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Deadly Ebola-like virus spreads to Angolan capital
2 hours, 47 minutes ago Health - AFP
LUANDA (AFP) - The Marburg virus, an Ebola (news - web sites)-like virus that has killed 98 people in northern Angola, has now spread to the capital Luanda, killing two people there, officials said.
A 15-year-old boy and an Italian paediatrician, Maria Bonino, who had both been in the northern Uige province to which the virus had previously been confined, died Thursday from the virus in Luanda, local health officials said.
At least three other people have been diagnosed with the virus in the capital, they said.
The Marburg disease, a severe form of hemorrhagic fever in the same family as Ebola, was first identified in 1967, affecting laboratory workers in Marburg, Germany and also in Frankfurt and Belgrade who had come into contact with infected monkeys from Uganda.
Bonino worked for the Italian medical aid group Medici con Africa Cuamm and had 11 years experience as a volunteer in Africa with the last two years as paediatrician in the provincial hospital of Uige.
Angolan health officials are battling to contain the outbreak detected in October in Uige that has claimed the lives of scores of children.
"Two nurses died Tuesday of the Marburg illness at the Uige provincial hospital," said Filomena Wilson, the spokeswoman of a commission tasked with monitoring the outbreak, late Wednesday.
A total of five nurses have died over the past weeks from the virus that is transmitted through contact with bodily fluids of infected people, she said.
The largest outbreak on record of Marburg virus occurred from late 1998 to 2000 in the Democratic Republic of Congo (news - web sites), killing 123 people.
The World Health Organisation said that 75 percent of the victims of the disease had been children under the age of five.
Angolan health officials assisted by WHO experts and teams from Medecins Sans Frontieres (Doctors without Borders) and the US Centers for Disease Control were in Uige to try to shore up measures to stamp out the outbreak.
"The situation is bad, very bad," said health ministry spokesman Carlos Alberto reached by AFP by phone. "There is no isolation room. We are setting it up."
Angolan health officials said this week there was no need to quarantine the region bordering the Democratic Republic of Congo, but tests were being conducted on the body of a man in Luanda who had exhibited the same symptoms.
Victims of the Marburg virus can suffer from a severe watery diarrhoea, abdominal pain, nausea and vomiting early on in the illness followed by severe chest and lung pains, sore throat and cough, according to the WHO.
Many cases result in severe bleeding, beginning from the fifth day and affecting the gastrointestinal tract and the lungs, accompanied by a rash, sometimes involving the entire body.
-Marburg Hemorrhagic Fever
http://www.cdc.gov/ncidod/dvrd/spb/mnpages/dispages/marburg.htm
What is Marburg hemorrhagic fever?
Marburg hemorrhagic fever is a rare, severe type of hemorrhagic fever which affects both humans and non-human primates. Caused by a genetically unique zoonotic (that is, animal-borne) RNA virus of the filovirus family, its recognition led to the creation of this virus family. The four species of Ebola virus are the only other known members of the filovirus family. Marburg virus was first recognized in 1967, when outbreaks of hemorrhagic fever occurred simultaneously in laboratories in Marburg and Frankfurt, Germany and in Belgrade, Yugoslavia (now Serbia). A total of 37 people became ill; they included laboratory workers as well as several medical personnel and family members who had cared for them. The first people infected had been exposed to African green monkeys or their tissues. In Marburg, the monkeys had been imported for research and to prepare polio vaccine.
Where do cases of Marburg hemorrhagic fever occur?
Recorded cases of the disease are rare, and have appeared in only a few locations. While the 1967 outbreak occurred in Europe, the disease agent had arrived with imported monkeys from Uganda. No other case was recorded until 1975, when a traveler most likely exposed in Zimbabwe became ill in Johannesburg, South Africa and passed the virus to his traveling companion and a nurse. 1980 saw two other cases, one in Western Kenya not far from the Ugandan source of the monkeys implicated in the 1967 outbreak. This patients attending physician in Nairobi became the second case. Another human Marburg infection was recognized in 1987 when a young man who had traveled extensively in Kenya, including western Kenya, became ill and later died. In 1998, an outbreak occurred in Durba, Democratic Republic of the Congo. Cases were linked to individuals working in a gold mine. After the outbreak subsided, there were still some sporadic cases that occurred in the region.
