Are we doing enough to prevent Ebola outbreaks?

A structured framework for public health surveillance does exist. What is needed is the political commitment backed with financial support.

Western Uganda sits at the heart of the Albertine Region that is endowed with all kinds of animal species, many of which are also disease reservoirs. In addition, Uganda shares borders with at least two socio-politically fragile states: South Sudan and the Democratic Republic of the Congo. The weak health systems on the other side of the border place Uganda at a heightened risk for disease outbreaks. Unfortunately, disease surveillance systems that would pick up these threats at source are either weak or absent.

According to the World Health Organisation Regional Office for Africa, between January and May alone, there have been at least seven major infectious disease outbreaks in Africa. The very first recorded cases of Ebola emerged from nearly simultaneous outbreaks in Zaire (now DRC) and Sudan in 1976. Uganda has had four Ebola outbreaks since 2000 that have claimed nearly 300 lives. Currently, Uganda is in the midst of another Ebola outbreak that began in Kibaale District and has already recorded at least 50 cases and claimed 16 lives as at August 2.

Effective control and prevention of outbreaks require reliable public health systems. To address the need for improved surveillance systems, most African countries have adopted the Integrated Disease Surveillance and Response (IDSR) strategy whose major goal is to strengthen district-level surveillance capacities for detecting, confirming and responding to priority diseases.

The disease surveillance system in Uganda follows the IDSR approach and is integrated within the existing health system structures right from the communities, lower health facilities and laboratories, to the regional and central level laboratories and the Ministry of Health. The system is designed to function as follows:

A surveillance focal person at each health facility receives and collates data from the health facility and community, which is then relayed to the health sub-district surveillance focal person, and then to the district focal person.

At the district level, a rapid response team provides supportive supervision, and spearheads investigation of suspected outbreaks.

The central level (Ministry of Health) provides support for investigation and response when district capabilities are inadequate or overwhelmed as well as training of district staff and teams.

Generally, there is limited laboratory support at the district level due to the limited capacity to conduct specific tests such as bacteriological culture and virology – with the latter almost exclusively done at Uganda Virus Research Institute in Entebbe. The Central Public Health Laboratory in Kampala undertakes the bulk of the bacterial laboratory diagnosis.

This surveillance system is, however, faced with a number of challenges. Whereas surveillance officers exist at district and regional levels and are willing to do their jobs, they are inadequate and often lack the necessary resources to undertake their work. With high staff attrition, regular training of new staff has become a permanent need. Only about one in five health facilities have adequate staffing levels which directly impacts on the capacity of the facilities to undertake effective surveillance. Only about 13 per cent of the health facilities in Uganda have adequate specimen collection and transport materials necessary for outbreak investigations. The surveillance officers lack adequate facilitation such transportation or communication. By the time action is taken, what might have started as a single case may turn into dozens of cases.

The Ebola outbreak underscores the urgent need for quality surveillance and laboratory services for timely detection. Weak surveillance systems are partly responsible for the continued occurrence of these epidemics. While the ministry may have the will, their limited resources make it difficult to operate. Funding for integrated disease surveillance and response from the government has decreased over the years, dropping from over Shs350m per annum in 2000 to less than Shs50m by 2007. Timely access to this inadequate funding to provide prompt response is often a nightmare!

The Ministry of Health should be provided with adequate resources to maintain a sound surveillance system and to respond to public health emergencies timely. In addition, the pool of trained human resources dedicated to surveillance needs to be increased. Laboratory strengthening to cater for disease surveillance activities such as provision of adequate protective gear, laboratory equipment and reagents is necessary.

A structured framework for public health surveillance at all levels does exist. What is needed is the political commitment backed with financial support. The private sector needs to donate towards this noble cause as part of its corporate social responsibility. The public too needs to play an active role in public health surveillance by being vigilant and reporting suspected cases of strange diseases to the nearest health facility.

Drs Olivia Namusisi, Peter Wasswa and Sheba N. Gitta all working at African Field Epidemiology Network, contributed to this article.