Expert’s Viewpoint:

Epidemiological Profile of

Waterborne Diseases in Uganda

and Ministry of Health’s

Response & Preparedness

By

Dr. Alex Opio

Co-Director PHFP

Presentation Plan

• Introduction

• Some key definitions

• Epidemiological Profile of Waterborne

Diseases in Uganda

• Ministry of Health’s Response &

Preparedness

– Using Cholera experiences for illustration

• Conclusion

• A water-borne disease or infection is one that

people can catch from infected water.

• Disease transmission is achieved through

drinking contaminated water.

• Infection commonly results during drinking, in

the preparation of food, or the consumption of

food that is infected.

• Waterborne diseases are caused by pathogenic

microorganisms that most commonly are

transmitted in contaminated fresh water.

Background & Introduction

• Waterborne diseases: Diseases that are transmitted through drinking water. The interruption of transmission is achieved by proper treatment of drinking water.

• Water-washed (water-scarce) diseases: Diseases where the interruption of the transmission is achieved through proper attention to effective sanitation, washing and personal hygiene..

• Water based diseases: Diseases transmitted by contact with water, e.g. recreational swimming.

• Water vector diseases: Diseases that are transmitted by a vector, such as the mosquito, which needs water or moisture in order to breed.

Water related diseases: 4 types

relating to the path of transmission

Epidemiological Profile

of Waterborne Diseases

• Bacteria: Cholera, Campylobacter, Typhoid,

Shigellosis, etc.

• Protozoa: Cryptosporidium, Giardia,

Toxoplasma, Amoebiasis, Cyclospora, etc.

• Virus: Adenovirus, Hepatitis E, Rotavirus,

Astrovirus, Enterovirus, etc.

Examples of Causative Organisms of

Waterborne Diseases

Disease Burden

• WHO estimates that every year more than 3.4

million people die as a result of water-related

diseases, making it the leading cause of disease

and death around the world.

• Most of the victims are young children, the vast

majority of whom die of illnesses caused by

organisms that thrive in water sources

contaminated by raw sewage.

• The numbers tend to be a gross underestimation

due to the weak surveillance system

Burden of Cholera

• Globally: Estimated that 2.9 million cholera

cases and 95,000 deaths occur annually in 69

endemic countries, Most are in sub-Saharan

Africa

• In Uganda: Estimated that about 89,000

cases and 3,000 deaths occur annually.

Source: Mohamed et al, June 4, 2015 Plos NTD

• A number of waterborne disease outbreaks have

been reported in Uganda over the last 2 decades

• The main outbreaks involved Cholera, Typhoid

and Hepatitis E. Will share some data (HMIS)

• The outbreaks have occurred in different parts of

the country, in general population and special foci

• The main underlying factors to the outbreaks have

been inadequate access to safe water, water

contamination and poor safe disposal of fecal

matter (poor sanitation)

Outbreaks in Uganda

Epidemic curve HEV outbreak in Napak

District 2013/2014 – N=1,113 Deaths = 26

25 of 26 deaths were pregnant women

Date of illness onset

Nu

mb

er o

f ca

ses

Epidemic curve of suspect Typhoid cases, based

on onset date: Kampala, 1 Jan – 4 Apr, 2015*

*Only those with known date

of onset were plotted here

Cases in this area

may not yet be identified

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1/1/2015 1/19/2015 2/4/2015 2/18/2015 3/4/2015 3/18/2015 4/1/2015

Death

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patient

Start of

investigation

Cases in this area may

have not be identified

yet

Jan Feb Mar

Risk factors for Waterborne Diseases

Contaminated Water

Inadequate Water

Risk factors for Waterborne Diseases

Cholera Outbreaks

• The first Cholera outbreak was reported in

1971, in Kampala City.

• In the 70s-80s, Uganda registered sporadic

small outbreaks which always got controlled.

• In the 90s, the outbreaks became more

frequent reaching the peak in 1997/98 .

Kampala City was seriously affected with

>5,000 reported cases.

• In the 2000s, outbreaks were reported

regularly in 15-30 districts

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Cholera cases in Uganda 1971-2014

Reported cholera cases, 2000-2015

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IDPs in N.UG

Suspected Cholera Cases & Bloody Diarrhea, 2001-2014

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2010 2011 2012 2013 2014

Monthly cholera cases, 2010-2014

Cholera Hot-spots in Uganda

DRC

South Sudan

Kenya

DRC

Kenya

Major Risk Factors for Cholera Outbreaks

• Influx of refugees from Sudan, DRC and

recently Burundi

• Floods especially leading to contamination of

water sources

• Inadequate provision of safe water

• Poor sanitation

• Population displacement for 2004-2006 cholera

outbreaks in N. Uganda was due IDP camps

• Low education level.

