Strategies from the 2000–01 Ebola outbreak in Uganda

AbstractBackgroundAn outbreak of Ebola virus disease was reported from Gulu district, Uganda, on Oct 8, 2000. Over a period of 3 months, the outbreak spread to two other parts of the country, namely Mbarara and Masindi districts. Response measures included surveillance, community mobilisation, and case and logistics management. Three coordination committees were formed: the National Task Force (NTF), the District Task Force (DTF), and the 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. This study documents this experience and draws lessons that are of interest to the rest of the world.MethodsThe international response was coordinated by the WHO under the umbrella organisation of the Global Outbreak and Alert Response Network. A WHO and Centers for Disease Control and Prevention case definition for Ebola was adapted and used to capture four categories of cases: alert cases, suspected cases, probable cases, and confirmed cases. Guidelines for identification and management of cases were developed and disseminated to people responsible for surveillance, case management, contact tracing, and information, education, and communication.FindingsFor the duration of the epidemic that lasted to Jan 16, 2001, 425 cases with 224 deaths were reported throughout Uganda. The case fatality rate was 53%. The attack rate (AR) was highest in women. The average AR for Gulu district was 12·6 cases per 10 000 inhabitants when the contacts of all cases were considered, and was 4·5 cases per 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 free of Ebola on Feb 27, 2001, 42 days after the last case was reported. The Government's role in coordination of both local and international support was of huge importance. The NTF and the corresponding district committees worked closely in the harmonised implementation of the mutually agreed programme. Community mobilisation using community-based health workers, cultural and religious leaders, and Members of Parliament was effective in transmitting information to the public.InterpretationPast experience in epidemic management shows that, in the absence of free availability of information to the public, rumours that are unhelpful to epidemic control efforts prevail and spread quickly. During this outbreak in Uganda, rumour was managed by frank and open discussion of the epidemic, daily updates, fact sheets, and press releases. Information was regularly disseminated to communities through mass media and press conferences. Community mobilisation and transmission of information to the public was critical in controlling the epidemic. All levels of the community spontaneously demonstrated solidarity and response to public health interventions—even in areas of relative insecurity, where the number of rebel abductions dropped considerably during the outbreak.FundingNone

Contact investigation for active tuberculosis among child contacts in Uganda.

BACKGROUND: Tuberculosis is a large source of morbidity and mortality among children. However, limited studies characterize childhood tuberculosis disease, and contact investigation is rarely implemented in high-burden settings. In one of the largest pediatric tuberculosis contact investigation studies in a resource-limited setting, we assessed the yield of contact tracing on childhood tuberculosis and indicators for disease progression in Uganda. METHODS: Child contacts aged <15 years in Kampala, Uganda, were enrolled from July 2002 to June 2009 and evaluated for tuberculosis disease via clinical, radiographic, and laboratory methods for up to 24 months. RESULTS: Seven hundred sixty-one child contacts were included in the analysis. Prevalence of tuberculosis in our child population was 10%, of which 71% were culture-confirmed positive. There were no cases of disseminated tuberculosis, and 483 of 490 children (99%) started on isoniazid preventative therapy did not develop disease. Multivariable testing suggested risk factors including human immunodeficiency virus (HIV) status (odds ratio [OR], 7.90; P < .001), and baseline positive tuberculin skin test (OR, 2.21; P = .03); BCG vaccination was particularly protective, especially among children aged ≤5 years (OR, 0.23; P < .001). Adult index characteristics such as sex, HIV status, and extent or severity of disease were not associated with childhood disease. CONCLUSIONS: Contact tracing for children in high-burden settings is able to identify a large percentage of culture-confirmed positive tuberculosis cases before dissemination of disease, while suggesting factors for disease progression to identify who may benefit from targeted screening

How Uganda Reversed Its HIV Epidemic

Uganda is one of only two countries in the world that has successfully reversed the course of its HIV epidemic. There remains much controversy about how Uganda's HIV prevalence declined in the 1990s. This article describes the prevention programs and activities that were implemented in Uganda during critical years in its HIV epidemic, 1987 to 1994. Multiple resources were aggregated to fuel HV prevention campaigns at multiple levels to a far greater degree than in neighboring countries. We conclude that the reversed direction of the HIV epidemic in Uganda was the direct result of these interventions and that other countries in the developing world could similarly prevent or reverse the escalation of HIV epidemics with greater availability of HIV prevention resources, and well designed programs that take efforts to a critical breadth and depth of effort

