Despite the Yellow Fever disease being endemic in Africa, in Uganda identifying a patient suffering from it takes several tests which usually follow failure to detect Malaria and other common infections.
The Assistant Commissioner for Disease Surveillance in the Ugandan ministry of health, Dr. Michael Mwanga, says there is no specific treatment for yellow fever; only supportive treatment is available to manage symptoms. Without treatment, up to 50% of severely affected persons die but there is a vaccine which provides life-time protection against the disease.
He explains that yellow fever is an acute viral hemorrhagic disease transmitted by infected mosquitoes. The “yellow” refers to the jaundice that affects some patients. Other symptoms of the disease include fever, headache, muscle pain, nausea, vomiting and fatigue, Dr Mwanga explains.
He says the disease is transmitted from humans to humans or from animals to humans by Aedes mosquitos. Its treatment is generally supportive care as there is no antiviral drug available for it. In severe cases, hospitalization is required to administer fluids, manage blood pressure and to replace blood in case of blood loss.
The disease is endemic in tropical areas in Africa where Uganda lies and is considered to be a re-emerging disease due to increasing reports of its occurrence in different parts of the world in the recent years.
According to the global yellow fever report by the US Centers for Disease Control 2021, the number of yellow fever cases Worldwide has increased over the past 20 years. This might be attributable to multiple factors, including declining population immunity to infection, increased human activities such as deforestation, urbanization, population movements and climate change. In 2013, the disease affected an estimated 130,000 people and caused about 78,000 deaths in Africa.
To continue protecting its people, Uganda launched the third Edition of the National Guidelines for Integrated Diseases Surveillance and Response (IDSR) in Kampala in September 2021. It highlights new methods of disease detection, reporting and provision of real-time surveillance data using new technologies and platforms.
The platforms include event-based disease surveillance, community-based surveillance, one health approach, cross-border surveillance, and electronic IDSR to improve disease surveillance in Uganda at all levels.
The IDSR guidelines incorporates lessons learnt from previous epidemics, new frameworks like the Global Health Security Agenda (GHSA), One Health, Disaster Risk Management (DRM), the World Health organization (WHO) regional strategy for health security and emergencies, and the rising non-communicable diseases, and aims to strengthen implementation of IHR (2005) core surveillance and response capacities. These guidelines have been adapted to reflect national priorities, policies and public health structures.
Under the IDSR, investigation of an acute yellow fever outbreak is made as quickly as possible. It starts with case management by trained health officers, picking samples and following up on them, risk communication by health educators after orientation, community outreaches through village health teams (VHTs) who coordinate directly with the communities to do contact tracing and then the laboratory tests at Uganda Virus Research Institute (UVRI) subsequently identifying the cases which are then managed.
According to Dr. Mwanga, as of August 2022, the health ministry had enrolled 33 surveillance entomologists who study the vector-insects through conducting intensive active search in over 1000 health facilities.
The aim is to strengthen indicator-based surveillance, event-based surveillance, improving community-based disease surveillance, improving cross border surveillance and response, improving reporting and information sharing platforms, improved data sharing across sectors and tailoring IDSR to emergency or disaster contexts.
The IDSR tool is used by health workers at all levels of public and private settings, National Focal Points, health authorities at Points of Entry, Hospital managers, clinicians, infection prevention and control officers, national and regional reference laboratories, district health teams, health training institutions and community leaders.
According to Dr. Mathias Lugoloobi, the Wakiso District Health Officer, tracking victims can be a lengthy, complex exercise which requires a thorough check of history of patient’s travel records, family and all other contacts. It is very key for family because since the virus is spread by a mosquito, they may also have been bitten by the same mosquito.
“Prioritizing family testing is very important if we are to trace all contacts of the victim. We always contact our VHTs who are always on standby to go down to the villages and trace all these contacts from whom we get samples which are then sent to the Uganda Virus Research institute to ascertain the numbers of those infected,” he adds.
Dr. Lugoloobi says the IDSR strategy has been of great impact in Wakiso district during the 2021 yellow fever outbreak where five yellow fever cases were confirmed out of which one was a contact to one of the original victims.
The cases were all found to have recently travelled and, therefore, imported the virus in to the district however the swift response of the district’s health team was able to mitigate a wide spread and none of the victims lost their lives, thanks to the IDSR strategy which enabled quick detection, surveillance and response.
The Wakiso district health team has a surveillance team of 25 clusters. Each cluster has members and each village is covered by at least five VHTs. The VHTs and health teams coordinate with other neighboring district teams and the central disease surveillance team since Wakiso districts forms part of the Kampala metropolitan regional public health emergency centre, which is now regularly active.
