Managing Epidemics, The Ugandan Experience

Dr Aceng Jane Ruth Director General Health Services

Outline • Country Background Information • Introduction • VHF Outbreaks in Uganda • Response Strategy • Lessons Learnt • Conclusions

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Background: Uganda • Location:

– East Africa; shares borders with Kenya, Tanzania, Rwanda

– South Sudan, and DRC

• Area: • 241,550.7 km²,

• Population: • 35 Million – (2012

census)

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Introduction • Over the last 15 years, Uganda has had several

viral haemorrhagic fever (VHF) outbreaks including Ebola, Marburg, Crimean Congo, and Yellow fever.

• The outbreaks have affected mainly Northern and Western Uganda, although other parts of the country are also at risk.

• The first and biggest Ebola outbreak in Uganda occurred in 2000 with cases being reported in the three districts of Gulu- Mid North, Masindi – Western and Mbarara – South Western

Why Uganda is prone to outbreaks • Increased interaction of man with forests, caves,

and animals due to economic and other activities

• The age old practice of hunting and eating game meat.

• Eating of bats and monkeys by some tribes. • Skinning and eating of dead animals without

ascertaining what the animals died. • Grazing of animals near game parks • Free and largely unchecked Cross Border

movements

Outbreaks in Uganda • 1999-present: Plague outbreaks (West Nile) • 2000: Ebola (Gulu) • 2007: Marburg (Kamwenge) • 2007: Ebola (Bundibugyo) • 2008: Hepatitis E (Kitgum/Pader); Botulism (Kampala);

Typhoid (Kasese); Anthrax (Bushenyi) • 2010-2011: Yellow Fever (Abim) • 2010 : Nodding Syndrome (Northern Uganda) to date • 2011: Ebola (Luwero) • 2011: Dengue (UPDF troops in Mogadishu) • 2012: Ebola (Kibaale); Marburg (Kabale); Ebola (Luwero) • 2013: Crimean–Congo Hemorrhagic Fever (Wakiso, Agago) • 2014: Marburg (Kampala)

Ebola VHF outbreaks in Uganda

Epidemic/Year Cases Deaths

Case fatality rate

Strain

Gulu (2000) 425 224 53% Sudan

Bundibugyo (2007)

146 39 27% Bundibugyo

Luweero (2011) 1 1 100% Sudan

Kibaale (2012) 24 17 71% Sudan

Luweero (2012) 7 4 57% Sudan

Marburg VHF outbreaks in Uganda

District/Year Cases Deaths Case Fatality Rate

Ibanda (2007) 4 3 75%

Kabale (2012) 20 9 45%

Kampala (2014) 1 1 100%

Progress in Ebola Outbreak Detection and Response in Uganda

• The time taken between reporting, confirmation and response determines the magnitude of the disease outbreak.

Year Response timeline No. of cases

2000 38 days from 1st known case to preliminary investigation

425 cases, 224 deaths

2007 2.5 months from 1st known case to preliminary investigation (Plus multiple investigations before confirmation of new strain of Ebola)

146 Cases, 39 deaths

2011 1 day between case confirmation and response 1 confirmed case

2012 2 days between lab confirmation & response 24 cases, 16 deaths

VHF Response Strategy used in Uganda

Social Mobilization and

Laboratory

Case Management

Coordination NTF

Sample Collection

Mobile Teams

Burial Teams

Screening IN / OUT

Barrier Nursing

Water Sanitation

Testing Reporting

Results Data

Management & Reporting

Contact Tracing

Case Finding

Medical Anthropology

Posters Radio

salaries Transports Vehicles

Media

Surveillance Epidemiology

and Funerals

Logistics and Security

Community Discussion

roads

police

Environment

Health Education

Traditional healers

Psycho Social support

Clinical trials

Coordination structures National Level • Uganda has a standing multi-sectoral and multidisciplinary task

force on epidemics (The National Task Force) • The National Task force is coordinated by Ministry of Health

chaired by the Director General • Includes experts from various fields i.e. epidemiologists,

laboratory scientists, communication experts, psychiatrists and psychologists, physicians, veterinarians, etc.

