September 8, 2014

West African Ebola – what can we learn from the Uganda experience?
by
Paul Conton

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.


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