Managing Epidemics, The Ugandan Experience. Dr Aceng Jane Ruth Director General Health Services

Transcription

1 Managing Epidemics, The Ugandan Experience Dr Aceng Jane Ruth Director General Health Services

2 Outline Country Background Information Introduction VHF Outbreaks in Uganda Response Strategy Lessons Learnt Conclusions 2

3 Location: East Africa; shares borders with Kenya, Tanzania, Rwanda South Sudan, and DRC Area: 241,550.7 km², Population: 35 Million (2012 census) Background: Uganda 3

4 Introduction Over the last 15 years, Uganda has had several viral haemorrhagic fever (VHF) outbreaks including Ebola, Marburg, Crimean Congo, and Yellow fever. The outbreaks have affected mainly Northern and Western Uganda, although other parts of the country are also at risk. The first and biggest Ebola outbreak in Uganda occurred in 2000 with cases being reported in the three districts of Gulu- Mid North, Masindi Western and Mbarara South Western

5 Why Uganda is prone to outbreaks Increased interaction of man with forests, caves, and animals due to economic and other activities The age old practice of hunting and eating game meat. Eating of bats and monkeys by some tribes. Skinning and eating of dead animals without ascertaining what the animals died. Grazing of animals near game parks Free and largely unchecked Cross Border movements

6 Outbreaks in Uganda 1999-present: Plague outbreaks (West Nile) 2000: Ebola (Gulu) 2007: Marburg (Kamwenge) 2007: Ebola (Bundibugyo) 2008: Hepatitis E (Kitgum/Pader); Botulism (Kampala); Typhoid (Kasese); Anthrax (Bushenyi) : Yellow Fever (Abim) 2010 : Nodding Syndrome (Northern Uganda) to date 2011: Ebola (Luwero) 2011: Dengue (UPDF troops in Mogadishu) 2012: Ebola (Kibaale); Marburg (Kabale); Ebola (Luwero) 2013: Crimean Congo Hemorrhagic Fever (Wakiso, Agago) 2014: Marburg (Kampala)

7 Ebola VHF outbreaks in Uganda Epidemic/Year Cases Death s Case fatality rate Strain Gulu (2000) % Sudan Bundibugyo % Bundibugyo (2007) Luweero (2011) % Sudan Kibaale (2012) % Sudan Luweero (2012) % Sudan

8 Marburg VHF outbreaks in Uganda District/Year Cases Deaths Case Fatality Rate Ibanda (2007) % Kabale (2012) % Kampala (2014) %

9 Progress in Ebola Outbreak Detection and Response in Uganda The time taken between reporting, confirmation and response determines the magnitude of the disease outbreak. Year Response timeline No. of cases days from 1 st known case to preliminary investigation 425 cases, 224 deaths months from 1 st known case to preliminary investigation (Plus multiple investigations before confirmation of new strain of Ebola) 146 Cases, 39 deaths day between case confirmation and response 1 confirmed case days between lab confirmation & response 24 cases, 16 deaths

10 VHF Response Strategy used in Uganda Traditional healers Medical Anthropology Burial Teams Screening IN / OUT Clinical trials Posters Radio Community Discussion Social Mobilization and Health Education Psycho Social support Case Management and Funerals Barrier Nursing Water Sanitation Media Mobile Teams roads police Logistics and Security salaries Transports Vehicles Coordination NTF Surveillance Epidemiology Laboratory Data Management & Reporting Reporting Results Environment Contact Tracing Case Finding Sample Collection Testing

11 Coordination structures National Level Uganda has a standing multi-sectoral and multidisciplinary task force on epidemics (The National Task Force) The National Task force is coordinated by Ministry of Health chaired by the Director General Includes experts from various fields i.e. epidemiologists, laboratory scientists, communication experts, psychiatrists and psychologists, physicians, veterinarians, etc. Members are drawn from the Ministries of Health, Agriculture, Education, the uniformed personnel, Office of the Prime Minister, partners including Research Institutions and the Universities, WHO, CDC, UNICEF, AFENET, Uganda Red Cross, and MSF. The NTF meets monthly; however during an epidemic it meets daily.

