In a paper published in the Journal of Public Health in Africa in September 2023 a team of authors explore the Ugandan government’s response to the September 2022 outbreak of Ebola Virus Disease (EVD). Readers may remember that this outbreak, caused by the Sudan strain of the virus, lasted a total of 69 days, comprising 164 cases and 77 deaths. The paper provides an insight into the response actions initiated by the government, and explores the challenges faced by public health officials. It also provides “key recommendations” for “better control of future outbreaks”.
A familiar foe
The paper suggests that over the last decade, 14 EVD outbreaks have been reported in Africa, across 8 countries. The geographic spread is concentrated in the Central and Western regions of the continent. Ebolavirus, a member of the filoviridae family, is “highly infectious and fatal” with a “high socio-economic impact”. Uganda has reported seven outbreaks of EVD since 2000, four of which have been due to the Sudan species.
Initiatives over time
The authors refer to “several initiatives” that have taken place to strengthen response capacities in Uganda:
- 2011: Prime Minister’s office developed a national disaster preparedness and management policy aimed at establishing institutions and mechanisms to reduce the vulnerability of people, livestock, and wildlife to disasters
- 2013: Uganda established a public health emergency operations centre (PHEOC) to coordinate and analyse health emergencies information in real time.
- COVID-19 pandemic: the country developed public health emergency policies, plans, and guidelines, including establishing rapid response teams (RRTs), improving surveillance and contact tracing management, and testing and confirming samples
Reflecting on the response
On 20th September 2022, Uganda declared the 7th outbreak of EVD after a case was confirmed at Mubende Regional Referral Hospital through testing at the Uganda Viral Research Institute (UVRI). Upon confirmation of this first case, the PHEOC was “immediately activated”. The Ministry of Health and the WHO Country Office declared the outbreak, urging the public to be vigilant and report suspected cases.
Immediate actions included the strengthening of an outbreak investigation in the Mubende district and convening a “high-level emergency stakeholder meeting” in Kampala with neighbours, Africa CDC, Africa Union, WHO, and partners. This meeting resulted in the establishment of the Africa Ebola Coordination Taskforce (AfECT), comprising at-risk Member States, with the goal of communication, preparedness, and response.
“The stakeholders endorsed the development of legal and regulatory processes for cross border deployment of rapid response teams and public health experts.”
They also agreed on building capacity for research and biomedical technologies. Furthermore, acknowledging that “timely sharing of technical expertise and other resources and assets” would be critical for preparedness and response, the stakeholders committed to undertake “prompt” communication of surveillance data and relevant reports.
Benchmarking visits, joint simulation exercises, and joint trainings were planned to build workforce capacity, and the meeting “successfully spearheaded” the development of a collaborative framework to coordinate preparedness and response to outbreaks and other public health emergencies.
The government institute three rounds of 21-day targeted lockdowns in the two most affected districts and to “shield the rest of the world”. The Ministry of Health repurposed the existing COVID-19 response structures and activated the Incident Management Team (IMT). This was responsible for day-to-day management and technical implementation of the response. The IMT was based on pillars: coordination, surveillance, laboratory, case management, WASH, risk communication and social mobilisation, community engagement, logistics, and continuity of health services and vaccination.
Other response actions are listed in the paper here, which then moves on to explore the challenges presented by the outbreak.
Challenges
“Despite significant coordinated response efforts, several challenges threatened the optimal control of the outbreak.”
The challenges listed include the co-circulation of malaria and Ebola, lack of resources, community non-compliance, and stigma.
Malaria and Ebola: As a country with a “high malaria prevalence”, Uganda faced a “compromised” window of suspicion for Ebola. This led to delays in referral for Ebola testing and overall treatment delays. Luckily, this was “overcome” after “notifications and sensitisations” of healthcare workers and communities.
Lack of centralised resource management pool: A limited capacity to manage financial, infrastructural, and human resources was observed, particularly in the context of concurrent health crises like the COVID-19 pandemic and pre-existing health problems. As in-kind support “streamed” in the country, a proper control mechanism to track what had been received was lacking.
“In an outbreak of this nature and magnitude, there is a need to establish a transparent, reliable, and regularly updated accountability system to win the trust of all partners and stakeholders.”
Lack of approved therapeutics and vaccines: Although there is progress against the Zaire strain, there are no approved therapeutics or vaccines for the Sudan strain. The authors believe this is because these outbreaks are “rare, and smaller in magnitude”. Despite the establishment of capacity to deploy therapeutics during the outbreak, no randomised controlled trials were implemented, and supportive care was prioritised.
“Acceleration of the development and deployment of therapeutics, vaccines, and diagnostics for SUDV is needed to improve outcomes for patients in future outbreaks.”
Community poor-compliance and sub-optimal community engagement: The authors refer to patients escaping from treatment centres and contacts relocating, resulting in “new foci of transmission”. These cases are not unique to this outbreak, previous outbreaks in DRC and Liberia saw “unprecedented case counts” after cases fled to urban areas. Sub-optimal community engagement was also noted, as “risky practices” continued: dead bodies were exhumed in Kassanda district for burial rituals, resulting in 23 infections.
“Upscaling risk communication and strengthening community engagement in affected districts remains critical to a successful response.”
Suggestions in the paper include “empowerment of community leaders” and collaboration to arrange interventions that consider their “values and cultures”. Additionally, clear and tailored messages should be translated into local languages.
Stigma: Reports of survivors and relatives of cases being stigmatised or ostracised give cause for concern, as this not only causes personal problems but can result in “non-reporting of suspected cases”.
“Support to monitor survivors when they eventually return to their communities in order to minimise the risk of stigmatisation, transmission of EVD to those not already affected, and post-EVD complications should be prioritised.”
Inadequate surveillance: The authors claim that inadequate surveillance resulted in “late detection” despite “clusters of deaths” in the district.
“Strengthening early warning systems including revitalising event-based surveillance systems at the community and health facility levels will enable detection.”
Furthermore, there is a need to “support sensitisation of clinicians and healthcare workers” on the EVD standard case definitions and reporting.
Inadequate health infrastructure and low healthcare worker compliance to standard Infection Prevention and Control (IPC): The health system cannot manage diseases with “limited treatment centres” or isolation facilities. Some cases had to be transported for treatment, resulting in the infection and death of an ambulance driver. There is also “minimal” adherence to IPC by healthcare workers.
Conclusion
Although the report recognises that the outbreak was met by “rapid containment”, the authors state:
“More needs to be done.”
Highlights include “high transparency” and stakeholder involvement, but challenges were identified in community engagement and adequate human and financial resources.
“Community engagement, facility-based IPC, vaccine development, and enhanced community surveillance will need to be prioritised in the short to medium term to control the future outbreaks.”
Do you agree with the analysis presented in this paper and how do you think Uganda can strengthen its response strategies?
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