Uganda: Walking Through the Rough, Smooth Road of Covid-19 Treatment

It's slightly more than a year since Covid-19 broke out in Uganda, claiming at least 334 lives. Some coronavirus patients remain in hospital and thousands of survivors are battling its after-effects, including stigma. The world is different. And the disruptions to our lives and livelihoods are massive. In this 14th and final instalment of our series marking one-year of the pandemic, senior consultant William Ofuti Worodria, the first head of the national Covid-19 Case Management, narrates the fear and lack of protective equipment during the initial response, and how a strong leadership by President Museveni and Health ministry rowed Uganda through the storm with comparably limited damage.

Walk us through the first days of Uganda's response to Covid-19 as you sat at the apex of national case management. What was that experience like?

The first Covid-19 case [in Uganda] was confirmed on March 21, 2020, a male adult who travelled from Dubai (United Arab Emirates). But our efforts in Covid-19 response started much earlier and I was involved in preparations at Mulago National Referral Hospital.

Later on, I was invited to join the case management pillar at Ministry of Health and the national Covid taskforce [chaired by Prime Minister Ruhakana Rugunda].

At the initial stages, there was difficulty of the unknown new disease, which was spreading rapidly yet the understanding of the virus was limited. There was fear of the unknown, fear of how well-prepared we were depending on the resources because in the past we have had epidemics which were fairly localised [unlike the new one with a] global reach. The uncertainty regarding the risk factors and vulnerabilities and how the disease was spread were [concerning].

How prepared were we for a such a health crisis?

The level of preparation was quite impressive. My usual work is hospital-based, mostly clinical.

The country had been involved in battling other epidemics [such as] ebola and Marburg, yellow fever.

There was a surveillance and epidemic response team in place but our strength was in the leadership provided by President Museveni, who took charge of managing Covid-19 and, the Health Minister [Ruth Aceng].

[Their messaging] sensitised the population and created awareness about what to do and what not to do. Support also came from Uganda's partners such as World Health Organisation, Centers for Disease Control, the Infectious Disease Institute, directly and through their [in-country] networks.

What I realised when I joined the Ministry of Health team was that there was an elaborate structure in place, resources were constrained because every country was trying to mobilise and conserve resources for their own use.

The Health ministry constituted a scientific advisory committee to support its pandemic response. It provided information and regular updates about the disease to the population, guided on quarantine and the best way to manage Covid patients and these were hand-in-hand with several other support structures.

But there were constraints like the health infrastructure capacity to handle very severely ill patients [as we saw] best developed countries run out of admission space. So, the worry was always if we had such huge load of patients with critical disease, we would not be able to save many of them. That led us to thinking outside the formal health facilities about [reconfiguring and converting] places like [Mandela National Stadium] Namboole and schools [as isolation and treatment centres] for mild cases.

The early nationwide lockdown allowed preparations and build-up of cases, enabling us to adapt and for health workers to know what to do [with the] new disease.

The ministry and partners always tried to mobilise resources, but there were times when we would not have personal protective equipment (PPEs) and then you have to limit health workers going to attend to patients [although there] were only a few of such days.

As head of the Case Management of the National Covid-19 Taskforce, what was the most challenging aspect of your work and that of your team?

At the beginning there was fear, which I mentioned earlier, of the unknown disease, lack of adequate protective gear. SARS-COV 2 affects all systems in the body but primarily the cause of [patients'] death was lung complications. So as a lung specialist, I and colleagues in the critical care had to take charge, but staff at Entebbe Grade B Hospital began before us.

Getting health workers [to handle coronavirus patients] was initially a challenge, but they became confident along the way as more resources and protective equipment became available and the virus was better understood.

There were concerns about the potential of health workers treating Covid patients to infect family members as such other health workers migrated to stay at isolated places and would not see their families for one week. Because of few staff, there was fatigue and others got infected. We sadly lost some colleagues on duty.

The biggest constraint was, I think, protective gear limitations and lack of critical care facilitates.

How did you navigate through the storm and what lessons did you learn?

We did navigate through as a team. There is nothing that I did on my own. I think I did learnt that team effort is critical, and there are usually principles of containing any epidemic such as surveillance, diagnostics, isolation and treatment.

