Posted on 4/16/2005, 9:01:01 PM by palmer
UÍGE, Angola, April 16 - For nearly four weeks, teams of health experts have been trying to set up a rescue operation in this town of windowless, crumbling buildings with no running water, intermittent electricity, poor sanitation and a perennially jammed telephone network.
They are trying to contain the worst outbreak of one of the world's most frightening viruses, known as Marburg. But with the death toll rising every day, no one is predicting success soon.
A cousin of Ebola, the Marburg virus has erupted periodically in Africa in sudden, gruesome epidemics, only to disappear just as mysteriously. This time it has struck with a vengeance, killing 9 out of 10 people infected - a total of 230 people so far, including 14 nurses and 2 doctors who cared for the sick.
The virus is highly contagious, making any outbreak a cause for widespread fear and fascination in a world shrunk by international travel and trade. Marburg spreads through blood, vomit, semen or other bodily fluids. Even a cough can prove fatal if a few drops of spittle hit someone else. Corpses, teeming with the virus, are especially dangerous. A contaminated surface can be deadly - the virus can find its way into someone's eyes, nose or mouth, or enter the bloodstream through a cut.
Once inside the body, it moves with terrifying speed, invading white blood cells essential to fighting off infection. On Day 3 of the infection, there are fewer than 200 viruses in a drop of blood. By Day 8, there are five million.
"That's why dead bodies are kind of like bombs," said Dr. Heinz Feldmann, a virologist from Winnipeg who is here working with the teams of specialists dispatched by the World Health Organization, the United States Centers for Disease Control and Prevention, and the international aid group Doctors Without Borders.
Their efforts to curtail the outbreak turn on whether distrustful local people in this poor and isolated town of 50,000 people alert health workers to suspicious cases. So far, persuading them has not been easy. Victims who are taken to the isolation ward are never seen again; their bodies, rapidly buried for safety, cannot be honored in the traditional funerals so important in this country.
Despite the best efforts of some dedicated doctors - like Maria Bonino, an Italian doctor who had run a children's ward in the Uíge hospital - the virus has a long head start, spreading for what may have been months from a brew of poverty, ignorance and government inaction.
For the people of Uíge, rampant death is now joined by the near equivalent of a space invasion: health workers encased in masks, goggles, zip-up jump suits, rubberized aprons and rubber boots as they collect corpses in the stifling heat. The garb is all white, a symbol of witchcraft here.
Teams of epidemiologists and provincial health workers have fanned out, checking reports of potential new cases and tracking down people who had contact with the dead or dying. So far, most reports from the community deal with the dead, not the sick. If that continues, the teams could be reduced to a high-tech, specialized burial service, helping prevent the transmission of the virus from the dead, but not from the living.
At the cemetery on the edge of this town of pastel-colored, decaying buildings, a section created for Marburg victims is filling up with graves marked by simple wooden crosses bearing names written in black.
But the 30-bed isolation ward for Marburg victims that was set up at the hospital here two weeks ago rarely has more than a patient or two. "The population is hiding sick relatives," said Col. Pascoal Folo, a military doctor dispatched by the Angolan government to help coordinate the effort here. "This upsets us very much."
Every morning between 9 and 10 at the World Health Organization quarters on a busy street in Uíge, medical teams pile into jeeps and vans and head out into the neighborhoods - bairros, in Portuguese - that surround the town. The teams include a pair of doctors and several local people who have been hired to help the outsiders find their way. Except for knee-high rubber boots, which can be sprayed with bleach, they wear street clothes. Their job is to check out "alerts" - reports of possible cases - or deaths, and to look in on people who had close contact with someone who died of Marburg.
This shoe-leather epidemiology - finding every case, tracing every contact, going door to door, day after day - is the backbone of the efforts here.
"This should be an easy day," William Pereira, a Colombian doctor who is in charge of all the surveillance teams, said on Wednesday. "No deaths, no alerts." But no news might be bad news, he said, a sign that new cases were being hidden.
Dr. Pereira's first stop on Wednesday was at the home of man whose wife, a nurse, had died of Marburg. He was not ill. Standing outside his house, curious neighbors looking on, he began berating and accusing the health team.
Where did this disease come from? he demanded. Why didn't they just give him medicine, or a vaccine? When were they going to disinfect his house?
There is no vaccine, Dr. Pereira told him. No medicine. All we can do is find the sick and isolate them so they cannot infect anybody else.
