More than 200 people have died so far from an outbreak of the Hamburg virus in the city of Oiga in northern Angola. Already a year ago, suspicions of an epidemic were raised there, but the authorities ignored it
Sharon Lafrene and Denise Grady New York Times, Oiga, Angola
WHO workers inspect a home of a possible victim of the Hamburg virus in Oiga. Two doctors and 14 brothers and sisters also died.
For nearly four weeks, teams of health experts have been trying to organize a rescue operation in Oiga, in northern Angola - a city of crumbling buildings, where there is no running water and where the electricity supply is often interrupted. The level of sanitation in the place is poor and the telephone network is often paralyzed. They are trying to contain one of the worst outbreaks of a virus known as Marburg. But no one predicts quick success, given the daily rising death rate.
Marburg, a cousin of the Ebola virus, causes horrific epidemics in Africa, which recur periodically. This time it struck with greater force than ever and killed nine out of ten people who contracted it - so far 230 people, including 14 medical brothers and sisters and two doctors.
Marburg is spread through blood, vomit, semen and other bodily fluids. Even a cough can prove fatal, with a few drops of saliva splashing onto bystanders. Dead bodies are especially dangerous, infesting viruses. The virus may also enter a person's eyes, nose, or mouth, or into their bloodstream, through a cut or wound.
From the moment the virus nests in the body, it progresses at a frightening speed and invades white blood cells, which are essential for fighting the infection. On the third day after infection, less than 200 viruses can be counted in one drop of blood, on the eighth day there are already five million. "That's why dead bodies are time bombs," said Dr. Heinz Feldman, a virologist from Winnipeg who came here with expert teams sent by the "World Health Organization", the "Centers for Disease Control and Prevention" in Atlanta in the United States and the international aid organization "Doctors Without Borders".
The effort to curb the epidemic in this poor and isolated city where 50 thousand people live depends on the cooperation of residents, who will call health workers and bring suspicious cases to their attention. So far it has not been easy to convince them to do so. Victims who are taken to an isolated wing of the hospital are no longer seen, and cannot be paid their last respects in traditional funerals. Despite the efforts of dedicated doctors, such as Maria Bonino, an Italian doctor who ran the children's department at the hospital in Oiga - the virus spread, perhaps for months, under the cover of the poverty, ignorance and inaction of the authorities.
The rampant death in Uiga is now accompanied by something that, in the eyes of the residents, is almost equivalent to an invasion from space: health workers protected by masks, goggles, sealed zipped suits, rubber aprons and rubber boots, collect corpses in the suffocating heat. To wear all white - in a place where the color white symbolizes witchcraft.
Teams of epidemiologists and district health workers who arrived in the area are checking reports of potential new cases and locating people who were in contact with the dead or dying. At the local cemetery, the area allocated to victims of the virus is now filled with graves, but the 30-bed isolation ward for Marburg victims, which was set up at the local hospital earlier this month, rarely has more than one or two patients. "The population is hiding sick relatives," said Colonel Pascual Pollo, a military doctor sent by the government to help coordinate efforts here, "this worries us a lot."
Every morning, between nine and ten o'clock, you can see at the local headquarters of the "World Health Organization" in Oiga, medical teams get on jeeps and commercial cars and go out to the neighborhoods surrounding the city. Each team has a pair of doctors and some local residents. They are supposed to check "alarms" - reports of possible cases of illness - or deaths, and track down people who had close contact with those who died from Marburg. "It should be an easy day," said William Ferreira, a Colombian doctor in charge of all surveillance teams, on April 13, "no deaths, no alarms." But the lack of news could be bad news, he said, a sign that new cases are being hidden.
Pereira's first stop that week was at the home of a man whose wife, a nurse by profession, died from Marburg. He himself was not sick. Outside the house, in front of curious neighbors, he began to accuse and attack the health team. Where does the disease come from? Ask. Why didn't they just give him medicine or a vaccine? When are they going to sanctify his house? There is no vaccine, Ferreira told him, no cure - all we can do is find the sick and isolate them.
On their way to the next station, a message came over Ferreira's walkie-talkie: all crews were called back down. A commercial vehicle was attacked by an angry mob. The day before, stones were thrown at a surveillance team car. A week before, all tours were suspended for two days, due to stone throwing. Hesitantly, the health organization deleted three neighborhoods from the watch list.
