H5N1

EBOLA DRC - Evolution of the response to the Ebola epidemic in North Kivu and Ituri on Sunday 18 November 2018

The Ministry of Health has published EBOLA DRC - Evolution of the response to the Ebola epidemic in North Kivu and Ituri on Sunday 18 November 2018. Eight new confirmed cases: not good. Excerpt from the Google translation:

EPIDEMIOLOGICAL SITUATION IN THE PROVINCES OF NORTH KIVU AND ITURI 

Sunday 18 November 2018   

The epidemiological situation of the Ebola Virus Disease dated November 17, 2018: 

• Since the beginning of the epidemic, the cumulative number of cases is 366, of which 319 are confirmed and 47 are probable. In total, there were 214 deaths (167 confirmed and 47 probable). 

• 66 suspected cases under investigation.  

• 8 new confirmed cases, including 5 in Beni and 3 in Katwa.  

• 1 new case death confirmed in Katwa.    

 /! \ Cleaning the current database   

Remarks: 

• To avoid that the total number of cases varies (up or down) daily, the suspect cases have been placed in a separate category. Thus, suspect cases with positive laboratory tests will be added to the confirmed category, while negative ones (non-cases) will be removed from the table. 

• The category of probable cases includes all reported deaths for which it was not possible to obtain biological samples for laboratory confirmation. The investigations will determine whether these deaths are related to the epidemic or not. 

• A community death is a death in the community, outside of a licensed health center. 

News of the response 

Security 

• Contrary to what has been reported in some international media, the Ministry of Health has not suspended the Ebola response. Following the attack of a MONUSCO base in the Boikene district, Ruwenzori commune, in the city of Beni, by an armed group on the evening of Friday, November 16, 2018, the field activities in Beni did not take place normally at the beginning of the day on Saturday 17 November. After assessing the security situation, all field activities, except vaccination, were able to resume [after] idling on Saturday afternoon. This Sunday, November 18, the response should advance normally in Beni.  

Vaccination 

• Since the beginning of vaccination on August 8, 2018, 31,953  people have been vaccinated , including  15,901 in Beni, 4,544 in Mabalako, 3,453 in Katwa, 1,663 in Mandima, 1,645 in Butembo, 1,672 in Kalunguta, 732 in Masereka, 434 in Bunia, 359 at Vuhovi, 355 at Tchomia, 292 at Mutwanga, 241 at Kyondo, 240 at Komanda, 210 at Musienene, 178 at Oicha, and 34 at Alimbongo. 

DR Congo: Ebola virus disease - External Situation Report 15

WHO AFRO has published Democratic Republic of Congo: Ebola Virus Disease - External Situation Report 15. The situation update:

Ministry of Health (MoH), WHO and partners continue to respond to the Ebola virus disease (EVD) outbreak in the Democratic Republic of the Congo, and remain confident that the outbreak can be contained, despite ongoing challenges. Over the past week (reporting data from 5 to 11 November), we observed the continuation of the outbreak in several areas of North Kivu Province, as well as geographical expansion to new areas, including Kyondo (30 km south-east of Butembo) and Mutwanga (50 km south-east of Beni). The initial cases in these areas were exposed through contact with cases in Butembo and Beni, respectively.

During this period, 31 new confirmed cases were reported, among which there were seven newborn babies and infants aged <2 years, three children aged 2-17 years, three women who were pregnant or breastfeeding, and three health workers.  

Furthermore, this week, a review and reconciliation of case records resulted in the addition of 14 probable cases, invalidation of 11 historic deaths previously reported as probable cases, and exclusion of duplicate case counts. Moreover, some confirmed and probable cases were recategorized to health zones where their infection most likely occurred (as opposed to location of Ebola treatment centres (ETCs) where they were admitted) (Table 1). 

Overall trends in the outbreak (Figure 1) reflect the continuation of transmission in several cities and villages in North Kivu. Given the persisting delays in case detection and the ongoing data reconciliation activities, trends in weekly incidence (especially in the most recent weeks) must be interpreted cautiously.  

As of 11 November 2018, a total of 333 EVD cases, including 295 confirmed and 38 probable cases (Table 1), have been reported from 14 health zones in the two neighbouring provinces of North Kivu and Ituri (Figure 2).  

