Posted on 04/12/2005 4:04:57 AM PDT by Mother Abigail
In Angola's Teeming Capital, a Suspected Virus Carrier Dies Alone
By DENISE GRADY
UANDA, Angola, April 11 - Bonifácio Soloca, 61, was alone when he died here Monday evening at Américo Boavida Hospital, in an isolation unit for patients suspected of being infected with the Marburg virus. He was admitted on Saturday, the unit's first patient, and never saw his family again. While doctors and nurses disinfected his lifeless body, his wife stood outside a fence on the grounds, waiting patiently for someone to come and get the dinner she had brought him.
The prospect of the Marburg virus spreading through this teeming capital city, with four million inhabitants and an international airport, inspires dread among health officials. Though the virus does not spread through the air like influenza - Marburg requires contact with infected bodily fluids - health officials believed Luanda had to be prepared for the worst.
So Doctors Without Borders created the isolation unit here, with room for 30 to 40 patients, by clearing out a building that had formerly been an H.I.V. clinic.
The few patients who have turned up in Luanda contracted the disease about 180 miles away in Uíge, the province at the center of the outbreak, and are not thought to have passed it one to anyone else. It is not known whether Mr. Soloca had the Marburg virus - one blood test was negative, but a second must still be done. He was admitted because he had some Marburg-like symptoms - fever, and blood in his urine and vomit - and he might have been exposed to the virus while being treated for malaria at another Luanda hospital where a Marburg patient had died. Because of that, his doctors said, they had to treat him as if he did have the virus.
Once in the isolation unit, Mr. Soloca probably received less medical attention than he would have gotten had he been on a normal ward where doctors and nurses could easily look in on him on the spur of the moment, without having to put on layer upon layer of protective gear first.
Relatives were discouraged from visiting because the precautions needed to enter are so arduous. Anyone who goes in must spend a half-hour or more suiting up in surgical scrubs, overalls, rubber boots, a hood, goggles, and double masks and gloves.
Keeping the family away poses a hardship for patients. Hospitals do not provide meals or much nursing, so patients depend on their families to bring food and take care of them. Mr. Soloca's family brought his meals to the hospital, but he spent much of his time alone.
Doctors and nurses generally suited up and visited him as a group three times a day, once during each of three daily shifts, and stayed in the room for an hour or two each time - as long as they could stand to wear the stifling suits. The rest of the time, he was by himself. There were no monitors. He had lost control of his bodily functions and often lay in his own wastes between their visits.
Dr. Benjamin Ip, a Doctors Without Borders volunteer from Las Vegas who had spent hours tending to Mr. Soloca the day before, emerged from the unit looking troubled after the man's death on Monday. Earlier in the day, he said, he had considered starting an intravenous line but did not, because it would increase the nurses' risk of being exposed to Mr. Soloca's blood or stuck by a contaminated needle. "I don't know whether it would have made a difference," he said. "It's a fine line to balance care for the patient and risk to yourself."
A psychiatrist walked Mrs. Soloca to a tent used for counseling, to tell her that her husband had died, and to explain that the family would not be allowed to claim his body. Rather, it would be buried in a special cemetery designated by the Ministry of Health for Marburg victims.
But the doctors said one important custom would be respected. When someone dies in Angola, tradition says it is essential that the family see the person's face, to know for sure that their loved one is dead. So, in the dark, Dr. Ip and an assistant, in full protective gear once again, carried Mr. Soloca, zipped into two body bags, to a patch of bare dirt outside the isolation unit and set him down on the ground.
The bags were open just enough to reveal his face, and the doctor shone a flashlight on it. Mr. Soloca's wife and sons and his priest looked at him from the other side of a fence, said a prayer and left. In a few days, they will learn whether he had the Marburg virus.
>> The few patients who have turned up in Luanda contracted the disease about 180 miles away in Uíge, the province at the center of the outbreak, and are not thought to have passed it one to anyone else.
