Ministry of Health update on Marburg 25th October

 Many of you are asking us about the current situation re the Marburg virus outbreak.  Here is today's Ministry press release re the national situation.  We have not had any cases in Kisiizi so far but are vigilant as we receive some patients from Kabale.  The index cases are from an area to the south of Kabale on the way towards the border with Rwanda at Katuna so not on this side of Kabale but nevertheless we clearly need to be very cautious as we don't know how far it may have spread...
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October 25th 2012
                                    MINISTRY OF HEALTH
                                    P. O.  BOX 7272,
                                    KAMPALA - UGANDA

PRESS STATEMENT ON THE UPDATE OF MARBURG OUTBREAK

The Ministry of Health declared an outbreak of Marburg in Kabale district on October 19th 2012 after receiving laboratory results from the Uganda Virus Research Institute (UVRI) confirming that two family members had died of the highly infectious viral hemorrhagic fever.  Three other members of the same family had earlier died of a strange disease in a period of one month.
The death of these people prompted the District Health Office to undertake further investigations of this strange disease that had ravaged Kitumba parish in Kitumba sub-county, Kabale district.
According to the reports, the patients presented with symptoms of diarrhoea, vomiting, fever, headache, dizziness and generalized convulsions. Initial samples of blood and cerebral spiral fluid taken from the sick people ruled out Malaria and Meningitis. The family then invited a cult leader, a retired Reverend from Rukungiri, district to visit their household and pray for the sick.
The index case is believed to have been a member of a family in Rwabirondo village, Kitumba parish in Kitumba sub-county which occurred on 20th September 2012.  After the death of the index case, two other people, a sister and mother reportedly got sick and died.
This outbreak comes barely two weeks after the Ministry declared an end to another viral Hemorrhagic Fever (Ebola) on October 4th 2012. The last Marburg outbreak was witnessed in October 2007in Kamwenge district.
Marburg is a highly infectious viral hemorrhagic fever which kills in a short time but can be prevented. Marburg is spread through direct contact with, body fluids like blood, saliva, vomitus, stool and urine of an infected person.
A person suffering from Marburg presents with sudden onset of high fever with any of the following; headache, vomiting blood, joint and muscle pains and bleeding through the body openings, i.e. eyes (red eyes), nose, gums, ears, anus and the skin.
How is Marburg Spread?
It is spread through;
•    Direct contact with wounds, body fluids like blood, saliva, vomitus, droplets, stool and urine of a person suffering from Marburg.
•    Unsterilised injections, contaminated linen, beddings and clothes.
•    Using skin piercing instruments that have been used by an infected person.
•    Direct physical handling of persons who have died of Marburg

Current Status (Update)
The Ministry of Health has developed a response plan and budget for the Marburg control amounting to sh2.3b of which sh1.75 is for central level activities including Ministry of Health, six general hospitals and Kampala Capital City Authority. This will be majorly for case management, surveillance, research and social mobilisation and procurement of protective gears. The district budget totals 651,047,576 and it covers case management, surveillance, research and social mobilisation.
•    Out of the six people who have died so far, only three were confirmed positive for Marburg.
•    Currently, there is only one confirmed case admitted in our isolation facility at Mulago National Referral Hospital. One convalescent case is detained at  Rushoroza Health Center III while five suspect cases linked to the initial cases  are admitted there awaiting blood results.  Special teams of doctors and nurses have been assigned to attend to the patients in both the isolation facilities. The patient admitted at Mulago National Referral Hospital is from Kitumba sub-county and is a relative of the index case.
•    The Ministry of Health surveillance team has listed up a total of 196 contacts for close monitoring. These contacts are mainly in Kabale, Rukungiri and Ibanda districts while 29 are from Kampala. Those being monitored reportedly got into contact with either the dead or confirmed cases. The team continues to monitor them on a daily basis for possible signs and symptoms of this highly infectious disease until they have completed 10 days without showing any signs and symptoms.
•    A team of experts from the Ministry of Health, U.S Center for Disease Control and Prevention and World Health Organization have so far collected a total of 18 n   samples from suspected cases for further investigations. The samples are being analyzed at the Uganda Virus Research Institute, Entebbe.
•    The Ministry is conducting an orientation of local healthcare workers in Kabale Regional Referral Hospital and in the other peripheral health facilities on infection prevention and control, barrier nursing, surveillance and clinical case management. This is being done to build health workers’ capacity to handle such cases. 
•    In Rushoroza Health Centre, a burial committee has  been set up to manage burials of people suspected to have died of Marburg. The committee has been oriented on burial procedures and infection prevention and control. This is one of the control measures to curb the spread of the highly contiguous disease. The committee has so far supervised two burials.
•    A team from the Centers for Disease Control (CDC) is expected in the country to undertake anthropological studies.
The Ministry of Health once again urges the public to take the following measures to avert the spread of the disease.
•    Report immediately any suspected patient to a nearby health unit
•    Avoid direct contact with body fluids of a person suspected to be suffering from Marburg by using protective materials like gloves and masks
•    Persons who have died of Marburg must be handled with strong protective wear and buried immediately
•    Avoid eating dead animals
•    Avoid unnecessary public gathering especially in the affected district
•    Burial of suspicious community deaths should be done under close supervision of well trained burial teams  
•    Report all suspicious deaths to a nearby health facility 