Newly discovered Ebola virus associated with hemorrhagic fever outbreak in Uganda

In this report we describe a newly discovered ebolavirus species which caused a large hemorrhagic fever outbreak in western Uganda. The virus is genetically distinct, differing by more than 30% at the genome level from all other known ebolavirus species. The unique nature of this virus created challenges for traditional filovirus molecular based diagnostic assays and genome sequencing approaches. Instead, we quickly determined over 70% of the virus genome using a recently developed random-primed pyrosequencing approach that allowed the rapid development of a molecular detection assay that was deployed in the disease outbreak response. This draft sequence allowed easy completion of the whole genome sequence using a traditional primer walking approach and prompt confirmation that this virus represented a new ebolavirus species. Current efforts to design effective diagnostics, antivirals and vaccines will need to take into account the distinct nature of this important new member of the filovirus family

Uganda's HIV Prevention Success: The Role of Sexual Behavior Change and the National Response

There has been considerable interest in understanding what may have led to Uganda's dramatic decline in HIV prevalence, one of the world's earliest and most compelling AIDS prevention successes. Survey and other data suggest that a decline in multi-partner sexual behavior is the behavioral change most likely associated with HIV decline. It appears that behavior change programs, particularly involving extensive promotion of “zero grazing” (faithfulness and partner reduction), largely developed by the Ugandan government and local NGOs including faith-based, women’s, people-living-with-AIDS and other community-based groups, contributed to the early declines in casual/multiple sexual partnerships and HIV incidence and, along with other factors including condom use, to the subsequent sharp decline in HIV prevalence. Yet the debate over “what happened in Uganda” continues, often involving divisive abstinence-versus-condoms rhetoric, which appears more related to the culture wars in the USA than to African social reality

Zoonotic disease research in East Africa

Abstract Background The East African region is endemic with multiple zoonotic diseases and is one of the hotspots for emerging infectious zoonotic diseases with reported multiple outbreaks of epidemic diseases such as Ebola, Marburg and Rift Valley Fever. Here we present a systematic assessment of published research on zoonotic diseases in the region and thesis research in Kenya to understand the regional research focus and trends in publications, and estimate proportion of theses research transitioning to peer-reviewed journal publications. Methods We searched PubMed, Google Scholar and African Journals Online databases for publications on 36 zoonotic diseases identified to have occurred in the East Africa countries of Burundi, Ethiopia, Kenya, Tanzania, Rwanda and Uganda, for the period between 1920 and 2017. We searched libraries and queried online repositories for masters and PhD theses on these diseases produced between 1970 and 2016 in five universities and two research institutions in Kenya. Results We identified 771 journal articles on 22, and 168 theses on 21 of the 36 zoonotic diseases investigated. Research on zoonotic diseases increased exponentially with the last 10 years of our study period contributing more than half of all publications 460 (60%) and theses 102 (61%) retrieved. Endemic diseases were the most studied accounting for 656 (85%) and 150 (89%) of the publication and theses studies respectively, with publications on epidemic diseases associated with outbreaks reported in the region or elsewhere. Epidemiological studies were the most common study types but limited to cross-sectional studies while socio-economics were the least studied. Only 11% of the theses research transitioned to peer-review publications, taking an average of 2.5 years from theses production to manuscript publication. Conclusion Our findings demonstrate increased attention to zoonotic diseases in East Africa but reveal the need to expand the scope, focus and quality of studies to adequately address the public health, social and economic threats posed by zoonoses

The Impact of Socio-Demographic and Religious Factors upon Sexual Behavior among Ugandan University Students