• Members are drawn from the Ministries of Health, Agriculture, Education, the uniformed personnel, Office of the Prime Minister, partners including Research Institutions and the Universities, WHO, CDC, UNICEF, AFENET, Uganda Red Cross, and MSF.

• The NTF meets monthly; however during an epidemic it meets daily.

Coordination Structures cont.. District level • All the 112 districts have task forces composed of the district

political, civic, and health leaders as well as technical advisors from different partners working in the districts.

• Both the National and district task forces have subcommittees that are responsible for overseeing and implementing the task force decisions and different components of epidemic response.

• The subcommittees include: coordination, Resource mobilization, surveillance and laboratory, case management, social mobilization, logistics, and psychosocial support and all have clear terms of reference.

• The subcommittees report to the task forces

Other supporting coordination structures • National Rapid Response Teams and District Rapid

Response Teams have been trained and remain on stand by to be constituted immediately an epidemic is notified.

• They conduct investigations and support the establishment of an appropriate response in collaboration with the task forces.

• To reinforce response coordination at the district level, two or three senior officers are deployed from the national level to the district level to work with the district task force.

Coordination Structures Community Level • All the 112 districts in Uganda have Community Health

Workers known as VHT’S. • A VHT is responsible for between 20 – 30 households

depending on the size of the village • Apart from other activities, the VHTs have been trained

in disease surveillance and reporting. • The VHTs report to the nearest facility, usually a health

center II or directly to the surveillance focal person in the health sub district or office of DHO.

• VHTs report any unusual occurrence (diseases, deaths, etc)

Coordination at Community level..

• Over the years, the communities have been educated and sensitized to alert VHTs immediately upon detection of any unusual occurrences or death.

• VHTs act as a link between the facility based surveillance system and the community and comprise of an early warning system at community level.

Surveillance, Epidemiology, and Laboratory

• Comprises of – Routine surveillance – Reporting – Sample collection and analysis – Case finding – Contact tracing – Data management

Surveillance • In 2000, Uganda adopted the Integrated Disease surveillance and

response strategy (IDSR). • Following the structure of the health system, there are

designated surveillance focal persons at the health sub - district, District and regional levels, and Laboratory focal persons

• The focal persons on a routine basis, receive information from the

health facilities and the VHTs and carry out investigations and report on priority diseases. Information is shared through the HMIS system .

• Recently with support from CDC, we started a Field Epidemiology

training program to build a pool of field epidemiologists to support surveillance

Surveillance …. • The trained field epidemiologists will boost capacity of the ESD as

well as the districts. • To improve detection of atypical outbreaks, we developed

standardized clinical and community case definitions for use by H/W and VHTs

• Information on unusual occurrences is immediately remitted to the

Epidemiology and surveillance Division (ESD) of Ministry of Health and the chair of the NTF.

• This division then verifies the information, carries out more

investigation and upon confirmation, alerts NTF through the chair, for action.

• This triggers daily task force meetings.

Surveillance …..contact tracing • A team of Surveillance officers are deployed to carry out contact

tracing. • Each officer is allocated to a specific number of contacts to follow

up on a daily basis and report to the surveillance committee. • Transport is provided to the officers to ease quick movements and

prompt feed back. • Officers are also facilitated with airtime to call and mobilize

efforts, this continues until all the contacts have been followed up for 21 days, and thereafter monitoring continues for another 21 days.

Ongoing surveillance • During the inter-epidemic periods, monthly taskforce

meetings are held to: – Review disease surveillance data – Update epidemic preparedness and response plans in regard

to the situation on the ground

• There is constant communication between district surveillance officers and ESD of the Ministry of Health

• With the support of WHO, Uganda has been working

with neighboring countries to strengthen cross border surveillance and management of epidemics

Laboratory System • Uganda has over time built a strong laboratory system. Different

levels of health care delivery have different lab capacity. • With support from CDC, a P3+ laboratory has been established at

UVRI (Special pathogens lab) for confirmation of VHFs and other pathogens

• This has reduced the turn around time for results to less than

24hours, enabling timely response interventions. • The results from the lab are sent directly to the Chair NTF and

relevant officers for immediate action. • The Central Public Health Laboratory (CPHL) acts as a

coordinating body for specimen transportation

National Specimen Transport Network • The country has also established a network of hubs - laboratories with enhanced

capacity to analyze and monitor disease trends (77 hubs reaching over 2400 health facilities). Each Hub is headed by a hub coordinator.