Where is Marburg virus found?
Marburg virus is indigenous to Africa. While the geographic area to which it is native is unknown, this area appears to include at least parts of Uganda and Western Kenya, and perhaps Zimbabwe. As with Ebola virus, the actual animal host for Marburg virus also remains a mystery. Both of the men infected in 1980 in western Kenya had traveled extensively, including making a visit to a cave, in that region. The cave was investigated by placing sentinels animals inside to see if they would become infected, and by taking samples from numerous animals and arthropods trapped during the investigation. The investigation yielded no virus. The sentinel animals remained healthy and no virus isolations from the samples obtained have been reported.
How do humans get Marburg hemorrhagic fever?
Just how the animal host first transmits Marburg virus to humans is unknown. However, as with some other viruses which cause viral hemorrhagic fever, humans who become ill with Marburg hemorrhagic fever may spread the virus to other people. This may happen in several ways. Persons who have handled infected monkeys and have come in direct contact with their fluids or cell cultures, have become infected. Spread of the virus between humans has occurred in a setting of close contact, often in a hospital. Droplets of body fluids, or direct contact with persons, equipment, or other objects contaminated with infectious blood or tissues are all highly suspect as sources of disease.
What are the symptoms of the disease?
After an incubation period of 5-10 days, the onset of the disease is sudden and is marked by fever, chills, headache, and myalgia. Around the fifth day after the onset of symptoms, a maculopapular rash, most prominent on the trunk (chest, back, stomach), may occur. Nausea, vomiting, chest pain, a sore throat, abdominal pain, and diarrhea then may appear. Symptoms become increasingly severe and may include jaundice, inflammation of the pancreas, severe weight loss, delirium, shock, liver failure, massive hemorrhaging, and multi-organ dysfunction. Because many of the signs and symptoms of Marburg hemorrhagic fever are similar to those of other infectious diseases, such as malaria or typhoid fever, diagnosis of the disease can be difficult, especially if only a single case is involved. Antigen-capture enzyme-linked immunosorbent assay (ELISA) testing, IgM-capture ELISA, polymerase chain reaction (PCR), and virus isolation can be used to confirm a case of Marburg hemorrhagic fever within a few days of the onset of symptoms. The IgG-capture ELISA is appropriate for testing persons later in the course of disease or after recovery. The disease is readily diagnosed by immunohistochemistry, virus isolation, or PCR of blood or tissue specimens from deceased patients.
Are there complications after recovery?
Recovery from Marburg hemorrhagic fever may be prolonged and accompanied by orchititis, recurrent hepatitis, transverse myelitis or uvetis. Other possible complications include inflammation of the testis, spinal cord, eye, parotid gland, or by prolonged hepatitis.
Is the disease ever fatal?
Yes. The case-fatality rate for Marburg hemorrhagic fever is between 23-25%.
How is the disease treated?
A specific treatment for this disease is unknown. However, supportive hospital therapy should be utilized. This includes balancing the patients fluids and electrolytes, maintaining their oxygen status and blood pressure, replacing lost blood and clotting factors and treating them for any complicating infections. Sometimes treatment also has used transfusion of fresh-frozen plasma and other preparations to replace the blood proteins important in clotting. One controversial treatment is the use of heparin (which blocks clotting) to prevent the consumption of clotting factors. Some researchers believe the consumption of clotting factors is part of the disease process.
Who is at risk for the illness?
People who have close contact with a human or non-human primate infected with the virus are at risk. Such persons include laboratory or quarantine facility workers who handle non-human primates that have been associated with the disease. In addition, hospital staff and family members who care for patients with the disease are at risk if they do not use proper barrier nursing techniques.
How is Marburg hemorrhagic fever prevented?
Due to our limited knowledge of the disease, preventive measures against transmission from the original animal host have not yet been established. Measures for prevention of secondary transmission are similar to those used for other hemorrhagic fevers. If a patient is either suspected or confirmed to have Marburg hemorrhagic fever, barrier nursing techniques should be used to prevent direct physical contact with the patient. These precautions include wearing of protective gowns, gloves, and masks; placing the infected individual in strict isolation; and sterilization or proper disposal of needles, equipment, and patient excretions. In conjunction with the World Health Organization, CDC has developed practical, hospital-based guidelines, titled Infection Control for Viral Hemorrhagic Fevers In the African Health Care Setting. The manual can help health-care facilities recognize cases and prevent further hospital-based disease transmission using locally available materials and few financial resources.
