Summary
In March 2017, WHO regional office for Africa notified the Uganda Ministry of Health about a cluster of patients presenting with life- threatening tumors in Isingiro district. On behalf of the Ministry of Health, the Public Health Fellowship Programme investigated these claims to determine the magnitude and likely tumor expo- sure factors. A case suspect was a resident of the study area who presented with an abnormal swelling in the head and/or neck region and a confirmed case was a suspected case with confirmed histopathology results. The team actively looked for cases, obtained venous blood samples for laboratory investigations and re- viewed facility records. We identified five suspected cases who developed symptoms between 1995 and 2009. Of these two were males. Cases were distributed in the villages of Kikooma (1) and Bihingi (2) in Mbaare sub-county and Kashwojwa (2) in Kashumba sub-county. No common exposures were identified. There was no cluster of tumor presentation in the district. We recommend strengthening of district cancer surveillance systems.
Introduction
On 15th March 2017, Uganda Ministry of Health received notification from WHO regional office for Africa of a cluster of patients presenting with an unusual type of life- threatening tumors in Isingiro district. These patients were re- ported to be residents of Rugagga sub county, Kikunyu village. They were identified during an outreach medical camp, which was organized by the Peninsula Community Church on 14 September 2016.
The patients travelled a 7-hour distance to attend the outreach camp, which was held in Bombo, Luwero District. The reports indicated that the tumors were mostly in young patients aged 2 years and above. The alert also highlighted verbal reports of many other people and animals in Kikunyu village with similar growths. A team made up of oncologists, epidemiologists, clinicians, laboratory technologist and district surveillance officer investigated these claims to; confirm the tumor outbreak, determine the magnitude and describe possible sources of exposure.
District Profile
Isingiro district (Fig.1), located in south- western Uganda has a population of 500,000 people (Census 2014). The district borders Tanzania to the south, Rakia in the east, Kiruhura in the northeast, Mbarara northwest and Ntunga- mo in the west. The district has 4 HCIV, 20HCIII and 55 HCII and the main activities in the area are banana farming, fishing and cattle raring.
Methodology
This investigation was conducted in; Rugaaga, Mbaare and Kashumbi subcounties. A suspect case was a resident of any of the sub-counties who had an abnormal swelling in the head and/or neck region. A confirmed case was a suspected case with confirmed histopathology results. We actively searched for cases in the community and reviewed hospital records from health facilities, in order to generate a line list.
We collected information on; social demographic characteristics, signs and symptoms for the disease, and likely exposure factors given suspected tumor types. We obtained venous blood samples for laboratory investigations including; full blood counts (FBC), HIV serology, HCV, electrolytes, liver function tests especially ALP and albumin, TSH, T3, T4, Vitamin D levels and parathormone. In addition, clinicians conducted thorough physical examinations to describe the tumors.
Results
We identified five case suspects (two males and three females) who developed symptoms over a period of five years (1995 to 2009). The two males aged 19 and 21 yrs. had facial tumors. The 19yr old had a facial deformity from birth and the 21 yr. old developed mouth swelling at 13yrs of age. Among the females, two females aged 17yrs and 30yrs developed swelling in the earlobes following ear pricking process for cosmetic purpose and the third female, 20yrs of age had a swelling of lower lip since birth.
Of the five patients, three were involved in only cultivation while the two were involved in both livestock keeping and cultivation. None of those who kept livestock reported any abnormal swelling in the animals. Four case patients used water drawn from a well for house-hold water use. All the five respondents had swelling on the head. The most affected sites were the palate, mouth and cheek. Of these, two swelling were keloids, one was a hemangioma and three were suspected to be malignant. The five cases scattered in different villages; Kikooma (1), Bihingi (2) and Kashwojwa (2).
Health facility records for patients seen between 2015- 2017 showed that there were two cases of head and neck tumors (burkitt’s lymphoma). Significantly, none of the identified cases had been tracked in any of the health facility. Two of the people in the notification report were not interviewed; one died on 16/12/16. The deceased was a resident of Kajumbura village, Rugaaga sub county. He had had a swelling on the lower jaw, which latter extended to the face, head. The second patient had a swelling in the jaw and had had successful treatment at Mulago National Referral Hospital.
Discussion
The team evaluated five cases of tumors in Isingiro district that fit the case definition. The cases identified were from two sub-counties; Mbaare and Kashumba. There was no clustering of cases in any particular villages. There were no cases found in Kikunyu village as earlier mentioned in the notification report. The team found that a pastor, resident in Kikunyu coordinated the transfer of these patients to the Bombo outreach camp.
The pastor’s village therefore became the point of reference for these patients. The tumors identified were of a varying spectrum; ranging from what looked benign to probable malignancy and what would clearly fit congenital or birth related abnormalities and acquired disorders. Of the five cases, two cases could be having malignant tumors and require biopsy for histological confirmation. The team could not obtain tissue biopsies in the field because the lesions were highly vascular and therefore susceptible to uncontrolled bleeding.
There is need to obtain samples in a hospital setting where facilities are available to control bleeding in the event of uncontrolled bleeding. These procedures are best carried out by maxillofacial surgeons based at Mulago National Referral Hospital. Two of the cases evaluated in this investigation admitted to having significant number of animals reared. However, there was no history of abnormal growths in animals in this study area. Despite the fact that these patients actively sought for treatment from Bombo, the surveillance system in the district did not capture the cases evaluated in this report showing a weakness in the system.
Conclusion
There was no clustering of cases in any village nor evidence of common exposure to account for the tumor occurrence. Likewise, no abnormal growths were reported in the animals. Therefore we recommend strengthening of cancer surveillance systems in the district.