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x x

x x Monday

Route

x

x x

x

x Tuesday Route

x

CPHL UVRI

HUB

• Each hub is given a motorbike and a bike rider, who visits 20-30 health facilities within 30-40km radius around the hub, bringing samples and delivering results weekly.

• The hub refers well-packaged highly dangerous specimens using the Posta bus.

UVRI

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A motorbike rider getting ready to transport samples

Laboratory capacity • For non routine / emergency samples there are dedicated back up

riders who are always on stand by.

• They are called upon by the Hub coordinator to pick emergency samples.

• Samples for highly dangerous pathogens move from the point of

collection to the hub center for registration and, re-checking of packaging and then to Posta Uganda for transportation to Entebbe ( this process is designed to take less than 24 hours)

Pictorial view of prepared specimen from suspect cases and Transport means

Posta Bus Laboratory focal Person hands over packed specimen to bike rider

In case the Posta system is not available; other options include; public transport, local airlines, Direct transport by DHO

Information Management • Standardized forms are used for collection of

data during the outbreaks – Case investigation forms, Line Lists, Laboratory requests, contact listing and tracing form.

• A data base is established for every outbreak; the

Epi Info 7 and the WHO FIMS software have been used for the Ebola outbreaks.

• A specified officer is assigned to data

management at the beginning of the outbreak

SMS Message Alerts • Using SMS, members of the District Rapid Response Team

(DRRT); including the District Health Officer, District Surveillance Officer and the Hub coordinator can send a message to the system.

• The message is preceded with a specific keywords such as ‘alertvf’ for VHFs or ‘alertch’, for cholera and sent to the number 8228.

• When received in the system, the message is forwarded as both an SMS to the phones and email to recipients who are members of the NTF or responsible for response.

• User groups include teams such as the PHEOC staff, lab and ESD

Specimen Tracking • For some priority diseases, modules with multiple

stages, i.e. the VHF module, were developed to facilitate tracking of the specimen and the the results for feedback.

• Stages include: specimen registration by the hub coordinator, acknowledgement of receipt of the specimen by UVRI and the release of the specimen results by the testing laboratory.

• At every stage, an SMS is sent to the phones and emails of the groups defined in the system for Action.

• User groups include: PHEOC, DRRT, ESD and the testing laboratory.

Information Management • IHR notification to WHO is done immediately

after confirmation, by the National Focal Point • A daily situation report (Sitrep) is produced,

including data on the different aspects of the outbreak; cleared by chair of NTF

• Sitreps are shared with all districts, National leaders, in-country partners, and WHO

• Data from the sitreps is used to monitor the response and adjust aspects of the response as necessary

The Emergency operations center, (EOC) • Coordination center activated during emergencies, and

an incident team constituted. • When activated, brings together all responsible

decision makers from all MDA • Provides capacity to receive, analyze, display and

monitor incident information. • Stengthens the ability to identify, organize, deploy and

track resources. • Improves communication, collaboration and

coordination from a central location • Supports decision makers to remain in charge of the

situation.

Case Management • Case management comprises of the following

– Set up of barrier nursing facilities or isolation facilities with the required logistics

– Ensuring safe burial procedures – burial teams, – Triage of patients at Health facilities, – Ensuring safe water and proper sanitation, – Clinical management and nursing care – Psychosocial support to the patient and relatives – Disinfection of Homes and property

Case management Health workforce • Over the years, we have trained a number of Health workers on

management of VHF and other epidemics. • The country has training guidelines that are updated constantly. • An inventory of the trained health workers is kept by the

secretariat of the NTF. • These trained HWs are quickly contacted and deployed in case

they are needed outside their usual place of work. • The HWs also train more health workers in the new outbreak

location to increase the number of people with this capacity

Case management • The case management teams work in collaboration with partners

like MSF and others. • Isolation facilities are set up in Health facilities close to the

affected communities to minimize transfer of patients. • Uganda has a permanent National Isolation Facility at Entebbe, for

Health workers and suspected cases who fly in. • In the isolation facilities, supportive care is given and Psychosocial

experts counsel patients and their immediate families on the natural progression of the disease and the expected out comes.

