2022 Uganda Ebola Outbreak: Select Lessons Learned

On September 20, 2022, the Uganda declared an outbreak of Sudan ebolavirus in the Mubende District. It was the country’s first Sudan ebolavirus outbreak in a decade, and its fifth of this kind of Ebola. In total during this outbreak, there were 164 cases (142 confirmed and 22 probable), 55 confirmed deaths and 87 recovered patients. Due to the Ugandan Government’s successful containment of the outbreak including with support from the World Health Organization and other public health partners, there were no documented cases of international transmission of the Sudan Ebolavirus. The outbreak was declared over on January 11, 2023, nearly 17 weeks after its detection.

Ebola Virus was first discovered in 1976 on the Ebola River in the DR Congo, giving it its name. Since then, it has emerged periodically across a number of African countries including Guinea, Sierra Leona, Liberia and Uganda, where thousands of people have been infected, and thousands more have died. It remains unclear what the reservoir for Ebola is. Though many suspect it remains the fruit bat, Ebola can infect a large number of mammals including gorillas, chimpanzees, and duikers likely act as intermediate, amplifying, dead-end hosts. And of course, humans.

Since 2018, there have been at least 8 outbreaks of Ebola virus, and they appear to be occurring more frequently across the African continent specifically in the in the Guineo-Congolian rainforest terrestrial ecosystem, defined as the area between latitude 10⁰ above and below Equator. It remains unclear why there has been an increase in outbreaks, however this may be strongly related to human habitat encroachment, human encroachment into animal reservoir habitats, and increased population density among other factors. The 2022 Ebola outbreak of Sudan ebolavirus species, one of six species of the Ebola virus against which there are no approved therapeutics and vaccines, caught many by surprise, and serves as a wakeup call to continue to prevent and prepare for future Ebola outbreaks.

On December 7, 2022, The Belfer Center hosted “2022 Uganda Ebola Outbreak: Situational Awareness,” in collaboration with the Belfer Center’s Africa in Focus series, a forum for the critical analysis of processes and policies from the continent and its engagement with the international community, to learn from experts on the ground and supporting the ebola response.  The panel was joined by Dr Amy Boore, Program Director for the US Centers for Disease Control and Prevention (CDC) Division of Global Health Protection in Uganda; Dr. Henry Kyobe Bosa, the National Ebola Virus Disease Incident Commander in the Ministry of Health of Uganda; Corti Paul Lakuma,  Research Fellow in the macroeconomics department at the Economic Policy Research Centre; and Dr. Joel M. Montgomery, PhD, CAPT US Public Health Service is the Chief of the Viral Special Pathogens Branch (VSPB) in NCEZID’s Division of High Consequence Pathogens and Pathology. The session was chaired by Dr. Syra Madad, Belfer Fellow and Senior Director at the System-wide Special Pathogens Program and introductions provided by Dr. Tarinee Kucchal.

Below are 4 select lessons learned from this Ebola outbreak that were covered during the seminar.

Lessons Learned

Lesson 1: Never Let an Outbreak Go to Waste.

“Uganda definitely believes you never let an outbreak go to waste, in terms of using it to boost capacity and progress in country” – Dr Amy Boore

During COVID-19, Uganda contended with a devastating wave of the Delta variant, a stagnated COVID-19 vaccination rollout, two major lockdowns and significant community apathy arising from the stringent COVID-19 response measures. However, COVID-19 also presented an opportunity to refocus on the importance of infection prevention and control, which ultimately informed Uganda’s response to the 2022 Ebola outbreak.

The Ugandan Ministry of Health appreciated that the response to Ebola required a fine balancing act:

“The optimum response to Ebola is a very thin line between overreaction and underreaction. Overreaction creates apathy in the population, and underreaction can lead to rapid escalation of the outbreak” -  Dr Henry Kyobe Bosa.

However, with the precedence set by COVID-19, both authorities and the public appreciated that locking down one part of the country prevented locking down the entire country. Familiar with COVID-10 protocols, Uganda was able to quickly impose targeted lock downs and restrictions of movement at the epicenters, and leverage contract tracing procedures to quarantine infected individuals within the city. As a result, both primary and secondary transmission was contained from an early stage. Particularly in the city, patients were identified, isolated, and treated early which contributed to the relatively low mortality rate of this outbreak. Along with international support from the US and others, Uganda also took significant strides toward increasing its internal diagnostics capabilities and strengthening its health networks after COVID-19 and began putting in place measures to protect its country from future outbreaks, well before Ebola returned.

