Although we are yet to clock 3 months since the start of this epidemic, this 10^th biggest Ebola outbreak ever has been full of twists, turns and strange tales. I penned this summary to help any regular Joe or Jill better understand to tell the outbreak. I tell a story, not trying to cover every detail. I’ve used three sections to tell the tale and have split each into three points, which I’m told is the way us humans like our information.

We start with Three epidemic Phases – how the epidemic has progressed. Key moments describes 3 key turning points, critical in shaping the epidemic to date. We then explore Three Upcoming Questions about the near future, before a final reflection.

Three epidemic Phases

Mubende steady spread – 1 month

The first month was defined by slow, steady spread in the epicenter of Mubende. Cases trickled in at only 2 new cases on average a day with almost all cases connected to known contacts. Luck was on our side with only a handful of cases spreading outside of the Mubende/Kassanda region. This was despite many stories of contacts escaping the district against government advice – some who even had Ebola. But Ebola never found a foothold in the 3 other districts where it briefly spread. For a time it seemed the outbreak might just begin and end in Mubende/Kassanda, but we were not to be so lucky.

Kassanda and Kampala clusters – 1 week

Just as it seemed we might have escaped the danger of a nationwide outbreak, two large clusters of cases emerged that threatened a national scale disaster. One large cluster emerged in Kassanda, the exact cause of which remains unclear. One possible cause was a body exhumed from the grave after a medical burial, which Dr. Geoffry Bire the assistant minister of health stated led to 23 Ebola cases in Kassanda.

The Kampala cluster however was the bigger worry as the city is highly populated, tightly packed and the gateway to the rest of the country for people, goods and diseases.

These two clusters led to as many new cases in just a week then we had seen in the previous month, and triggered the harsh Mubende / Kassanda lockdown, a huge U-turn from the government after they had “ruled out” lockdowns just a week earlier.

After these clusters emerged, the country held its collective breath as we wondered whether the outbreak really was under control as the government claimed? The Doctor’s association asked for a brutal Kampala lockdown, while many called for schools to be closed. The WHO rated the epidemic at having “very high” chance of national spread.

But in a remarkable turn of events, these two clusters haven’t produce the cascade of cases and exponential spread into a fully fledged epidemic that many expected – quite the opposite. We have seen an unexpected lull in new cases.

• Unexpected Lull: – 1 week

For the last week, we have only seen 5 cases. Hundreds of contacts from the Kassanda and Kampala clusters produced only a handful of cases, and only a few other cases appeared outside these clusters. If the Mubende epicenter has cooled, and Kassanda and Kampala clusters have been contained then there’s a chance we could be in the beginning of the end of the epidemic, and there even remains a small chance for the epidemic to be officially over by the end of the year.

Key moments

1. Late Identification of First Case: The previous 5 ebola outbreaks in Kampala were over almost before they started – for one key reason. Patient zero, the first case was quickly identified, contacts were traced and the disease wasn’t able to spread beyond a handful of cases. This outbreak however was detected far too late.

Patient zero was never identified and around 30 people caught ebola, half of who died before Ebola was even suspected. The first case tested positive perhaps a month after our mystery patient zero first caught the disease. This allowed Ebola at least a couple of cycles of unchecked spread in the community and outbreak wasn’t immediately snuffed out.

• Mubende and Kassanda Lockdown

The government re-iterated their clear position continually during the first month of the epidemic. President Museveni said “No need for a lockdown, Ebola is easy to fight”. The health minister repeated many times “there will be no lockdown”.

But probably for the better, they changed their mind and on the 15^th of October president Museveni announced a harsh 3 week lockdown in the 2 affected districts which allowed no public transport, evening to morning curfew and heavy army presence. We will never know for sure, but this lockdown could well have helped slow Ebola spread and contributed to the current unexpected lull.

• Kampala Death and Spread.

