Containing Hemorrhagic Fever Epidemic, The Ebola Experience in Uganda ( O ct ob er 2000 – January 2001)

Document reports success to combat Ebola in Uganda. Relates the importance of control interventions addressed weakness prior to outbreak detection and aimed at improving preparedness for future out break detection and response.

Revisiting the ABC strategy: HIV prevention in Uganda in the era of antiretroviral therapy.

The ABC strategy is credited for bringing the HIV/AIDS epidemic under control in Uganda. By promoting abstinence, being faithful, and condom use, safe(r) behaviours have been identified that are applicable to people in different circumstances. However, scaling-up of antiretroviral therapy in the country raised concerns that HIV prevention messages targeting the uninfected population are not taking sufficient account of inherent complexities. Furthermore, there is debate in the country over relative importance of abstinence in reduction of HIV incidence as well as over the morality and effectiveness of condoms. The purpose of this paper is to examine each component of ABC in light of current developments. It is argued that there is still a strong justification for condom use to complement abstinence and being faithful. There is an urgent need to update and relaunch Uganda's ABC strategy--its three elements are complementary, synergistic, and inseparable in the national HIV prevention programme.

Containing a haemorrhagic fever epidemic: the Ebola experience in Uganda (October 2000-January 2001).

INTRODUCTION: The Ebola virus, belonging to the family of filoviruses, was first recognized in 1976 when it caused concurrent outbreaks in Yambuku in the Democratic Republic of Congo (DRC), and in the town of Nzara in Sudan. Both countries share borders with Uganda. A total of 425 cases and 224 deaths attributed to Ebola haemorrhagic fever (EHF) were recorded in Uganda in 2000/01. Although there was delayed detection at the community level, prompt and efficient outbreak investigation led to the confirmation of the causative agent on 14 October 2000 by the National Institute of Virology in South Africa, and the subsequent institution of control interventions. CONTROL INTERVENTIONS: Public health interventions to contain the epidemic aimed at minimizing transmission in the health care setting and in the community, reducing the case fatality rate due to the epidemic, strengthening co-ordination for the response and building capacity for on-going surveillance and control. Co-ordination of the control interventions was organized through the Interministerial Committee, National Ebola Task Force, District Ebola Task Forces, and the Technical Committees at national and district levels. The World Health Organization (WHO) under the Global Outbreak Alert and Response Network co-ordinated the international response. The post-outbreak control interventions addressed weaknesses prior to outbreak detection and aimed at improving preparations for future outbreak detection and response. Challenges to control efforts included inadequate and poor quality protective materials, deaths of health workers, numerous rumors and the rejection of convalescent cases by members of the community. CONCLUSIONS: This was recognized as the largest reported outbreak of EHF in the world. Control interventions were very successful in containing the epidemic. The community structures used to contain the epidemic have continued to perform well after containment of the outbreak, and have proved useful in the identification of other outbreaks. This was also the first outbreak response co-ordinated by the WHO under the Global Outbreak Alert and Response Network, a voluntary organization recently created to co-ordinate technical and financial resources to developing countries during outbreaks.

An outbreak of Ebola in Uganda.