It is not known whether Mr. Soloca had the Marburg virus - one blood test was negative, but a second must still be done. He was admitted because he had some Marburg-like symptoms - fever, and blood in his urine and vomit - and he might have been exposed to the virus while being treated for malaria at another Luanda hospital where a Marburg patient had died.
Because of that, his doctors said, they had to treat him as if he did have the virus.
Earlier in the day, he said, he had considered starting an intravenous line but did not, because it would increase the nurses' risk of being exposed to Mr. Soloca's blood or stuck by a contaminated needle. "I don't know whether it would have made a difference," he said. "It's a fine line to balance care for the patient and risk to yourself." <<
The above comments on the first Marburg patient in the Amerido Boavida hospital in Luanda raise additional issues regarding the true state of Marburg transmission in Luanda. Moreover, the descriptions clearly demonstrate why such isolation wards are to be avoided at all costs.
From the patient's point of view,Mr. Soloca was clearly in the wrong place at the wrong time. Exactly where that place and time were would be of interest, but it seems that at a minimum it was not in contact with bodily fluids from the Marburg patient who died in another location in Luanda.. If Mr Soloca was infected by another patient, he would be the "official" first transmission of Marburg in Luanda and his infection would raise some serious questions about ease of transmission and infection control in the hospital.
If Mr Soloca is not infected with Marburg, then being somewhere in the vicinity of the patient caused him to be transferred to an isolation ward with minimal care. As noted he then would have needlessly been isolated from his family, and die a death that did not even include painkillers to ease his passing. The failure to start an IV raises serious questions about the level of care as well as sample collection for testing. The situation sounds remarkably like SARS in Toronto in 2003. Virus was readily isolated from initial cases, but as nurses became ill and infection control procedures became more rigorous, the recovery of virus from clinical samples fell to zero.
If samples were collected from Mr Soloco, the integrity of the clinical samples may have been compromised by the long delays linked to changing into and out of the heavy protective gear. Thus, the isolation units may create conditions that limit the care given the patient and also reduce the quality of samples collected, which could lead to false negatives.
The status as the first Marburg transmission would also be questioned, because it seems quite clear that transmission of Marburg in Luanda has already happened. This was noted last week by MSF and two of the transfers to Amerido Boavida were from Cacuaco, a slum on the outskirts of Luanda.
The number of patients described in media reports would seem to be more than a few. 5 have already died - the 15 year-old and Italian pediatrician on March 24, the Vietnamese physician on March 25, a 1 year old on March 27 and another patient on March 31. In addition, there was a Portuguese national who entered a military hospital as well as the two patients from Cacuaco, where were transferred to Amedico Boavida.
It is unclear if any of the above eight was the patient who died near Mr Soloca. However, it seems unlikely that there was cintact with bodily fluids. Since he was diagnosed with TB, it seems that he would have been on a floor with respiratory cases, which again suggest airborne transmission or some other efficient method or transmission that has killed 17 nurses, and now possibly a TB patient who was in the wrong place at the wrong time.
12 Apr 2005
Local resistance in Angola to the World Health Organizations efforts to stem the spread of the Marburg virus is hindering the WHO's effectiveness, say local members. Angolans are afraid of sending their relatives to hospitals.
If infected people are not sent to hospital, the chances that this outbreak spreads are much greater.
WHO is carrying out a public awareness campaign aimed at getting local people to cooperate.
Marburg haemorrhagic fever seems to have a higher mortality rate than the Ebola virus.
Many infected people are refusing to admit they may have the Marburg virus. By the time their relatives do get to hospital it is usually too late.
Their relatives' dead bodies have been lying around - bodies have to be disposed of quickly, say WHO members.
The current Marburg outbreak in Angola is the largest in its history.
UIGE, Angola - The staff in the pediatric ward of Uige's regional hospital suspected something terribly wrong as early as October, when children who had been admitted with seemingly treatable illnesses began, suddenly and wrenchingly, to die.
But did the Marburg virus cause those early deaths in Angola? If it did, and had it been diagnosed at the time, might the current epidemic have been averted?
"Nobody really has a sense of where or when it started," said Dr. Thomas Grein, a medical officer in the World Health Organization. "The widespread belief that it began in October is speculation."