We had a difficult decision to make too. Before September, anybody suspected was being tested, but when September came, we got significant evidence of community transmission. Kampala became a hotspot. We had to decide and prioritise clinical testing because if somebody is sick and in hospital, you need to quickly separate them from the others.

So, we were focusing on clinical testing because the disease was widespread, making diagnostics very important. Surveillance teams did us proud because they picked up the initial cases form Entebbe.

Quarantine was initially a nightmare for many people, but surveillance teams picked up the initial cases. When infections became generalised, we had to see how to manage the community cases. So, early diagnostic surveillance is important, adequate protective equipment is important, adequate logistics is a very strong thing.

Health workers provided with protective gear were willing to work whether the allowance came or not. But we ended up in a stronger position because everybody was working together for common purpose with solid leadership provided by the President.

The military also did a very good job. The [army team leader, Lt Col Dr Henry Kyobe] is also the national Covid incident manager. Entebbe Grade B Hospital was the main centre for Covid response trainings. When the numbers started increasing, we knew that staff from Mulago hospital had to be trained and we approached partners to start training the Mulago team.

Before we could finish the training, somebody announced that 'people who went to Dubai should come to Mulago for screening'! Then suddenly more than 200 people showed up at Mulago hospital on the first day. So, we had to abandon training and go to the triage and screen [the new arrivals]. The coordination was a challenge.

We requested for UPDF support and they joined. They were willing to be trained and be to part of the response. The discipline in the army was a big asset because it helped to put in law and order.

In the conversations at the national level, what specific argument informed the deployment of soldiers to oversee response to the pandemic when Ministry of Health appears to already have the required competence?

Well, I was not privy to that discussion, but these soldiers were medical workers [serving] in the army. So, the medical fraternity should be harnessed to support in pandemics, epidemics and other disasters.

Uganda has previously experienced serious health challenges; ebola and other haemorrhagic fevers. How different was the required response to this pandemic?

The difference was simply because it was massive. The other difference is ebola does not jump from place to place rapidly as the coronavirus. [In the case of ebola], one can easily track the contact and it is not airborne. Covid-19 is airborne and is likely to spread much faster. Of course, ebola is more lethal but it is easier to contain and it is more localised. If ebola was also global, very few people would survive.

What thoughts would you offer in terms of what Uganda should do now to better its preparedness to respond to unknown future epidemics and health emergency?

We need to think of building isolation facilities and people need to be trained regularly whether there is a pandemic or not. We need to improve our health facilities to care for critical patients and particularly improve oxygen supply because for this particular pandemic, oxygen was the most important drug.

We need to improve our diagnostic capacity for rapid testing and release of results so that our laboratory teams are not overwhelmed.

Involving, training and informing people in the community. Can you believe some people upto today do not believe Covid exists!

Research is a very critical tool because that's the only way we can understand the best way to contain the epidemic. We need to train and deploy specialists in all hospitals for better care and leadership.

Is there a time when you felt you wanted to give up? You were the head case management. Is there a time you felt like I am done and I am leaving?

The issue is, what is the alternative if you give up? Actually, I was quite impressed because you look at the team and everybody is giving their best. So, you just have to make your contribution because you look at the Minister of Health, you look at President Museveni, you look at your staff in the team, even with basic equipment, they are giving their best, you [just get motivated] to continue.

The uptake of the Covid-19 jabs is low since the start of vaccination last month amid worries about its safety. What would you propose the government should do differently to reboot citizens' confidence?

There is an anti-vaccination lobby globally and there is always scepticism regarding vaccination and the Oxford-AstraZeneca vaccination has not been without question. Those questions can only be validly answered if you have adequate research data and you need to build data over time.

Those are difficult issues, but it (inoculation) is one of the tools we have in the fight against Covid and we would urge people to embrace it.

We saw the President took the jab publicly, the Health minister took the jab publicly and several high-ranking people have taken the vaccine publicly. This action by the leadership should comfort and make people confident to accept the jab.

Covid-19 cases in the country are again rising, triggering fears of a possible second wave. What should be done to stem further spread?

