Ebola Bundibugyo, Wednesday numbers

One of the World Health Organization experts told us that in the best case scenario we would see the number of cases cut in half each week. The admitted caseload peaked at 40 about 2 weeks ago, so with the current admissions numbering 6, things are looking pretty good.

Today's numbers:
- Cumulative cases: 130
- Cumulative deaths: 34 (CFR = 26.2%)
- Current admissions: Bundibugyo Hospital 1, with no new admissions, 3 discharged, and no deaths. Kikyo has 5 current, with 2 new cases (both identified from the pool of contacts who are being visited daily), 1 discharge and no deaths.
-Contacts: 571 total of which 450 are being actively followed (77 have finished their 21 day incubation monitoring and the remainder were lost to follow-up). 86.4% of the contacts were visited today.
-Lab confirmations: of the 108 samples sent for testing in the CDC/UVRI lab in Entebbe, 32 have been positive (29.6%). Of the 32 positive samples, 11 died (CFR = ~34%, slightly higher than the overall clinical CFR mentioned above)...probably closer to the "true" CFR of the Ebola-Bundibugyo strain (Btw, still waiting on that name to be officialized).

The District Task Force meeting continues to chase administrative details rather than medical or epidemiological questions. Today's issues related to the number of individuals of a village health team who could receive renumeration for assisting the surveillance teams and who would distribute food donated by the World Food Programme. Every confirmed Ebola case will receive a month's worth of food for a family of six.

My favorite anecdote of the meeting came out in the Surveillance Committee report. When a patient is discharged from either of the two MSF Isolation Units, they are asked to surrender all of their properties for incineration. Their mattress, their clothes, their toiletries...up in smoke -- along with any residual virus. Well, one patient was asked to surrender his cell phone (any studies out there on the duration of Ebola virus viability in a cell phone?)...which he relinquished without complaint. However, he did follow-up over the next couple of days with a couple of calls...and found that his phone is still in use! The surveillance committee is pointing the finger at the Isolation Ward staff for poaching the infected cell phone.

"Burn it or give it back," the patient has asked (he's not afraid...he's immune now).

Tuesday Night Numbers-Still in Bundibugyo

Dueling posts? Jennifer has posted this evening from Kampala because she flew out of Bundibugyo with MAF this afternoon to re-join our kids, capitalizing on her first opportunity in 14 years to sit in the co-pilot's seat. Flight protocol states the plane must be loaded heaviest in front, so Jennifer has always been relegated to the rear with the small kids. As the only passenger on today's return leg to Kampala, she had no competition for the premium seat.

This evening's District Ebola Task Force Meeting revealed a continuing tapering of the epidemic...

- Cumulative Cases: 128
- Cumulative Deaths: 34 (CFR = 26.6%)
- Current Admissions: Bundibugyo Hospital 4 ; with no new admissions, 1 discharge, and no deaths. Kikyo also with 4 inpatients; 2 new admissions, 3 discharges and no deaths. Of the 8 currently admitted to the Isolation Wards, they hope that 6 might be discharged tomorrow.
- Contacts: 535 have been listed with 426 actively followed (the remainder finished their 21 day waiting period--the Jonah family will hit their 21 day goal tomorrow). 85.2% of the contact list were visited today, a huge and punishing task in the unrelenting sunshine today.

The most intense discussion of the evening again revolved around the issue of "traditional healers" , also known as "herbalists", "traditional herbalists", "alternative practitioners","witch doctors" or "jujus". The lines between these practitioners seem indistinct, and in fact, they appear to jump back and forth between the roles depending on circumstances. Hundreds of these healers prescribe their concoctions of locally gathered substances (77 different tree sources) in drinkable teas, smearable pastes, or otherwise unspeakably applied mixtures for all sorts of common illnesses...and now they are taking credit for the successful treatment of Ebola patients.

Where does the Task Force draw the line between challenging engagement versus tacit endorsement? Clearly, this group is out in the community on the front line of caring for people with illness and cannot be ignored. However, their practices and pharmaceuticals have not been scientifically studied and cannot be endorsed. They commonly make small incisions to "let bad blood out" and to promote the absorption of their smeared herbs, a practice that could put them at extremely high risk of contracting Ebola themselves or promoting the transmission of the virus to others. Thankfully, reason prevailed and the Task Force unanimously agreed today that this group should be strongly discouraged from treating any Ebola patients. Whether they can be convinced is an entirely different question.