An outbreak of Ebola disease was reported from Gulu district, Uganda, on 8 October 2000. The outbreak was characterized by fever and haemorrhagic manifestations, and affected health workers and the general population of Rwot-Obillo, a village 14 km north of Gulu town. Later, the outbreak spread to other parts of the country including Mbarara and Masindi districts. Response measures included surveillance, community mobilization, case and logistics management. Three coordination committees were formed: National Task Force (NTF), a District Task Force (DTF) and an Interministerial Task Force (IMTF). The NTF and DTF were responsible for coordination and follow-up of implementation of activities at the national and district levels, respectively, while the IMTF provided political direction and handled sensitive issues related to stigma, trade, tourism and international relations. The international response was coordinated by the World Health Organization (WHO) under the umbrella organization of the Global Outbreak and Alert Response Network. A WHO/CDC case definition for Ebola was adapted and used to capture four categories of cases, namely, the 'alert', 'suspected', 'probable' and 'confirmed cases'. Guidelines for identification and management of cases were developed and disseminated to all persons responsible for surveillance, case management, contact tracing and Information Education Communication (IEC). For the duration of the epidemic that lasted up to 16 January 2001, a total of 425 cases with 224 deaths were reported countrywide. The case fatality rate was 53%. The attack rate (AR) was highest in women. The average AR for Gulu district was 12.6 cases/10 000 inhabitants when the contacts of all cases were considered and was 4.5 cases/10 000 if limited only to contacts of laboratory confirmed cases. The secondary AR was 2.5% when nearly 5000 contacts were followed up for 21 days. Uganda was finally declared Ebola free on 27 February 2001, 42 days after the last case was reported. The Government's role in coordination of both local and international support was vital. The NTF and the corresponding district committees harmonized implementation of a mutually agreed programme. Community mobilization using community-based resource persons and political organs, such as Members of Parliament was effective in getting information to the public. This was critical in controlling the epidemic. Past experience in epidemic management has shown that in the absence of regular provision of information to the public, there are bound to be deleterious rumours. Consequently rumour was managed by frank and open discussion of the epidemic, providing daily updates, fact sheets and press releases. Information was regularly disseminated to communities through mass media and press conferences. Thus all levels of the community spontaneously demonstrated solidarity and response to public health interventions. Even in areas of relative insecurity, rebel abductions diminished considerably.

A Strategy for home based management of fever in Uganda

A significant proportion of morbidity and mortality in Uganda is due to malaria and malaria-related illnesses. Malaria accounts for 46of illnesses in children; 20-40of outpatient visits 25of admissions to hospitals and 14of inpatient deaths (MOFPED 1995). Unfortunately; the magnitude of the malaria problem in the country is worsening for instance malaria accounted for 25-40of the OPD cases in 1922/3; 27-51in 1998 and 29-50in 1999 (MOH 2001). Some of the reasons for this include mismanagement of malaria cases; misuse of anti-malarial drugs and resistance of malaria parasites to drugs resulting in increasing level of treatment failures

Fighting HIV/AIDS: is success possible?

The fight against HIV/AIDS poses enormous challenges worldwide, generating fears that success may be too difficult or even impossible to attain. Uganda has demonstrated that an early, consistent and multisectoral control strategy can reduce both the prevalence and the incidence of HIV infection. From only two AIDS cases in 1982, the epidemic in Uganda grew to a cumulative 2 million HIV infections by the end of 2000. The AIDS Control Programme established in 1987 in the Ministry of Health mounted a national response that expanded over time to reach other relevant sectors under the coordinating role of the Uganda AIDS Commission. The national response was to bring in new policies, expanded partnerships, increased institutional capacity for care and research, public health education for behaviour change, strengthened sexually transmitted disease (STD) management, improved blood transfusion services, care and support services for persons with HIV/AIDS, and a surveillance system to monitor the epidemic. After a decade of fighting on these fronts, Uganda became, in October 1996, the first African nation to report declining trends in HIV infection. Further decline in prevalence has since been noted. The Medical Research Council (UK) and the Uganda Virus Research Institute have demonstrated declining HIV incidence rates in the general population in the Kyamulibwa in Masaka Districts. Repeat knowledge, attitudes, behaviour and practice studies have shown positive changes in the priority prevention indicators. The data suggest that a comprehensive national response supported by strong political commitment may be responsible for the observed decline. Other countries in sub-Saharan Africa can achieve similar results by these means. Since success is possible, anything less is unacceptable.

Epidemiology of cholera outbreak in Kampala, Uganda.