The control procedures are the same as the said the standard operating procedures (SOPs) in place, which unfortunately some sections of the public do not closely follow. Using a mask, sanitising hands with alcohol solution, hand-washing, physical distancing should be practised to control the epidemic. We need discipline because the pandemic is not yet over.

Uganda has registered 335 deaths and 40,000-plus infections which is comparably much lower when some developed nations were losing more than 1,000 citizens a day to the pandemic,

What was Uganda's magic?

I think that is a research question, but on the surface, we may say the population in Uganda is quite young yet the most vulnerable group is older persons with comorbidities [more than one disease or condition is present in the same person at the same time].

Here (in Uganda), I think the outdoor environment, the weather, probably has a role [in limiting infections]. It is really speculative, but I think it has shown that the transmission is less likely outdoors than indoors...

I think there are a lot of unknowns. [This subject] has to be researched to understand it better, but clearly there was a difference [yet] it would have been worse here seeing what happened elsewhere.

Are our health facilities prepared in case we experience a second wave? How do you get citizens to follow the SOPs?

We have to just continue talking and sensitising them about the disease and its dangers. There is a department of risk communication. The health infrastructure is capable of handling the epidemic as best as it can within its capacity.

Of course, we have been lucky in many ways to not get the numbers that we have been seeing elsewhere but we do not know for how long that will be and besides we do not know what reasons are there for this kind of [our situation]. We still need to be vigilant, that is all I can say and the health workers now have experience on how to handle coronavirus. If the logistics are in place, they will work.

What exactly did you or are you using to treat Covid-19 patients?

Well, we have the guidelines. We wrote the first guidelines sometime in April 2020 and revised them in June and they have been revised again.

There are medications of known benefit and medications on unproven benefit but based on their mechanism they are thought to be beneficial. Of course, as when in epidemic situation, you would not know what was precisely the best medicine to give. You must have heard of medicine like Vitamin C, Azithromycin, Vitamin D, Zinc.

Many of these are anti-oxidants and they help to modulate the immune system. What happens in Covid is that after the initial infection which usually lasts probably a week, for the people who worsen, the immune system gets heightened stimulation. So, it is that reaction of the immune system that causes damage more than the viral infection.

Actually, by the 10th day, most people would have cleared the virus, but that is also when they are beginning to fall sick if their condition is going to get severe. This [combination of] medicines is mainly used because of their immuno-modulatory role.

There are other medicines like Dexamethasone which is a steroid from a trial in the United Kingdom that showed it was beneficial in people with severe disease. It is recommended that if somebody has severe disease and needs oxygen, it helps to dampen that immune reaction.

People tried other medicines, including hydroxychloroquine, which has been thrown out completely. Based on evidence, there was no benefit. They tried antivirals, including Remdesivir, which was used for ebola but it is expensive but you have to always weigh the risk-benefit ratio for any intervention. But the far-most important treatment is oxygen for those people who are severely ill and supporting their breathing.

As a professional who was at the heart of the case management, what was your worst and most fulfilling experience?

The most fulfilling experience was working with multidisciplinary teams [and] I did learn from people that I never knew. The fact that we could design guidelines and train other health workers to make them confident was satisfying. We did what we could and it was part of our responsibility to our nation and there were no regrets of being part of the team.

With the benefit of hindsight, what do you think should have been done differently regarding Uganda's response to Covid-19?

I really don't know what could have been done differently because nobody knew better. We were learning on the go because I thought the structure was in place, the people were committed and they kept on reviewing the work they were doing. So, that flexibility was the most important thing. I think the response was great, I mean they deployed the scarce resources appropriately at border points.

In bid to control the spread of cases some sectors such as bars are still closed, how can we open these sectors without compromising safety?

I had information that the breweries were working with Infectious Disease Institute and they were piloting in a number of centres whether their intervention can be used to safely open some of these places. If those are found to be feasible the idea can be sold to the strategic committee which will then decide. We can only decide on that based on the coherent evidence.

Should bars be given an opportunity to operate just like most of the other sectors?

If they can be opened safely why not?

Any other thoughts?

I think the Covid thing has been a learning experience not only for us here, but globally. It has been a great equaliser in a way because what we thought was adequate resources didn't match the epidemic and yet with the minimal resources that we had the threat was equally met. So, everything is not what you think it is.

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