Background
On 6th Feb 2015 Kampala Capital City Authority (KCCA) notified Ministry of Health (MoH) of a strange illness in the Central Business District. The disease had reportedly affected more than 30 persons causing 5 deaths in a month. The report indicated that majority of cases started having symptoms in early Jan 2015 and was mainly affecting adult males and females working in Nakasero market, Disabled market and Qualicel Bus terminal. The symptoms of the Index case included high grade fever, severe abdominal pain, and jaundice. Further investigations pointed to and confirmed typhoid. Epidemiological and laboratory investigations revealed that the outbreak was caused by people drinking water from underground wells and locally processed juices contaminated with sewage. Treatment centers were set up at various KCCA health centres in the city.
UNICEF provided aqua tablets for household water treatment, made safe water temporarily available to the affected communities and supported house to house health education and mass media sensitization on typhoid. Referral of suspected typhoid patients was carried out. KCCA sealed off all the underground wells. By 12th June 2015, a total of 14,304 suspected typhoid cases: 1,038 tubex positive and 52 cases confirmed on blood culture cases had been documented. MoH declared Kampala free of typhoid outbreak on the 17th/June/2015.
A number of laboratory related activities were conducted during this outbreak, and afterwards. These included confirmation of cases, verification of the outbreak in other districts aside Kampala, identification of the source of the outbreak, monitoring the effectiveness of control measures among others. Following the confirmation of the typhoid outbreak in Kampala, all districts enhanced their surveillance and reporting and the number of suspected typhoid cases in the Health Management Information System (HMIS) increased in over 30 districts. These districts had reported cases beyond the IDSR national set threshold of 5 cases / 50,000 population to levels of 20 cases / 50,000 population. This therefore required verification and investigation to ascertain the possibility of a national typhoid outbreak. In this article we provide an overview of the challenges, lessons learnt and recommendations of the 2015 typhoid outbreak n Uganda.
| No | Issue | Recommendations/Responsible institution/persons |
| Surveillance | ||
| 1. | Difficulties in identifying outbreaks in mobile and urban settings: This typhoid outbreak occurred in the underprivileged populations – those working in the disabled’s’ market, taxi parks, farmers’ market in downtown Kampala. These are low in- come earning people who could hardly afford to spend long times off their work stations due to fear of missing out on their clientele. Due to long waiting times in public health centers, manyopted to go to nearby private clinics once they fell ill. Most of the clinics do not routinely feed into the HMIS. Worse still these clinics the widal test in the diagnosis of typhoid. It is therefore very hard to detect outbreaks in such populations using traditional methods. In fact, this typhoid outbreak was never detected by the public health surveillance system. | MoH-ESD/KCCA: Work with the administrative persons in such populations to report any outbreaks/ unusual clusters of cases. For example, in the Disabled’s Market there was a main “chairperson” and several “area chairpersons,” who were very knowledgeable on what’s going on in their communities.
MoH/CPHL/Resource centre: Public private partnerships/ supervision should be strengthened making sure that private clinics conduct the right tests and also ultimately feed into the HMIS. MoH/CPHL/KCCA:A program for regular monitoring of water sources, open air foods, etc. would be one of the long term solutions.
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| 2. | A lot of data is generated in the laboratories but very limited analyses are done to inform decision making | MoH-ESD/CPHL: Laboratory staff should be oriented on the basics of surveillance and if possible should be part of the surveil- lance teams at all levels |
| 3. | Lack of basic laboratory materials: Early in the investigation exercise, the team was ready to collect blood specimens for culture. However, it was noted that basic sample collection bottles were not available the national laboratory-CPHL. | CPHL: Modern microbiological methods like the Bactec be introduced at CPHL. A SOP should be set up to ensure timely testing of specimens collected during outbreaks.
MoH-ESD/CPHL: There is need for more staff in the unit to help fasten the processes. |
| 4. | Delay in release of results: The investigation team collected about 20 blood specimens and sent half of them to CPHL. The rest were sent to the Makerere University Microbiology laboratory which produced results within a week CPHL was still preparing samples in the same period. It was noted that CPHL was still using conventional microbiological methods which could affect the timeliness in release of results. Important to note was the glaring human resource gap to handle the work at the institute specifically microbiologists. Most of the “staff” were volunteers. | CPHL: Modern microbiological methods like the Bactec be introduced at CPHL. A SOP should be set up to ensure timely testing of specimens collected during outbreaks.
MoH-ESD/CPHL: There is need for more staff in the unit to help fasten the processes.
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| 5. | Use of widal for typhoid testing: Ministry of Health stopped supply of widal test reagents in public health facilities due to its limitations. However, it was discovered that many private clinics and a few government facilities are still using the test. | CPHL/District Laboratory Focal Persons (DLFPs): Mentorship/supervisions should be strengthened at private facilities to ensure that widal is correctly used or not used at all. The DLFPs/CPHL should ensure presence and use of the Guidelines for sample collection, transportation and referral for facilities to know the steps to follow when there is need of a test they cannot perform. Blood culture bottles should be provided at health facilities. All the regional laboratories should be equipped to handle some microbiological procedures. |
| 6. | Communication problems: The procedure for accessing results was not clear to all need to know parties.
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MoH-ESD/CPHL:CPHL should consider establishing
an SOP (or revise any existing SOPs) to ensure smooth and timely communication with all need-to-know parties. Alternatively, all the parties should be informed about the |
| 7. | Coordination issues with referral and shipment of services: There was no means of transport dedicated for referral and shipment of samples to the testing centers (MRC/Medical Microbiology Laboratory Makerere University) within Uganda. This affected the turnaround times for results.
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MoH-ESD/CPHL: During outbreak times funds/means of transport should be allocated for sample referral and transit to avoid any delays in releasing results.
Guides/information should always be established on how the sample referral is to be done if deemed necessary. A standard Operating Procedure (SOP) on sample referral and shipment during outbreak situations should be established. Use of the National HUB Sample Transportation Network during outbreak situations should be strengthened |
| 8. | Testing environmental samples: Water/ juice samples were collected and submitted to CPHL for analysis. However, there was no protocol for testing environmental samples. It took a good number of days for the environmental samples to be worked upon.
Currently, there is no environmental microbiology section at CPHL. This is key in identifying the source of outbreaks. |
MoH-ESD/CPHL:
Testing environmental samples are essential for identifying the source of outbreaks. An environmental microbiological testing section should be established and the respective SOPs put in place.
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Conclusion
The laboratory played a critical role in the detection and monitoring of typhoid cases in this outbreak and beyond. There were however, glaring gaps in medical commodities and essential sup- plies, human resource (both in number and specialized staff like the microbiologists) and overall coordination of the response. Well-equipped labs, and well-maintained supply chains, ensure that laboratory staff do not find themselves limited by their materials. Unexpected rapidly increasing caseloads associated with outbreaks require organizational leadership from laboratory management. Preparedness and flexibility, in both training and work time are necessary for facing an outbreak. The lessons learnt in this response should enable us to prepare and respond better in future similar outbreaks.