OBJECTIVE: To provide epidemiological description of the cholera outbreak which occurred in Kampala between December 1997 and March 1998. DESIGN: A four-month cross-sectional survey. SETTING: Kampala city, Uganda. MAIN OUTCOME MEASURES: Number of cases reported per day, attack rate per age group and per parish, case fatality ratio. RESULTS: The cholera outbreak was due to Vibrio cholerae O1 El Tor, serotype Ogawa. Between December 1997 and March 1998, 6228 cases of cholera were reported, of which 1091 (17.5%) were children under five years of age. The overall attack rate was 0.62%, similar in the under-fives and five and above age groups. The case fatality ratio among hospitalised patients was 2.5%. The peak of the outbreak was observed three weeks after the report of the first case, and by the end of January 1998 (less than two months after the first case), 88.4% of the cases had already been reported. The occurrence of cases concentrated in the slums where the overcrowding and the environmental conditions resembled a refugee camp situation. CONCLUSION: The explosive development of the cholera outbreak in Kampala, followed by a rapid decrease of the number of cases reported is unusual in a large urban setting. It appeared that each of the affected slums developed a distinct outbreak in a non immune population, which did not spread to contiguous areas. Therefore, we believe that, a decentralised strategy, that would focus the interventions on each heavily affected area, should be considered in these circumstances.

Tuberculosis and HIV infection association in a rural district of northern Uganda: epidemiological and clinical considerations.

59 (18.3%) of 323 patients with tuberculosis (TB) tested for HIV-1 antibody by ELISA technique (Wellcozyme) were seropositive. In the control group selected among the health personnel working in the Arua Hospital, 7.7% were found positive for HIV-1 antibody, thus showing a significantly lower prevalence compared with the TB patients (P < 0.005). The prevalence of HIV infection was 50% in the urban TB patients, 7% in TB patients living in rural areas surrounding Arua town and 1.6% in the peripheral rural setting. Of 27 TB patients with clinical AIDS, 18 died during the course of the study. The AIDS patients' survival rate was 46.4% 6 months after diagnosis, and 21.4% after 16 months, the median period of survival being 5.0 months. Risk factors, sputum conversion rate, clinical and radiological findings were analysed. No significant difference was found between seropositive and seronegative TB patients for clinical drug-related toxicity (P > 0.05).

PIP: Between June 1987 and August 1989, physicians enrolled 323 tuberculosis (TB) patients and 116 health employees at the Arua Regional Hospital in a rural district of northern Uganda in a case control study. They wanted to look at the link between TB and HIV infection. TB patients were more likely to be HIV seropositive than the employees (18.3% vs. 7.7%; p .005). HIV seropositive individuals tended to be men (71.2% vs. 54.9% for controls; p .05) whose mean age was 27.69 years. Most HIV/TB patients lived in the town of Arua (50% vs. 7% in rural areas peripheral to Arua and 1.6% in a rural area near the district border; p .0001). HIV seropositive TB patients were more likely to have a sexually transmitted disease (STD) than HIV seronegative TB patients (47.4% vs. 12.5%; odds ratio [OR] = 6.32; p .0001), especially gonorrhea (p .0001). They also tended to have had more than 5 sexual partners in the past 2 years (mean number of partners among HIV seropositive TB patients = 10.6; 35.6% vs. 9.5%; OR = 9.24; p .0001). HIV seropositive TB patients were more likely to have participated in prostitution and to have had a blood transfusion than HIV seronegative TB patients (33.9% vs. 3.8%; OR = 13.03; p .001 and 6.8% vs. 1.1% OR = 6.33; p .05). Skin piercing, widely practiced in rural areas, appeared to have a protective effect against HIV infection (OR = .33; p .0005). HIV seropositive TB patients were significantly more likely to have a persistent cough of more than 4 months duration (p .001), fever lasting for more than 1 month (p .05), oral thrush (p .0001), lymphadenopathy (p .0005), and amenorrhea (fertile women only, p .005). 27 or 28 TB patients had AIDS. At the time of submission of this study for publication, 18 HIV seropositive TB patients died during treatment. The case fatality rate was indeed higher among HIV seropositive TB patients than among HIV seronegative TB patients (30.5% vs. 8.7%; p .0001). The TB-AIDS survival rate was 46.4% at 6 months, 32.1% at 12 months, and 21.4% at 16 months. Median survival time was 5 months.

Seroepidemiology of HIV infection: an early survey in a peripheral area of Uganda.

