The nurse wanted the boy with a high fever transferred immediately from a private clinic in Uganda to a public hospital despite the boy testing positive for malaria amid an Ebola outbreak that has unsettled health workers.
But the owner of the clinic was not convinced as he examined the child on his lap. The boy did not have Ebola, he concluded after looking for the telltale bloody signs of the virus, then sent the patient and his grateful mother home after administering medication intravenously.
The incident highlights the pitfalls facing health workers in their response to a new Ebola outbreak in central Uganda. Because some symptoms of malaria are similar to those of the Sudanese strain of Ebola now circulating in three districts, community clinics that are often the first port of call for those seeking care may be ill-equipped to make the right decisions in the right moment.
“You can’t say that everyone who is dying is dying of Ebola,” said nurse Edgar Muhindo of Mubende’s St. Florence Clinic, who unwittingly treated two Ebola patients for malaria before they sought care at another place. “But if it is Ebola, it is important to confirm that it is Ebola. That is why it is important that more health units have the machines that can detect this Ebola virus.”
Simple microscopes in such remote clinics can quickly confirm malaria or typhoid fever, possibly masking the possibility that the same patient could have Ebola simultaneously.
This was the case of a 24-year-old man who fell ill in mid-September, was treated for malaria and pneumonia, and died the day before a sample from him confirmed the Ebola outbreak.
By that time, six others had died from what authorities called a rare disease.
Mellon Kyomugisha, a medical laboratory assistant who recalled touching the first confirmed Ebola victim when she arrived at St. Florence Clinic with malaria, said she felt there was no need to isolate herself until worrying symptoms emerged. She was at work several days later, donning protective gear when she had to see a patient.
There have been 35 confirmed cases of Ebola since September 20, including six health workers, and a doctor is among at least seven confirmed deaths.
Only one government-run facility, located 180 kilometers (111 miles) away in Entebbe, is equipped to test for Ebola, with officials sometimes waiting up to 48 hours before receiving results.
Ebola, which manifests itself as a viral hemorrhagic fever, spreads through contact with bodily fluids of an infected person or contaminated materials. Symptoms include fever, vomiting, diarrhea, muscle pain, and sometimes internal and external bleeding.
Scientists don’t know the natural reservoir of the virus, but they suspect that the first victim of an Ebola outbreak becomes infected through contact with an infected animal or by eating its raw meat.
The 2014-16 Ebola outbreak in West Africa killed more than 11,000 people, the highest death toll since the virus was discovered in 1976.
Uganda has had multiple Ebola outbreaks, including one in 2000 that killed more than 200. Authorities don’t expect the current outbreak to be that deadly, but urge people to report suspected cases immediately. There is no proven vaccine for the Sudanese strain of Ebola.
Health authorities are still investigating the source of the current outbreak, which likely started in August, Ugandan President Yoweri Museveni said in a televised address earlier this week. It was a surprising admission for an East African country often cited for its leadership in fighting disease outbreaks.
Crippled by testing difficulties from the start, the initial response was sometimes chaotic, as health officials scrambled to round up contacts and set up an isolation unit, according to health workers and others on the ground. .
Some health workers said they felt helpless when ambulances were slow to pick up patients suspected of having Ebola. A woman whose farmworker died of Ebola recalled being taken to an isolation unit where some quarantined patients began bleeding, worrying those without symptoms who knew they were at risk of infection.
Since then, health authorities in Mubende have created separate isolation spaces for Ebola patients and their contacts, said Rosemary Byabasaija, leader of a government task force fighting Ebola. She said that she has since corrected the "disorganization" early in case management.
“When the news broke, it caused a stampede both in the hospital and in the communities,” he said.
Ugandan authorities had documented 427 known contacts as of Friday. But some quarantined escaped and remain at large, complicating the tracing work that is key to preventing a widening outbreak.
“It’s like someone throwing a grenade,” Dr. Emmanuel Batiibwe, director of Mubende Hospital, said of the early days of the outbreak. “There’s that explosion. They all run for cover and then start slowly coming back to see what’s going on… So it was a similar scenario that happened here.”
The hospital raised “the biggest alarm you can imagine,” he said, and efforts were soon under way to set up an isolation unit with the help of Doctors Without Borders. That unit was still being installed 10 days after the outbreak was declared.
Farmer Margaret Nakanyike, one of those taken to the isolation unit after two members of her household showed signs of Ebola, said she was lucky to escape infection in hospital. After testing negative, she isolates herself in her house, not far from the garden where her worker who died of Ebola was buried.
In Madudu, the Mubende sub-county that has been the hardest hit, ambulances speed down the dirt road to respond to Ebola alerts.
Kaamu Kato, who runs a government-run health center in Madudu, was anxiously awaiting an ambulance to take a 16-year-old mother with a baby who had arrived with a fever and bloody diarrhoea. She did not have malaria, so Kato and others immediately alerted her to Ebola for an ambulance.
The transport arrived two hours later. The patient, after attempting to leave, lay on the grass, apparently in pain, as health workers watched from a distance. Kato said that he couldn’t do anything.
“There are things that are out of my control,” he said. “I have done my part. Now it’s up to them to come here quickly or be delayed.”
