1. 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

2. Presentation outline Background Objectives and rationale Investigation methods Description of the 2012 FHF outbreaks in Uganda Conclusions & recommendations Acknowledgements

3. 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

4. Background... Uganda has experienced escalating Filovirus outbreaks in recent years 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

5. 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 Study Team. Bull World Health Organ. 1978;56:247–70. Ebola hemorrhagic fever in Zaire, 1976. Bull World Health Organ. 1978;56:271–93

6. 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)]

7. 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 7

8. 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 8

9. 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

10. EBOLA - KIBAALE & LUWERO FHF outbreaks in Uganda, 2012

11. Index Case Investigations, Ebola Kibaale, 2012 June 12, 2012 Onset of illness 16 yr; Female; Kikaara village, Buchuhya Parish, Bubango sub-county Treatment at Local HC June 13-17 & 18-19 th, 2012 Subsequently admitted to hospital – not isolated Death of Index Case in hospital June 19, 2012 Unsupervised Burial of Index case June 21, 2012 Discharged & stays with in- laws

13. Index Case Investigations - Ebola Central Uganda, 2012 Oct. 13, 2012 Onset of illness 30 yr; Male; Kakute village, Ssambwe Parish, Nyimbwa s-county Treatment at local HC Oct. 20-23, 2012 Subsequent care at Bombo GMH Death of Index Case at Bombo GMH Oct. 23, 2012 Un supervised burial of Index case Oct. 24, 2012 Oct. 14-19, 2012

14. All Ebola cases- Uganda, 2012 Cases Deaths Case StatusCentralWesternCentralWestern Confirmed6113 (50%) 4 (36.4%) Probable1131 (100%) 13 (100%) Total7244 (57.1%) 17 (70.8%) Overall, there were 24 cases in Western Ug. & 7 cases in Central Ug. with CFR of 57% in Central Ug. & 71% in Western Ug.

15. Ebola Epidemic Curve –Western Uganda, 2012 Cluster of cases among in-laws to index case DHO reports strange illness to MoH

16. Ebola Epidemic Curve –Central Uganda, 2012

17. Ebola case distribution by sex, 2012 80% of probable/ confirmed cases in Kibaale (Western Ug.) were females Case distr. by sex was nearly even in Luwero (Central Ug)

18. Ebola case distribution by Age, 2012 Majority [46-86%] of the cases were 20-39 years of age

19. Ebola Symptoms – Western Uganda, 2012 SymptomPresent Fever23 (95.8%) Vomiting21 (87.5%) Diarrhea19 (79.2%) Abdominal Pain 13 (54.2%) Any Bleeding13 (54.2%) Ebola case symptoms were largely non-specific Unexplained bleeding reported in 54% cases & was often late & not overt

20. Map Ebola cases in Western Uganda, 2012 Epicentre with majority being contacts (also in laws) to the index case Index case Caves with bats

21. MARBUG IN WESTERN UGANDA FHF outbreaks in Uganda, 2012

22. Marburg Index Case Investigations – Uganda, 2012 July 20, 2012 Onset of illness Kafunzo III village Ibanda: Cluster –[3 confirmed; 6probable/deaths] Treatment at Ibanda hospital /TBA Sept 3, 2012 Onset Index case for Kabale Death of Kabale index Case at Kabale RRH Sep 20, 2012 Burial of Kabale Index case Sep. 22, 2012 Late July- Early Aug. 2012

23. All Marburg cases – Western Uganda, 2012 CasesDeaths Case Status/districtKabaleIbandaKabaleIbanda Confirmed962 (22%) 2 (33.3%) Probable585 (100%) 6 (75%) Total14 7 (50%) 8 (57%) Overall, there were 14 cases each in each of the two districts in Western Uganda with CFR of 50-57%

24. Marburg Epidemic Curve- Uganda, 2012

26. Marburg cases by sex - Uganda, 2012 The majority [60-69%] of the cases were females

27. Marburg cases by age – Uganda, 2012 Majority [50%] of the cases were 20-39 years of age

28. Marburg case symptoms – Uganda, 2012 SymptomFrequency Fever25 (89.3%) Loss of Appetite21 (75.0%) Vomiting20 (71.4%) Headache19 (67.9%) Fatigue19 (67.9%) Abdominal Pain15 (53.6%) Diarrhea11 (39.3%) Any Bleeding11 (39.3%) Muscle/Joint Pain10 (35.7%) Symptoms largely non-specific Bleeding reported in 39%

29. Map Marburg cases - Uganda, 2012 Tanzania DRCONGODRCONGO DRCONGODRCONGO Lake Victoria Kampala Kitaka Mines

30. 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 AOR 5.3 (1.9-14.8); p<0.001 – Participating in funeral AOR 33.4 (4.3-256.7); p<0.0001

31. 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

32. 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

33. 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

34. Thank You