What needs to be done to address the threat of Marburg hemorrhagic fever?
Marburg hemorrhagic fever is a very rare human disease. However, when it does occur, it has the potential to spread to other people, especially health care staff and family members who care for the patient. Therefore, increasing awareness among health-care providers of clinical symptoms in patients that suggest Marburg hemorrhagic fever is critical. Better awareness can help lead to taking precautions against the spread of virus infection to family members or health-care providers. Improving the use of diagnostic tools is another priority. With modern means of transportation that give access even to remote areas, it is possible to obtain rapid testing of samples in disease control centers equipped with Biosafety Level 4 laboratories in order to confirm or rule out Marburg virus infection. A fuller understanding of Marburg hemorrhagic fever will not be possible until the ecology and identity of the virus reservoir are established. In addition, the impact of the disease will remain unknown until the actual incidence of the disease and its endemic areas are determined.
Canada helps Angola with fatal virusEbola-like fever has killed more than 100 people since October By ANDRÉ PICARD
Monday, March 28, 2005 Updated at 1:16 AM EST
From Monday's Globe and Mail
Canada has dispatched one of the world's foremost experts on hemorrhagic fevers to Angola to help tackle the ever-worsening outbreak of Marburg virus in the impoverished African country.
Heinz Feldmann, head of the special pathogens program at the National Microbiology Laboratory in Winnipeg, is slated to arrive today along with an international team of "disease firefighters..."
Kenya Issues Alert over Deadly Marburg Fever
Xinhua News Agency
03/29/05 8:55 AM PT
The Marburg virus, which first broke out in Angola's Uige province last October, has now spread to the capital, Luanda. The outbreak is now approaching the most serious recorded when 123 people died in the Democratic Republic of the Congo between 1998 and 2000.
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The Kenyan government today issued an alert over the possible outbreak of Ebola-like Marburg virus which has so far killed over 100 people in northern Angola.
Kenya's Director of Medical Services James Nyikal told a news conference in Nairobi that the east African nation will improve infection control in hospitals and intensify efforts to detect cases, as well as improve public understanding of the disease and how it is transmitted.
"The Ministry of Health has issued an alert to all health facilities about the Marburg outbreak and directed that all health workers strictly adhere to the standard guidelines for infection prevention and control for all infectious condition including virus hemorrhagic fevers in health care settings," Nyikal told reporters.
Spreading Quickly
"We have intensified disease surveillance in all health facilities. We have also set up passenger screening system at the airport for passengers coming from Angola," he said.
The virus, which first broke out in Angola's Uige province last October, has now spread to the capital, Luanda.
The outbreak is now approaching the most serious recorded when 123 people died in the Democratic Republic of the Congo between 1998 and 2000.
Nyikal said the outbreak of Marburg virus disease has no vaccine or curative treatment and can be rapidly fatal.
Nyikal said previous outbreaks have indicated that the risk of infection is increased by close contact with body fluids of infected people, as may occur during treatment or burial practices.
"Marburg virus disease is similar to Ebola virus disease. The disease occurs very rarely and appears to be geographically confined to a small number of countries in the southern part of the African continent," Nyikal said.
"When cases do occur, the disease has epidemic potential, as it can spread from person to person, most often during the care of patients," he added.
-Marburg Case Fatality Rate of 93% in Angola Exceeds Ebola Virus
Recombinomics Commentary
March 27, 2005
http://www.recombinomics.com/News/03270501/Marburg_Angola_CFR.html
Marburg is similar to the deadly Ebola virus. Dr. Michael Bell a Marburg specialist at the CDC says that Marburg is less deadly than Ebola, but spread in the same way, through bodily fluids. About 25 % of those infected with Marburg die, usually from shock or liver failure.
The larger outbreaks of Marburg Virus (MBGV) and Ebola Virus (EBOV) have similar case fatality rates. Like influenza (type of Orthomyxoviridae), they are single stranded negative sense RNA viruses. MBGV and EBOV are the two types of Filoviridae.
