Uganda: 9 cases, 7 deaths, due to unidentified hemorrhagic disease in Bunyoro Region - Ebola, Marburg, Lassa, CCHF, RVF, yellow fever ruled out

[Gert van der Hoek]

1 OCTOBER 2015

Uganda: Mysterious Disease Kills Five in Bunyoro Region

Buliisa — The Ministry of Health has dispatched a team of medical professionals to Buliisa District to investigate a mysterious disease that has so far claimed lives of five people.

Health officials have told Daily Monitor that those who died were vomiting blood, had fever and were passing watery and blood-stained stool.
Buliisa District hospital administrator, Mr Hannington Tibaijuka, said medical officials obtained seven samples from the victims and sent them to the Uganda Virus Research Institute, Entebbe.

He said the samples tested negative to all haemorrhagic fevers, including Ebola virus, Marburg and Congo haemorrhagic fever. The patients were reportedly from Butiaba Sub- county which is on the shores of Lake Albert in western Uganda.

The disease has caused anxiety and panic among residents but medical officials have called for calm and vigilance. "We have intensified community health sensitisation where we are cautioning the public to report any suspicious illnesses to public health centres and we are discouraging them from self-medication," said Mr Tibaijuka.

 

[Pathfinder]

See also:

Uganda - Suspected Ebola case reported in Hoima District - negative for Ebola

https://flutrackers.com/forum/forum...reported-in-hoima-district-negative-for-ebola

 

[Pathfinder]

From the link provided by Gert:

"Hoima hospital principal administrator, Mr Salim Kivejinja said the two patients who are admitted to the hospital have tested negative for haemorrhagic fevers.

He said the samples from the UPDF soldier who died have been flown to Atlanta in the USA for further examination."

 

[Pathfinder]

Epidemiological week 38 of 2015 [13th Sep 2015 ? 19th Sep 2015]

Disease Outbreaks

Unknown illness in Buliisa district: On 23rd September 2015, the Ministry of Health responded to an alert of suspected haemorrhagic fever in Buliisa and Hoima districts. The team is using a working case definition of a patient presenting with vomiting blood OR bloody diarrhoea AND any of the following: abdominal pain, fever and general body weakness. Eight cases have been identified and have tested negative for Ebola, Marburg, RVF and CCHF. Four community deaths have been reported from Buliisa district and two deaths have occurred in Hoima Regional Referral Hospital. Community case finding from contacts has been done but no cases have been identified.

Actions: Health workers at Hoima Regional Referral Hospital and Butyaba Health Centre (Buliisa district) have been oriented on Viral Haemorrhagic Fever. Community sensitization and supervision burial of dead suspected cases have been initiated.

http://reliefweb.int/sites/reliefweb.int/files/resources/week 38 2015.pdf

 

[alert]

The labs in Uganda are pretty good at detecting Ebola and Marburg. If they are getting negative results, this isn't due to those viruses.

Notably absent from the list of excluded diagnoses is yellow fever, a hemorrhagic illness previously reported from Uganda that they have had some difficulty detecting:

https://flutrackers.com/forum/forum/...k-yellow-fever

Also under consideration should be some kind of poisoning, especially if human-to-human transmission of the illness is not suspected.

The fact that this illness is occurring in more than one district might mean that the cases do not form a contact cluster.

 

[Emily]

Uganda: Bunyoro Struggles With Strange Illness

http://allafrica.com/stories/201510091478.html

[h=2][/h] [h=1]Uganda: Bunyoro Struggles With Strange Illness[/h] 9 October 2015
By Francis MugerwaKampala

...
Wanichan is one of five people who have succumbed to a mysterious disease in Buliisa District in the last few weeks.
The victims, who have died at separate times, but all in Butiaba Sub-county, within a period of about three weeks, develop fever, vomit and pass blood before dying.

...
No haemorrhagic fevers
The Buliisa District hospital administrator, Mr Hannington Tibaijuka, however, said the samples that were sent to the Uganda Virus Research Institute tested negative to all haemorrhagic fevers, which include Ebola, Marburg, Lassa, and yellow fever viruses.

