Waterborne disease admissions to Kagando are rising

It is sad to report a resurgence of the types of disease that were a large part of the reason for the enlargement of hospital development at Kagando in the 1980s.  Following a Cholera epidemic that killed 3,000, 'TEARFUND' provided the resources for the building program that remains the core of the hospital today.  With generous funding from the a charitable foundation in the USA set up specifically to help Kagando, many kilometres of clean piped water from capped springs have been laid since then stretching well beyond the supply to the Hospital.  Without this the problems would have been worse, but many people still do not have access to clean water.  Low incomes and poor educational levels still result in widespread unsafe drinking water practices.  There was a mini-epidemic of Cholera with patients admitted to Kagando in 2009 and late complications of Typhoid are increasing.

Recent History - the rise in spontaneous bowel perforations

Doctors and nurses working in Kagando have been aware of a steady increase in admissions of seriously ill patients with peritonitis due to spontaneous perforations, usually of the small intestine. The incidence has been rising rapidly since 2005 (see graph) and shows no sign of reducing in 2011. Although such presentations would normally be regarded as due to Typhoid until proved otherwise, there was an initial delay in recognising this due to conflicting laboratory results, but it is now clear these cases are examples of typhoid in its later and less common stage.  It represents the 'tip of the iceberg' in terms of the likely number of cases of Typhoid in the area.

There has been no similar awareness of a rise in less serious cases, but there are many conditions with similar symptoms and Typhoid will often respond to the antibiotics given to patients with bowel symptoms and fever without a definite diagnosis being established.  Due to the large numbers, not all patients with a suggestive history have specific tests for Typhoid.  The test used in Kagando is low-cost, but is also known to have low reliability.

High Mortality despite treatment

Throughout Africa many serious conditions treated  in hospitals like Kagando, are in an advanced stage by the time the patient arrives.  Quite apart from the inherent dangers of the disease, this makes treatment and cure much more difficult and death rates for admissions with gut perforations are typically between 20% and 30%.  Death often occurs despite a prolonged period of treatment and repeated operations. 

To add to the distress it is the younger age groups that are most affected (see graph).  The peak age for admissions was between 5 and 10 years of age with those less that 20 years old representing the majority of cases, though it must be remembered that the majority of the people living in the hills and valleys around Kagando are also aged less than 20.  It is likely that all age groups are equally susceptible.

Equally sad is the knowledge that Typhoid is largely preventable, being an example of a waterborne disease contracted exclusively by poor hygiene and contaminated water supplies.  Although Typhoid and Cholera are the highest profile waterborne diseases, there are likely to be substantial numbers of other similar gastro-intestinal infections, which are substantial causes of illness and sometimes death particularly in infancy (those aged 5 or less).

Volunteer-led research

A substantial boost to tackling the problem has come from a detailed survey of cases over the last five years.  These studies were initiated in a limited way by Ugandan resident Kagando doctors and volunteers working with the German Medical Mission Team (GMMT).  However it was the teaming up of a Surgery trainee volunteer from Australia, (Jeffrey van Gangelen) and a Biology undergraduate from Wheaton College, Illinois, USA (Chris de Boer) that has led to a substantial document being submitted for publication.  The graphs above are taken from a draft of that paper, with permission.

The Centre for Disease Control and Prevention in Kampala also completed a study, based on Kasese in 2010, supported by a team from CDC Atlanta USA, which had similarly reported an excess of cases.  This study had a significant laboratory input and was in no doubt that Typhoid was the underlying cause of the rise in small bowel perforation.

A new 'Task Force'