Then it will be gone.
On the way to their next stop, a message crackled across Dr. Pereira's radio: all teams back to headquarters. A van had been attacked by an angry crowd armed with sticks. The day before, rocks were thrown at a surveillance vehicle. The week before, all trips had been suspended for two days because of rock-throwing.
Reluctantly, the health organization crossed three bairros off the list that surveillance teams could visit. Now, if anyone died or got sick there, health officials might not know - a breach of the defenses they were trying to build.
Each person who may have been exposed to the disease has to be followed for 21 days, and hospitalized if symptoms develop. Symptoms usually appear within 5 to 10 days of infection.
First come a headache, high fever, and aches and pains, followed by diarrhea and vomiting. The virus invades the spleen, liver and lymph nodes and then moves into other tissues all over the body, including skin and sweat glands.
The disease interferes with blood clotting, and about half the victims hemorrhage. They may vomit blood and pass it in their urine, and bleed from their eyes, gums, rectum or vagina.
It is a misconception that Marburg victims bleed to death, said Dr. Feldmann, the Winnipeg virologist. They actually die from shock as fluid leaks out of the blood vessels, causing blood pressure to drop. There is no specific treatment, but more patients would probably survive if they could get the kind of intensive care available in developed countries.
In what is probably the only recorded outbreak outside Africa, in 1967, among laboratory workers in Germany and Yugoslavia, the death rate was only 23 percent. That outbreak was traced to monkeys imported from Uganda for medical research.
The much higher death rate in Angola has brought international health care experts running. In Uíge, workers from Doctors Without Borders sleep five to a room. The World Health Organization's team has commandeered the only hotel and turned a wing of the provincial health department into a command center. The 19-person team includes epidemiologists, virologists, two anthropologists, a community outreach specialist, a computer programmer, two logistics experts and a press spokesman.
Dr. Feldmann has created a high-tech laboratory at the Uíge Provincial Hospital with a four-hour turnaround for Marburg tests. Infection control experts are working furiously to disinfect wards, closed after the first suspected case was identified here, so that the 390 beds can be used again. Now, the hospital takes on patients who need emergency operations. When the cleaners did not show up Friday, the international experts took up the mops themselves.
Adriano G. Duse flew into Uíge from Johannesburg, where he is head of infectious diseases at the University of Witwatersrand. "We went to a meeting from 7:30 to 9, and after that it was scrubbing and scrubbing and mopping and swishing and scrubbing," he said, showing up for lunch in damp, soiled T-shirt.
At a training session on Friday for cleaners and laundry workers, Dr. Michael Bell of the Centers for Disease Control and Prevention in Atlanta was asked by workers how they could protect themselves. Was it safe to carry a bundle of used sheets and blankets on her head, one young woman wanted to know. "No," Dr. Bell said. "We want you to be safe."
Armand Bejtullahu set up a computer program for the team to record each suspected death or new case and track hundreds of people who have had contact with infected Angolans. The computer analysis allows the doctors to map out geography of the epidemic and spot trends. Adults are gaining on children as primary victims.
That data may help them, eventually, trace the virus back to its source.
No one knows where the virus lurks between outbreaks. Some scientists say bats are its most likely host because they can be infected for long periods without showing symptoms. In this outbreak, tests have shown only one strain of virus, meaning the epidemic is likely to have started with the infection of one person. Finding out who that was may also help identify where the virus was hiding.
Dr. Bonino, from the charity Doctors With Africa, began suspecting that there was something dreadful in the children's ward of the sprawling regional hospital in March of last year, months before anyone else became alarmed. The ward of 97 cots was crammed with youngsters suffering every ailment that Angola's oppressive climate and primitive sanitation could muster. She noted that one child stood out, suffering from vomiting, fever and bleeding, symptoms she recognized as classic indicators of hemorrhagic fever, her colleagues say. The child died within days.
Dr. Bonino had worked for 15 years in Africa, including a spell in Uganda during an Ebola outbreak, and understood hemorrhagic fevers. She moved to Uíge in 2003, and won the loyalty of the children's ward nurses with her hard work, compassion and expertise in illnesses unique to Africa.
"She was very, very, very experienced, " said Moco Henriques Beng, the provincial health director.
In July, a new hospital director, Dr. Matondo Alexandre, was installed. He said Dr. Bonino quickly told him of the possible case of hemorrhagic fever. She pointed out another case in October, he said, and four blood and tissue samples were sent to the capital, Luanda, and then to the Centers for Disease Control and Prevention. The tests, generally considered reliable, turned up negative; recent retests came up negative again.
