In the second 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.
On October 19th 2012, two weeks after Uganda was officially declared Ebola-free, the Ministry of Health declared an outbreak of Marburg virus. Like Ebola, Marburg virus is in the filovirus family. Like Ebola, Marburg causes a viral hemorrhagic fever (VHF). It is spread in infected body fluids, is highly virulent, and carries a case-fatality rate of between about 25 to 80%. For all intents and purposes, Marburg and Ebola are the same.
Having only recently dealt with an Ebola outbreak that started shortly after my arrival in Uganda, it was easier to mobilize our task force and begin the work of setting up the isolation camp. There was greater urgency, as well – a pregnant woman at our hospital in Mbarara had died within 24 hours of admission, and her blood test returned positive for Marburg. A post-mortem caesarean section was performed to remove the fetus according to local custom. Not appreciating the danger, the deceased patient’s husband took the bodies back to his village to prepare for burial—one of the highest risk opportunities for viral spread.
Eighteen hospital staff had been in contact with the patient. Each of them were quarantined at home and monitored twice daily for fevers or other concerning symptoms. The outbreak had reached us and it was imperative that we activate the isolation ward immediately.
We needed to obtain fencing to separate the high risk from the low risk zones. We needed supplies – chlorine, high power sprayers, buckets and bins, and the three layers of protective gear, in addition to the clinical supplies necessary for patient care. We needed to construct changing rooms for health staff, and laundry and supply areas. We needed to construct the ward where suspected cases would be housed. The old TB ward would serve as the ward for suspected cases until another patient was confirmed positive, at which time we would need another area to keep the “suspects” isolated from the “confirmed.” And since the bodies of patients who have died of VHF are highly infective, we also needed to construct a morgue. We had a lot of urgent needs, but not a lot of readily available funds to meet them.
Meetings and conversations were underway with the Uganda Ministry of Health, World Health Organization, and Médecins Sans Frontières. Personal protective equipment was en route. The hospital was working to restructure schedules to allow for the additional staff-time needed to run the isolation ward. Clinical supplies were being reallocated. And thanks to unrestricted funds available from an anonymous donor to Massachusetts General Hospital’s Center for Global Health, we were able to fund the construction of the isolation ward.
This time the ward was complete within a few days. The design was simple: plastic sheeting for walls, hung over the edges of wooden frames and corrugated tin for the roof. Dirt floors were leveled and packed. WHO provided training to hospital staff on the infection control and how to properly don protective gear. Lectures were given on the differences between “contacts” (people who have been in contact with a patient with known VHF, but are asymptomatic), “suspects” (people with fever and bleeding, or contacts who have developed fever), and “confirmed” (people whose blood sample tests positive for the virus). Over the next couple of weeks, we evaluated and treated several more patients with suspected VHF in the isolation ward. Some had malaria. Some had other infections. All had fevers. One or two eloped in the night before the results of their blood work returned. Thankfully, none had VHF. They received certificates documenting that they were Marburg-free. Even with such documentation, however, one woman was denied admission to the hospital ward and was left to receive her medical care outside on the lawn.
Twenty-one days after the pregnant woman’s death, the eighteen contacts were invited to a “reintegration” ceremony. Just as some hospital staff were unwilling to care for patients who had been suspects, some hospital staff were wary of their colleagues who had been contacts. We held a debriefing meeting, provided reassurance, and shared food and drink together as a demonstration of our confidence in their health. That day, during the ceremony, I learned that elsewhere in Uganda three patients suspected of having Marburg were confirmed Ebola-positive. Another outbreak cycle began.
In all, forty-nine Ugandan people died in 2012 of VHF. Seventeen out of the twenty-four (about 70%) of the confirmed and probable cases of Ebola succumbed to their illness during the July-August outbreak. By the end of November, about 65% (fifteen of the fifteen confirmed and eight probable cases) of patients with Marburg virus had died. By early December, the Ugandan Ministry of Health reported seven cumulative cases (probable and confirmed) of Ebola virus infection, including four deaths.
On January 16, 2013, Uganda was once again declared Ebola-free. But experience this year has taught us to expect another outbreak at any time, and that we need to be ready.
Read the related post here: July 28, 2012: “Emergency Message – Confirmed Case Of Ebola Virus In Uganda”
Raquel Reyes is an Internist and Pediatrician. She works in Uganda at the Mbarara Regional Referral Hospital and Bugoye Health Center as the Site Director for Massachusetts General Hospital’s Global Primary Care Program.
The author declares no competing interests.