Some day our love of open borders will come with a very heavy price.
Stalking a Deadly Virus, Battling a Town’s Fears
By SHARON LaFRANIERE
and DENISE GRADY
ÍGE, 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.”
Posted by James Bowery on April 16, 2005, 10:31 PM | #
A VDARE blog entry describing the need for true cost accounting so that those profiting from open borders pay for the public risks they impose:
http://vdare.com/blog/041105_blog.htm#b2
A link to the Wikipedia article on the current outbreak which includes weekly statistics:
http://en.wikipedia.org/wiki/Marburg_virus#2004-2005_outbreak_in_Angola
A post to FreeRepublic.com claiming the best fit to the current data is exponential—meaning it is following a simple pattern of epidemic transmission to a very high degree of confidence:
To: Judith Anne
I think we’ve seen the last of the accurate numbers. But I think your projections are correct.
I reluctantly agree. Normally, I believe that the final answer is always the data. However, the countervailing arguments in this case are:
1. The data fit to the growth curve was excellent. Data were taken over 3.5 months, with several different measuremnts. The Pearsons correlation coefficient was .998. I ran the data in TableCurve, which tests against several thousand functional forms. The exponential was the best fit. Also, the numbers are sufficiently large that statistical fluctuation is small; it is unlikely that this good a fit is a statistical fluctuation. The curve seems robust.
2. An exponential curve signifies a simple mechanism for contagion and spread. The close fit to the data suggests that we have an accurate model (if it were a complicated function I might assume that there were many competing processes and we would really not be able to predict). Simple process, simple function.
3. None of the posts from WHO and others suggests they have done anything for containment. Indeed, the hospital isolation ward is empty.
4. Reading between the lines, they are “reclassifying” data. This suggests there is something they do not want released. It certainly suggests they don’t like the numbers they are getting.
I don’t want to get alarmist, but the only real test of a model is its predictive capability. Therefore, I will continue to follow the growth curve and compare to whatever numbers are released.
18 posted on 04/15/2005 6:17:22 PM PDT by 2ndreconmarine