By Namiganda Jael
In August 2020, Mr. Mark Oguma Oguti, and his daughter Claudia, were thrilled when they received news about the launch of the Yellow Fever Vaccination campaign in their area.
Indeed, when the vaccination campaign rolled out in West Nile region, Oguti and his daughter were among the first people to be vaccinated. They were followed by hundreds of others who gathered at the Moyo Town Council headquarters to receive the jab.
The vaccination exercise targeted about 1.6 million people, including children. According to Dr. Nsubuga Fred, the Uganda National Expanded Program on Immunization (UNEPI) senior Medical Officer, division of vaccines and immunization, and the Yellow Fever focal person, the campaign was a complete success ‘since the outbreak was managed with no new infections’. He says the campaign recorded a 92 percent success rate.
According to the Quarterly Epidemiological Bulletin,July to September 2020 Volume 5
Issue 3 Article, on 10 December 2019, the Ministry of Health received an alert from the Uganda Virus Research Institute (UVRI) of a confirmed case of Yellow fever from Buliisa District, Mid-Eastern Uganda.
During January and February 2020, UVRI confirmed more yellow fever cases in Moyo and Maracha Districts, both located in West Nile. “We investigated to determine the scope of the outbreak, identify exposures for transmission, and recommend evidence- based control and prevention measures. We line listed 13 case-patients, 7 confirmed, and 6 probable”, says Dr Nsubuga.
The median age of case-patients was 32 years, with a range of 3 to 59 years. Moyo District had the highest attack rate of 5.7(9/158,600), followed by Buliisa, 2(3/149,300), and Maracha, 0.48 (1/208,300). The overall case fatality rate was 54%. Men had the highest attack rate of 3.9/100,000 compared to women 1.2/100,000. Common symptoms reported were fever (100%), headache (77%), unexplained bleeding (54%), and jaundice, vomiting, joint pain, chest pain each at 31%.
Reports show that majority (92%) lived or worked within 500 meters of a forested area with monkeys and standing water. There was very close interaction of humans with sylvatic monkeys in 54% of the case-patients who lived within 10 meters of monkey inhabited forested areas and hunted them for food.
These outbreaks were possibly sylvatic, affecting unvaccinated individuals. Thus medics recommended mass vaccination campaigns in the affected districts and subsequent inclusion of Yellow Fever Vaccine in Uganda’s routine vaccination schedule.
The medics also recommended controlled interaction of humans with wild animals and their habitats and removal of potential mosquito breeding sites.
Dr. Nsubuga, the immunization expert and the Yellow Fever focal person, says the the vaccination exercise was carried out at community centers and various health centers, starting from health center IIs to the regional referral hospitals in the affected regions.
Effective mass mobilization and sensitization of the people for the jab was mounted through local radio stations and through mobile public address announcements.
According to Dr. Alfred Driwale, the UNEPI program manager,, the mass vaccination campaign was rolled out in West Nile in the affected districts. Dr. Driwale reveals that the outbreak followed the sudden death of two young males who dealt in timber in South Sudan. This was confirmed by serological testing, a diagnostic method used to identify antibodies and antigens in a patient’s sample to diagnose infections and to check if a person has immunity to certain diseases.
“The puzzled community, however, thought the disease was witch-craft or some sort of curse from the gods or their ancestors but when health workers swung in to action and drew samples from their contacts and carried out further investigations with UVRI, it was ascertained that there was a yellow fever outbreak in the region,” he narrates.
Yellow fever is an acute viral hemorrhagic disease caused by the yellow fever virus, a single-stranded RNA virus that belongs to the genus Flavivirus. It is transmitted from humans to humans or from animals to humans by Aedes mosquitos, explains Dr. Driwale.
During the same period, there was another outbreak in Buliisa where fishermen straddling between the Democratic Republic of Congo and Uganda also suffered unexplained deaths, Dr. Driwale says.