Of the total 333 cases, 209 died, including 171 among confirmed cases, and 101 recovered. As of 11 November 2018, 77 patients (confirmed and suspected cases) were hospitalized in ETCs. Females account for 62% of confirmed and probable cases. A total of 30 health workers have been infected to date, including three deaths. 

The Ministry of Health (MoH), WHO and partners continue to monitor and investigate all alerts in affected areas, in other provinces in the Democratic Republic of the Congo and in neighbouring countries. Since the last report was published, alerts were investigated in several provinces of the Democratic Republic of the Congo as well as in Uganda and South Soudan. To date, EVD has been ruled out in all alerts from neighbouring provinces and countries. 

WHO in collaboration with regional and global partners have deployed over 110 experts in the nine neighbouring countries (Angola, Burundi, Central Africa Republic, Republic of Congo, Rwanda, South Sudan, Tanzania, Uganda and Zambia) and in non-affected provinces in the Democratic Republic of the Congo to support EVD preparedness activities. Four of the nine neighbouring countries have been sensitized on EVD vaccination. Uganda received the approval for EVD vaccination of health and frontline workers and initiated vaccination on 7 November 2018. Preparation for vaccination of frontline health workers is ongoing in Rwanda and South Sudan.

Papua New Guinea is rich in resources but poor in health

Via The New York Times: Papua New Guinea Is Rich in Resources but Poor in Health. Excerpt:

PORT MORESBY, Papua New Guinea — Polio was vanquished by the Pacific nation of Papua New Guinea 18 years ago. Now, as world leaders gather there for the Asia-Pacific Economic Cooperation summit meeting this week, polio has returned — on top of raging drug-resistant epidemics of tuberculosis, malaria and H.I.V., and deadly flash points of preventable diseases like whooping cough and measles.  

All over the country, there are symptoms of a profound public health emergency; young and old are getting sick and dying unnecessarily, while facilities lack basic medicines and equipment. 

Doctors and experts say the unfolding crisis is the realization of their worst fears after years of deterioration and neglect.  

“We were expecting something like this,” Dr. Anup Gurung, a public health specialist with the World Health Organization, said of the polio outbreak at a news conference in the capital, Port Moresby, in September. 

He pointed to the erosion of vaccination rates, which are down to 30 percent in some parts of the country. “It’s like someone lit a paper castle where everything is on fire,” he said. 

Officials in Papua New Guinea hope that hosting the Asia-Pacific Economic Cooperation, or APEC, meeting in Port Moresby will elevate the country’s international profile, but the health crisis has become an embarrassment for a nation with an abundance of gold, copper, silver, oil and gas. 

Public frustration with the summit spending has already led to two national strikes. The collapse of health services has been a focus of the protests. 

The return of polio is a clear indicator of the failures, with Papua New Guinea accounting for 21 of 109 cases found globally this year. 

The Papua New Guinea outbreak is vaccine-derived, which means that weakened live virus excreted by vaccinated children has mutated and escaped into the rapidly increasing unprotected population. Dr. Gurung blamed “the steady breakdown of the health system” for the country’s polio emergency.  

Local and international experts point to three interlinked causes of the country’s health crisis: the collapse of the medical supply chain; changing relations with the country’s biggest aid donor, Australia; and rampant corruption. 

Getting medicines, equipment and other supplies around Papua New Guinea has always been challenging. The country has few roads, formidable geography and a widely dispersed population, with about 80 percent living in rural and remote locations.  

That improved with assistance from Australia, but the Australian government withdrew from the arrangement in protest in 2013 after Papua New Guinea awarded the national medicine supply contract to a local company that Julie Bishop, then the Australian foreign minister, said had no accreditation and “a history of supplying substandard drugs.” 

The company, Borneo Pacific, won the contract — worth 32 million Australian dollars, or $23 million — despite its bid being millions of dollars higher than those of reputable international organizations. At the time, the Medical Society of Papua New Guinea said the deal would “lead to the deaths of many Papua New Guineans.”  

Reports from health facilities across the country indicate those fears have been borne out. (Borneo Pacific did not respond to requests for comment.)

Containing the latest Ebola outbreak

Via Harvard Business Review: Containing the Latest Ebola Outbreak. Excerpt:

Given that outbreaks can grow quickly and exponentially, definitive action is needed now.  