At the end of 1985, when the AIDS epidemic was in its early stages in Uganda, a survey was carried out in a peripheral area of the country. Sera were collected from groups of people, and examined for the presence of HIV infection. The results show a very limited number of positive cases, present only among sexually active subjects. High specificity and sensitivity in the laboratory tests was shown by the Western blot technique.

AIDS and HIV infection in Uganda--are more women infected than men?

In countries in sub-Saharan Africa, HIV is transmitted primarily heterosexually. HIV infection and AIDS in women not only affects women's health but also has implications for the other members of society. Maternal infection is the source of most childhood HIV infection in Africa and maternal health is a strong predictor of child survival. In Uganda, a review of passive AIDS surveillance has shown almost equal numbers of clinical cases reported in men and women. However, in three population-based HIV serosurveys, women were consistently found to have a higher infection rate (approximately 1.4 times) than men. In addition, both AIDS case surveillance and seroprevalence studies demonstrate an earlier age of presentation and mean age of infection in women. The higher rate of HIV infection in women suggests either differential rates of transmission between women and men, higher rates of female sexual exposure to infected men, or longer survival among HIV-infected women compared with men. Although further studies are required to illuminate both the biology and the epidemiology of heterosexual HIV transmission in Africa, these findings of earlier and higher infection rates in women have important implications for women's health and child survival in Uganda and indicate the need for specially targeted interventions to reduce transmission in this group.

AIDS and HIV infection in Uganda--are more women infected than men?

In countries in sub-Saharan Africa; HIV is transmitted primarily heterosexually. HIV infection and AIDS in women not only affects women's health but also has implications for the other members of society. Maternal infection is the source of most childhood HIV infection in Africa and maternal health is a strong predictor of child survival. In Uganda; a review of passive AIDS surveillance has shown almost equal numbers of clinical cases reported in men and women. However; in three population-based HIV serosurveys; women were consistently found to have a higher infection rate (approximately 1.4 times) than men. In addition; both AIDS case surveillance and seroprevalence studies demonstrate an earlier age of presentation and mean age of infection in women. The higher rate of HIV infection in women suggests either differential rates of transmission between women and men; higher rates of female sexual exposure to infected men; or longer survival among HIV-infected women compared with men. Although further studies are required to illuminate both the biology and the epidemiology of heterosexual HIV transmission in Africa; these findings of earlier and higher infection rates in women have important implications for women's health and child survival in Uganda and indicate the need for specially targeted interventions to reduce transmission in this group

Risk factors associated with HIV infection in Uganda.

Risk factor data were collected in 1,328 inpatients and outpatients in 1987 in 15 hospitals throughout Uganda; 42% were positive for HIV antibodies by ELISA. Seropositivity was associated with urban residence, sexually transmitted diseases (STD), number of sex partners, and sex for payment or with a person with an AIDS-like illness. Homosexuality and intravenous drug abuse, recognized risk factors in western countries, were not seen as risk factors. By multivariate analysis, urban residence and sex for payment were not independently associated with infection. Among females, number of sex partners, sex with a person with an AIDS-like illness, and numbers of episodes of STDs were significantly associated with seropositivity. In males, similar associations were seen, although number of reported sex partners was not independently associated with infection. These findings support the view that heterosexual contact is the predominant mode of transmission in Uganda and suggest that the main risk factors relate to high-risk heterosexual behavior.

Surveillance for AIDS in Uganda.

In the developed world, surveillance for AIDS has provided up-to-date information for researchers, clinicians, public health workers and policy makers. In Africa, however, there is no standardized format or methodology for AIDS surveillance. In August 1987, Uganda developed a clinical case definition for AIDS reporting, based upon the World Health Organization (WHO) clinical case definition for AIDS in Africa and began formal surveillance. Surveillance is passive and primarily hospital-based. At the end of July 1988, 5142 cases of AIDS had been reported to the Ministry of Health; 4583 (89%) had confirmatory HIV-antibody testing. Of the 4938 (96%) cases that had their sex recorded, 2358 (48%) were male and 2580 (52%) were female. The mean age of 28.4 years for male patients is higher than that of 24.4 years for female patients (P less than 0.0001). Only 18 (less than 1%) cases have been reported in children between 5 and 12 years of age. Case reports are returned via the District Medical Officers to the Ministry of Health where they are entered into a microcomputer from which a monthly report is generated for feedback to the reporting stations. Here we describe a simple national reporting system to follow the progression of the AIDS epidemic which could be established in Africa using limited resources.