“In Uganda by law, any unexplained deaths must be investigated with a postmortem; the postmortem in this case confirmed that it was a yellow fever outbreak”, he says. As a result, the two regions were, therefore, prioritized for a mass yellow fever immunization campaign, targeting people aged between nine months and 60 years.
Mark Oguma’s whole family responded to the vaccination campaign, including his elderly mother, who was already above the targeted top age bracket of 60 years. “My wife, my mother, my children and I always ensure that our family benefits from all government vaccination programs,” he asserts.
The yellow fever vaccination campaign was launched by the Ministry of Health, supported by the World Health Organization (WHO), the Global Alliance on Vaccines Initiative (GAVI) and the United Nations Children Fund (UNICEF).
According to Dr. Driwale, Uganda is considered a high-risk country for yellow fever by a comprehensive global strategy to Eliminate Yellow fever Epidemics (EYE).
He says the disease became a global concern following the 2016 urban yellow fever outbreak in Angola, which spread to neighboring countries and generated local transmission, exhausted global emergency stockpiles of vaccine, and highlighted the risk of international spread, as 11 cases were exported to China.
The world health organization yellow fever fact sheet of the year 2019 indicates that Worldwide, the number of yellow fever cases 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.
Dr. Driwale confirms that the mosquitoes which transmit yellow fever are available and widespread in Uganda. “Because it is found in monkeys, the germs can be carried by the mosquitoes from these monkeys to humans and then from human to human. So, if someone came in to the country with it, transmission would be very rapid because the mosquitoes are here in plenty,” he stresses.
He expresses concern that the risk is now even higher due to the increased travels and migrations of people across borders. “One can have lunch in Uganda and have dinner in London and breakfast the next morning in New York. So, you see there is an accelerated transmission of the diseases from people to people and that’s why after the 2016 Angola global transmissions, Yellow fever elimination through vaccination became a global concern,” Dr. Driwale says.
According to Dr. Nsubuga, there is no specific treatment for yellow fever; only supportive treatment to manage symptoms. However, without treatment, up to 50% of severely affected persons die.
Fortunately, he says, yellow fever has a single dose vaccination that lasts a life time.
“Previously it was a travel requirement for travelers and Ugandans had to pay about 25 dollars to get a shot but the Government of Uganda together with global partners have rolled out the first phase of a nationwide mass vaccination campaign to eliminate Yellow fever by 2025,” Dr. Nsubuga explains.
The Ministry of Health applied to GAVI and WHO for the inclusion of the Yellow Fever vaccination into the routine immunization schedule. Having faced 4 outbreaks, Uganda qualified to introduce yellow fever vaccine as a long-term measure to prevent Yellow Fever outbreaks.
Before, only travelers would get the vaccine as a requirement which still stands, for now travelers are encouraged to comply with this travel requirement to ensure that the risk of spread of yellow fever through international travel is minimized. Government has also set up a toll free line to the public 0800-203-033 to report any suspected cases to the nearest health facility
People responded positively by making constant phone calls whenever they encountered suspected cases or patients with similar symptoms to those outlined by the health ministry team during the mass sensitization exercise in the affected areas.
According to Dr. Driwale, yellow fever vaccination will now be included in the routine immunization for babies at 9 months while a mass immunization campaign is to be rolled out starting in October this year 2022.
“The yellow fever infections have not been that rampant in children but as a preventive measure to ensure that children are shielded and kept safe, we shall be immunizing all children as a mandatory measure effective October 2022.” Says Dr. Driwale.
Dr. Driwale stresses that they have prioritized the routine immunization for babies whose vaccines have already been secured along with that to cater for the first phase target populations. He is quick to add: “just like all the other vaccines administered during routine immunization for babies, the yellow fever vaccine is safe and effective.”
The nationwide vaccination campaign is to be covered in a phased manner presenting an opportunity to all Ugandans to receive the vaccine free of charge. Children of nine months will receive the vaccine in their routine immunization exercise while older Ugandans of up to 60 years will also receive it during the exercise expected to end by 2025.