Once again the Ministry of Health calls upon the public to stay calm as all possible measures are being undertaken to control the situation. 

Hon. Dr. Christine Ondoa
Minister of Health 

birthdays...

Dr. Francis Banya, our Obstetrician, came in from a game of badminton to find a surprise birthday party producing what must surely be the smile of the year!  The photo on the right shows him with his 1 year old daughter Gloria, and his wife Confidence.

 Ian, being a fair bit older, was dubious when asked to come urgently for “an emergency in the staff room” on his birthday and so he nipped around the back of  the building and popped his head through the window to catch out the waiting party! 

Great laughter resulted followed by sharing the largest cake he has had for a birthday! [thanks Hanna!]

 

 Birthdays come and birthdays go... and its amazing how time flies.  

Whilst reviewing a preterm baby recently Ian said, as a throwaway comment to Damari, one of our nursing team, " You probably weren't even born when I first came to Kisiizi in 1987!"

He was rather shocked when she replied that her mum had told her that he was the one who had delivered her!

Damari

deja-vu.....

Unfortunately, as you may have seen or heard from the media, we have another outbreak of viral haemorrhagic fever in Uganda.  This time not Ebola but Marburg, an equally unpleasant highly-infectious serious infection.  And this time the outbreak is relatively close to us being near Kabale, a town about an hour and a half's drive from Kisiizi.

As a consequence we are having to triage all our patients at the main hospital gate again, and have moved the overflow patients from our surgical ward, which we had been renovating, back from the old theatre which is once again ready to act as a high-isolation area.

cleaning the ward area ready to move patients back....note the new ceiling but still needs walls, windows and floors renovating...

We pray that the disease does not spread but have tried to put the contingency plans in place promptly.  Reluctantly we have had to cancel the planned orthopaedic camp due to take place this next week, and have postponed some training seminars linked to the African Patient Partnership Scheme operated by the World Health Organisation.

Comings and goings...

After a long period apart, I was pleased to set off in a minibus from Kisiizi to head for Kampala to collect Hanna... got in minibus 6am, set off 6.30am, puncture 7.30am, reached Mbarara 80 miles away 9.30am.  Met by Esther Kobusingye, recently retired Principal Nursing Officer from Kisiizi, and moved to the coach park to join the queue to board... about 5 hours later arrived Kampala to be met by Augustine Tusingwire, our driver.  Unfortunately the hospital vehicle I was to have picked up was out of action in the garage so alternative plans had to be made.

Hanna, Moses [with cake!] and Angela

 But thankfully Hanna arrived safely accompanied by Dr. Angela, a Consultant Anaesthetist who is with us for six months working to support our anaesthetic clinical officers Gershom, Medius and Andrew.  Angela has an interest in pain relief so we will upgrade our pain service and review our palliative care protocols.

Medius, Anaesthetic Clinical Officer

Uganda Protestant Medical Bureau sent a team to undertake a supervision exercise.  They brought the date forward by a fortnight at the last minute so it was a mad rush to get everything ready in time but it seemed to go well and the member of the team who had been before, last visiting in May, reported she noted a significant improvement.

They toured the hospital patient areas but also found a few moments to look at the hydro-electric generator and try on a few of the necklaces made by patients in our Rehabilitation Unit.

 

back from the brink...