But local officials in Uige, the center of the outbreak, believe it began around that time, and spread from the pediatric ward of the regional hospital, which has now been declared off limits, except for its isolation ward.
Experts say at least 214 people have caught the virus and 194 have died, including eight pediatric nurses and the doctor in charge of the pediatric ward, six other nurses and one other doctor. It is the largest Marburg epidemic ever reported.
Marburg is spread by contact with bodily fluids, from blood to sweat, and kills with gruesome efficiency. Victims suffer from vomiting, diarrhea, high fever and bleeding from body orifices. Nine in 10 are dead within a week. There is no effective treatment.
When strange deaths first began to appear in October, mystified local health officials shipped samples of tissue and blood from four children to the United States. In November the Centers for Disease Control and Prevention tested them for at least three types of hemorrhagic fever, including Marburg. The results, which nearly all agree to have been accurate, came back negative.
By the end of December, at least 95 children were dead, local health workers say. How many deaths were Marburg-related is unknown, but the numbers were alarming.
"In October, November, December, we were seeing so many children dying -- just children," said Dr. Gakoula Kissantou, 31, the hospital's acting administrator.
"It was becoming scarier."
He recalled the doctor in charge of the pediatric ward at the time, Dr. Maria Bonino of Italy, calling a meeting with the staff and asking, "What is going wrong here in the hospital?" She herself died in March, a victim of the virus.
It was not until February that Angolan authorities shipped more samples to the CDC in Atlanta. This time, 9 of 12 came back positive for Marburg, which by then was claiming more victims by the day.
In early March, the provincial health officials alerted a WHO representative that they had found 39 suspected cases of Marburg. When a larger international team arrived, the members identified more than 60 suspected cases.
Since new lab tests positively confirmed the virus on March 18, a growing number of epidemiologists, anthropologists, public health experts and emergency medical workers have descended on Uige in a race to cut off the disease.
Thanks for posting this.
>> A total of 203 people have died in Angola from the Marburg virus, the worst outbreak recorded of the Ebola-like bug, the Angolan health ministry and the World Health Organisation said on Monday.
The greatest number of deaths - 184 - was recorded in the northern Uige province, the epicentre of the epidemic that was first detected in October, according to the figures from health authorities released in a statement in Luanda.
A total of 221 cases of the Marburg virus have been discovered, out of which 203 resulted in death, the statement said, putting the mortality rate countrywide from the outbreak at 92%. <<
The 221 discovered Marburg cases gives a lower limit on cases with Marburg symptoms. These numbers clearly lag the number of people in Angola infected with Marburg. The infected patients is markedly higher than 221, but that number is largely unknown. WHO uses the term confirmed cases to generate an even lower number, which appears to lag the numbers identified for several weeks.
Media stories tonight still maintain that there has been no transmission of Marburg in Luanda and the number of confirmed Marburg deaths in Luanda remains at two. However, the first two deaths in Luanda, a 15 year old male and the Italian pediatrician, died on Match 24, over two weeks ago.
Last week MSF conceded that urban transmission of Marburg in Luanda had begun because there were cases that had no connections to Uige.
Moreover media reports described patients in Cacuaco, a Luanda slum, that also had no clear ties to Uige. The number of deaths in Luanda last month was at least 5, so the comments on Marburg Luanda transmission attributed to WHO a clearly quite dated.
These comments on last month's situation are transmitted almost daily to Lunda residents and foreign workers. It is not clear if these dated comments are believed by the residents, but clearly they have had little effect on the spread of the virus. Daily repeating of the same dated material offers little confidence in WHO's ability to control the spread of Marburg.
WHO is either citing dated material or is significantly lagging on the confirmation of patients.
Since these patients are already dead and buried and clear Marburg victims, the delay may simply offer some validation for the cited numbers which are several weeks old. The rapid spread of the virus has produced a much more serious situation, that WHO has chosen to either misrepresent or allow media to misrepresent for them.