One of the cases in Wakiso only identified as Margaret says she at first thought she was suffering from ulcers.” When I went to see the doctor at Masuulita Health Centre IV, the doctor said he was drawing a blood sample, I didn’t understand because I knew I had ulcers but to my shock days later when the results came in, I was informed that I had yellow fever. I was enrolled on treatment and got better with time” she says.
Margaret says she doesn’t visit health facilities that regularly due to transportation costs given the remote area she lives in but is very glad that she took the decision to visit a health center this time round. “Who knows? I could have died. I thank the health workers for their timely response and ensuring that my entire family was safe,” she narrates.
The largest yellow fever outbreak in Uganda affected 181 people and resulted in 45 deaths in northern Uganda in 2010.
Since 2000, surveillance for yellow fever in Uganda has been conducted through the IDSR strategy. This strategy enables timely detection of and response to outbreaks to prevent further spread.
Over the years, there has been improved completeness and timeliness of reporting, case detection and data analysis and better response to disease outbreaks as key achievements following the implementation of the new strategy.
To address persistent inconsistencies and inadequacies in the core and support functions of IDSR, Uganda initiated an IDSR revitalization programme in 2012. The objective of this evaluation was to assess IDSR core and support functions after implementation of the revitalised IDSR programme.
On 26 March 2016, the IDSR focal person in Masaka District, southern Uganda, alerted the Public Health Emergence Operations Center (PHEOC) of the Ministry of Health (MoH) that within a one-month period, three men from the same extended family had died of a “strange disease” with bleeding symptoms.
Fearing an outbreak of a viral hemorrhagic fever (VHF), the MoH immediately activated the VHF response plan, established an isolation unit at the Masaka Regional Referral Hospital, and initiated active case-finding.
Six blood samples were collected from patients at the isolation unit and tested for Ebola Virus, Marburg Virus, Crimean-Congo Hemorrhagic Fever, and Rift Valley Fever in the Viral Special Pathogen Laboratory at the Uganda Virus Research Institute (UVRI).
However, the samples tested negative for all the tested VHFs. Based on the clinical presentation of the patient and the initial laboratory results, the reserved samples were then sent to the Arbovirus laboratory for further testing including yellow fever testing.
On 8 April 2016, three samples from Masaka District tested positive for yellow fever by both PCR and IgM antibody tests. On 9 April 2016, MoH declared a yellow fever outbreak and launched an outbreak response. After the declaration, another cluster of cases was reported in Rukungiri District, southwestern Uganda.
Subsequently, four years after the Masaka outbreak, another outbreak occurred in Uganda from 4 November, 2019 through 14 February 2020, eight laboratory confirmed cases of yellow fever in Buliisa (3), Maracha (1) and Moyo (4); including four deaths (50% case fatality rate), were detected through the national surveillance system.
The very first case this time was reported on 10th December 2019 when the Ministry of Health (MoH) was notified by the UVRI Regional Reference Laboratory of a case of yellow fever confirmed by reverse-transcriptase polymerase chain reaction (RT-PCR).
The case was a 37-year-old male with suspected VHF. His occupation was cattle farming with a history of travel to trade milk between Kizikya cell, Buliisa district in Uganda and the Democratic Republic of Congo (DRC).
On 30 October 2019, he visited hospital with symptoms of fever and headache of a five-day duration.
His symptoms worsened with vomiting, abdominal pain and epistaxis and he died on 4 November 2019. During an in-depth investigation in December, eight samples were collected from close contacts, including family members and neighbours, and tested for yellow fever.
On 22 January 2020, UVRI notified the MoH of a second case of yellow fever confirmed by serological testing (IgM and PRNT) in Buliisa with connection to the index case and with similar occupation. The other samples collected during investigation were negative for yellow fever.
Two other confirmed cases of yellow fever were identified in Moyo district in West Nile region which shares a border with South Sudan. The cases were aged 18 and 21 years, traded timber between Uganda and South Sudan and spent time in both countries. Onset of illness for both cases was 3 January 2020 and they were admitted at a Health Center in Moyo District.
They were later referred to a General Hospital with symptoms of fever, vomiting, diarrhoea, fatigue, headache, abdominal and joint pains, confusion and unexplained bleeding.
The patients conditions worsened and died in the hospital on 5 and 6 January 2020. Results from UVRI confirmed yellow fever infection by RT-PCR performed at UVRI.
Subsequently, Moyo district notified a second cluster of suspected and confirmed yellow fever infection in a different village. The confirmed case in the suspected cluster was a 59-year-old patient who presented with symptoms including unexplained bleeding and fever on 22 January and died on 23 January 2020. A blood sample collected tested positive for yellow fever by RT-PCR at UVRI. His death was preceded by the death of two of his family members in early January with similar symptoms.