In Kampala

I flew to Kampala today, and am now with my four children after two weeks and one day of separation.  Thanks to the many who prayed.  Now Scott will be updating the blog from Bundibugyo.  It was amazing to fly out over the epicenter today, seeing the white MSF isolation tents like mushrooms sprouting around the Kikyo health center.  Smoke rose from forest-clearing fires, the ridges shone with the diamond glitter of tin roofs reflecting the afternoon sun, and the line of the forest where the elusive viral reservoir hides was clearly visible.  All so orderly and peaceful from the air . . .

21 Days! Ebola Bundibugyo on Monday Night

Today we are celebrating emerging from the danger zone, though the joy is heavily mingled with the deep sadness of those who lost their lives, particularly Jonah.  In the dark hours after his death we truly thought we might not be writing this today.  So we should thank God that for His inscrutable reasons He has ordained that we remain symptom free for 21 days, and in the clear.  Melen and family reach their safety zone on Wednesday.  In our daily visits I sense a slight lightening of spirit, a hope.

Tonight’s meeting saw the RDC, the LC5, the DDHS, and the CAO (chief administrative officer), the four most powerful men in the district, all back in place.  The RDC opened with the statement that the enemy has just made a tactical withdrawal but is not defeated, so don’t relax.  The struggle continues.

• Cumulative cases:  126
• Cumulative deaths: 34 (holding for DAYS now); CFR 27%
• Current Admissions:  Bundibugyo 5; with 2 new admissions, 1 discharge, and 0 deaths.  Kikyo also 5, with 1 new admission, 4 discharges, and 0 deaths.  More discharges expected tomorrow.
• Contacts:  487 have been listed, with 408 being actively followed (others like us have reached the 21 day limit).  Today 88% of those were evaluated by energetic mobile teams, now boosted by five young MPH students from the Institute of Public Health, all Ugandan doctors who have joined the CDC in their efforts.
• Complaints:  tribalism surfaces again, with the Bakonjo claiming that the social mobilization teams are speaking only in Lubwisi . . . Which prompted a LONG discussion of the mobilization effort.  Are the Bakonjo areas just harder to reach (steep, scattered), or are the complainers angling for jobs and pay, or is there really any problem at all?  Much emphasis was put tonight on using the LC1 system, the political organization of the country, to address communities.  I think they ended up deciding that various big men should volunteer to train LC1 chairmen to reach every community.
• Dissension:  much discussion again of local herbal remedies, with some herbalists now spreading the word that certain recovered cases only recovered due to their medicines . . . And not so surprisingly, many of the people in the task force are not so sure, the power of the belief in traditional medicine is widespread.  A couple of brave voices asked for science to interpret the results, and warned that if herbalists are invited to participate as part of the official task force then we will be inadvertently authenticating their claims.
• Money:  there is now a 2 billion shilling plus budget, but the Ministry has to approve it.  Refreshing moment: In contrast to all the grabbing we see in the political sphere, we were handed a document today by one of the translators who works on the Lubwisi Bible project, who had taken the information about Ebola and translated it.  Unlike everyone else we have encountered, this man wrote at the bottom:  translated at no cost, for the good of the people of Bundibugyo and the glory of God.  Amen.
  

And the emotions of the day for us:  relief, and eager anticipation of going to Kampala tomorrow (Jennifer) to see the kids.  At this point we are still planning that the non-medical team stay out, and Scotts and Pat join the rest for Christmas.  But our kids call several times a day asking when they can come home, and why not for Christmas.  Now that the epidemic has slowed in its relentlessness, we are torn.  We don’t want anyone to be exposed.  But the chances of that are remote for those who don’t see sick patients.  Our kids’ friends, who are flocking back to our house, asked today, when are they coming, and why not now if you are safe?  Once again, we are torn by our care for these kids, and the painful reality that our standards for our kids and team are different than our standards for local people.  Unfair, and stressful when you’re here facing reality.  Actually most of the rest of the country and the world is probably more uptight about Ebola than the average person in Bundibugyo, and for good reason.  If you aren’t here, then Bundiubugyo = Ebola.  If you are here, then you see that 99% of life is about other things, the normal human interactions that constitute a day.  Pray for wisdom for us and our mission leadership, who have to buy into the decision on when to sound the all clear.