Evaluation of the WHO clinical case definition for AIDS in Uganda.

Infections with human immunodeficiency virus are common in areas of the world where laboratory testing and sophisticated diagnostic facilities are unavailable. A World Health Organization clinical case definition for acquired immunodeficiency syndrome was developed in 1985 for use in such areas. In 1987, we tested this definition on 1328 inpatients and outpatients in 15 hospitals throughout Uganda. Five hundred sixty-two patients (42%) were positive by enzyme-linked immunosorbent assay for human immunodeficiency virus antibody. The World Health Organization definition had a sensitivity of 55%, a specificity of 85%, and a positive predictive value of 73%. Modification of the case definition by excluding a known cough from tuberculosis as a minor criteria decreased sensitivity slightly to 52%, but specificity and positive predictive value increased to 92% and 83%, respectively. Amenorrhea, although not specifically asked about, was a symptom noted by many female patients (26% of females who were positive by enzyme-linked immunosorbent assay); as a symptom indicative of human immunodeficiency virus infection, amenorrhea had a specificity of 99%, with a positive predictive value of 89%. These findings support the generalizability of the World Health Organization clinical acquired immunodeficiency syndrome definition and its use (especially the modified version) in areas of Uganda without sophisticated facilities.

Towards a national AIDS-control program in Uganda.

A national AIDS-control program was developed in Uganda to deal with a potentially serious epidemic of the acquired immunodeficiency syndrome (AIDS). A cumulative total of 1,138 cases of AIDS has been reported in Uganda between 1983-since AIDS was introduced into the country-and March 1987. More than 80% of the victims are sexually active persons whereas less than 10% are infants and children younger than 5 years. Virtually no cases or seropositivity is reported in persons between the ages of 5 and 14 years or after the age of 60 years. Most transmission has been through the heterosexual route, and, unlike in the United States, the male-female ratio is 1:1. Heterosexual high-risk behavior is cited as an important mode of transmission. A survey of household contacts showed that despite the closeness, only the sexual partners were seropositive.A five-year plan of action has been developed, and health education is the main thrust. It also includes blood screening, improved sterile procedures, improved surveillance and notification, research and terminal patient care. The plan stresses integration based on primary health care. There are unresolved moral issues of whether or not to tell the truth to an AIDS victim or any healthy seropositive person in developing countries, especially unstable persons. The best approach is to sensitize everyone so that they become guardians of their lives because sexual behavior is an issue of individual responsibility.

Estimating health service utilization, immunization coverage, and childhood mortality: a new approach in Uganda.

PIP: Interviews were conducted in the 75 households nearest to each of the 36 rural health facilities in Uganda's Mbale District in order to estimate childhood morbidity/mortality and the utilization of health services. Data were obtained on 2596 children under 5 years of age. There were 50 deaths in the 527 live births in the 12 months preceding the survey, giving an infant mortality rate of 95/1000. There were an additional 51 deaths among the 2069 children 1-4 years of age (25/1000). 34% of deaths among infants and 69% of deaths among children 1-4 years of age were associated with diarrhea. Of the 2495 children 0-4 years of age who were alive at the time of the survey, 506 (20%) had diarrhea in the 2 weeks preceding the survey and there was a diarrhea morbidity rate of 3.2 episodes/year/child. Only 60 (12%) of the children with diarrhea were treated with some form of oral rehydration; 314 (62%) were given drugs obtained from local pharmacies. Finally, only 38% of children 1-4 years of age and 21% of infants under 1 year of age were fully immunized for their age. These findings suggest high rates of childhood mortality and underutilization of preventive health services among households in the immediate vicinity of health facilities. This research approach can be used to facilitate program evaluation, even though the results cannot be generalized to the entire population of the district. It provides local health workers with an opportunity to assess their community's health needs and motivates them to improve health care delivery.^ieng