The Minister of Health, Dr. Jane Ruth Aceng, declared an outbreak of yellow fever on 23 January 2020. It was then that the National rapid response teams swung in to action with massive deployments in Moyo and Buliisa districts to conduct further investigations and initiate outbreak response.
Other response activities included enhancing surveillance and active case finding in all districts in the north-west region, and entomological surveys in the affected districts of Buliisa and Moyo. Cross-border notification with South Sudan in reference to the cases in Moyo district was done, she says.
A reactive campaign was then launched, approved by the International Coordinating Group on Vaccine Provision for Yellow Fever Control targeting approximately 1.7 million people to stop transmission and prevent imminent risk of the outbreak spreading in the north-west part of country particularly in Buliisa, Koboko, Maracha, Moyo and Yumbe districts.
To achieve sustained protection across the country, the MoH took on preparations for introducing yellow fever vaccination into the routine immunization programme in 2021 as well as the implementation of preventive mass vaccination campaigns nationally.
The State Minister of Health in Charge of General Duties, Hon. Anifa Bangirana Kawooya, noted during the launch of the IDSR third edition that, “We are working in tricky times when a disease in one country can easily cross to another, therefore with these IDSR guidelines in place, we should equip our systems to detect and respond to diseases effectively.”
The WHO Representative to Uganda, Dr. Yonas Tegegn Woldemariam, noted that IDSR is a cost-effective public health method.
“Africa is challenged by recurrent disease outbreaks. These guidelines provide an opportunity to build resilient systems and contribute to attaining the SDGs. COVID-19 has taught us enough about building resilience and preparation for disease outbreaks and we ought to do that,” he said.
Although the revitalized IDSR program in Uganda has been associated with improvements in performance; Dr. Mwanga says that the program still faces significant challenges and some performance indicators are still below the target. “It is important that the documented gains are consolidated and challenges are continuously identified and addressed as they emerge” he stresses.
Dr. Mwanga says the limited financial support also still cripples the strategy implementation that has over these years proven a great potential. He says they are very optimistic about the strategy which has a targeted goal of 2030 to wipe out neglected diseases such as yellow fever.
Dr. Mwanga notes that IDSR strategy is quite broad and deals with all outbreaks, especially VHF with epidemic potential such as yellow fever, but operate on meager resources as well as unclear policy specifications which guide how they respond which sometimes delays response in affected areas.
“The ministry of health leverages on support and interventions by support partners such as USAID and CDC. However, the government has of late stepped up, injecting in a lot of funding, looking at prevention and managing yellow fever in hospitals,” he adds.
The ministry now targets all 14 regions in the country first looking at Bunyoro region, Ssezibwa, Masaka, Karamoja, Lango, West Nile, and Kampala metropolitan area, among others, where they hope to start a mass vaccination as a prevention strategy. “The strategy is to detect disease outbreak early for early response and minimize spread, from community to regional, national and cross-border levels. Actually the whole of Africa is integrating as a means of mitigating effects of out breaks,” he said.
Dr. Mwanga notes that the strategy skills health workers at community level, support supervision and mentorship from community to district and regional level equipping them on how to prevent, detect and respond.
IDSR strategy looks at outbreaks, tracks them and provides adequate response; they also follow the trend to see whether numbers are increasing or decreasing and advise response teams on how to mitigate.
The WHO intends to roll out vaccination in Kampala metropolitan areas together with the Government of Uganda at the end of this year or beginning of 2023 as a preventive measure. This follows intensive social mobilization in communities with the WHO as a key partner on yellow fever mitigation.
Mr. Mawejje Edward Titus, the surveillance focal person for Masuulita Sub county, Namayumba health sub district in Wakiso district, where one of the cases was detected, says they were enabled as front line workers after they tracked the victim for a while. A test was carried out at UVRI and it was confirmed that she had yellow fever and she was subsequently enrolled on treatment. All her contacts turned out negative, he says.
Dr. Mwanga says there are many success stories especially at boarder districts where IDSR impact has been very visible citing refugees crossing to Uganda with the virus but they are mitigated early enough before they spread it amongst their host communities.
Mawejje points out that the challenge of the dynamic population that they work with is that “these people often live in one district but work in another making surveillance and tracking hard.” He adds that the other challenges include the inadequate number of trained staff, funding, irregular supervision, and lack of key logistics.
The delayed results from tests taken at the UVRI is a huge challenge, too, because the time factor is important in health service delivery. Also problematic are some private clinics which intentionally give wrong diagnosis in order to keep patients for long to earn more from the hapless victims, also hinders the IDSR strategy goal of early detection, Mawejje says.
Dr. Mwanga concludes that improving IDSR efficiency and effectiveness will require intensified pre-service and community training including private clinic owners, mentorship, regular supervision or inspection and improving funding at the district level.