12 Coordination Structures cont.. District level All the 112 districts have task forces composed of the district political, civic, and health leaders as well as technical advisors from different partners working in the districts. Both the National and district task forces have subcommittees that are responsible for overseeing and implementing the task force decisions and different components of epidemic response. The subcommittees include: coordination, Resource mobilization, surveillance and laboratory, case management, social mobilization, logistics, and psychosocial support and all have clear terms of reference. The subcommittees report to the task forces

13 Other supporting coordination structures National Rapid Response Teams and District Rapid Response Teams have been trained and remain on stand by to be constituted immediately an epidemic is notified. They conduct investigations and support the establishment of an appropriate response in collaboration with the task forces. To reinforce response coordination at the district level, two or three senior officers are deployed from the national level to the district level to work with the district task force.

14 Community Level Coordination Structures All the 112 districts in Uganda have Community Health Workers known as VHT S. A VHT is responsible for between households depending on the size of the village Apart from other activities, the VHTs have been trained in disease surveillance and reporting. The VHTs report to the nearest facility, usually a health center II or directly to the surveillance focal person in the health sub district or office of DHO. VHTs report any unusual occurrence (diseases, deaths, etc)

15 Coordination at Community level.. Over the years, the communities have been educated and sensitized to alert VHTs immediately upon detection of any unusual occurrences or death. VHTs act as a link between the facility based surveillance system and the community and comprise of an early warning system at community level.

16 Surveillance, Epidemiology, and Laboratory Comprises of Routine surveillance Reporting Sample collection and analysis Case finding Contact tracing Data management

17 Surveillance In 2000, Uganda adopted the Integrated Disease surveillance and response strategy (IDSR). Following the structure of the health system, there are designated surveillance focal persons at the health sub - district, District and regional levels, and Laboratory focal persons The focal persons on a routine basis, receive information from the health facilities and the VHTs and carry out investigations and report on priority diseases. Information is shared through the HMIS system. Recently with support from CDC, we started a Field Epidemiology training program to build a pool of field epidemiologists to support surveillance

18 Surveillance. The trained field epidemiologists will boost capacity of the ESD as well as the districts. To improve detection of atypical outbreaks, we developed standardized clinical and community case definitions for use by H/W and VHTs Information on unusual occurrences is immediately remitted to the Epidemiology and surveillance Division (ESD) of Ministry of Health and the chair of the NTF. This division then verifies the information, carries out more investigation and upon confirmation, alerts NTF through the chair, for action. This triggers daily task force meetings.

19 Surveillance..contact tracing A team of Surveillance officers are deployed to carry out contact tracing. Each officer is allocated to a specific number of contacts to follow up on a daily basis and report to the surveillance committee. Transport is provided to the officers to ease quick movements and prompt feed back. Officers are also facilitated with airtime to call and mobilize efforts, this continues until all the contacts have been followed up for 21 days, and thereafter monitoring continues for another 21 days.

20 Ongoing surveillance During the inter-epidemic periods, monthly taskforce meetings are held to: Review disease surveillance data Update epidemic preparedness and response plans in regard to the situation on the ground There is constant communication between district surveillance officers and ESD of the Ministry of Health With the support of WHO, Uganda has been working with neighboring countries to strengthen cross border surveillance and management of epidemics

21 Laboratory System Uganda has over time built a strong laboratory system. Different levels of health care delivery have different lab capacity. With support from CDC, a P3+ laboratory has been established at UVRI (Special pathogens lab) for confirmation of VHFs and other pathogens This has reduced the turn around time for results to less than 24hours, enabling timely response interventions. The results from the lab are sent directly to the Chair NTF and relevant officers for immediate action. The Central Public Health Laboratory (CPHL) acts as a coordinating body for specimen transportation