Everyone feared Ebola spreading within Kampala – and for good reason. As the only jam-packed, bustling city in Uganda, Kampala may be the only place in Uganda where Ebola has a realistic chance of exponentially spreading and becoming an uncontrolled public health problem.

And the worst case scenario happened. A man travelled while sick with ebola from Mubende to Kampala, stopping at 4 health centers and a traditional healer on the way. While on his deathbed in a huge Kampala hospital he lied about his identity to medical staff while his wife and brother who had been caring for him disappeared into the Kampala ether and couldn’t be traced. Until a few days after he died when his wife turned up to deliver her baby in a health center, sick with Ebola… Through a potentially country-saving stroke of luck or genius, some brilliant human (they deserve to be knighted) figured out the man might have had ebola, his blood was tested and his body intercepted on the way home. You couldn’t make this stuff up.

Through this saga he spread Ebola to 7 people, with one of those spreading Ebola to 7 people and another spreading it to yet 4 more (see diagram below). Other contacts already under observation then caught Ebola. Fortunately, we haven’t seen spread outside of known contacts and based on the best information we have, we’re breathing a sigh of relief that the Kampala cluster might not lead to catastrophe.

Big upcoming questions

1. Is it really under control? The unexpected lull in the last with hardly any new cases has been an amazing development, and brings a huge sigh of relief, but we don’t yet know if this is the beginning of the end. Concerning cases continue to emerge, like this one in Masaka which appears not to be connected to a contact. Further clusters could still emerge out of sight of contact tracers.

• When will Vaccine trials start? At least 3 vaccines are ready for final stage testing, at least one of which will probably work. We have been told for weeks vaccine trials may start “in a week or two” but they haven’t yet started. If the outbreak is on the way out, could the arrival of vaccines even be “Too late” and they won’t even get tested properly?

• Will restrictions end? We are getting mixed messages on restrictions. The ministry of health called for early closure of schools, even as the epidemic is in a lull. Mubende/Kassanda restrictions are due to be lifted soon, and we’ll see whether they will really be lifted. As we saw during covid, lockdowns cause enormous suffering and can we really justify ongoing restrictions with so few new cases at the moment?
  

Final reflection – This strain of Ebola doesn’t spread easily.  

There have been so many missed cases, escaped sick people and other opportunities for Ebola to spread widely that never led to new clusters of spread. Here are just a few examples. Early in the epidemic a group of contacts including two positive cases escaped from Mubende isolation, some moving as far as Tanzania on public transport and never spread the disease. A medical student with Ebola broke isolation rules and travelled many hours to his home village with no consequences. A woman in Mityana’s mother AND baby died before anyone thought to test for Ebola, and yet again there was no spread outside the family. A small but significant number of cases haven’t been traced to any known case, meaning that Ebola must have spread on a small scale and fizzled out without public health officials ever knowing.

With this in mind, and after seeing so many “lucky misses”,  it seems that this strain of Ebola isn’t highly infectious like covid, influenza or measles and may even be less infectious than other Ebola strains. This strain of Ebola doesn’t spread easily. Given what we have seen so far in this outbreak, it’s hard to imagine Ebola ever spreading beyond a few cases in country with a strong health system with high trust in government institutions. Despite late recognition of the outbreak, slow public communication about new cases, low public trust of government and numerous incidents where infectious patients had many community contacts, this outbreak hasn’t spread widely or got out of control.

This is good news for low income countries like Uganda that have functional health systems but can’t yet mount slick, tightly controlled public health responses to outbreaks. With help from exeperinced international partners, reasonable contact tracing and vaccines, perhaps Ebola as a public health issue is starting to seem somewhat less scary than after the horrendous 2014 West African outbreak.

But it’s far from over yet. Even though this strain doesn’t spread easily, a national public health disaster may still be possible if more mistakes are made and we are unlucky. Keep following our ebola updates every day or two on our St. Philips facebook page here.

https://www.facebook.com/stphilipshealthcenter

Stay safe Uganda