And tonight, to close, a little reminder of life going on.  Dear team mate and friend Heather Pike Agnello is in labor with her first baby, while a few hours from now dear team mate and friend Rick Gray will celebrate the milestone of 50 years (Dec 18!!!).  Happy birthdays.

Dr. Jonah's ship...out of our sight...

Fellow WHM colleagues in Ireland passed on this poem to us. A poignant image of death as merely transition... I am standing on the sea shore, A ship sails in the morning breeze and starts for the ocean. She is an object of beauty and I stand watching her Till at last she fades on the horizon and someone at my side says: "She is gone." Gone! Where? Gone from my sight, that is all. She is just as large in the masts, hull and spars as she was when I saw her And just as able to bear her load of living freight to its destination. The diminished size and total loss of sight is in me, not in her. And just at the moment when someone at my side says, "She is gone", There are others who are watching her coming, and other voices take up a glad shout: "There she comes" - and that is dying. An horizon and just the limit of our sight. Lift us up, Oh Lord, that we may see further. Bishop Brent 1862 - 1926

Ebola Bundibugyo: Sunday night report

Today, the non-medical side of Ebola . . . Or the real-life, long-term side of it perhaps. After Scott did his very public thanks and contact-greeting with survivor Fred, Pat gave him a Bible, and he came to our house for a coke and sandwich. Meanwhile a reporter for a Christian Dutch news service who had traveled to Bundibugyo showed up at church too, so he took advantage of the time to do interviews with the nurse, then with Scott, and briefly with me. He lives in Kampala but earns a living by writing stories and radio shows for the Netherlands. He was just leaving when the CDC team came, we had invited our fellow-Americans to cheer and encourage them with pizza and a break from the front lines. It was one of the hidden blessings of the outbreak, to enjoy the company of these young doctors, swap stories, and send them back into the battle a little fortified. Also the evening briefing is a bit more palatable after a good meal . . . The medical side continues to improve:

• Cumulative Cases: 123
• Cumulative Deaths: 34 (stable number once again); CFR 27.6%
• Laboratory: no news, no planes on Sunday, so no new samples analyzed.
• Contacts: reporting was a bit more fuzzy, the teams are definitely out there tracing, there is a concerted effort to add contacts of new cases to the list. The surveillance team seems to find questionable people on a daily basis who have some sort of symptom, but rarely get admitted, so then aren’t counted as cases. There seems to be a gap between contact tracing and case identification, hard to tell from the briefing but we might be missing some people, or focusing attention on people who aren’t real contacts, because the stakes are high. Either mistake is potentially costly, to leave infectious cases in the community, or to distract resources towards non-Ebola sick people.
• Admitted to Bundibugyo Isolation Unit: 4. Quite an improvement since last week! 0 new admissions, 1 discharge, 0 deaths.
• Admitted to Kikyo Isolation Unit: 8. 1 new admission (was a support staff who worked in isolation, so yet another health care worker contact falls ill), 1 discharge, 0 deaths. There was also a readmission of a previous Ebola case but he is a man with chronic hypertension, so his readmission was judged to be due to this chronic problem and not to Ebola.
• Politics: The entire two weeks we’ve discussed the lack of a vehicle for Kikyo to serve as an ambulance. They are supposed to have two separate trucks, one to bring patients in (ambulance) and one to go out and bury the dead. Every day the hard-working staff complains about the lack of a vehicle. Every day there is a different person to blame. It is broken, it is in the shop, the district hasn’t paid the bill, the fuel wasn’t available, it is back in the repair shop . . .and today’s explanation: the driver could not be found. It seems that drivers signed up for the extra allowance of being Ebola-response team members, but none actually want to go anywhere with Ebola, so Kikyo is not a preferred route. WHO suggested that drivers only be paid AFTER driving. Sounds good to me too.
• Cultural issues: a doctor from Kampala warned that Christmas might be a risky time because the local people would want meat and therefore poach wild animals from the forest, accelerating the epidemic. While isolated cases of this hunting probably did trigger the initial transfer of the virus from the supposed animal reservoir to humans, the entire district certainly doesn’t go poaching for Christmas. I guess I’ve lived here long enough that I felt personally offended by the underlying cultural superiority of the comment, people from other parts of Uganda look down on Bundibugyo people as primitive. I wanted to raise my hand but had already been attacked for a previous question, so I waited and was actually quite happy when our own DDHS very politely explained that as the senior indigenous person present, he wanted them to know that this is a season for cocoa, and the local people get money for their cocoa and use it to buy beef, goat, pork for Christmas, they do not go poaching from the parks. There was also a suggestion that circumcisions be deferred until after the epidemic. This was agreed to be a wise move. Usually Dec/Jan is the main season for circumcisions, boys are off school and can go through their initiation in groups. Some years seem to be more popular than others. Any procedure that involves blood and is not urgent should be delayed. So next year might be a better choice.