• Families are also briefed on the situation of the patient in Isolation on a daily basis.

• In addition, the team provides psychosocial support to the health workers to avoid burn out and depression.

Case management Prevention of transmission • Suspected cases are immediately notified to case management by

the surveillance and contact tracing teams; • Suspected cases are transported from the community immediately,

to the isolation facility, to prevent further infection transmission • Affected homes are disinfected and contaminated personal effects

of the patient are destroyed. • The property that the patient came with to the facility are also

disinfected and incinerated on discharge or death • Upon discharge, the patient and the family are given a discharge

package to replace what was destroyed. (This act enhances cooperation of the families and communities)

• Burial teams are immediately constituted and trained to promptly bury the dead with dignity following infection control measures.

Logistics and Security • This comprises of transportation systems including that

for specimen collection, ambulance system, transportation of PPE and infection control materials, medicines and health supplies.

• Coordination is carried out through the EOC which is activated immediately an outbreak is detected.

• Partners support Government to procure PPE. Infection control materials and medicines are provided for by Government free of charge.

• Security is provided for by the uniformed personnel who are members of the NTF.

Social Mobilization • Local capacity has been developed over the years. • Political leaders both at the National and local level, Religious

leaders, Elders and opinion leaders have been educated and sensitized.

• During an epidemic, effort is made to understand the knowledge,

attitudes and beliefs of the affected people, this informs the social mobilization efforts and messages.

• Effort is made to reach out to the traditional healers, and other

groups to create dialogue and share information.

Social Mobilization • Messages are disseminated country wide by use of posters,

Leaflets, radios, Television and community discussions • Political leaders including The President of the Nation take it

upon themselves to educate the public about prevention at every possible opportunity and to encourage them to cooperate with the health professionals.

• Health workers are also mobilized, sensitized, educated and

counseled to dispel fear and encourage them to take care of the patients (This addresses the issue of patients being turned away or health workers running away)

• The psychosocial teams also interact with the affected communities to offer counseling and support as well as reintegrate discharged patients back into the communities.

H.E The President educates the communities during inter-epidemic period to avoid eating bats and

monkeys and to seek health care promptly.

Support Supervision • During out breaks, The Ministers of Health, members of the

NTF and other senior officers visit the affected districts and Isolation facilities.

• They engage with the district leaders and representatives of

communities to explain government action, seek community cooperation, motivate and encourage the response teams.

• This act provides them with first hand information about

challenges on the ground and empowers them to lobby and advocate for improved services.

Ministers and members of the NTF dressed in PPE ready to tour

the isolation facilities

A team from MSF ready to orient on the layout of the isolation facility

Media and Public information • During out breaks, its important to keep the media and the

population informed about progress on control. • Updates are given to the media on a daily basis as per the situation

report that comes to the NTF. • Information is shared with the Public on daily basis in the form of

press releases in print and social media. • The Chair of the NTF, engages the media every week and makes

statements on Radio and Television. • There is continuous sensitization of the public through radio spots

and announcements on behavioral change, infection control and what to do and where to report any suspected cases.

Challenges • Inadequate funding for control of Epidemics. This is often

bridged by Partners. • Inadequate Isolation facilities

– Set up temporary tents in affected areas – Plan is underway to construct another National Isolation facility next

to the National Referral Hospital

• Inadequate Human resources. – training of field epidemiologists and Field Laboratory

epidemiologists (Track to begin soon). – Constant recruitment and training. We have now

embarked on training of all health workers. • Myths, misconceptions and beliefs – On going education and

sensitization.

Lessons Learnt • A strong Coordination system is paramount. • Readily available protected funding is is critical • Timeliness of detection of VHFs outbreaks determines the

magnitude of the outbreak. • A strong laboratory system for sample collection and

confirmation is paramount • Dealing with cases dispersed over a wide geographic area

requires a decentralized response. • Need for a team of well trained motivated health workers. • There is need to constantly engage the communities and

understand their cultures and beliefs. • Involvement of local leaders is a crucial component of

ensuring community compliance. • It is important to keep the Public informed at all times

Thank you for Listening to me