INTRODUCTION: More knowledge is needed about structural factors in society that affect risky sexual behaviors. Educational institutions such as universities provide an opportune arena for interventions among young people. The aim of this study was to investigate the relationship between sociodemographic and religious factors and their impact on sexual behavior among university students in Uganda. METHODS: In 2005, 980 university students (response rate 80%) were assessed by a self-administered questionnaire. Validated instruments were used to assess socio-demographic and religious factors and sexual behavior. Logistic regression analyses were applied. RESULTS: Our findings indicated that 37% of the male and 49% of the female students had not previously had sex. Of those with sexual experience, 46% of the males and 23% of the females had had three or more sexual partners, and 32% of the males and 38% of the females did not consistently use condoms. For those who rated religion as less important in their family, the probability of early sexual activity and having had a high number of lifetime partners increased by a statistically significant amount (OR = 1.7; 95% CI: 1.2-2.4 and OR = 1.6; 95% CI: 1.1-2.3, respectively). However, the role of religion seemed to have no impact on condom use. Being of Protestant faith interacted with gender: among those who had debuted sexually, Protestant female students were more likely to have had three or more lifetime partners; the opposite was true for Protestant male students. CONCLUSION: Religion emerged as an important determinant of sexual behavior among Ugandan university students. Our findings correlate with the increasing number of conservative religious injunctions against premarital sex directed at young people in many countries with a high burden. of HIV/AIDS. Such influence of religion must be taken into account in order to gain a deeper understanding of the forces that shape sexual behavior in Uganda

Relatively Low HIV Infection Rates in Rural Uganda, but with High Potential for a Rise: A Cohort Study in Kayunga District, Uganda

BACKGROUND: Few studies have been conducted in Uganda to identify and quantify the determinants of HIV-1 infection. We report results from a community-based cohort study, whose primary objectives were to determine HIV-1 prevalence, incidence, and determinants of these infections, among other objectives. METHODOLOGY: Consenting volunteers from the rural district of Kayunga in Uganda aged 15-49 years were enrolled between March and July 2006. Participants were evaluated every six months. A questionnaire that collected information on behavioral and other HIV-1 risk factors was administered, and a blood sample obtained for laboratory analysis at each study visit. PRINCIPAL FINDINGS: HIV-1 prevalence among the 2025 participants was 9.9% (95% CI = 8.6%-11.2%). By the end of 12 months of follow-up, 1689.7 person-years had been accumulated, with a median follow-up time of 11.97 months. Thirteen HIV-1 incident cases were detected giving an annual HIV-1 incidence of 0.77% (95% CI = 0.35-1.19). Prevalence of HSV-2 infection was 57% and was strongly associated with prevalent HIV-1 infection (adjusted Odds Ratio = 3.9, 95% CI = 2.50-6.17); as well as incident HIV-1 infection (adjusted Rate Ratio (RR) = 8.7, 95% CI = 1.11-67.2). The single most important behavioral characteristic associated with incident HIV infection was the number of times in the past 6 months, a participant had sex with person(s) they suspected/knew were having sex with others; attaining statistical significance at 10 times and higher (adjusted RR = 6.3, 95% CI = 1.73-23.1). By the end of 12 months of follow-up, 259 participants (13%) were lost to follow-up, 13 (0.6%) had died, and 2 (0.1%) had withdrawn consent. CONCLUSIONS: Despite relatively low HIV-1 incidence observed in this community, prevalence remains relatively high. In the presence of high prevalence of HSV-2 infection and the behavioral characteristic of having sex with more than one partner, there is potential for increase in HIV-1 incidence

Human Fatal Zaire Ebola Virus Infection Is Associated with an Aberrant Innate Immunity and with Massive Lymphocyte Apoptosis

Ebolavirus, especially the species Zaïre (ZEBOV), causes a fulminating hemorrhagic fever syndrome resulting in the death of most patients within a few days. In vitro studies and animal models have brought some insight as to the immune responses to ZEBOV infection. However, human immune responses have as yet been poorly investigated, mainly due to the fact that most outbreaks occur in remote areas of central Africa. Published studies, based on small numbers of biological samples have given conflicting results. We studied a unique collection of 50 blood samples obtained during five outbreaks that occurred between 1996 and 2003 in Gabon and Republic of Congo. We measured the plasma levels of 50 soluble factors known to be involved in immune responses to viral diseases. For the first time, using a cell staining technique, we analyzed circulating lymphocytes from ZEBOV-infected patients. We found that fatal outcome in humans is associated with aberrant innate immunity characterized by a “cytokine storm,” with hypersecretion of numerous proinflammatory mediators and by the noteworthy absence of antiviral interferon. The adaptive response is globally suppressed, showing a massive loss of CD4 and CD8 lymphocytes and the immune mediators they produce. These findings may have important pathological and therapeutic implications