The current plan for stopping this outbreak is based on contact tracing (the identification and monitoring of people who were exposed to Ebola-infected individuals for the 21 days during which they may develop infection) and “ring” vaccination (immunizing these contacts and those close to them with an experimental Ebola vaccine). This approach efficiently contained an Ebola outbreak in western DRC just a few months ago but requires a comprehensive and precise understanding of who is infected and who their contacts are — something that necessitates having unimpeded daily access to their communities for months. 

That has not been possible this time around: Areas affected by violence have been inaccessible for days at a time. Therefore, while contact tracing and ring vaccination should continue where transmissions can be tracked, mass vaccination of larger portions of populations should be considered in areas where that is not possible such as Beni, which has a population of about 230,000. Expanding vaccinations in this manner could immediately halt the spread of the disease. 

While such a mass vaccination sounds ambitious, the World Health Organization (WHO) and others have executed much larger national campaigns  in over 40 low-income countries, including DRC, where millions of children were immunized against polio or measles within a single week. These campaigns were also implemented successfully during conflicts in Somalia, Afghanistan, and Liberia. 

Though a mass-vaccination effort targets an entire population, it need only reach the proportion required for “herd immunity” — immunizing enough people so that the virus cannot spread. Early studies of the Ebola vaccine found that it might be possible to achieve herd immunity by vaccinating as little as 42% of the population. 

To be successful, the mass vaccination effort would require the buy-in of the communities and the Ebola response teams being able to securely access the areas in question for the day or two it would take to immunize everyone. Promisingly, a recent study showed that even communities with high levels of distrust appear to be open to vaccination. 

Anthropologists are already on the ground working tirelessly to engage community leaders and armed groups. In areas not amenable to outreach, a neutral “white helmet” security force, ideally drawn from the African Union or other countries without past involvement in the DRC conflict, should be deployed with the sole mission of securing vaccination efforts. It should be made abundantly clear to the population that this force has no allegiance to any political or institutional actors and is there only to deter violence against responders. At the end of the day, communities and militias do not want their loved ones to die from Ebola and would respect such a presence if they were reassured its mission is strictly medical. 

Mass vaccination will also require an adequate supply of the Ebola vaccine. Its manufacturer, Merck, has committed to maintaining a supply of 300,000 doses at all times. Doing so could become difficult if vaccination efforts are expanded, but at the current juncture, the number of people who would need to be vaccinated in order to stunt the outbreak still appears to be within the range of existing stockpiles. Nonetheless, production of the vaccine should be increased and the bottlenecks to doing so should be assessed and cleared to ensure an adequate supply.  

It’s true that the Ebola vaccine is still experimental and its health risks are not yet fully known. However, for people living in areas where everyone who is infected is not known, the heightened risk of unknowingly contracting a fatal Ebola infection may, at this point, outweigh the potential danger posed by the vaccine.

Branswell: A pivotal day in world's response to Ebola nears

Via STAT, Helen Branswell writes: A pivotal day in world's response to Ebola nears: the launch of a clinical trial. Excerpt:

Health officials are preparing to launch a clinical trial designed to test whether experimental Ebola therapies improve patients’ chances of survival in the outbreak in the Democratic Republic of the Congo — a landmark moment in the world’s efforts to respond to this and future crises. 

The randomized controlled trial will compare three different antibody treatments and an antiviral drug to each other, rather than involving a placebo. It is unlikely that the trial will produce clear results based on a single epidemic; it is expected to span several outbreaks and countries — a novel and challenging design.  

In the current outbreak, the trial will be made all the more complicated by a difficult security environment. 

“I don’t think the world quite appreciates the challenge of the environment in which this is happening,” said Dr. Jeremy Farrar, head of the Wellcome Trust and co-chair of a group that has been working under the auspices of the World Health Organization to draft the trial protocol.  

“People are being shot at, and it’s not just the occasional bit of gunfire,” Farrar said of the security environment in North Kivu. “There’s mortars, there’s kidnappings — it is an intensely fragile environment with a lot of conflict that’s been going on for years.” 

The four experimental therapies that will be tested have been used for weeks in Ebola treatment units being operated by nongovernmental organizations Doctors Without Borders (MSF) and Alima. Those therapeutics are the Gilead antiviral drug Remdesivir and three monoclonal antibody preparations: ZMapp, made by Mapp Biopharmaceuticals, Regeneron’s REGN 3470-3471-3479, and mAb 114, which is being developed by the National Institutes of Health and DRC’s National Institute of Biomedical Research. 