Today’s sermon was on Elizabeth and Zachariah, on God bringing joy into a situation of barreness. We so easily criticize Zachariah for his lack of faith, but I sympathize with him this year. This is a bleak season for health and the Kingdom in Bundibugyo. To see God’s work here takes faith, and I’m sure I’d be tempted to point out the facts to an angel. Praying for hope, for the nine-month view ahead to what God will do.

Ebola Heroes

Today Scott stood up to introduce Fred Lubwasa in church—Fred is a UPDF soldier and nurse who volunteered to work in the isolation unit back when we didn’t understand the epidemic, then stayed on when he knew it was Ebola. We first met him three weeks ago, the first time we were examining patients there. His exposure led to infection, and he battled for his life. Now discharged, he thanked Scott for the prayers of the people, so Scott invited him to church. As they stood together, Scott put his arm around him and shook his hand to show that post-Ebola patients are not infectious and should not be ostracized. He pointed out that God looks at the heart and in God’s kingdom this nurse is a “Big Man.”

We are also posting some additional pictures today of the other Heroes of Ebola.

Rosa Crestani, the MSF Medical Coordinator who led the advance team, moving in to create order in the chaos, passionately caring, with that core of steel that allows her to do her job even when criticized by politicians (and she’s had plenty of that in the meetings!).

Dr. Yoti Zabulon, the energetic and patient young doctor, who survived the Gulu Ebola epidemic of the year 2000 and then pursued a career in Infectious Diseases with the WHO in Uganda, flying to every trouble zone in the country to offer service, leadership, and wisdom.

Our Resident District Commissioner Sam Kazinga, who represents the President's Office to the District, with his commanding presence and insistence on work, pulling all the agencies together and keeping the Ebola District Task Force focused on their task, dispelling rumor and insisting on excellence.

Monday Julius, the Clinical Officer In-Charge at Kikyo Health Unit, who has been caring for Ebola patients at the epicenter since it began, seeing more Ebola patients than any other person in the district...and who has managed not to get sick with the disease!

And there are many others, the fresh faces from CDC who track contacts and draw blood samples and diagram transmission chains. The voices of experience from WHO and elsewhere who have seen this all before and know what to do next. The doctors from Ministry of Health who left their homes and families behind to shore up the devastated medical system here. The committed and competent field workers from the Red Cross who scour the district for contacts and cases.

Dr. Ian Clarke writes a weekly column, and in today’s he praises two doctors in Kampala working with paediatric AIDS. In that same spirit we applaud the heroes we’ve seen here. Just when one is tempted to despair over Uganda, these people remind us that God has his people everywhere, fighting the good fight, showing mercy, using their talents to serve others.

Ebola Bundibugyo: Saturday numbers

Encouraging statistics from today:

• Cumulative cases: 122
• Cumulative deaths:  34 (same as yesterday, no new ones!)
• Admitted on isolation wards:  Bundibugyo 4 . . . 0 admissions, 4 discharges, 0 deaths.  Kikyo 8 . . . .2 admissions, 4 discharges, 0 deaths.
• Contacts:  423 identified, 327 being followed, 286 seen today (87%).  42 people moved off the list at the end of their 21 days.
• Surgeries Scott performed today: 3.  He was called this morning by the police surgeon from Fort Portal who said he needed to go home for the weekend, so could Scott be on call. . And a few minutes later the first emergency C-section call came.  So Scott and Scott spent the whole day at Bundibugyo hospital, once again the only people seeing non-Ebola patients.  This pinch-hitting is very stretching for them, dealing with cases that come very late and very sick . . . Thankfully a healthy baby boy was delivered by C section, an 18 year old bleeding excessively from a miscarriage had a d and c, and another lady’s life was saved when she came with a retained placenta.  Before and after all that Scott was dealing with airstrip maintenance.  It’s a lot of work to be here these days.  
  

