How Uganda stopped Ebola at its border – and inspired a new health tool

In August of 2018, health officials in North Kivu province in eastern Democratic Republic of the Congo reported four cases of Ebola, marking the start of what would become known as the Kivu Ebola epidemic that eventually claimed more than 2,200 lives. What the world barely noticed at the time, however, was that despite a busy border regularly crossed by refugees, the neighboring country of Uganda was not reporting any cases. In fact, by May 2020, Uganda had reported only four imported cases and no cases of in-country transmissions.

How? Having managed a number of Ebola outbreaks in the past, the country had prioritized preventing outbreaks and detecting cases. In terms of prevention, the country had created multisectoral Ebola teams and ensured there were open lines of communication between them. It ran simulation exercises to assess the country’s readiness and aggressively vaccinated frontline health workers and contacts of suspected cases. It also established clear channels of communication with health officials in the DRC and surveillance systems to help with early detection. When the DRC outbreak occurred, Ugandan officials and their partners were able to mobilize quickly to prevent the importation of cases and contain the spread of the disease, as well as treat any patients.

Researchers from Makerere University School of Public Health (MakSPH) and the Johns Hopkins Center for Health Security recently released a study that breaks down exactly how Uganda managed the crisis – and created a framework tool for other countries to follow in similar situations.

We spoke with three of the authors of the study, Steven Ssendagire, a Senior Resident Mentor with the Health Policy Planning and Management Department at MakSPH, Dr. Alex Riolexus Ario of the Uganda National Institute of Public Health, and Dr. Jennifer Nuzzo, formerly of Johns Hopkins and now the inaugural Director of the Pandemic Center and Professor of Epidemiology at the Brown University School of Public Health, about their experience managing the outbreak and helping create the framework tool.

Could you describe the situation around the border region between eastern Democratic Republic of Congo and Uganda between June and August 2019? Why was Uganda at risk?

Dr. Riolexus Ario: The Uganda-Congo border is characteristic of a problematic border – it is porous with multiple emerging and reemerging disease transmission belts. On August 1, 2018, the Democratic Republic of Congo declared an outbreak of Ebola in North Kivu province, about 100 kilometers from the Uganda border. We immediately initiated multiple activities to prepare for the possible importation of cases because we know what actually goes on around these borders. It's not surprising that, as we were busy preparing, a family that had gone for a funeral in Congo entered the country.

Your research identified specific preparedness capacities and activities that virtually stopped the spread of the Ebola virus across the border. What was the genesis of this research?

Dr Nuzzo: This project is part of a larger project I run, called the Outbreak Observatory. For years we've been talking about building partnerships with in-country organizations that have a window into outbreak responses, and we had been in conversation with Makerere University about possibly partnering on these efforts. When the Ebola situation occurred, we reached out to our Makerere colleagues and said this might be a good opportunity for us to partner. They're in a great position to not only work with founder organizations, but also take an active role in conducting the research themselves.

What we had planned was a series of interviews with key informants who had been involved in the Ebola response on the Uganda side. We started doing that work remotely due to some delays initially with travel and started conducting interviews jointly. That work basically got stopped by the COVID pandemic, in part because some of the key informants were understandably pulled off to do other things and just simply didn't have time to participate in a research study. Those initial findings were published by Exemplars in Global Health.

But separately, our team - led by Christina Potter at Hopkins - did a very lengthy document review and a tremendous amount of credit goes to Uganda for being quite transparent in its preparedness activities and in publishing a lot of reports and after-action reports. Through that document review, plus the key informant interviews, we were able to come up with a framework that not only identified what preparedness activities were relied upon in the response, but also the framework itself, which is potentially something that could then be applied to future responses.

One of the challenges is that there are existing lists of preparedness capacities that countries are asked to develop – like the joint external evaluation framework the WHO uses. It's a very lengthy list and when there are lots of gaps it's hard for countries to identify which ones to prioritize and address first. The biggest contribution of this paper is creating this framework for evaluating preparedness activities so that we have a better sense of what floats to the top in terms of being important.

Could you break down these activities – what did they look like in real life – and why were they successful?

Ssendagire: In Uganda, we have had experience managing Ebola outbreaks for over 20 years. We have routine capabilities and capacities that we continue to implement irrespective of whether we have a heightened risk of Ebola importation or not.

We have a very strong syndromic disease surveillance system, largely based in health facilities, where health workers, upon suspicion that a patient is likely to have Ebola or any other viral hemorrhagic disease, would quickly start investigating that case. We have also, over the years, developed a very strong laboratory system we call the hub model. Every region in the country has the capacity to take samples, put them in the hub system, and they get delivered to the Uganda Virus Research Institute for testing. Previously, this testing would take ages but currently, the lab is able to give us results within as little as six hours. These are capacities we have built over time and they continue to help the country, irrespective of whether there is any heightened risk or not.