WHO's track record in Angola is less than ideal. The WHO has consistently underplayed the seriousness of the outbreak. They did not view the situation seriously until health care workers were infected about a month ago. They then stated that the number of infected patients was too high because cases had been mis-diagnosed.
When Marburg was identified as the etiological agent, WHO failed to correct two major media misconceptions. WHO knew that the case fatality rate was at or near 100% when they initially announce that 95 of 102 patients had died.
WHO certainly knew that all or most of the 7 diagnosed patients who were still alive were newly admitted patients who would also soon probably die. However, initial reports indicated that Marburg was milder than Ebola and had a case fatality rate around 25%. When the number of cases was only a few more than the number of deaths, media reported the total number of cases as those diagnosed plus those who had died, when in fact the total number of patients was just those diagnosed, most of whom were dead.
Media reports continue to misreprent the case fatality rate, although now it is generally cited as being in the 80-90%. WHO knows that there are few if any survivors and the fatality rate is close to 100%.
Now WHO is continuing to ignore the fact that Marburg is transmitting in densely populated slums of Luanda. If the only two cases WHO has been able to confirm in Luanda are the two victims who died on March 26, then WHO should explicitly state that as of March 26 there was no evidence of transmission in Luanda.
To repeatedly state that there are only two confirmed cases in Luanda is at best misleading and clearly scandalous, either because the confirmation process lags the cases on the ground by over two weeks, or because the media is allowed to publish misleading information on a daily basis without comment from WHO.
No cases of the deadly Marburg virus have been reported in South Africa.
This is the word from the Eastern Cape health authorities following the death of a man suspected to have been infected with the disease.
Eastern Cape health department spokesperson Sizwe Kupelo said samples from the 50-year-old man, who died after experiencing Marburg-like symptoms, were sent to the Centres for Disease Control in Atlanta in the US to determine whether he had been infected with the disease, which is on the rampage in Angola.
"The samples came back negative. He was not infected with the virus," Kupelo said.
He added that the department had had to take the necessary precautions and send the samples for testing.
Marburg/Ebola symptoms are pretty dramatic. What other jungle diseases cause those types of symptoms with death? Could the variant be eluding the test?
I was wondering the same thing.
It seems to me that either they are lying (to keep people calm) or something else (some other disease?!) is going on.
It may be easily confused with more common diseases, including malaria, yellow fever, typhoid fever, Dengue hemorrhagic fever etc.
Thanks for keeping me up to date!
If an autoimmune response is the cause of death, can that be triggered in such a way as to make collecting a sample containing sufficient viral particles and/or specific antigens difficult? In other words, are we also looking at a potential sample collection issue?
On a tangential note, have autopsies been carried out at a well equipped research hospital, with associated analysis of the findings?
Likewise, have genetics been compared between samples of Marburg and Ebola, and the virus from this new outbreak?
It appears to me that your posts on this thread are the most current and complete publicly available information on this topic in the world.
Thanks for an outstanding summary of the current status of this outbreak. And thanks for the insightful comments you added.
All of this, of course, also raises big questions about the people in charge of this situation. And if this is the best they can do early on, what will they be able to do if/when it rages through Luanda?
Let's hope and pray it is genetically unstable enough to burn itself out naturally, and soon.
Angola Launches Marburg Campaign as Toll Tops 200
Tue Apr 12, 2005 10:11 AM ET
By Zoe Eisenstein
Reuters
LUANDA (Reuters) - Angola launched a massive public information campaign on Tuesday in a bid to stamp out the killer Marburg virus as the toll from the worst ever outbreak topped 200.
Five TV and radio advertisements in both the official language Portuguese and the most widely spoken local languages were broadcast throughout the day on national media.
"The only way to control this epidemic is to stop the transmission. People need to adapt their behavior, put in practice preventative measures," UNICEF spokesman Celso Malavoloneke told Reuters.
He said 750 boy scouts and 450 health ministry volunteers were on standby to help a weekend distribution of information pamphlets including suggested ways to halt the spread of the disease. At least 203 people have died from the rare hemmorhagic fever out of a total of 221 known cases and health officials say they have yet to get the epidemic under control.
