July 28, 2012: “Emergency Message – Confirmed Case Of Ebola Virus In Uganda”
In the first of two linked posts Raquel Reyes from Massachusetts General Hospital describes the challenges of providing health care during viral hemorrhagic fever outbreaks in Southwest Uganda. (Originally published on PLOS blogs).
Shortly after my arrival to Uganda in July 2012, I received an email with the subject heading “Emergency Message – Confirmed Case Of Ebola Virus In Uganda”. I was taken aback. Earlier in the day, one of the lead physicians in the Department of Internal Medicine at Mbarara Regional Referral Hospital had shown me the small area used for isolation during the last major Ebola outbreak in 2007, now used to house patients with TB. It was a small area near the back of the hospital with a six-room building and a few wooden sheltered areas with tin roofing. That evening, still before receiving the alert, I had written to family and friends about how strange it was to see the isolation ward and posters describing signs and symptoms of Ebola hanging on the walls of the clinics I had visited.
I remember when I first learned about Ebola as a child. It was a strange illness with no cure that made people very sick very quickly, and before people died, they would bleed. It seemed like such a frightening and horrible disease, but foreign and far away. Like the famine in Ethiopia and the earliest reports of HIV/AIDS, it was one of the news stories about Africa that really struck me as a child. The Ebola virus was first recognized in 1976, the year I was born. More than thirty years later, now a doctor, I found myself in Mbarara, Uganda, working in health facilities that, among many other things, provide food for severely malnourished children and life-saving drugs for patients with HIV. And I find myself reading an email warning of an Ebola outbreak: “On July 27, 2012, local Ugandan press reported 12 deaths due to a “strange illness.” Laboratory tests conducted by the Uganda Virus Research Institute and the United States Centers for Disease Control and Prevention (CDC) have confirmed, to date, that at least one victim was infected with the Ebola virus.”
There were many news reports and stories about the outbreak in the western media. I’m sure that for many who read them, it was still something foreign and far away. One headline I read online was “Could the Ebola outbreak spread to the U.S?” In the era of urbanization and globalization, it may not be such an unreasonable question. But from here, in southwest Uganda, it seemed odd to ask a question from the viewpoint of the United States. Here, when Ebola or Marburg strikes, health workers are focused on caring for patients, trying to curtail the spread of the virus, and preparing for the worst.
I currently live in Mbarara, but much of my work is in a small village called Bugoye, situated in the foothills of the beautiful Rwenzori mountains. Some 50,000 people live in the many smaller neighboring villages that dot the hillsides. For their health care needs, the people rely on their local village health workers, and for more complicated or serious problems, they travel to the level three health facility in Bugoye town.
I was in Bugoye in August when rumors of someone in a nearby village with a bleeding illness reached the health facility staff. The In-Charge told us that a woman had died, and shortly after, two of her family members had become ill and started to bleed. They had been taken directly to the nearest hospital in Kasese Town, he told us.
“What supplies do you have here?” I asked.
“A few gloves,” he answered. “That’s all. No masks. No gowns. Just gloves.”
We talked about reviewing the situation with the other health workers at the clinic, and some ways to try to isolate and triage patients. It would be a very difficult situation if the outbreak arrived in Bugoye.
Later that day, I was asked to return to Mbarara. “You’re the only doctor there,” my colleague told me. “If someone gets sick, they’ll bring them to you, and you won’t have any way to care for them or to protect yourself.”
It was a sound concern. Because Ebola is spread via direct contact with body fluids, not by aerosolized droplets, it is actually relatively unlikely that an unrelated member of the community will become ill. Health workers, by contrast, have close contact with the patients for hours a day, and therefore have a greater risk of contracting the disease. In the early stages of an epidemic the risk is greatest because the symptoms of early viral hemorrhagic fever (VHF) are the same as many more common diseases, like malaria or typhoid. Without the proper protection, nurses and clinical officers and doctors are much more likely to contract the virus. Depending on the strain, up to 90% of people infected with Ebola are expected to die.
During the most recent Ebola outbreak in Uganda in 2007, the case-fatality rate was about 25%—149 cases were detected and 37 patients died. The first identified outbreak in this country was much larger. In 2000 and 2001, Mbarara was one of the three villages across Uganda affected, during which a total of 425 patients were identified. The case-fatality rate at that time was over 50% and 224 of those patients died. Across the border in the Democratic Republic of Congo, three outbreaks of the Zaire strain of Ebola between 2001 and 2003 carried a case-fatality rate of 75%, 89%, and 83%.
I apologized to my Ugandan friends and returned to Mbarara. I hoped the health workers would be ok. If I couldn’t care for the hypothetical patients nor protect myself, neither could they.
Back in Mbarara, the Mbarara Regional Referral Hospital had a suspected case of Ebola. The patient had fever, body aches, jaundice, and was vomiting blood. He was isolated immediately, along with the family members who brought him. The TB ward had been transformed back into the Ebola ward. And now there was a fence around the area and a long hose to bring water. As I passed by, I watched as the nurses washed in chlorine, donned their gowns, masks, eye shields, head coverings, gloves, and rubber boots, and were sprayed with disinfectant before entering the ward.
I was on my way to an Ebola Task-Force meeting. Doctors, nurses, cleaning staff, lab technicians, representatives from the Ministry of Health, Ugandan Red Cross, and Epicenter, and hospital leadership attended. We spent hours dividing up the necessary tasks and forming committees. There were committees for direct clinical care, laboratory technicians and supervisors, transport, communications, infection control, sanitation, security, and a burial team. I volunteered for the clinical care team and infection control.
Over the coming days, we worked on setting up the isolation ward to be more in line with Médecins Sans Frontières and Centers for Disease Control and Prevention recommendations. The isolation area was a small area near the back of the hospital with a six-room building and a few wooden sheltered areas with tin roofing. We began by walking the perimeter and deciding where the different entrances should be, where the low risk and high risk zones should be, where the suspected cases should be housed and where the confirmed cases should be housed. We determined where the latrines and the burning pit should be, and we determined where the various changing rooms for the health staff should be.
Fortunately, by the following day, the patient’s blood test returned negative, and things in Mbarara quickly returned to normal. Steadily, the outbreak was contained and there were fewer and fewer reports of patients suffering strange febrile illnesses. The isolation ward remained essentially as was. On October 4, after the requisite 42 days had passed from the last confirmed case, (twice the maximum period of time between contracting the virus and the onset of symptoms), Uganda was declared officially Ebola-free. However, the respite would be brief…