There have been several large outbreaks involving the two viruses, and most of the larger outbreaks have been characterized by a high case fatality rate. In 1976 there were two large EBOV outbreaks. In southern Sudan 117 out of 284 patients died, giving a case fatality rate of 42%. In adjacent Zaire 280 out of 318 patients died, case fatality rate of 88%.
The largest MBGV outbreak was between 1998 and 2000 in the Democratic Republic of the Congo where 123 out of 149 patients died, case fatality rate of 83%.
For the current outbreak, a retrospective analysis by the WHO, after the causative agent was identified, indicated 95 out of 102 patients died, case fatality rate of 93%. Recently updated figures of 115 out of 123 deaths, also generates a case fatality rate of 93%, which is the highest rate recorded for larger EBOV and MBGV outbreaks.
-Marburg Outbreak Is Deadliest on Record
Stefan Lovgren for National Geographic News
April 5, 2005
http://news.nationalgeographic.com/news/2005/04/0405_050405_marburgangola.html
An outbreak of Marburg, an Ebola-like virus, had killed at least 150 people in Angola as of yesterday, making it the deadliest outbreak of the rare Marburg disease ever recorded.
Scientists are puzzled by the epidemic's remarkably high fatality rate. So far, the Angolan Ministry of Health has reported 163 cases of the hemorrhagic fever, putting the fatality rate around 90 percent. In previous outbreaks, the disease has had a fatality rate as low as 25 percent.
This time, at least 75 percent of the victims have been children under the age of five.
"This is something we haven't seen in previous Marburg outbreaks," said David Daigle, a spokesperson for the infectious disease program at the U.S. Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia.
There is no known cure for the virus, which spreads on contact with body fluids such as blood, urine, excrement, vomit, and saliva. Symptoms include diarrhea, stomach pains, nausea, and vomiting, which give way to bleeding.
Efforts at containing the Angolan epidemic have been complicated by the country's poor health care system. Officials worry that the epidemic will spread from its epicenter in the remote, northern Uige province to more densely populated areas.
So far, two deaths have been confirmed in Luanda, the Angolan capital, according to Dick Thompson, the spokesperson for the World Health Organization (WHO) in Geneva, Switzerland.
Lethality
The Marburg virus was named after the German town where it was first identified in 1967, when monkeys imported from Uganda infected laboratory workers.
Before the current epidemic in Angola, the worst Marburg outbreak occurred between 1998 and 2000 in the neighboring Democratic Republic of Congo, where it killed 123 people. That was also the last known outbreak until the latest flare-up.
Marburg is a relative of Ebola (both viruses are in the Filovirus family), and Marburg is believed to primarily inhabit countries in East and Central Africa. The current outbreak marks the first time the virus has struck Angola, which is in southwestern Africa.
There are at least four different strains of Ebola with different degrees of lethality, ranging from 50 to 90 percent. Although no separate strains of Marburg have been identified, experts speculate that a particularly virulent strain of the virus could be behind the Angolan outbreak.
"Indeed there could be different pathotypes [degrees of virulence] of the Marburg virus," said Fred Murphy, a virologist at the University of California in Davis.
But, he added, "when you see the pathology of human infections caused by Ebola or Marburg, the question becomes, How does anyone survive? The infection is devastating, rapid course, with extreme damage to key tissues."
But some scientists suggest that the lethality of the virus may be due to the overreaction of the innate human immune systemour first line of defenserather than the virus itself.
"Any virus worth its salt causes as little damage as possible to its host," said David Sanders, a biologist and Ebola expert at Purdue University in West Lafayette, Indiana. "We run around with viruses all the time. [These are] adapted to us and in equilibrium with our immune system, which doesn't get too aggressive about trying to eliminate them."
Sanders suggests that when a new virus, such as Marburg, enters humans, it may provoke an overreaction of our innate immune system, which in turn causes harm to the body.
"Humans are not a natural host of this virus, so [the virus] wouldn't have evolved to provoke this response," he said. "Instead it may be that the immune system responds inappropriately."
The theory does not explain why most of the victims in the Angolan outbreak have been children. While the innate immune system isas the name impliespresent from an early age, the adaptive immune system develops slowly.
"I would hypothesize that an inappropriate response is responsible for the pathology, while an appropriate response can allow one to survive," Sanders said. "Stopping viral multiplication can reduce the triggering of the harmful reaction."
Containment
There is also the possibility of a difference in the susceptibility of individuals due to general health status and nutrition, scientists say.