Aid workers told Reuters on Monday that terrified families suspicious of health workers in protective gear looking like space suits were keeping the sick at home, thereby fanning the spread of the disease through communities at the epicenter of the outbreak in Uige province, northeast of the capital Luanda.
UNICEF's Malavoloneke said rebuilding public trust in the health system -- left in tatters after the end of a civil war lasting nearly three decades -- was vital.
"This is a matter of trust. People become afraid of losing loved ones, they are afraid to let them go to hospital because they fear they won't see them again," he said.
There is no known cure for Marburg fever, meaning most treatment is purely palliative.
"People have also started losing trust in the quality of services offered by hospitals. Our colleagues working in the health sector also need to improve the quality of services," Malavoloneke said.
The first recorded outbreak of the disease was in the 1960s when scientific researchers working in the German town of Marburg contracted it from imported African monkeys.
The disease is spread through bodily fluids including sweat, blood and saliva, and symptoms include headaches, internal bleeding, nausea, vomiting and bloody diarrhea.
I had read this yesterday and realized that there must not be a lab anywhere in Africa that can confirm these deadly pathogens. The place where these things tend to start and everything has to be sent somewhere else to verify. The lost time is deadly in itself.
New variant seems the most likely. And, sadly, the mortality figures being cited are wrong. They are based on reported deaths divided by total reported cases, all of whom are apparently in the process of dying.
The sad fact is that AT MOST one person may have recovered. Since the details are mostly unknown about that case, the likelihood is that not a single person is known to have recovered so far. If that holds up, the mortality rate is 100%.
We don't really know much about this thing at all. It is not following the previous pattern of either Marburg or Ebola. We don't even know the incubatin period. Some reports have stated 3-4 days, and some have stated 20 days or so.
In the worst case, which would include a long period before symptoms become evident combined with high contagion prior to the onset of severe symptoms, the outbreak could reach an uncontrollable level in Luanda long before the reported numbers would seem alarming. Spread to other cities would be likely.
I should emphasize that this would be a worst case scenario, and we do NOT have evidence that this is so. And even if the worst case turns out to be true, this particular variant of Marburg could turn out to be genetically unstable enough to burn itself out naturally long before it runs its course through a given population.
In other words, it is too soon to say what to expect from this. But it is NOT too soon to say it could be extremely serious.
Angola's Marburg death toll rises to 210
LUANDA,
April 12 (AFP)
- A total of 210 people have died in Angola from the Marburg virus, the worst outbreak ever recorded of the Ebola-like bug, the Angolan health ministry and the World Health Organisation said Tuesday.
They said 361 people across the country were under observation for the virus, which can kill a healthy person in a week by diarrhoea and vomiting followed by severe internal bleeding, and is not treatable with any known drugs.
The Marburg virus, whose exact origin is unknown, spreads through contact with bodily fluids such as blood, excrement, vomit, saliva, sweat and tears, but can be contained with relatively simple health precautions, according to experts.
The health ministry and WHO said in a statement that the greatest number of deaths -- 190 -- was recorded in the northern Uige province, the epicenter of the epidemic that was first detected in October.
A total of 202 cases have been detected in Uige, it said.
The highest number of deaths after Uige was in the Kwanza Sul province with six fatalities and six cases, followed by five deaths and 11 cases in Luanda, five deaths and six cases in Zaire, two deaths and four cases in Mananje, and one death and one case each in the provinces of Cabinda and Kwanza Norte.
Meanwhile, health ministry spokesman Alberto Carlos told reporters that six other bodies had been found in a hospital morgue in Uige and that laboratory tests proved that they had succumbed to the virus.
He underlined that these deaths did not figure in the toll released Tuesday, without giving a reason.
Health authorities say the majority of the victims of the virus are children under five.
Until now the most serious outbreak of the disease was in the Democratic Republic of Congo, where 123 people died between 1998 and 2000.
mak-ach/rl
Copyright (c) 2005 Agence France-Presse
Received by NewsEdge Insight: 04/12/2005 14:05:01
ping
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