The epidemiology of three back to back filovirus outbreaks in central western uganda 2012
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The Epidemiology of Three Back-to-Back Filovirus Outbreaks in Central & Western Uganda, 2012. Joseph F. Wamala, MD, MPH Senior Epidemiologist, Uganda Ministry of Health The Fifth AFENET Conference, UN Convention Centre – Addis Ababa, Ethiopia 17 – 21 November 2013. Presentation outline.

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The Epidemiology of Three Back-to-Back Filovirus Outbreaks in Central & Western Uganda, 2012

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The epidemiology of three back to back filovirus outbreaks in central western uganda 2012

The Epidemiology of Three Back-to-Back Filovirus Outbreaks in Central & Western Uganda, 2012

Joseph F. Wamala, MD, MPH

Senior Epidemiologist,

Uganda Ministry of Health

The Fifth AFENET Conference, UN Convention Centre – Addis Ababa, Ethiopia

17 – 21 November 2013


Presentation outline

Presentation outline

  • Background

  • Objectives and rationale

  • Investigation methods

  • Description of the 2012 FHF outbreaks in Uganda

  • Conclusions & recommendations

  • Acknowledgements


Background

Background

  • International public health security is essential for the globalised world (WHO, 2008)

  • Global threat of emerging & re-emerging infectious diseases like Filovirus hemorrhagic fevers [FHF] of Ebola and Marburg is escalating (Jones et al., 2008)

  • Uganda located in the Congo basin - a major hotspot for emerging & reemerging disease like FHF (Jones et al., 2008)

    World Health Organization. (2008). International Health Regulations (2005) (2nd ed). Switzerland, Geneva: WHO Press.

    Jones, K. E., et al (2008). Global trends in emerging infectious diseases. Nature, 451(7181), 990-993. doi:http://dx.doi.org/10.1038/nature06536


Background1

Background...

  • Uganda has experienced escalating Filovirus outbreaks in recent years (Mbonye et al., 2013)

  • 8 FHF outbreaks in the last 12 years

    • Ebola: 2000, 2007, 2011, 2012a, 2012b

    • Marburg: 2007, 2008, 2012

  • FHF outbreaks increasing in frequency

    • 3 FHF outbreaks in five districts in 2012 alone

      Mbonye, A., et al (2013). Repeated outbreaks of Viral hemorrhagic fevers in Uganda. African Health Sciences, 12(4): 579-583. http://dx.doi.org/10.4314/ahs.v12i4.31


Filovirus hemorrhagic fevers fhf

Filovirus hemorrhagic fevers [FHF]

  • Family: Filoviridae

  • Reservoir:

    • Ebola virus: forest-dwelling fruit eating bats

    • Marburg virus: cave-dwelling fruit eating bats

  • Transmission: person-to-person spread

  • Incubation period: 3-21 days

  • Clinically: initially non-specific; ~45% bleeding , high CFR [53-90%]

  • Treatment: supportive

  • Control: infection control, follow contacts

    Ebola hemorrhagic fever in Sudan, 1976. Report of a WHO/International StudyTeam. Bull World Health Organ. 1978;56:247–70.

    Ebola hemorrhagic fever in Zaire, 1976. Bull World Health Organ. 1978;56:271–93


Fhf 2012 investigation objective

FHF 2012 - Investigation objective

  • Describe the epidemiology of the 2012 Filovirus outbreaks in Uganda to inform interventions for disease prevention and control within the context of the Integrated Disease Surveillance strategy and the International Health Regulations of 2005 [IHR (2005)]


Methods

Methods

  • Rapid response teams deployed to investigate and initiate response interventions

  • Standard & working case definitions were used to identify FHF cases

  • Standardised FHF case investigation forms used to obtain epidemiological information

  • Blood & skin snips obtained for testing at the Uganda Virus Research Institute [UVRI] using standardised WHO/CDC FHF laboratory protocols


Methods1

Methods....

  • Suspect FHF cases were actively sought among contacts

  • All new suspect FHF cases were promptly isolated and started on supportive therapy

