Friday, November 30, 2007
Ebola Update - Day 3
The International Emergency Epidemic Response Team (including reps from WHO, Ug MOH, MSF-Swiss, and UNICEF) flew in on a MAF Caravan and spent 7 hours on the ground in Bundibugyo yesterday. The District Director of Health, Dr. Sikyewunda, invited me (Scott) to participate in all of their site visits and meetings. The WHO rep, a sharp, experienced, epidemiologist emphasized in the first meeting of the day with local govt leaders that this seems to be a new (fifth) strain of Ebola, atypical both clinically and genetically from previously identified strains. A more non-specific clinical syndrome (fewer specific hemorrhagic signs) will make the containment of this epidemic more challenging, he said. That first meeting also revealed a lack of consensus on what public health message should be disseminated to the pubic. Will schools, markets, basic health services be shut down or curtailed? Hand-shaking cease? There was no debate about the answers, only a request from the experts to wait for their final assessments.
The visit to the Ebola Isolation Units at Kikyo Health Unit and Bundibugyo Hospital consisted of physical assessment of terrain, potential tent and gate locations, patient traffic patterns, water and latrine availablity, and staffing evaluations. Surprisingly (to me), not one member of the International Team donned protective gear in order to lay eyes on any patient. Their mandate, they said, was logistical assessment not clinical management. At Kikyo Health Unit, the staff and community seem much less aware of the ramifications of the Ebola diagnosis. People milled around the grounds of the Health Unit gawking at the entourage with its six vehicles and foreign visitors.
At Bundibugyo Hospital a significant portion of the hospital staff have gone AWOL or called in sick. A few brave nurses volunteered to staff the Isolation Unit, previously built by MSF for Cholera Isolation. During our discussion of potential layouts of an expanded unit at Bundibugyo Hospital, I received the short message on my cell phone that Dr. Jonah admitted himself to the Mulago Hospital (Kampala) Isolation Unit with fever, headache, and vomiting (and a history of contact with Ebola cases). Up to that moment, we had all expected Jonah to return today to resume his active role in the assessment and management of this crisis. Not possible now.
The last meeting of the day served as a Summary Wrap-up. Each expert presented their assessments. Basically, the plan of attack involves four arenas of activity: Surveillance (case identification and contact tracing), Clinical Case Management ( the resource-intensive task of setting up complete and safe isolation and management of patients with the disease), Logistics (management of all the stuff required to manage this crisis—UNICEF said there is 35 tons of supplies on the way now), and Social Mobilization (the massive task of educating the general population about the disease and measures necessary to control it).
I realized this morning that there are, in reality, two related emergencies. The Ebola Epidemic trumps all as the primary crisis. However, there is a secondary Medical Staffing Emergency in this District. Our only two Ugandan Medical Officers lay ill, presumably from Ebola. The official Ministry of Health initial press release revealed 51 cases and 16 deaths. That’s a 31% case-fatality rate. Nearly three-quarters of those afflicted may survive (according to the official numbers). So, our doctors may survive, but are likely to be out of commission for weeks.
Yesterday as I left the Wrap-up meeting the District LC5 Chairman (Governor) asked me to go to the Bundibugyo Hospital to attend to a woman in labor with a “hand coming out.” This mother delivered the first baby of a set of twins at Nyahuka Health Center in the middle of the night, but the second baby got stuck in a transverse position and ended up with an arm prolapsing through the cervix. Two options existed. Referring her to the Fort Portal Regional Referral Hospital, a brutal three ride in the back of a pick-up truck for an exhausted anemic woman in labor...or a Cesarean Section. I’ve been trying to resurrect my C-Section skills under the tutelage of Dr. Jonah for the past several months, but wasn’t really planning to fly solo quite yet. By faith and prayer, Scott Will and I did the surgery. It was smooth, controlled, and though very stressful, also enjoyable to be able to complete the surgery and save the life of the mother (I had confirmed by ultrasound that the baby was dead before the surgery). This type of situation happens on a weekly basis at Bundibugyo Hospital. 150 deliveries per month, on average, occur at Bundibugyo Hospital. At least 2-3 week need surgical delivery. I cannot be the one to shoulder this responsibility alone. I have also been asked to replace Jonah as the Head of the District Clinical Epidemic Task Force. This will require some work initially, but the MSF Team will be able to take the clinical load almost immediately.
We desperately need at least one more physician at Bundibugyo Hospital who can do emergency operative obstetrics. The District has failed miserably in recruiting doctors even before Ebola. The likelihood of a Ugandan Medical Officer volunteering to come to Bundibugyo now seems slim and none. I have appealed to MSF to recruit a doctor from their ranks to come and do non-Ebola hospital work (they are sending two already to manage the Ebola cases).
For Dr. Jonah, Dr. Sessanga, Joshua Kule (a senior Physician Assistant), and Fred (a nurse)--health workers who have all fallen sick with symptoms of Ebola this week.
For another doctor to come in and serve at Bundibugyo Hospital.
For Jennifer and I as we balance the responsibility of leading our team and being involved in District-level response and planning.
For Jennifer and I...for our health. We have personally examined patients (using some protective measures—but not the head-to-toe suits which are on the way), but I do not believe our exposure has been to the level of our Ugandan colleagues.
For Bundibugyo. It’s another bad rap for a disdained district. We know, however, that God has a special concern for the poor, the lowly, the despised. He has not forgotten or forsaken us.