Though it can be very hard work with so many patients to see and so many other demands from staff or on email, we occasionally pause and rejoice when we are privileged to see the fruit of our labours.

standing by the fountain with childrens' ward [ground floor] 

 

and maternity behind

This youngster nearly died on the ward, she had rheumatic fever causing her to have joint swelling, abdominal pain, fevers etc but particularly she struggled with carditis, inflammation of her heart which went into failure.  She was struggling to breathe in spite of oxygen with a very high pulse and respiratory rate.  She also developed an abscess in her left arm which required surgical drainage.

chest x-ray of the patient

She needed a range of medications and was in the ward for quite a while but here she is ready to go home and really looking well.

She and her family were supported by the Good Samaritan fund as, being in a long time, her hospital bill was more than they could afford.  So thank you to all who have contributed, including our medical students on elective who automatically pay a contribution to the fund to help us care for patients like this.

Celebration - Independence Day

yes, it's 50 years since Uganda gained its independence so there are a lot of flags here in Kampala today and cavalcades of high speed vehicles carrying visiting leaders and guests to the celebrations.

Clearly Uganda has been through times of turmoil in the past 50 years but through it all, remarkably, Kisiizi Hospital has never closed its service to patients.  Now there are some prospects of economic progress with oil in the west of the country and the recent opening of a new hydro-electric scheme on the Nile and plans for more in future. 

However, one big challenge is the rapidly growing population and giving parents the opportunity to plan and space their children must be a key goal as so many are struggling to feed and educate their children...  This is an area Kisiizi is looking at and hopes to develop in the coming months.

I don't have any photos of the celebrations in Kisiizi as I am in Kampala, but planned were a series of serious and not so serious sports events, speeches etc followed by an informal fellowship meeting in the evening...

basking in reflected glory!

We are very proud of Ruth, who has just started her post-graduate certificate of education at Cambridge.   She won 3rd prize in a special competition, see the details on the webpage link below:


Ruth's prize - see Leeds University website page - click here

Her extensive dissertation included a significant contribution from work at Kisiizi Hospital Primary School, and she produced some very interesting comparative data from Kampala, Mbarara and Kisiizi in Uganda, and Leeds, Sutton and Macclesfield in UK.  Thanks to all who helped including Sister Esther Kobusingye and her family who spent ages sending photos one at a time on a very slow internet connection, and the teachers and pupils at Kisiizi and the other schools involved.

Little problems...

Our Special Care Baby Unit admitted 373 babies in the year up to 30th June.  The majority are born here but some come from home or sent to us from other hospitals.

Here is a picture I took on my night round showing an incubator with a 960 gram baby born about 12 weeks too early.  On the left you see the oxygen concentrator which removes nitrogen from room air leaving (mainly) oxygen which is humidified then administered to the baby with nasal prongs.  You can also see a glass bottle on the floor, this takes the expiratory arm of the circuit to provide some back pressure, giving the baby Continuous Positive Airway Pressure.  This is beneficial in babies with surfactant-deficient lung disease, a common problem in pre-term babies especially here where we don't have any surfactant to give ( it costs a couple of hundred pounds a dose but of course is freely available in the NHS).

On the right you will see the syringe pump for his intravenous fluids to ensure he doesn't get too much too fast which would be risky.  This size of baby may only be on a few mls an hour.

The incubator itself, of course, is keeping his temperature at the right level and also forms an isolation chamber in one sense.  Happily our Staff are trained in how to keep such incubators clean as otherwise there is a risk of infection.

Above the incubator is a light giving phototherapy for jaundice.  This photo-oxidises the yellow pigment bilirubin and makes it easier for the baby to excrete.  No, its not ultra-violet, though many of the medical students still seem to think so!  Its just visible blue light.  It's important to control jaundice, especially in such tiny infants, as an excessive level may cause deafness or brain damage.

Now, you are asking, what is that on the upright stand on the left?!  Those are hand towels drying on a convenient hook!  We have small towels to use whenever we wash our hands between each patient, they then go in a bucket to soak and then are washed, rinsed and hung to dry... no disposable paper towels here.

This baby also received antibiotics intravenously (penicillin and gentamicin) and breast milk via an oro-gastric tube.  He may need a blood transfusion at some stage as it is not uncommon for very small babies to become anaemic.  He has aminophylline to reduce the risk of him stopping breathing due to his immaturity.