Between November and January, Dr. Alexandre said, he sent two more samples to Luanda, taken from people apparently killed by hemorrhagic fever. He said he got no response.
Dr. Alexandre said the initial negative test results might have blinded the government. This is, after all, a country where one in four children dies before the age of 5; the causes for a slew of deaths on the pediatric ward could be legion.
"I think the results maybe influenced people to think that there is something normal going on, and this was just one disease out of so many diseases we have going on," he said.
On the pediatric ward, though, the situation seemed anything but normal after October.
More than 200 patients filled the ward, according to Luiza Maria Costa Pedro, the chief pediatric nurse, and two other doctors who worked at the hospital. Children slept two to a bed. Mattresses were spread upon the floor for those who could not fit in the bunks.
Dr. Bonino was increasingly worried. "She sat across from me in that chair and said we are having too many strange deaths," said Dr. Enzo Pisani, who works at the hospital, also for the Italian charity.
Mrs. Costa Pedro said the children were admitted with vomiting, diarrhea and fever. Those symptoms are typical of malaria and many other tropical diseases. But after October, the death rate went up from three to five children a week to three to five a day, she said, and many died bleeding from the mouth or other orifices.
"We were very, very upset," she said. "We didn't have any way to help the patients, and we couldn't discover who brought here this sickness."
When national authorities failed to respond to requests for more tests, Dr. Alexandre took to the radio. In February, he announced that he suspected an outbreak of hemorrhagic fever in Uíge.
Now, he said, he has been cast as a scapegoat. Traditional leaders, he said, circulated rumors that he had used witchcraft to create the virus in hopes of winning a job promotion, a charge that can carry substantial weight in a region where deep superstitions blend seamlessly with modern beliefs. He was dismissed as hospital director.
His aunt was beaten by angry residents, he said. Last week, national authorities sent a helicopter to carry him and his family to Luanda.
The radio broadcast did, however, provoke the national Health Ministry to send a team to Uíge in early March. The World Health Organization quickly followed.
Dr. Bonino gave the arriving teams a list of 39 suspected cases of hemorrhagic fever. The investigators found two dozen more. New samples were flown to Atlanta.
On March 21, 9 of 12 came back positive.
Less than a week later, Dr. Bonino died of Marburg virus. Fourteen nurses and a Vietnamese surgeon who worked at the hospital have also died. The surgeon was probably infected while performing an autopsy on a Marburg victim, Dr. Pisani said.
On the whiteboard mounted on a wall in the pediatric ward, Dr. Bonino's cellphone number is still scrawled.
"I feel a tremendous sense of failure because she died," Dr. Pisani said. "We should have sent samples earlier."
Dr. Alexandre said many deaths might have been prevented had the authorities acted more rapidly.
"The emergency public health service should have begun investigating right in October, or at least in November," he said. "What happened was we lost a lot of time."
Even now, health experts say, Angola's government has failed to mount a full-scale response to the epidemic, leaving the bulk of the burden to the outside groups that have come to Uíge. The government has sent only four or five medical specialists to the province, and 30 to 35 soldiers, who are mainly helping to collect and bury bodies. Unless the government does a better job of explaining the epidemic to its people, the health workers fear, they face a long, uphill battle.
"What we are doing now is having almost no impact," said Monica de Castellarnau, who headed the Doctors Without Borders team here until Friday. "We cannot replace the government."
There is a special place in heaven for the doctors and nurses who died trying to save the Marburg victims. These are saints.
Just as there is a special place in Hell for those who ignored the call to stop this virus.
I agree, from the sound of it, the health care workers and family care givers are the ones most at risk, especially for those hopeless patients with 5 million viruses in each drop of their blood. Hard to imagine.
A ping about a good, in-depth article to those I remember from the Marburg threads.
Thanks for posting this, palmer.
One side note--I think we're supposed to excerpt NY Times articles. You may want to check it out & see if the moderators can help you.
(FR was sued for copyright infringement by the NY Times and LA Times, I believe).
And what is sad is that the families are afraid to send their sick loved ones to the hospital now.
So they're isolating themselves with people with the virus, and probably entire families will soon be wiped out.
I'm pretty sure the copyright case was with the Washington Post and the LA Times, not the NY Times. But I'll ask about it.