As of Friday, 139 patients had received one of the four. 

To date, there have been 329 confirmed and probable cases of Ebola and 205 deaths, making this Ebola outbreak, which began in July, the third largest on record.  

It is unusual for unlicensed drugs to be used in such quantities outside of the context of a clinical trial. In this case, the authorization came through a sort of compassionate use protocol established by the WHO.

EBOLA DRC - Evolution of the response to the Ebola outbreak in North Kivu and Ituri to Sunday 11 November 2018

The MOH has published EBOLA DRC - Evolution of the response to the Ebola outbreak in the provinces of North Kivu and Ituri to Sunday 11 November 2018. In addition, Dr. Tedros reports that Beni was violently attacked last night, apparently with fatalities though not among WHO personnel. Excerpt from the Google translation:

EPIDEMIOLOGICAL SITUATION IN THE PROVINCES OF NORTH KIVU AND ITURI 

Sunday, November 11, 2018   

The epidemiological situation of the Ebola Virus Disease  dated November 10, 2018: 

• Since the beginning of the epidemic, the cumulative number of cases is 329, of which 294 confirmed and 35 probable. In total, there were 205 deaths (170 confirmed and 35 probable). 

• 38 suspected cases under investigation. 

• 3 new confirmed cases, including 2 in Beni and 1 in Kyondo. 

• 4 new confirmed deaths, including 2 in Beni and 2 in Butembo.

  

Remarks: 

• To avoid that the total number of cases varies (up or down) daily, the suspect cases have been placed in a separate category. Thus, suspect cases with positive laboratory tests will be added to the confirmed category, while negative ones (non-cases) will be removed from the table. 

• The category of probable cases includes all reported deaths for which it was not possible to obtain biological samples for laboratory confirmation. The investigations will determine whether these deaths are related to the epidemic or not. 

• A community death is a death in the community, outside of a licensed health center. 

News of the response 

Ebola Survivors Tracking Program 

• At the ninth Ebola outbreak in Equateur Province, the Ministry of Health launched an Ebola survivors follow-up program to provide clinical, biological and psychosocial follow-up for people who have recovered from Ebola. The Minister of Health, Dr. Oly Ilunga Kalenga, also initiated the establishment of the National Association of Ebola Winners to bring together all survivors in the Democratic Republic of Congo. The national coordinator of the program and association is Dr. Richard Kitenge. Survivors' monitoring centers will be set up in Beni, Butembo and Mangina. The Ministry of Health gives priority to local health personnel in all areas of the program to build local capacity. The survivor monitoring program teams are reviewing the database of all survivors since the start of this tenth outbreak. The Ministry of Health will resume sharing survivor data as soon as this cleanup of the database is complete. 

Vaccination 

• Since the start of vaccination on August 8, 2018, 28,727  people have been vaccinated , including 14,966 in Beni, 4,544 in Mabalako, 2,152 in Katwa, 1,663 in Mandima, 1,435 in Butembo, 1,237 in Kalunguta, 732 in Masereka, 434 in Bunia, 355 in Tchomia, 293 in Vuhovi, 258 in Mutwanga, 240 in Komanda, 178 in Oicha, 160 in Musienene and 80 in Kyondo.

EBOLA DRC - Evolution of the response to the Ebola outbreak in North Kivu and Ituri at Friday 9 November 2018

The MOH has published EBOLA DRC - Evolution of the response to the Ebola outbreak in the provinces of North Kivu and Ituri at Friday 9 November 2018. Not good: seven new confirmed cases, one of them in a new health zone, and a reminder of the violence healthcare workers must risk. Excerpt from the Google translation:

EPIDEMIOLOGICAL SITUATION IN THE PROVINCES OF NORTH KIVU AND ITURI 

Friday, November 9, 2018   

The epidemiological situation of the Ebola Virus Disease  dated November 8, 2018: 

• A total of 319 cases of haemorrhagic fever were reported in the region, of which 284 confirmed and 35 probable. 

• Of the 284 confirmed, 163 died and 97 are cured . The others are hospitalized in the different Ebola Treatment Centers (ETCs) installed. 

• 52 suspected cases under investigation. 

• 7 new confirmed cases, including 3 in Beni, 2 in Butembo, 1 in Kyondo and 1 in Vuhovi. 