• Poverty

Ministry of Health’s

Response &

Preparedness

MOH’s Response & Preparedness

• The National Preparedness and Response is

conducted within the broader National

Epidemic Preparedness and Response

• In essence, the above consists of Health

System Preparedness to respond

• The interruption of transmission is achieved by

proper treatment of drinking water.

• In this presentation, will use the Cholera

experiences to illustrate some points

MOH’s Response & Preparedness - 1

• Coordination of EPR

– National level EPR Coordination Structures (NTF)

to provided leadership with Sub-Committees

– District level EPR Coordination Structures (DTF) to

provide leadership at that level

– Community level structures

• Epidemiological Surveillance

– Routine surveillance, Reporting, Sample collection

and analysis, Case finding, Contact tracing and Data

– IHR 2005 (Detect, Assess, Report and Respond)

– Global Health Security Agenda

MOH’s Response & Preparedness - 2

• Information Management and EOC

– Coordination center activated during emergencies, and an

incident team constituted.

– IHR notification to WHO is done immediately after

confirmation

– Daily situation report (Sitrep). Sitreps shared with Districts,

National leaders, in-country partners, and WHO

– Monitoring the response

• Laboratory System

– With a strong laboratory system. Different levels of health

care delivery have different lab capacity.

– CPHL acts as a coordinating body for specimen

transportation

National Specimen Transport Network

• A network of lab hubs with enhanced capacity to analyze and monitor

disease trends (77 hubs reaching over 2400 HFs). Each hub headed by a

hub coordinator.

27

x x

x x Monday

Route

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x Tuesday Route

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CPHL UVRI

HU

B

• Each hub with a motorbike and a bike rider, who visits 20-30 HFs

within 30-40km radius, bringing samples and delivering results

weekly.

• The hub refers well-packaged using the Posta bus.

UVRI

MOH’s Response & Preparedness - 3

• Case Management

– Treatment centres set up in health facilities close to

the affected communities to minimize transfer of

patients.

• Logistics and Security

– Stockpiling health commodities and supplies ahead

of predicted outbreaks such as pre-El Nino period

– A strong PPP exists to rally the required support

• Human resource development

– Training of Field Epidemiologists (PHFP)

MOH’s Response & Preparedness - 4

• Social Mobilization

– Capacity for development and dissemination

of messages

– Effort is made to understand the knowledge,

attitudes and beliefs of the affected people

– Community mobilization by leaders

– Updates given to the media

Responses explaining Cholera trend

• There has been steady improvement in key indicators namely

– Water and sanitation

– Capacity for early detection and response – IDSR, RRT at

district level, mobile communication vs radio call.

– Contingency planning for disasters eg El Nino starts early

assessments followed by monitoring of evolution

– IDP Camps in northern Uganda were dismantled,

Sudanese refugees return home

– Drainage in Kampala – Nakivubo channel was widened

controlling the floods which used to disturb Kaleerwe,

Bwaise etc; last cholera outbreak in Kampala was in 2008.

The current outbreak is much small and restricted to

localized areas

Existing low cost technologies that

can save lives today

1. Chlorination: Adding chlorine in liquid or tablet form to drinking

water stored in a protected container

2. Solar disinfection: Exposing water in clear plastic bottles to

sunlight for six hours e.g. on the roof of the house

3. Filtration: Water filtration is another way to purify water

4. Combined flocculation/disinfection systems: Adding powders or

tablets to coagulate and flocculate sediments in water followed by a

timed release of chlorine.

5. Boiling: Households can disinfect their drinking water by bringing it

to a rolling boil, which will kill pathogens

6. Safe Storage:

7. Practice of personal hygiene: Hand washing is essential in limiting

the spread of waterborne diseases.

Major Challenges

• Inadequate access to safe water

• Poverty especially in the urban slums

associated with poor living conditions

• Weak data management

– Incomplete data, Underreporting, etc

• Inadequate funding; EPR is resource

intensive

• Inadequate human resource

• Uganda has continued to report waterborne

disease outbreaks, including cholera outbreaks.

• The major risk factors are poor sanitation,

inadequate safe water, adverse weather

conditions (El Nino), etc.

• Although a multi-sectoral approach has been

used to respond, a lot still needs to be done.

• The ongoing efforts need to be consolidated so

as to reduce the frequency of outbreaks.

Conclusion

Acknowledgement

• Dr, Godfrey Bwire

• PHFP

• FETP Fellows

• Dr. Immaculate Nabukeera

• Resource Centre, Ministry of Health

• Conference Organizers