I saw the first mainstream newsclip on Fox News last night showing a team of white-clad bio hazard covered workers in Angola loading dead Marburg victims on a truck and hauling them away for burial. The news reporter mentioned how the locals are hiding their sick to avoid giving them up to the hospital where they'll never be seen again. Very sad and dangerous at the same time. News reporters are there now so hopefully we'll learn more about this nightmare soon.
Could you estimate how many bodies they were loading?
It was just a few bagged bodies I could see that they were sliding into the back of an open bed truck. Couldn't see how many were in the truck. The last of the clip showed a truck driving away with health workers standing in the back dressed in white from head to toe. Very spooky. The report came during a Fox news update. If they ever release another body count it may spark more news coverage. That may be part of what they're worried about.
The point was made by a commentary on recombinomics.com that white is the color traditionally associated with witchcraft.
Truthfully, and once again, I just do not expect to see any where near accurate numbers on this outbreak, nor any confirmation when it starts winding down (if that happens) or warning when it grows exponentially (if that happens). The numbers vary from source to source, from writer to writer, among news organizations with some clinging to old numbers, etc.
And in addition, I doubt that there are a cumulative total of 230 dead, with a total dead and alive case number of 250, meaning that there are only 20 now alive with the disease. Does anyone here believe that figure?
It may be the number of living victims who have been found and are being treated by WHO, or Doctors Without Borders, or some such, but that cannot be accurate for the number of total non-deceased cases of the disease.
In order to follow the initial curve, which was looking very accurate, there would HAVE to be over 100 cases right now of people with the disease, whether they are being treated or not by health authorities, unless the outbreak is levelling off.
Does anyone here think it's likely to level off, with the burial practices, and the habit of people lying to the medical authorities?
Does anyone think that WHO, which has been driven off by locals, has any real idea how many cases there are? Does anyone think that WHO will accurately report the actual number of Marburg deaths they in fact know about, without having the magic piece of paper from the CDC in Atlanta telling them it was in fact Marburg?
And those results, from the CDC, take two weeks. We're two weeks behind the curve, at the very least. And we know from other, earlier articles that the CDC has reported some false negatives.
I'm not ACTUALLY worried until there are proven cases outside Africa. That still may not happen. At this point, I am concerned.
I am sure your skepticism is justified. The numbers are probably those cases known to the WHO, or whatever reporting agency, and are probably a bit behind at that. It just seems logical to assume that the large majority of cases are not known to the agencies.
I don't think they are malfeasant, but I think they just don't have a handle on what is actually happening, given all the difficulties just finding bodies.
If I were a citizen and starting to get sick, or a relative was, I sure as heck would hide from those witches in the white suits who come and take corpses and relatives away, never to be seen again.
Agreed. After all the turmoil in Angola, anyone who says, "I'm from the government and I'm here to help you" is likely to be stoned, or attacked with sticks, etc.
Conversely, if I were in one of those dreadful spacesuits, which are so hot that you can only stay in them a few hours, and which take a long time to put on, disinfect, and take off properly, I would be leary of getting a hole it it from a stick or stone...
Still, I want numbers...good luck to me, I guess.
Bttt
It appears that WHO's Marburg plan is to wish it away, drive it back to the bush people and hope the news media continue to ignore it.
I think you have asked all of the right questions, and indeed, you are correct that the data are probably no longer believable.
At this point we have speculation, but it is worthwhile to consider:
1. Since the growth curve fit so well to data from such a long period, we would expect it to continue until something changes about the behaviour of people in Uigie. Therefore, has anything changed?
2. Could it be that finally everyone got scared and just decided to stay at home, for instance? That would mean that the disease would burn itself out and the epidemic would end.
3. By contrast, could it be that everyone just stopped going to the hospital so that they no longer have accurate data?
What I find a bit unsettling is the speed with which the growth seemed to stop. It was precipitious. One moment, we are growing exponentially, the next, all growth as stopped. The original 237 cases seem to die out and we have a grand total of 13 new ones. If true, this is unbelievably good news--they have stopped the epidemic cold and we can stop worrying about it. Perhaps I am somewhat the pessimist; I cannot quite believe that it was stopped that fast.
We'll see.
late to the party- ping
I can think of only two possibilities. Either the virus mutated into something far less deadly or harmless, or the government and WHO have lost the ability to track new patients.
This story certainly makes me think it is the latter.
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