...
"Nine cases have been registered out of which seven people have died. Three samples have been obtained from the dead and they have been sent to Atlanta, USA," Ms Nakamatte told the Daily Monitor on Tuesday.
"The team is conducting more investigations, case finding and active surveillance. But preliminary investigations have revealed that the disease is not contagious," she said.

...
Mysterious deaths have also occurred in Hoima District. Jackson Byamaka, a UPDF soldier attached to Bunyoro Kitara Kingdom's royal guards, died with symptoms similar to those of patients that have died in Buliisa District.
His workmates say he had returned to Hoima from the army headquarters in Bombo where he had attended a short training course.
He died after passing and vomiting blood. His wife and another patient with similar symptoms were admitted to Hoima Regional Referral Hospital.
The hospital's principal administrator, Mr Salim Kivejinja, says the two patients tested negative to haemorrhagic fevers but samples obtained from the body of Byamaka have been sent to the Centres of Disease Control (CDC), Atlanta, USA for further tests and examination....

 

[alert]

And yellow fever is ruled out too, pretty much completing the list of common hemorrhagic fever viruses. And H2H spread is not suspected.

Could these be the most severe cases of something more widespread, like dengue, malaria, typhoid, or dysentery? Perhaps a mass or repeated poisoning of some kind? If this is a previously unknown virus, how is it spreading if not H2H? Ticks? Animals?

There are lots more questions than answers at this point. We'll see what, if anything, the CDC can find in the samples it received.

 

[Pathfinder]

Preliminary report on strange illness in Buliisa district,2015
By:

?
ATEK KAGIRITA

?
BERNARD LUBWAMA

?
JOYCE NGUNA

• MICHAEL MULOWOOZA

Lay Out
Background
Objectives
Methodology
Findings
Activities done
Recommendations
Back ground/Introduction

•
Buliisa District Health Office reports mysterious deaths in Butiaba Sub County on 17thSeptember 2015 to the MOH

•
MOH Rapid Response Team (RRT) arrives on 23rd September 2015

•
RRT comprises 2 Epidemiologists, a Lab Specialist and Clinician conducts further investigations

Objectives

Verify the report
Laboratory confirmation
Epidemiological classification
Differential diagnoses
Control, prevention and actions

Methodollogy

Meeting the ADHO – MCH, the DHI and the in-charge and staff of Butiaba HC 3
Interviews and discussions with VHT, LCs, fishermen, cases, health workers and relatives to the deceased cases
Records reviews for GE cases (Jan 2015 – to date)

Activities

The team met the ADHO – MCH Sr Kusemererwa Harriet, and the Health Inspector Buliisa Health Sub-District Mr Tibaijuka Hannington, and the in-charge and staff of Butiaba Health Centre 3 Mr Adoko Michael (where one of the cases was reported).
The team held interviews and discussions with the Butiaba area VHT, LCs and relatives to the deceased cases.
Medical record reviews
Group discussion with Fishermen
Meeting local leadership
Visiting deceased homes
Orientation of staff on VHF and infection control
Distribution of PPEs
Distribution of laboratory supplies

Case Descriptions

Ramadhan Wani: Male, 30, Fisherman from Magale village, Booma Parish, Butiaba Sub County. Died Saturday 5th September 2015 report buliisa.doc

•Bitum Nesi: Male, 40, Fisherman from Magale Village, Piida Parish, Butiaba Sub County. Died 12th September 2015report buliisa.doc

Komakech Joseph Ocan: Male, 22, Fisherman from Magale Village, Piida Parish, Butiaba Sub County. Died 14th September 2015 report buliisa.doc

Oweka Joyce: Female, 58, from Kamagongoro Village, Walukuba Parish, Butiaba Sub County. Died 16th September 2015 report buliisa_Day 3.doc