Dr. Nsubuga reveals that the first phase is expected to be rolled out in October 2022 will cover six high risk regions including the districts of West Nile that were not reached during the 2020 campaign, Kabale, Kabalore, Hoima, Gulu, Lira and Arua. The second phase will start in October 2023 and the last one in October 2024.
The districts were chosen after a thorough risk assessment singled them out as those with high risk. “We started with a training exercise for all our health workers as well as mass media sensitizations to mobilize the public for the vaccination campaign”, he adds.
Uganda is affected by most diseases with epidemic potential thus the vigorous and constant monitoring and surveillance in communities to detect and eliminate , among others, Yellow fever, Malaria, meningitis, Ebola, Marburg Virus, Cholera and Diarrhea.
They all have a high potential of spreading rapidly and thus a swift response is always required to avoid an outbreak or contain one, he says.
For this, Dr. Driwale says, health workers are trained to flag certain symptoms through these monitoring-where trained and oriented health workers do community investigations, draw blood samples and carry out extensive laboratory tests at the UVRI which helps speculate and subsequently confirming an outbreak if they happen to detect abnormal numbers in certain infections or certain symptoms.
“For any suspicions they may have, our health workers at village and district levels draw the samples and send them to the UVRI for further detailed investigations which will subsequently confirm whether it is indeed an outbreak which will then be announced by the health ministry,” he says.
However, Sister Endreo Aurelia, a nurse in charge of immunization at Moyo General hospital, points out that the COVID-19 vaccination has created mistrust among a few members of the general public towards government immunization programs.
“People think that vaccines are the ones spreading the infection, others that there is a hidden agenda in these mass immunization exercises by the Western world but we continue to educate and inform them that vaccines are here to save their lives,” she says.
Oguti agrees with Sr Endreo, saying that as an elder in the society, he has always sensitized members of his community on the safety and benefits of vaccines. “I always tell them that these vaccines go through various tests before they are given to the public and as such they (vaccines) should not be feared,” he says.
Oguti also adds that when the Ministry of Health introduced the measles-rubella vaccine in 2019, he ensured that all his eligible children received the vaccine, as an example.
“There is no better protection for my family against diseases than vaccination”, he says.
In his remarks at the launch of the yellow fever mass vaccination in Moyo District, the World Health Organization representative to Uganda, Dr Yonas Woldemariam, commended the leadership of the country for embracing vaccine programs.
Dr Yonas said that immunization remains the main strategic approach to prevent, contain and eliminate Yellow fever outbreaks. “High vaccination coverage helps sustain immunity and is key to eliminating the risk of disease outbreaks,” he emphasizes.
The 2022-2025 yellow fever mass immunization campaign aims at eliminating the disease, Dr. Driwale notes. “The downside is that we can only hope for reduction not eradication in humans and minimizing the harm through the vaccine protection because the virus is transmitted by mosquitoes from animals to humans and yet we cannot vaccinate animals, so the virus will always exist in animals,” he explains.
According to Dr. Nsubuga, limited vaccines have hindered a wider coverage. “For now we are rationing what is available for babies’ routine vaccination and we shall start with six regions this year,” he says.
He discloses that so far global partners, such as GAVI, have injected over US$ 9 million for the first phase of the vaccination exercise, translating in to 13.5 million doses, while the government of Uganda has also committed a million dollars to the exercise.
“This is a joint venture between the government of Uganda and its global partners. The vaccines are already secured and the global partners have already provided the seed funds for training of health workers and the mass sensitization of communities,” Dr. Nsubuga asserts.
He is optimistic that the targets of immunizing about 40 million Ugandans against yellow fever by 2025 will be met, given the experiences gainedfrom the Moyo and Buliisa districts mass vaccination exercises in 2019-2020.
“We may be lacking a specific anti-viral drug for yellow fever right now but the good news is that yellow fever is prevented by an extremely effective vaccine, which is safe.
It is single dose that lasts a life time which is even being administered at no charge this time round. So I encourage all our people to grab this opportunity,” he concludes.