“We did what we had not done before – institutional quarantining of contacts which helped us limit further transmission in the city, and restriction of movement to epicenter districts helped us to limit further spread and shield the city” – Dr Henry Kyobe Bosa 

“Each outbreak is different, from different areas, the dynamics are different, and also the times in which some of these outbreaks are happening are very hard” – Dr Henry Kyobe Bosa

Lesson 2: Leveraging Existing Infrastructure

Each outbreak of any infectious pathogen represents an opportunity to identify and fill gaps in the health architecture of a nation.

“Uganda decided to build [their systems] following the 2000 outbreak of Ebola in Gulu, and overtime they have called upon the US government and other partners to build these systems and capacities to be ready to respond to outbreaks”-Dr Amy Boore

Ordinarily, Ugandan authorities have been unable to identify the virus in country because Uganda lacked the laboratory capacities, which significantly delays the identification of the disease. However, the CDC has been investing in the Uganda Virus Research Institute to establish the Viral Hemorrhagic Fever laboratory that was ultimately responsible for diagnosing the 2022 strain of Ebola within a day. The CDC further supported programs to train advanced expert level field epidemiologists, who were critical in case investigations and connecting transmission trees during both the COVID-19 and 2022 Ebola outbreak.

The U.S. President's Emergency Plan for AIDS Relief (PEPFAR) also provided significant baseline infrastructure and supply systems that could be leveraged during outbreaks. This included a sample transport system that is ordinarily used to transport viral samples for patients with HIV, which was able to be expanded upon to transport any kind of sample, including hemorrhagic fever samples.  PEPFAR local partners in the regions and districts were at the epicenter of the Ebola outbreak and Uganda was able to utilize their relationships with local clinics to increase infection prevention control education and sensitization of healthcare workers during the Ebola outbreak. By creatively redeploying PEPFAR and utilizing the programs and services already established in conjunction with international partners, Uganda was able to leverage its existing resources to coordinate a timely response to the Ebola outbreak, without reinventing the wheel.

“Given the biodiversity and broader Sub-Saharan Africa, it is hard to differentiate epidemiologically and clinically [between cases], and really underscores the importance of the lab” – Dr Joel Montgomery

Lesson 3: Contain the Virus, Contain the Fallout.

The 2022 outbreak transverse the nation in a matter of weeks to reach the city, due to the proximity of its epicenter to a major highway connecting Kampala to the western parts of Uganda. Recent increases in commuter transit facilitated by different forms of travel (boda bodas, commuter taxis) and the risk of the rapid dissemination of misinformation created further challenges. In the wake of COVID-19, and the impact of the Russia-Ukraine war, inflation remained a major concern for the Ugandan government and concerns were raised that Ebola would compound this further.

“The coming of the Ebola virus wasn’t planned for, so there was an additional need of about 30 million USD in extra resources needed in addition to what was already allocated” – Paul Lakuma

As with any outbreak, Ebola did have significant budgetary implications, with many resources being redirected from electricity, animation vaccinations, export priorities and combating climate change.  With these significant government investments and rapid control measures, the Ugandan government was able to contain the outbreak to a single region. Although small local businesses suffered from lock down measures and compromised supply chains and price rises resulted in regional inflation, the far-reaching economic effects of Ebola were contained. In the city, business and services continued operations uninterrupted.

Ultimately, the rapid control of the outbreak meant the budgetary restraints and economic fallout only lasted a matter of months, instead of years, as we witnessed with COVID-19.

Lesson 4: Building Networks Builds Resilience

The United States has for decades maintained a presence in Uganda through the first days of PEPFAR, the CDC Division of Global Health Protection, the US Department of Defense, and USAID. Each agency works collectively to build systems in response to the needs of Uganda.

Due to its longstanding presence, the United States works very closely with the Ugandan ministry of health, which provided the US with a unique and early understanding of the situation and informed its local response.

Although there remained very few exported historical cases, the US was equally prepared at home through three key strategies. First, the capabilities of the CDC Ebola response teams were expanded to increase coordination with departments of health in the event of an imported case, establish a 24/7 clinical call line to provide updated guidance, and creating boarder control protocols should the Ugandan crisis worsened. Second, there was close liaison between agencies including the CDC, health services and the Regional Ebola and Other Special Pathogen Treatment Centers (RESPTCs) where patients received high-level care in the event of a positive case. Finally, the US expanded its laboratory capacity through the Laboratory Response Network (LRNs), ensuring that all 50 states were equipped with both basic diagnostics like the Bio Fire panel, and more advanced capabilities including high throughput PCR assays that are currently undergoing further FDA regulations.