22 National Specimen Transport Network The country has also established a network of hubs - laboratories with enhanced capacity to analyze and monitor disease trends (77 hubs reaching over 2400 health facilities). Each Hub is headed by a hub coordinator. CPHL UVRI x x x Monday Route x x x HUB x Tuesday Route x x x Each hub is given a motorbike and a bike rider, who visits health facilities within 30-40km radius around the hub, bringing samples and delivering results weekly. The hub refers well-packaged highly dangerous specimens using the Posta bus. UVRI 22

23 A motorbike rider getting ready to transport samples 23

24 Laboratory capacity For non routine / emergency samples there are dedicated back up riders who are always on stand by. They are called upon by the Hub coordinator to pick emergency samples. Samples for highly dangerous pathogens move from the point of collection to the hub center for registration and, re-checking of packaging and then to Posta Uganda for transportation to Entebbe ( this process is designed to take less than 24 hours)

25 Pictorial view of prepared specimen from suspect cases and Transport means Posta Bus Laboratory focal Person hands over packed specimen to bike rider In case the Posta system is not available; other options include; public transport, local airlines, Direct transport by DHO

26 Information Management Standardized forms are used for collection of data during the outbreaks Case investigation forms, Line Lists, Laboratory requests, contact listing and tracing form. A data base is established for every outbreak; the Epi Info 7 and the WHO FIMS software have been used for the Ebola outbreaks. A specified officer is assigned to data management at the beginning of the outbreak

27 SMS Message Alerts Using SMS, members of the District Rapid Response Team (DRRT); including the District Health Officer, District Surveillance Officer and the Hub coordinator can send a message to the system. The message is preceded with a specific keywords such as alertvf for VHFs or alertch, for cholera and sent to the number When received in the system, the message is forwarded as both an SMS to the phones and to recipients who are members of the NTF or responsible for response. User groups include teams such as the PHEOC staff, lab and ESD

28 Specimen Tracking For some priority diseases, modules with multiple stages, i.e. the VHF module, were developed to facilitate tracking of the specimen and the the results for feedback. Stages include: specimen registration by the hub coordinator, acknowledgement of receipt of the specimen by UVRI and the release of the specimen results by the testing laboratory. At every stage, an SMS is sent to the phones and s of the groups defined in the system for Action. User groups include: PHEOC, DRRT, ESD and the testing laboratory.

29 Information Management IHR notification to WHO is done immediately after confirmation, by the National Focal Point A daily situation report (Sitrep) is produced, including data on the different aspects of the outbreak; cleared by chair of NTF Sitreps are shared with all districts, National leaders, in-country partners, and WHO Data from the sitreps is used to monitor the response and adjust aspects of the response as necessary

30 The Emergency operations center, (EOC) Coordination center activated during emergencies, and an incident team constituted. When activated, brings together all responsible decision makers from all MDA Provides capacity to receive, analyze, display and monitor incident information. Stengthens the ability to identify, organize, deploy and track resources. Improves communication, collaboration and coordination from a central location Supports decision makers to remain in charge of the situation.

31 Case Management Case management comprises of the following Set up of barrier nursing facilities or isolation facilities with the required logistics Ensuring safe burial procedures burial teams, Triage of patients at Health facilities, Ensuring safe water and proper sanitation, Clinical management and nursing care Psychosocial support to the patient and relatives Disinfection of Homes and property

32 Case management Health workforce Over the years, we have trained a number of Health workers on management of VHF and other epidemics. The country has training guidelines that are updated constantly. An inventory of the trained health workers is kept by the secretariat of the NTF. These trained HWs are quickly contacted and deployed in case they are needed outside their usual place of work. The HWs also train more health workers in the new outbreak location to increase the number of people with this capacity

33 Case management The case management teams work in collaboration with partners like MSF and others. Isolation facilities are set up in Health facilities close to the affected communities to minimize transfer of patients. Uganda has a permanent National Isolation Facility at Entebbe, for Health workers and suspected cases who fly in. In the isolation facilities, supportive care is given and Psychosocial experts counsel patients and their immediate families on the natural progression of the disease and the expected out comes. Families are also briefed on the situation of the patient in Isolation on a daily basis. In addition, the team provides psychosocial support to the health workers to avoid burn out and depression.

