on the importance of prompt laboratory
testing in an outbreak to identify Ebola cases and non-cases and direct
medical resouces accordingly.