Best comment of the day:  Dr. Sessanga’s son.  It is a privilege to be a source of information even for Ebola patients’ family members in Uganda, to encourage prayer and hope.  A small way in which this crisis bridges cultural barriers and connects us all.

Ebola Bundibugyo: Friday Night Numbers

Two weeks and one day since the diagnosis of Ebola was made public.  Two weeks since the MSF preparation team came, 12 days since the first real medical staff, and 10 days since the overall organized response took shape.  In that time it is good to think about what has NOT happened.  Ebola has NOT been confirmed anywhere outside of Bundibugyo.  Hundreds of new cases have NOT materialized.  Health centers in addition to the two primary foci have NOT been swamped with cases.  It has been a stressful and uncertain two weeks, and a time of great loss and sorrow.  There were many points at which it seemed we might be reaching the potential beginning of the end of life as we know it, with diffuse spread of the infection and overwhelming fatalities.   Thankfully that has not happened, but now the weariness of grief is beginning to catch up with us, the change in pace to the long-haul.  And with that shift comes the district and ministry wrangling over money, power, and control.  Scott spoke up in tonight’s meeting on behalf of compensation for health workers who were infected and recovered, as well as the families of those who died, concerned that these people were getting lost in the scramble for the money flowing in.  He was immediately attacked by at least three people who sensed a threat or challenge to the proposal of huge allowances for all numbers of people, some of whom are quite peripherally involved. Sigh.  I think it is a small reflection of the kind of pressure Jonah faced.  If we aren’t a threat to the way things are, we shouldn’t be here.  And so it goes.

• Cumulative Cases:  120.
• Cumulative Deaths:  34 (CFR 28.4%)
• Admitted:  Bundibgugyo 8, 1 new admission, 1 discharge, 0 deaths.  Kikyo 10, 1 new admission (a health worker sadly), 0 discharges, 0 deaths.
• Confirmed cases by lab:  32 still, but now we got the information that 11 have died, 7 are still admitted, and 14 have recovered.  If those 11 are the only ones to die then the CFR among laboratory confirmed cases will be slightly higher than the overall, at 34%.  The numbers are small, and this CFR could be falsely lowered by the fact that the sickest patients did not survive to get their labs drawn, or falsely elevated if we go back and test lots of people for antibodies since we’ll only find the survivors.  Still it is the best number we have, and would suggest this strain is less lethal than other strains of Ebola.
• Contacts:  345 (17 were removed from the list for reaching their 21 day limit, a milestone we look forward to next week!).  Over 90% were followed up today.  
• Interesting stories:  the two biggest clusters of related cases  have been mapped out.  There do not appear to be multiple sources of this infection crossing from the supposed animal reservoir to humans.  This is excellent news, since it was certainly possible that Bundibugyo might have had lots of little mini-epidemics all cropping up in this time period.  Most cases seem to be directly related to each other.   However not all are testing positive, which may mean that we are looking at not just another strain of Ebola but something else as well.  We continue to be thankful for the excellent and inquisitive minds who are focusing their energies on this.
• Sad news:  there was a massive turn over in staff today, especially WHO, including three of the men whom we have grown to really trust and respect over the last ten days.  They will be missed.  Dr. Yoti promised to come back.  Other sad news was that a mission house was broken into, the thieves dragging a safe a long distance and then sledgehammering it to pieces.  They were probably disappointed to find it was pretty much empty.  Sad for all of us that people would use this time to take advantage of others.
• Happy news:  The UPDF nurse Fred, whom we met in the Bundibugyo isolation unit the first time we went to investigate patients, recovered.  
  

Some men that Scott lived with in college, 25 years ago, let us know that they are coming together to pray for us.  A dear friend whom I have known since I was born, and almost never had an email from, wrote today.  We continue to be humbled by the outpouring of love and concern from the amazing network of friends God has blessed us with.  We even had a call today from the National Forestry Authority official who nearly arrested us last Christmas when we cut down a pine tree (with permission, but it turned out that the permission was not from the people who had authority to give it . . . ).  He wanted to be sure we are OK, and asked us if we had our Christmas tree yet for this year!  For the first time in my memory I have not done any preparations for Christmas at all beyond packing a hurried trunk of things for my children when we sent them off.  But the team in Kampala had tree and decoration plans for tonight, so we politely declined the NFA friend, though we appreciated the thought!