º A new confirmed case has been identified in a new Kyondo Health Zone, located next to Butembo Health Zone. The investigations are in progress. 

• 7 new confirmed deaths, including 3 in Beni, 2 in Butembo, 1 in Kyondo and 1 in Mutwanga.   

• 6 new people healed, including 5 in Beni and 1 in Butembo.

  

Remarks: 

• To avoid that the total number of cases varies (up or down) daily, the suspect cases have been placed in a separate category. Thus, suspect cases with positive laboratory tests will be added to the confirmed category, while negative ones (non-cases) will be removed from the table. 

• The category of probable cases includes all reported deaths for which it was not possible to obtain biological samples for laboratory confirmation. The investigations will determine whether these deaths are related to the epidemic or not. 

• A community death is a death in the community, outside of a licensed health center. 

News of the response   

Vaccination 

• Since the beginning of vaccination on August 8, 2018, 27,832  people have been vaccinated , including 14,653 in Beni, 4,515 in Mabalako, 2,152 in Katwa, 1,663 in Mandima, 1,385 in Butembo, 715 in Masereka, 947 in Kalunguta, 434 in Bunia, 355 at Tchomia, 250 at Vuhovi, 240 at Komanda, 185 at Mutwanga, 178 at Oicha, and 160 at Musienene. 

Message from His Excellency the Minister of Health   

On Friday, November 9, 2018, the Ebola Virus Disease epidemic in the provinces of North Kivu and Ituri just exceeded that of the first epidemic recorded in 1976 in Yambuku, the province of Equateur. To date, 319 cases and 233 deaths have been recorded.   

At the sight of these figures, my thoughts and prayers go to the hundreds of bereaved families, the hundreds of orphans, and the missing families.   

At the heart of this unprecedented response are hundreds of men and women who have been working tirelessly for more than three months in a difficult and volatile environment to prevent this epidemic from spreading to other provinces in the Democratic Republic of Congo. Congo and neighboring countries.   

No other epidemic in the world has been as complex as the one we are currently experiencing. Since their arrival in the region, the response teams have faced threats, physical assaults, repeated destruction of their equipment, and kidnapping. Two of our colleagues in the Rapid Response Medical Unit even lost their lives in an attack.   

Yet, despite the risks and with the support of a majority of the population, our agents continue to do their job with passion and dedication to protect the Nation and the world.   

Among their achievements, we particularly remember the vaccination, including in red areas, of more than 27,000 high-risk contacts, at least half of which could have developed the disease. Without the prompt and effective intervention of national and international experts, it is a drama of considerable magnitude that we would be experiencing at the moment. For this courage, they deserve all our gratitude.   

However, this epidemic remains dangerous and unpredictable, and we must not let our guard down. We must continue to pursue a very dynamic response that requires permanent readjustments and real ownership at the community level.   

We are writing a new page in history and public health. It is with the cooperation and the commitment of all, the Government, the international community, and especially the population, that we will overcome this epidemic.   

Thank you.

EBOLA DRC - Evolution of the response to the Ebola outbreak in North Kivu and Ituri on Thursday 8 November 2018

The MOH has published EBOLA DRC - Evolution of the response to the Ebola outbreak in the provinces of North Kivu and Ituri on Thursday 8 November 2018. Excerpt from the Google translation:

EPIDEMIOLOGICAL SITUATION IN THE PROVINCES OF NORTH KIVU AND ITURI 

Thursday 8 November 2018   

The epidemiological situation of the Ebola Virus Disease  dated November 7, 2018:

• A total of 312 cases of haemorrhagic fever were reported in the region, 277 confirmed and 35 probable. 

• Of the 277 confirmed, 156 have died and 91 are cured. The others are hospitalized in the different Ebola Treatment Centers (ETCs) installed. 

• 40 suspected cases under investigation. 

• 4 new confirmed cases, including 1 in Beni, 2 in Kalunguta and 1 in Mutwanga. 

º Mutwanga is a new health zone affected. It is a health zone close to that of Beni. The new case is a known contact followed by a confirmed case of Beni who refused the vaccination and fled to Mutwanga before the end of his follow-up. The central office of the Mutwanga Health Zone, which had been informed of the presence of a high-risk contact in their territory, found him ill. He finally agreed to be transferred to the CTE of Beni.   

