In her own words: A researcher first - hand experience of a Measles outbreak in Uganda
Image Credit: Prossy Namuwulya
Author: Prossy Namuwulya
Between 2020 and 2023, 144 measles-confirmed outbreaks from 29 districts in Uganda were reported by the World Health Organization (WHO) measles regional reference laboratory located at the Uganda Virus Research Institute (UVRI). Lamwo district in Northern Uganda and bordering the Republic of South Sudan (RSS), reported 28 laboratory-confirmed cases.
As a researcher at UVRI, and a doctoral candidate assessing the aetiology of measles disease and measles-like illness in Uganda, I was instantly interested in traveling in Lamwo to find out more details of the outbreak. I was able to travel on 17th September 2023 to the area, thanks to the Ministry of Health and partners, and the UVRI-EPI team. A special thank you also to the Mawazo institute for funding this exercise, and for the mentorship applied while accomplishing this activity.
Image Credit: Prossy Namuwulya
Upon arrival in Lamwo, we met with the district health team and developed a micro plan on how to execute the field exercise. Before going to the community, the District Surveillance Focal Person (DSFP) briefed us regarding the status of measles vaccination and outbreaks in the district. While scrutinising the metadata of the measles laboratory-confirmed cases, he informed us that all the cases we came to assess were migrants from RSS who had moved away from the camp after sample collection and hence were very difficult to trace.
There are four official entry points to Lamwo district from RSS where the screening of entrants takes place, and over 28 unofficial entry points with over 80,000 refugees from RSS currently settled in Lamwo. Given the political situation in the country, the measles outbreak in RSS has never been addressed and disease surveillance and immunisation coverages in South Sudan remain irregular.
As much as Ugandan health workers endeavour to vaccinate all entrants in the target age group, the majority remain unvaccinated as they use unofficial entry points. The district reported an outbreak around the same time of our visit and revealed that it was predominantly among migrants from South Sudan. Given this background information, we made a new plan on how to obtain relevant data from this visit. We visited the district headquarters, refugee settlement camps, and the health facilities serving the camps. While there, we sensitised the health workers, the community, and refugees about the clinical symptoms of measles, how the disease is spread and its prevention.
At Palabek Refugee Settlement Centre close to 80,000 refugees are temporarily accommodated there. Near this camp is the Lokung Collection health centre II where we met parents who had brought their children for vaccination. The health team here reported that when migrants from RSS arrive, they are screened for infectious diseases and malnutrition, detained, and monitored for clinical symptoms for about 3-5 days. In addition, all children get vaccinated for EPI target diseases regardless of their previous vaccination status. However, the majority of migrants lack immunisation cards to provide evidence of vaccination.
Image Credit: Prossy Namuwulya
The good news is that all health facilities had measles vaccines, stored appropriately, and administered in the right way. The vaccine control books were in place and well documented. All health facilities had solar fridges with displayed temperature control charts. The vaccines were routinely monitored for potency using vial monitors before administration.
Image Credit: Prossy Namuwulya
As a PhD Fellow, this was a great opportunity to reach the field and work with health workers. I came to appreciate what transpires when refugees cross over into the country. I also affirmed that vaccination coverage is high in districts at the borders due to the high influx of refugees who are vaccinated. However, this coverage does not effectively produce herd immunity because of the unvaccinated or infected refugees who come through unmonitored routes. These end up spreading the infection leading to outbreaks in Lamwo district.
I now have a deeper understanding of the challenges faced by the health authorities in the district. Interacting with health workers directly has profoundly impacted me, after observing an overwhelming number of refugees striving for better health care from only a small number of health workers attending to them. The healthcare infrastructure is also wanting and I look forward to using that data to inform policy makers on how to address those gaps in the districts.
Prossy Namuwulya is a Laboratory Scientist at the Uganda Virus Research Institute, and a 2023 Mawazo Fellow. She is pursuing her PhD at Makerere University.