Ebola Bundibugyo: Thursday Night, Living on the Edge

The facts:

• Cumulative cases: 118
• Laboratory confirmed cases:  32, all still from Bundibugyo
• Cumulative deaths:  34 (28.8%CFR)
• Contacts:  368, with 264 seen today (71.7%)  This is the heart of containment, having surveillance teams face to face daily with contacts to monitor any who become ill, and encourage them to come in for isolation and care.
• Admitted in Bundibugyo:  8 (!), with 5 discharges, 3 new admissions, and 1 death.
• Admitted in Kikyo: 9, with 0 new admissions, 0 discharges, and 1 death.  We learned today that two of these are women who are breast feeding babies (age 3-4 months), and since the virus is highly transmissible in breast milk we are providing formula tomorrow so that the babies can be watched in isolation for symptoms but separated from their mothers . . . Another sinister aspect of this disease and the way it insinuates into the very relationships that should bring comfort and support.
• Stories:  well, there were a couple of sad ones.  First, a pastor died, a man who had prayed for Ebola patients before we knew it was Ebola.  In my view it is just like the health workers dying.  This man laid down his life by caring for others.  He probably laid his hands on Jeremiah Muhindo as he prayed for him.  So did Scott.  That always sobers us, though each day we move further and further from the common incubation period, and closer to the 21 day safety zone.  The clinical officer Joshua Kule’s son is another problem story—it came out in the meeting that a surveillance team visited him and determined that the fever he had was improving on antimalarials so he did not have Ebola.  At that point our MSF nurse spoke with obvious conviction and care:  it is DANGEROUS, she said, for the surveillance team to think they can make that judgment.  Any contact with fever has to be evaluated by a medical person and tested!!!!  This man was the primary caretaker for his father, who died, and is exactly in the incubation period for symptoms. Cases like this make it clear that we are not yet out of the woods.  Because people fear the isolation ward, they will try to hide or minimize symptoms, and thereby put their families and communities at risk.  
• High of the day:  Scott was able to visit four of the five families of health workers who died, taking them some food and comfort and words of Scripture about God’s care for the orphan and widow.  I think it was a touch of kindness and contact in a disease that is otherwise frightening and isolating.  And a way to show extra respect for the lives of these men and women.  He also tracked down the children of a woman admitted now, who is not dead, but whose children have been reported to be fending for themselves.  
• Low of the day:  Well, several really.  One is that the voices of reason and wisdom and experience may be thinning out as we end our second week of crisis response.  We hear rumblings that the CDC team is narrowing down to one (a really nice guy, but still only one of him) and our trusted WHO doctors and epidemiologists are also hinting they won’t stay much longer.  An experienced person warned us today to expect things to temporarily deteriorate again between Christmas and New Year as people slack off .. . Which makes us feel like we should be here then.  I miss my kids a lot tonight, more than usual, maybe hearing about them first-hand from Pat.  It was a discouraging meeting tonight, focused on money, and while I respect the hard work and leadership of most people involved, I feel the cross-cultural tension of distaste for the fact that the biggest budget items are extra allowances for most of the politicians.  My American viewpoint is that they are doing their job, so why should UNICEF money go to their pocket?  But I know the African view would be that they are underpaid, and that they are putting in extra hours, and that it is only right that their work be valued in this way.  But I have to confess it still grates on me.
• Unlikely heroes:  MAF.  Mission Aviation Fellowship flies people in and out almost daily, ferries blood samples to the lab, brings supplies here.  They also have found our team a house to stay in in Kampala, and helped them with everything from a generator to groceries.  We are a small mission, and in many ways MAF functions as our support base.  The pilot today even took an extra hour on the ground just to visit us and pray for us.  We are so grateful.
  

I’m wearing a shirt tonight in honor of Pat returning, a shirt that she gave me after buying it right off the back of a man in the market who was wearing it, during the ADF years.  It says:  If you aren’t living on the edge, you’re taking up too much room.  Here we are on the edge, hanging on.