  • All FHF case & contact data were entered into a centrally managed database

  • Regular epidemiological analyses were disseminated to guide national response


Enhancing local response capacities

Enhancing Local Response Capacities

  • Trainings were conducted to

    • Enhance local coordination & response

    • Enhance infection control in health facilities & at community level

    • Enhance local capacities for case management & barrier nursing


Ebola central western uganda

FHF outbreaks in Uganda, 2012

Ebola - Central& western Uganda


Index case investigations ebola kibaale western uganda 2012

Index Case Investigations, Ebola Kibaale, Western Uganda - 2012

16 yr; Female; Kikaara village, Buchuhya Parish, Bubango sub-county

Subsequently admitted to hospital – not isolated

Unsupervised Burial of Index case

Death of Index Case in hospital

Treatment at Local HC

Discharged & stays with in-laws

June 13-17 & 18-19th , 2012

June 12, 2012

June 19, 2012

June 21, 2012

Onset of illness


Index case investigations ebola central uganda 2012

Index Case Investigations - Ebola Central Uganda, 2012

Subsequent care at Bombo GMH

30 yr; Male; Kakute village, Ssambwe Parish, Nyimbwa s-county

Un supervised burial of Index case

Death of Index Case at Bombo GMH

Treatment at local HC

Oct. 20-23, 2012

Oct. 13, 2012

Oct. 14-19, 2012

Oct. 23, 2012

Oct. 24, 2012

Onset of illness


All ebola cases uganda 2012

All Ebola cases- Uganda, 2012

  • Overall, there were 24 cases in Western Ug. & 7 cases in Central Ug. with

  • CFR of 57% in Central Ug. & 71% in Western Ug.


Ebola epidemic curve western uganda 2012

Ebola Epidemic Curve –Western Uganda, 2012

Cluster of cases among in-laws to index case

DHO reports strange illness to MoH


Ebola epidemic curve central uganda 2012

Ebola Epidemic Curve –Central Uganda, 2012


Ebola case distribution by sex 2012

Ebola case distribution by sex, 2012

  • 80% of probable/ confirmed casesin Kibaale (Western Ug.) were females

  • Case distr. by sex was nearly even in Luwero (Central Ug)


Ebola case distribution by age 2012

Ebola case distribution by Age, 2012

  • Majority [46-86%] of the cases were 20-39 years of age


Ebola symptoms western uganda 2012

Ebola Symptoms – Western Uganda, 2012

  • Ebola case symptoms were largely non-specific

  • Unexplained bleeding reported in 54% cases & was often late & not overt


Map ebola cases in western uganda 2012

Map Ebola cases in Western Uganda, 2012

Epicentre with majority being contacts (also in laws) to the index case

Caves with bats

Index case


Marbug in western uganda

FHF outbreaks in Uganda, 2012

MARBUG in western Uganda


Marburg index case investigations uganda 2012

Marburg Index Case Investigations – Uganda, 2012

Kafunzo III village Ibanda: Cluster –[3 confirmed; 6probable/deaths]

Burial of Kabale Index case

Onset Index case for Kabale

Death of Kabale index Case at Kabale RRH

Treatment at Ibanda hospital /TBA

Sept 3, 2012

July 20, 2012

Sep 20, 2012

Sep. 22, 2012

Late July-Early Aug. 2012

Onset of illness


All marburg cases western uganda 2012

All Marburg cases – Western Uganda, 2012

Overall, there were 14 cases each in each of the two districts in Western Uganda with CFR of 50-57%


Marburg epidemic curve uganda 2012

Marburg Epidemic Curve- Uganda, 2012


Marburg epidemic curve uganda 20121

Marburg Epidemic Curve- Uganda, 2012


Marburg cases by sex uganda 2012

Marburg cases by sex - Uganda, 2012

  • The majority [60-69%] of the cases were females


Marburg cases by age uganda 2012

Marburg cases by age – Uganda, 2012

  • Majority [50%] of the cases were 20-39 years of age


Marburg case symptoms uganda 2012

Marburg case symptoms – Uganda, 2012

  • Symptoms largely non-specific

  • Bleeding reported in 39%


Map marburg cases uganda 2012

Map Marburg cases - Uganda, 2012

DR

CONGO

Kampala

DRCONGO

Tanzania

Kitaka Mines

Lake Victoria

Tanzania


Marburg risk factors uganda 2012

Marburg Risk Factors – Uganda, 2012

  • Exposures assessed

    • Travel to affected areas, contact with case, participating in funeral, nursing a case, visiting spiritual/native healers, contact with wild animal

  • Significant risk factors included

    • Contact with a case AOR5.3 (1.9-14.8); p<0.001

    • Participating in funeral AOR33.4 (4.3-256.7); p<0.0001


Conclusions

Conclusions

  • Uganda experienced three (3) FHF outbreaks in 2012

    • Ebola: Kibaale & Luwero

    • Marburg: Ibanda, Kabale, Kamwenge

    • Cases were more likely to have been exposed to another case or to have participated in a funeral

  • Uganda remains prone to the two FHF outbreaks

    • Source of the Ebola outbreaks not identified

    • Marburg outbreak linked to mining activity in Kitaka


Recommendations

Recommendations

  • Surveillance for FHF should be enhanced

    • Strengthen Clinical & lab diagnostic capacities & specimen referral at all levels

    • Surveillance for clusters of strange illnesses/deaths at community level

  • Research into FHF ecology & risk factors for introduction of FHFs into human populations

  • Regulation of mining activities in Western Uganda


Acknowledgements

Acknowledgements

  • Ministry of Health

  • The District Local Governments

  • World Health Organization

  • Centres for Disease Control and prevention

  • African Field Epidemiology Network

  • Medecins Sans Frontiers

  • USAID

  • Uganda Red Cross Society

  • All other partners


Thank you

Thank You


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