Natukunda Edward: Male, 19, Boda Boda cyclist from Lindimule village, Kyabeya Parish, Nalweyo Sub County in Bugangaizi West, Kibaale district. Admitted to RRH on Monday 21st September 2015 report buliisa_day 2.doc

Bitagasa Julius: Male, 45, Shopkeeper in Waaki Village, Walukuba Parish, Buliisa. Family is in Siiba Village, Kapapi Parish, Kigorobya Sub County in Hoima district. Admitted to RRH on Tuesday 22nd September 2015 at 10:00pm report buliisa_day2.doc

Byamaka Jackson: Male, 50, Bunyoro Kingdom Royal Guard. Transferred to Bombo and later to Singo for further training before deployment in Somalia. Died Tuesday22nd September 2015 report buliisa_day 2.doc

Akumu Janet, Female, 37, housewife. Neighbour and contact to Oweka Joyce. Developed symptoms on Wednesday 16th September 2015 report buliisa_Day 3.doc

Laboratory Investigations

8 blood specimen collected, 1 autopsy conducted
Blood from 8 contacts and 2 cases from Waaki
All blood samples tested negative for all Ebolas, Marburg, CCHF and RVF
Autopsy samples yet to be analyzed

Differential Diagnosis

VHF????
Yellow Fever
Chemical Exposure????
Toxin exposure – Aflotoxin
Acute Gastroenteritis
Shigellosis
Vector – borne disease?????

Discusssions with fishermen

Fishermen aware of reported deaths of fellow fisherfolk with bleeding tendencies
Usually meet while on the lake fishing, also find dead fish but it is rare
Get bites from “tsetse fly – like” insects at night on the lake and from snails.
“Bilharzia killed their colleagues” or something in the lake shore swamp
Carry food on their fishing boats and “cook” it while on their long fishing trips. Shore is home to many brands of alcohol sachets that may have endangered their friends’ lives.
Drink “dirty” lake water where they urinate, bathe and defecate
One colleague, still alive, vomited blood a month ago.
Affected colleagues do not tell they vomited blood for fear of stigmatisation
Take long fishing trips on the water of up to six months.
The second victim, Bitum Nesi, had a history of vomiting blood in Panyamur (L. Albert shore end at Nebbi District) five months before his death. He was taken to Angar Hospital in Nebbi district where he was treated and improved.
During the meeting, the team established that vomiting blood was not a new event at this shore. However, cases rarely report these for fear of victimisation.
The fisher men asked that the district conducts mass sensitisation of the Butiaba communities on the current problem and the appropriate prevention measures.
They were asked to report all such cases to Butiaba HC 3 privately and immediately.

Activities/Actions taken

Visiting of deceased families
Meeting of local leaders
Orienting HF staff on VHF infection control
Orientations on donning and doffing of PPE
Sensitization of Fishermen
Distribution of PPEs and laboratory supplies

Recommendations

Continue with active search for suspect cases
Train H/Ws in IDSR
Social mobilization of Butiaba communities
Include outbreak response in district annual plan
Enforce latrine use and coverage to combat sanitation related health issues
Sensitization on food hygiene for fishermen
Further testing of samples
Enhance support for surveillance with the EPI/IDSR regional office
2 MO trained in EDPs
CME going on
Reporting was poor
Personal protection for health response
Isolation unit
Preparedness plan

Additional Reporting by:
Tibaijuka Hannington Public Health Inspector Buliisa HSD.

http://www.buliisa.go.ug/services/he...ry-health-care

 

[alert]

That is a gold mine of information. Several things stand out. First, all the cases are adults, with the majority male and the majority also fishermen. None of the cases are HCW. That argues in favor of an occupational exposure. Secondly, some of the cases are or have been ill for weeks or months, something inconsistent with an acute VHF.

Two of the cases are indeed neighbors (the only two female cases) but possibly with very close onset dates. It is certainly possible that those two cases are unrelated to the outbreak among the fishermen.

Poisoning, perhaps related to alcohol, certainly seems more likely than infection at this point, but shigella must also be ruled out.