Now, when we have any heightened risk, then we do what we call enhanced preparedness activities, including simulation exercises at all levels so we can evaluate or assess how the country would respond if there were any suspected or confirmed case of Ebola.

During heightened preparedness, we also, for example, make sure we intensify screening across the border. As Dr. Riolexus Ario mentioned, we have many border crossing points and we cannot do thorough screening at each one, but we have about two or three that are very active, including Mpondwe. During times of heightened preparedness, we deploy teams to these border crossing points that screen everyone entering Uganda. If they suspect a patient or traveler meets the case definition, then they quickly link that person to the health care services where they will be delivered to a health facility so [blood] samples can be taken.

I think this is what we can mostly attribute our success to. But, of course, it's important to stress that Uganda is very transparent – we've now learned and mastered the art of collaborating with so many actors. We quickly mobilize the required resources to beef up our preparedness activities.

Your research notes that Uganda didn’t establish robust preparedness capacity overnight – it was a 20-year effort informed by multiple previous Ebola outbreaks. What do you think other countries can learn from Uganda’s experience?

Dr. Riolexus Ario: We have learned over time and built our capacities over time and we have very good coordination mechanisms. I think many countries could learn something about these things from us. Countries could also learn from our response coordination mechanisms – we have a stand-by national Rapid Response Team that we deploy in the field within 24 hours to 48 hours. We have a national task force that provides oversight and it can be activated within a very short time. We also have an Emergency Operation Center that is activated very quickly when we receive an alert. We also have district coordination mechanisms, such as district Rapid Response Teams and the District Task Forces. Our response coordination mechanisms actually start from the community level up to the national level.

The second thing that countries could learn from us is that we actually do risk mapping. We look at population movement patterns. We can actually predict where something's going to occur.

The third thing is our readiness assessments. We can predict that facilities in a particular area may not be able to respond. Should we beef up its human resources? Should we beef up its laboratory capacity? Should we beef up its isolation capacity?

Another thing countries could learn from us is response planning. We have contingency plans for almost all known emerging diseases that occur or have occurred in Uganda in the past 20 years. We have all those ready and we're able to pick them from the archives within a very short time and tweak them to fit the current situation. The final thing is the way we monitor and provide accountability for the national preparedness plan.

You and your colleagues have developed a framework evaluation tool that other countries may be able to adopt to emulate Uganda’s success. Could you tell us more about this tool and how it might be implemented by other countries?

Dr. Nuzzo: The tool was really informed by speaking to practitioners about what they referenced in their response to Ebola, as well as the literature. We were able to see the range of preparedness activities, classify them, and do a retrospective analysis of what was cited in terms of being used in not one but two importation events. That gave us a sense of the ones that were actually used and cited as being particularly helpful.

As I mentioned, it's difficult for countries to know, when there are a lot of gaps, what activities are worth focusing on. One of the hopes is that when we inevitably go through such events, we can do some analysis afterward to understand what resources were relied upon. What were the things that helped us? What didn't we really need to use after all?

Now, that doesn't mean that just because you didn't use something in one event, you won't use it in the future. But if you get into the habit of regularly evaluating responses, it will hopefully give you a better sense of which preparedness activities are most important, so we make sure that those activities are supported and maintained. That's really important in an age of sustainable financing and budgeting – making sure we're maintaining the preparedness activities and capacities that are most important.

Could this tool be used for other types of outbreaks – notably for COVID-type outbreaks – and how so?

Dr. Nuzzo: First of all, it's my hope that all places that are involved in outbreak responses do some analysis afterwards, understand how it went, what worked, what didn't, and what could be improved. Having some structure to those conversations is important so we can document them in a systematic way and be able to compare over time. I have to give credit to Christina Potter for the framework tool – she was the one who developed it in reviewing the literature and participating in the key informant interviews. It's a first draft and potentially one that could be modified with repeated use. It is an attempt to provide some structure to those reviews that should happen.

The key premise of the outbreak observatory is that we try to review lessons learned, understand what activities and capacities are helpful, what may have been missing that would have been useful, but in a nonpunitive way. Having a tool like that can start a conversation that is a constructive dialogue about what resources and activities really matter so that we can continually improve and get better because we are going to continue to face events, outbreaks, everywhere. Having a commitment to trying to learn from them, and to better prepare for the future is really important so that we can learn and grow and expand the evidence-base for future preparedness.