Any person suspected of being exposed to the disease must be monitored for 21 days. Symptoms of the disease usually appear within five to ten days of infection. First appear a headache, high fever and pain - then, diarrhea and vomiting. The virus invades the spleen, liver and lymph nodes and then moves to other tissues, including the skin and sweat glands. The disease disrupts blood clotting and about half of the victims have hemorrhages. They may vomit blood, urinate blood, and they bleed from the eyes, gums, anus, or vagina. But the victims of the disease do not bleed to death, said Feldman, in fact they die of shock - the fluid leaking from their blood vessels causes the blood pressure to drop. There is no specific treatment, but it is likely that many more patients would survive if they received the type of treatment available in developed countries.
In the outbreak of the virus which is perhaps the only documented outbreak outside of Africa - in 1967, among laboratory workers in Germany and Yugoslavia - the death rate was only 23%. The source of the outbreak was monkeys brought from Uganda for medical experiments. The much higher death rate in Angola has resulted in an influx of international health experts to the region. In Oiga, "Doctors Without Borders" people sleep five in one room. The World Health Organization team expropriated the only hotel in the city and turned a wing of the district health department into a command headquarters. The team consists of 19 people, including epidemiologists, virologists, two anthropologists, a community relations specialist, a computer programmer, two logistics experts and a press spokesperson.
Feldman established a laboratory with advanced technology in the district hospital of Oiga, where tests to detect Marburg last four hours. Infection control experts are working feverishly to disinfect wings that were closed after the first suspected case was identified - and allow the 390 beds to be used instead. The hospital is now accepting patients who need emergency surgery. When the cleaning workers did not show up one Friday, the international experts took the brooms and mops and started scrubbing.
Armand Bjetulho created a computer program for the team to record every suspicious death and track hundreds of people who had been in contact with infected Angolans. The computer analysis allows doctors to map the geography of the epidemic and identify trends.
No one knows where the virus lurks between the outbreaks. Some scientists believe that bats are its most likely hosts because they can be infected with Marburg for long periods with no visible symptoms. In the current outbreak, the tests revealed only one strain of the virus, so it is likely that the epidemic began with the infection of one person. Discovering his identity may help locate where the virus is hidden.
Dr. Bonino began to suspect already last March that something horrific was happening in the children's department of the regional hospital. The ward, with 97 cribs and beds, was full to the brim with sick children. Bonino noticed in particular a child who suffered from vomiting, high fever and bleeding - a combination of symptoms known as "hemorrhagic fever", which can be caused by a variety of viruses, including Ebola and Marburg. He died a few days later.
Bonino worked for 15 years in Africa and was aware of the possibility of an epidemic. In Oiga, to which she moved in 2003, she won the loyalty of the staff in the children's department thanks to her professionalism and humanity. "She was very, very experienced," said Moko Enriquez Bang, the district's health commissioner. In July, the new director, Dr. Matondo Alexander, arrived at the hospital. He said Bononi told him about a case of high fever accompanied by bleeding, and that she pointed to another case in October. Following this, four blood and tissue samples were sent to the capital Luanda and then to the Centers for Disease Control. The tests were negative. So are the repeated tests.
Between November and January, Alexander said, he sent two more samples to Luanda taken from those who apparently died of hemorrhagic fever. He said he had not received any reply. Alexander believes that the initial negative results misled the government and caused it to ignore what was happening.
But since October the children's department was flooded with patients. More than 200 sick children filled the ward. Children sleep two in a bed. Mattresses were placed on the floor for others. Bonino's concern grew. "She sat in front of me and said we have too many strange deaths," said Dr. Enzo Pisani, who also works at the hospital on behalf of the Italian charity. After October the death rate increased from three to five children per week to three to five per day.
When the central government in Luanda did not respond to requests for more tests, Alexander announced on the radio in February that he suspected there was an outbreak of hemorrhagic fever in Ouagadougou. Following this, the Ministry of Health dispatched a team to Oiga in early March. The World Health Organization also rushed to send a team. New samples were flown to Atlanta. On March 21, nine of the 12 samples had positive results.
Less than a week later Bonino died of the Marburg virus. 14 sisters and brothers and a Vietnamese surgeon who worked at the hospital also died. The surgeon apparently became infected when he performed a post-mortem on the Marburg victim, Pisani said.