34 Prevention of transmission Case management Suspected cases are immediately notified to case management by the surveillance and contact tracing teams; Suspected cases are transported from the community immediately, to the isolation facility, to prevent further infection transmission Affected homes are disinfected and contaminated personal effects of the patient are destroyed. The property that the patient came with to the facility are also disinfected and incinerated on discharge or death Upon discharge, the patient and the family are given a discharge package to replace what was destroyed. (This act enhances cooperation of the families and communities) Burial teams are immediately constituted and trained to promptly bury the dead with dignity following infection control measures.

35 Logistics and Security This comprises of transportation systems including that for specimen collection, ambulance system, transportation of PPE and infection control materials, medicines and health supplies. Coordination is carried out through the EOC which is activated immediately an outbreak is detected. Partners support Government to procure PPE. Infection control materials and medicines are provided for by Government free of charge. Security is provided for by the uniformed personnel who are members of the NTF.

36 Social Mobilization Local capacity has been developed over the years. Political leaders both at the National and local level, Religious leaders, Elders and opinion leaders have been educated and sensitized. During an epidemic, effort is made to understand the knowledge, attitudes and beliefs of the affected people, this informs the social mobilization efforts and messages. Effort is made to reach out to the traditional healers, and other groups to create dialogue and share information.

37 Social Mobilization Messages are disseminated country wide by use of posters, Leaflets, radios, Television and community discussions Political leaders including The President of the Nation take it upon themselves to educate the public about prevention at every possible opportunity and to encourage them to cooperate with the health professionals. Health workers are also mobilized, sensitized, educated and counseled to dispel fear and encourage them to take care of the patients (This addresses the issue of patients being turned away or health workers running away) The psychosocial teams also interact with the affected communities to offer counseling and support as well as reintegrate discharged patients back into the communities.

38 H.E The President educates the communities during inter-epidemic period to avoid eating bats and monkeys and to seek health care promptly.

39 Support Supervision During out breaks, The Ministers of Health, members of the NTF and other senior officers visit the affected districts and Isolation facilities. They engage with the district leaders and representatives of communities to explain government action, seek community cooperation, motivate and encourage the response teams. This act provides them with first hand information about challenges on the ground and empowers them to lobby and advocate for improved services.

40 Ministers and members of the NTF dressed in PPE ready to tour the isolation facilities A team from MSF ready to orient on the layout of the isolation facility

41 Media and Public information During out breaks, its important to keep the media and the population informed about progress on control. Updates are given to the media on a daily basis as per the situation report that comes to the NTF. Information is shared with the Public on daily basis in the form of press releases in print and social media. The Chair of the NTF, engages the media every week and makes statements on Radio and Television. There is continuous sensitization of the public through radio spots and announcements on behavioral change, infection control and what to do and where to report any suspected cases.

42 Challenges Inadequate funding for control of Epidemics. This is often bridged by Partners. Inadequate Isolation facilities Set up temporary tents in affected areas Plan is underway to construct another National Isolation facility next to the National Referral Hospital Inadequate Human resources. training of field epidemiologists and Field Laboratory epidemiologists (Track to begin soon). Constant recruitment and training. We have now embarked on training of all health workers. Myths, misconceptions and beliefs On going education and sensitization.

43 Lessons Learnt A strong Coordination system is paramount. Readily available protected funding is is critical Timeliness of detection of VHFs outbreaks determines the magnitude of the outbreak. A strong laboratory system for sample collection and confirmation is paramount Dealing with cases dispersed over a wide geographic area requires a decentralized response. Need for a team of well trained motivated health workers. There is need to constantly engage the communities and understand their cultures and beliefs. Involvement of local leaders is a crucial component of ensuring community compliance. It is important to keep the Public informed at all times

44 Thank you for Listening to me