On Tuesday, June 11, WHO Uganda confirmed the country’s first case of Ebola tied to the ongoing outbreak in the DRC. The case was diagnosed and isolated in Kasese District, which is adjacent to the DRC border. The next day, two more cases were confirmed in the same district. Outbreak Observatory has been closely following the ongoing Ebola outbreak in the DRC, sharing updates and commentary through our Outbreak Thursday posts. Our most recent Ebola-related post can be found here. In this post, we will synthesize news surrounding these new Ebola cases in Uganda and what it means for the outbreak response.

Timeline of Cases

According to the Ugandan Ministry of Health and the DRC’s Ministry of Health, the index case was a five year-old boy who had traveled with his mother to the DRC to care for the mother’s Ebola-stricken father. After the boy’s grandfather succumbed to the disease, the mother, child, and other Congolese family members traveled towards Uganda. When the family arrived at the Kasindi health checkpoint in DRC on June 10, 12 family members were ill. DRC authorities identified the family members as symptomatic case contacts and transferred them to the transitional isolation center at Kasindi Hospital. Six of the symptomatic family members left the isolation area that evening and crossed the border into Uganda, bypassing the official checkpoint and evading detection. DRC alerted Ugandan authorities that the family had fled.

When the five-year old boy began to develop severe symptoms, the family sought medical care at Kagando Hospital where health workers were already on alert for the Ebola case contacts from DRC. Health workers quickly moved the family to Bwera Hospital for isolation, and the child was admitted to the Ebola Treatment Unit. On June 11, the boy’s blood sample came back positive for Ebola. Two of the family members at Bwera Hospital were also reported as confirmed cases on June 12. Sadly, two of the confirmed cases died, and according to Uganda Minister of Health, safe and dignified burials were arranged.

The DRC and Ugandan Ministries of Health mutually agreed to repatriate the remaining patients back to DRC to receive better access to therapeutics and be closer to their relatives in DRC who are also infected. The repatriated patients are all family members of the index case, so all members of the family who traveled from DRC to Uganda have now been accounted for. While there have been no more confirmed cases in Uganda, three suspected cases that are not family of the index case are currently in isolation.

The Ugandan Response and Collaboration with DRC & Other Partners

Twenty-seven contacts of the confirmed cases are currently being followed up on. The Ugandan Minister of Health, the Director-General of Health Services, and the WHO Uganda country representative have gone to Kasese District to evaluate the situation and to hold  an EVD Joint Task Force meeting.

A delegation of DRC officials met with Ugandan officials in Kasese district on June 12 to discuss how best to support and collaborate with each other as Uganda enters response mode. It was decided that the two countries would strengthen surveillance along the border, particularly at non-official points of entry, and continue their quick exchange of response-related information. Uganda and DRC plan to sign a Memorandum of Understanding to specify cross-border movement of patients.

Rapid response teams from Uganda’s Ministry of Health, US CDC and WHO have also been deployed to conduct contact tracing, case management, risk communication, and psychosocial support. Ring vaccination of case contacts as well as vaccination of non-vaccinated frontline health and non-health workers has also commenced under the supervision of the Ministry of Health, CDC and WHO. Uganda has already vaccinated nearly 4,700 health workers in 165 health facilities, including at Bwera Hospital. WHO has shipped an additional 3,500 vaccine doses to Uganda and the delegation from DRC brought 400 doses as well.

The Ugandan government is now appealing to the public to continue good hygiene practices, suspend large communal gatherings near the DRC border, avoid contact with and report suspected cases, as well as suspend social norms such as shaking hands and hugging. However, WHO Uganda pointed out that there are no restrictions to movements and business in the country, specifically mentioning that school, international travel, and tourism will continue. The Ugandan Ministry of Health is also preparing for the funeral of the Queen Mother of the Kingdom of Rwenzururu which is expected to increase population movement across the DRC border as well as within the country.

Uganda’s Previous Experiences with Ebola and VHF Outbreaks

Uganda is no stranger to Ebola or other viral hemorrhagic fevers. The country has had five outbreaks of Ebola and six outbreaks of other viral hemorrhagic fevers since 2000, one of which we covered in an old Outbreak Thursday post. After one of the most severe Ebola outbreaks in history hit Uganda in 2000 - the third biggest on record after West Africa and the current outbreak - Ugandan authorities and the esteemed Uganda Virus Research Institute became adept at drastically decreasing response times in terms of case tracing, specimen collection, and turn around time for lab results. Due to their exhaustive experience, the country has become a sort of “hub for Ebola experts” with some even going to assist with the West Africa outbreak in 2014-2016. On top of Uganda’s existing preparedness efforts, WHO has also published numerous reports highlighting the timeline of Uganda’s preparedness scale-up since the beginning of the DRC outbreak. Helen Branswell noted that while this outbreak will mark the first time Uganda has dealt with the Zaire strain of the virus, the country has significant experience and is prepared to deal with an Ebola outbreak response.

Concerns for International Spread

Nearby countries including Rwanda, Kenya, and Tanzania are also scaling up Ebola preparedness measures in response to the Ugandan cases by running simulation exercises, enacting border screening, and increasing community education and engagement regarding Ebola. International support for the overall Ebola response, both technical and financial, has increased since the new cases in Uganda. The EU in particular released 3.5 million euros to bolster response activities in Uganda and preparedness activities in South Sudan. In addition, the International Health Regulations Emergency Committee will be reconvening tomorrow to discuss if a Public Health Emergency of International Concern (PHEIC) should be declared. This will be the third time that the committee has met to discuss the issue. The previous times the committee met, it was decided that the DRC outbreak did not constitute a PHEIC due to lack of international spread. However, not all experts feel as though that should constitute a barrier. You can read our previous post about PHEIC declaration decisions for the current DRC outbreak here.

Conclusions

It is important to note that while Uganda has been making great efforts to rapidly scale up preparedness since the beginning of the DRC epidemic in August 2018, Ebola cases still managed to cross into the country, highlighting the challenging nature of preventing cross-border spread. Even if the current cluster of cases stays contained, it will be important for countries to remain vigilant for additional potential introductions of the disease, as the advance warning given by DRC may not be possible in the future. Given these circumstances, it is important to support and enhance response activities such as screening, case tracing, and community engagement in both DRC and Uganda.

Outbreak Observatory aims to collect information on challenges and solutions associated with outbreak response and share it broadly to allow others to learn from these experiences in order to improve global outbreak response capabilities.

 

Photo courtesy of CDC Public Health Image library (https://phil.cdc.gov/Details.aspx?pid=19983)