The strains of Ebola

Inside tiny Kikyo Health Centre nestled high in the Rwenzori Mountains of Uganda, a sheet on the office wall entitled “Weekly epidemiological cases,” tracks incoming patients. The list gives testimony to the challenges faced when a 10-bed facility with no doctor on staff has to cope with medical conditions that, in Western countries, rarely surface anywhere but in text books: acute flaccid paralysis, rabies, dysentery, Guinea worm, meningitis.

And now, added to the bottom of the list, in big black block letters, is “EBOLA.”

This health centre, reached only by foot across the Bwamba Pass or by an arduous mountain drive from Bundibugyo town, was the epicenter of an Ebola outbreak late in 2007 that killed 37 and confounded medical experts for months, until they realized what they had on their hands was a new strain of the deadly virus.

While the experts grappled with the “mysterious illness,” people in western Uganda began dying of it in August 2007. It was not until Nov. 29, 2007, that the government publicly announced the Ebola outbreak. In all, 91 of the 149 reported Ebola cases that surfaced in western Uganda between August 2007 and January 2008 were admitted to Kikyo, where staff struggled to manage the outbreak without even rubber gloves or face masks.

“We were not so much prepared for an epidemic of that proportion,” says Julius Monday, an animated man who runs the health centre and is now something of a local legend for having handled the virus for months without himself getting sick.

But others did. In all, 6 workers at the health centre contracted Ebola and 1 died. The first to get sick was a nurse named Isaac Kiiza, who had been ordered to take stool samples from some of the first patients.

Kiiza recovered (though the nurse who treated him contracted Ebola and later died), and 2 days after being discharged from hospital, was back at work. “What choice did I have?” he asks. “We were understaffed and more and more patients were coming in.” The situation in Uganda is similar to that faced by many countries in Africa and other developing regions. There are not enough staff, equipment or medicines to handle everyday health care needs, so an outbreak like Ebola breaks the back of an already overburdened system.

What baffled experts for so long was the lack of bleeding among those who were getting sick. Because of that, as late as Nov. 18, 2008, more than 3 months after the first case surfaced, Ugandan Ministry of Health officials discounted Ebola as a possibility.

The fact that a neighbouring area was then managing a Marburg virus outbreak also delayed the Ebola diagnosis because the 2 hemorrhagic fevers have similar symptoms.

Ebola first surfaced in humans during simultaneous outbreaks in Sudan and Zaire (now the Democratic Republic of Congo, whose border is within walking distance of Bundibugyo town). Those outbreaks in 1976, and subsequent ones, have had a mortality rate between 50%–90%. The fact that the Bundibugyo outbreak had a 25% mortality rate further delayed diagnosis as the virus's behaviour was uncharacteristic of known Ebola strains. Symptoms were less extreme and the mortality rate much lower because the strain was much weaker than previously known forms of Ebola, according to Ministry of Health officials.

“The disease presented in a very unusual manner, very different from the previous Ebola outbreaks,” said Uganda's health minister, Dr. Stephen Mallinga, in declaring the outbreak over in February 2008. World Health Organization guidelines say an Ebola outbreak can be declared over after 2 incubation periods (totaling 42 days) have passed without a new case.

This region tucked closely along the Congolese border is familiar with serious medical conditions. The district has an officer in charge of managing tuberculosis and leprosy, and the district's main hospital in Bundibugyo town has a ward dedicated to treating cholera. It is not uncommon for the health centre in Kikyo to treat 850 malaria cases a month.

Despite that familiarity with dangerous illnesses, Ebola carries with it here the same stigma as a deadly and highly contagious virus that it carries elsewhere in the world.

As such, those who were infected, and their families, were shunned. In a neighbouring district, where a teenage girl died as a suspected Ebola patient, villagers threatened to stone any member of her family who tried to leave their home, for fear they would spread Ebola. Elsewhere, a community ransacked an Ebola isolation ward, sending 5 suspected Ebola patients fleeing into the surrounding hills.

“That was the worst because we didn't know where [the patients] had gone because they ran away,” says Catherine Kemigabo, a health educator in Fort Portal, a town on the other side of the Rwenzori Mountains. The patients were eventually found and quarantined. In all, the Fort Portal area had 48 suspected Ebola patients, but none who had samples taken tested positive for the virus.

By the time humanitarian agencies like Médecins Sans Frontières, the International Committee of the Red Cross and UNICEF stepped in, most of the reported cases had already surfaced. Once proper isolation wards were established, protective gear supplied and information on avoiding infection circulated to the communities, the outbreak was quickly contained.

Officials have acknowledged that the outbreak's impact was compounded by the lack of protective equipment and shortage of facilities. For instance, several people contracted the virus when they came into the health centre with other ailments, Monday says. One woman was exposed when she came into the centre to give birth.

In response to the outbreak, the Ugandan government released about US$3.5 million, half of which was spent on stocking facilities with protective gear. There has been no talk, however, of a long-term plan beyond the one-time influx of cash.