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Fever in Uganda

By Dr Dick Stockley

Welcome to all new arrivals in Uganda! August and September are usually the months when most one year volunteers arrive, and also when a lot of short term posts change over.

You may have read before you left about 2 “outbreaks” of Yellow Fever and Ebola this year. People are asking “where do they come from?” and “what else is out there?” and of course “is it safe?”

These periodic epidemics might not come from anywhere. There are dozens of tropical fevers in Uganda, many of these diseases are quite probably here all the time, grumbling away in various locations, unrecognized and mostly invisible, and mostly getting better by themselves while being treated as “malaria and typhoid”. As I have been on record as saying many times: “Uganda is a very healthy place to live”. Many of us live here for years and never get sick: for example none of my family has had malaria since 1983, and we take no precautions at all, other than to live in Kampala. I don’t even use a net. At my age you need to get up to pee every night and I don’t want to get tangled up in a net. My wife smothers herself with husband repellent every night, seems to work well.

So what is out there? And how does the enthusiastic volunteer in Gulu survive a year without any major health issues?

The quick answer is everything is out there: every tropical disease on the map if you go looking for it, they are rare but we see a constant trickle of things you read about but never see. Up to 50 years ago there was no effective and specific treatment for most infections, and yet people survived. Why? Well the local herbalist did his best, but most people simply got better because that is the natural history of infectious diseases. As a general rule, by the time you were 5 years old you were either immune or dead. A few people got sick, and most got better and joined the ranks of the immune. So these febrile diseases grumbled away in the community, with most people pretty well most of the time as they were immune, and there were just enough naïve cases or visitors and newborns to keep the diseases alive.

In a year here we will see a few cases of Ricketsia, in English called tick typhus and flea born typhus; Borellia, similar to Lyme disease but a different species; Brucellosis, mostly the sheep and goat type we think; Q Fever; and Weil’s disease for example. They are not necessarily “tropical” as they can be found in many places, and they all cause fever and headache. Add to that specific “arboviruses” in different places, some with wonderful names like Chikungunya, On’ong On’ong, Semliki Forest virus and Rift Valley fever as well as the ones you have heard of like Yellow Fever and Dengue. Which we probably actually don’t have. They all cause fever and headache too. Add on simple respiratory viruses, flu, TB, dysentery, salmonella and other acute gastric infections all causing fever. The WHO and CDC has recognized 6 neglected diseases which they consider common and serious enough to start prioritising for specific management, including Bilharzia and Onchocerciasis. Faced with that little lot just for starters, and you can see why tropical and travel disease doctors have to smother a smile when someone who has been here 6 months reckons he can recognize malaria because he has seen it many times. Many probably haven’t seen a real case even once, what he has seen is lots of fevers and headache which got better on their own while diligently swallowing antimalarials.

So back to the volunteer in Gulu whose parents have paid for her ticket and hope she comes back with a tan and a smile but nothing else.

7 pieces of advice:

First, ignore the local bore who thinks he knows all about disease in Africa. Ask for his transcripts. If you are a group of 10 or more we give a free seminar on staying healthy in Uganda. One to 2 hours if you can stay awake that long.

Second, use your common sense. There is not a box in Entebbe saying “welcome to Uganda, please leave your brain here and collect on departure”. Common things occur commonly and if you have fever and a cough it is probably a cold not “malaria and typhoid”! Fever and diarrhoea is probably acute gastro; and if your baby has a fever and a sore ear it is probably an ear infection. If you were in the lake 5 weeks ago think Bilharzia and if you have a tick bite think typhus or Borellia.

Thirdly if you leave Kampala take your antimalarial. We mean it! Actually we really do – and if you take a night flight out of Entebbe. For Gulu, Doxycyclin is probably best, as it prevents about 12 fairly common diseases many in that list in the last paragraph, and also improves your acne. Ignore all silly and dangerous advice that you cannot take an antibiotic for longer than 6 weeks. Be logical! Millions of school girls take it for acne for 2 years, what is the difference? Get real malaria once and you will certainly change your mind. Doxy is safe for ever, ask anyone with rosacea.

Fourthly you are not here for a “long time”, a very silly reason often used for not taking antimalarials. When we worked for CMS there was a programme called “STOP” which stood for “short term overseas personnel” Short term was 6 years! Full time CMS missionaries were for 9 to 12 years or more. From the point of view of immunity 2 years is “very short term”. 1 year is a visitor.

Fifthly, if you have a baby, or you have been here 6 years and know your way around, or you really are allergic to doxy, react badly to lariam and cannot afford malarone, or if you are simply too stubborn to take antimalarials, then up country you must use good quality RDT’s. That is malaria rapid diagnostic tests. They really are the best thing since canned beer, and are 100% sensitive in significant malaria. If it is negative, and still negative on a repeat test the next day, you do not have malaria. Trust them. However buy them from us or know the brand: we have seen some on the market that simply do not work, which is horribly dangerous. If you want to know more, go on line to the eye website, and read old articles on malaria.

Sixthly, if you are taking your antimalarial and you get a fever it is extremely unlikely to be malaria, and if you were vaccinated it isn’t typhoid either. Look for another cause: almost certainly it will be one of the 20 odd febrile diseases we breezed through earlier. Don’t listen to nonsense about malaria being there but not seen. Malaria in non-immunes is a potentially fatal disease that makes you very ill indeed, and we don’t mess about with it. However half a dozen of the other causes of fever can make you very ill indeed too, so look for other causes and if what you are told doesn’t fit with common sense, email us.

Seventhly: er…… have a nice time in Gulu

For more information, please contact:
The Surgery

Plot 2 Acacia Avenue, Kololo, Kampala
Tel: (041) 4256003. 24 HRS Emergency Service, Mobile: +256 752 756003.
Email: Stockley@thesurgeryuganda.org. Website: www.thesurgeryuganda.org