• No confirmed case deaths.

    

* A confirmed case reported in the bulletin of November 7, 2018 was counted in Kalunguta while he came from Butembo. 

• Remarks: 

• To avoid that the total number of cases varies (up or down) daily, the suspect cases have been placed in a separate category. Thus, suspect cases with positive laboratory tests will be added to the confirmed category, while negative ones (non-cases) will be removed from the table. 

• The category of probable cases includes all reported deaths for which it was not possible to obtain biological samples for laboratory confirmation. The investigations will determine whether these deaths are related to the epidemic or not. 

• A community death is a death in the community, outside of a licensed health center. 

News of the response   

Vaccination 

• Since the start of vaccination on August 8, 2018, 27,398 people have been vaccinated , including 14,479 in Beni, 4,480 in Mabalako, 2,152 in Katwa, 1,663 in Mandima, 1,385 in Butembo, 690 in Masereka, 807 in Kalunguta, 434 in Bunia, 355 in Tchomia, 240 in Komanda, 185 in Mutwanga, 178 in Oicha, 160 in Musienene and 190 in Vuhovi.

DRC: Several cases of Ebola reported in a village occupied by Mai-Mai militiamen

Via Actualite.cd: DRC: Several cases of Ebola reported in a village occupied by Mai-Mai militiamen in North Kivu. Excerpt from the Google translation:

Several cases of Ebola have been identified in a village occupied by Mai-Mai militia in the health zone of Kalunguta in Beni territory (North Kivu), reported Tuesday, November 7 the Ministry of Health without giving the name of the town. 

The epidemic spread in this village "following the escape of a confirmed case of Beni to this village in order to escape the teams of the response," says the health authority. 

Among the new confirmed cases, there is a 6-day newborn baby from a confirmed case who died on November 4 at Butembo's Ebola Treatment Center (ETC).  

The child's mother began to show symptoms of the disease 5 days before giving birth to her son.  

To reach the village, the health teams negotiated with the "leaders" of the village. Several deaths have been reported in the village during the previous weeks.  

An investigative mission has been organized to "identify deaths caused by Ebola and classify them as probable cases," according to the ministry, saying the villagers have been "cooperative" for the vaccination.

WHO: Uganda vaccinates front-line health-workers against Ebola

WHO AFRO has published Uganda Vaccinates Front-line health-workers against Ebola. Excerpt:

Kampala, 7th November 2018:- The Ministry of Health (MoH) with support from the World Health Organization (WHO) has started vaccinating frontline health workers against the Ebola Virus Disease (EVD). The exercise has begun today in Ntoroko district and will initially be implemented in the five high-risk districts bordering the Democratic Republic of Congo (DRC).  

A total of 2100 doses of the ‘rVSV-Ebola’ vaccine will be administered to the health workers to protect them against the type of Ebola virus strain that is currently circulating in some parts of DRC. Indeed, this particular vaccine is currently being administered in DRC and is demonstrating positive protective results and potency against the Ebola virus-Zaire type. 

In vaccinating frontline health workers against EVD even before Uganda detects a single case, health authorities are being cautious having learnt bitter lessons from previous outbreaks. A number of health workers including the renowned Dr Mathew Lukwiya contracted the disease and died as they cared for EVD patients. These could have been saved had a vaccine been available then. 

Although the ‘rVSV-Ebola’ vaccine is not commercially licensed, it is being used under “expanded access” or what is also known as “compassionate use” in the ongoing Ebola outbreak DRC. This vaccine was also used in the Ebola outbreak in Equateur province in May-July 2018. In 2015, the vaccine was given to more than 16,000 volunteers involved in several studies in Africa, Europe and the United States where it was found to be safe and protective against the Ebola virus. 

Several studies have shown that the vaccine is safe and protective against the Ebola virus but more scientific research is needed before it can be licensed. The vaccine is, therefore, being used on a compassionate basis, to protect persons at highest risk of the Ebola outbreak, under a “ring vaccination” strategy, which is similar to the approach used to eradicate smallpox. In this strategy, informed and written consent is needed from people, for them to be vaccinated which in turn may limit mass media coverage of the exercise. 

It is highly likely that Uganda may import EVD from DRC given the closeness of the current epicenter, the high population movements due to trade, social-cultural connections and easy accessibility of health services in Uganda.