If I was caring for this baby in Macclesfield I would have done a lot of blood tests for full blood counts, chemistry screen, blood gases etc but this infant has had very little investigation but, happily, is doing well so far.
You can see this is therefore on the one hand quite basic neonatal care compared to what is available in the west but it is quite sophisticated by Ugandan standards.  It shows the importance of our reliable hydro-electricity to run the above equipment.  It also highlights the value of our staff.  It's good to see Sister Ann Moore, who has faithfully led the work on the Special Care Baby Unit for many years together with Nurse Edith, having more support from Dr. Josephine and our paediatric intern and myself.  We now try and do a Neonatal Grand Round on Thursday mornings to review the babies and incorporate some teaching.

We are grateful to have Dr. Gabriel,  consultant Surgeon, here at Kisiizi as he will do some operations on newborns if required.  For example, we had a baby recently with a spina bifida which he closed, and another with a large growth over the lower spine which he resected.  As has quite rightly been pointed out to me after my initial publishing of this post, I should not forget to praise the anaesthetic team as well as the surgeon!  We are actually working hard to develop our Anaesthetic Clinical Officers.  Gershom was able to spend a month in UK, 2 weeks in Chester and 2 in Reading, quite recently, and then Dr. Neil Fergusson, Consultant Anaesthetist from Chester, did a return visit here for a fortnight.  Now we are looking forward to Dr. Angela Cooper, also a consultant, joining us for six months.  Angela is a volunteer with Church Mission Society, and has a particular interest in pain control.  Medius, another Anaesthetic Clinical Officer, will hopefully be able to attend the annual scientific conference of the Uganda Society of Anaesthetists to be held in the north of the country in Gulu later this month. 

Please pray for the Staff on the unit, it can be very busy and at times frustrating, and we do lose some babies but this is balanced by the satisfaction of seeing some very unwell or very premature babies going home well. 

never a dull moment...

Time flies when you are enjoying yourself... and there is so much to pack into every 24 hours it seems sometimes our feet don't touch the ground...


but there are occasional pauses,  in fact, just to prove to those of you who accuse me of never putting my feet up, here is photographic evidence!

yes, that's the waterfall in the background....



Life would of course be much more predictable and more routine if it wasn't for the patients who tend to cause problems at unsociable times...at 6.20 this morning I was called urgently to see a 2 week infant with gram positive bacteria in the cerebro-spinal fluid = meningitis... we tried full resuscitation but having obtained initial stabilisation the baby died a couple of hours later... had all happened very quickly, in this case the parents had not delayed bringing their child to hospital as sometimes happens.  Then we have an 8 month child with a different type of meningitis who had convulsions, but now stabilising.  Opposite, a girl of 10 with rheumatic fever that had caused her to have severe heart failure but now she is improving.  In the next bay a new patient of 4 years with nephritic and nephrotic syndrome [swelling of the body due to protein leaking from the kidneys due to inflammation due to a previous infection due to skin sores untreated promptly due to poverty due to unequal sharing of resources due to...] well, maybe I am going on too long but you get the picture.

Happily, our new interns are settling in really well and are proving a great help.  We try to invest in training and support to encourage them.

Now switch to a completely area to see progress on renovation of our old surgery ward part one... here is the latest view of the ceiling [previous views earlier in the blog for those of you following the unfolding drama!].  Mortar has been applied to the netting on the wooden framework put in place on the original beams.

 Then to administration block where a supply lorry has just arrived from Kampala, about 9 hours or so away for a lorry.  This has brought us medicines and medical supplies like sets for giving intravenous fluids etc.  You will be pleased to know that, unlike our initial time in Kisiizi a couple of decades ago, we no longer have to recycle things like surgical gloves and needles.

Now an enquiry about the new phone system being installed - there are a limited number of extensions available on the system so which houses should or should not have them... not always an easy decision!

yes, that is genuine Kisiizi dust on the phone....ummm....

Next a discussion with colleagues about the optimal way to run our ultrasound service as demand steadily increases.  Brenda Kamwesigye, our senior ultrasonographer, is in fact in Chester at present on a 2 week visit for experience and training.  She will be able to attend Friends of Kisiizi day, less than a week away now, in Reading on Saturday 6th October.

after the service this Sunday

after Staff prayers in the morning

Well, that is a taster of the sort of mix that fills each day, very varied, often interesting, sometimes frustrating, occasionally sad, but we press on, strengthened by our time of prayer each morning as we gather in our little chapel and speak with and listen to the One who made it all.

 And now, as I complete this post, and head off down for my night round, I will pause a while on the way back and marvel at the heavens, at the enormity of it all, at the majesty, at the awesome beauty, and, like David, ask "what is man that you are mindful of him?".