Angola is one of the poorest countries in the world. Its infrastructure was wrecked by a two-decade civil war that ended in 2002. Sanitation facilities are inadequate or non-existent, and hospitals are understaffed and poorly equipped.
The prospect of the virus gaining a foothold in Luanda, almost four million people live in the Angolan capital, is ominous.
"The first thing that comes to mind is the international airport," said Daigle, the CDC spokesman. "We saw with SARS how fast it was able to spread to Canada and other countries once people started getting on planes."
Containing an outbreak is more difficult in a densely populated area where people are crowded together. The virus has the potential to rapidly spread to other people, especially health-care staff and family members who care for patients.
At Americo Boa Vida, Angola's largest hospital on the outskirts of Luanda, a special isolation ward has been created to treat incoming cases from around the country. Volunteer workers have been outfitted with special suits to work as cleaners and washers.
"The practices needed to contain the virus in the hospital setting are rather simple and can be quickly introduced by international teams," Murphy, the UC Davis virologist, said.
A team of CDC scientists will arrive in Angola this week to assist WHO officials already there with outbreak investigation, infection control, and laboratory diagnosis.
"Our guys are very anxious to get on the ground and start doing some testing and contact-tracing to find out if this is a case of an unusually high fatality rate, or if we're just not able to track all those who are sick," Daigle said.
Natural Reservoir
The outbreak also presents a valuable opportunity for scientists to learn more about the virus. Scientists don't know the environmental reservoir for either Marburg or Ebola. (A reservoir is where a virus hides between outbreaks.) But most experts believe the two viruses share the same host.
"We got some evidence, but not conclusive, that bats may have been the source of the Marburg outbreak in the mining village of Durba in the Congo," said Bob Swanepoel, who heads the Special Pathogens Unit at the National Institute for Communicable Diseases in Sandringham, South Africa.
"Genetic evidence of the virus was found in cave-dwelling bats in the mine where primary human cases arose, but we were not able to isolate live viruses from bats, and the outbreak stopped when the mine flooded," he said.
-Marburg Airborne Transmission in Angola?
Recombinomics Commentary
April 10, 2005
http://www.recombinomics.com/News/04100501/Marburg_Airborne_213.html
Medical workers warn visitors not to shake hands with anyone and not to stand directly in front of residents when talking to them, for fear that a cough could release an infectious spray of spittle.
Silo Margarita is one of the few nurses still working at the 500-bed regional hospital here, a sprawling collection of well-kept, one-story concrete buildings that appeared almost deserted on Saturday afternoon. Wearing a surgical mask and plastic wrapped on her boots, she continued to care for 12 patients despite the fact, she said, that as many as 15 of the hospital's nurses and two doctors have died from the Marburg virus. Two nurses died only last Thursday, she said.
The deteriorating situation in Uige is raising the obvious question. Is Marburg transmitting through the air in Angola? Although there have always been warnings about transmission via contact with body fluids, the concern about coughing raises questions about ease of airborne transmission.
Initially most of the Marburg cases were children under the age of one, suggesting transmission via contaminated needles during childhood vaccinations. However, about 1 month ago the first health care worker died, and as noted above, that number has grown to 17. Although protective gear was in short supply initially, the deaths of health care workers are still being recorded.
The total number of Marburg cases alive is relative small. When the the WHO first announced the sequence results on March 23, there were only 7 Marburg patients alive. 95 out of 102 had died. The number diagnosed has risen to 213 and the number still alive has grown to 30, but the increase in patients alive simply reflects the fact that newly diagnosed patients are being tallied quicker than older existing cases are dying. As noted above, there are only 12 patients in the main hospital at the epicenter of the outbreak.
The ability of such a small number of patients to infect so many health care workers, especially after infection control efforts have been increased, raises the possibility that airborne transmission is fairly efficient. The current outbreak in Angola has a case fatality rate at or near 100%, high than any prior large outbreak of Marburg or Ebola. It has now begun transmitting in Luanda, and will easily eclipse the old record of 280 deaths set for Ebola in 1967.
Marburg has now been reported in 7 provinces in Angola, and all of these cases outside of Uige have also happened in the past several weeks. The widespread transmission, coupled with the near 100% fatality rate, suggests the Marburg virus is a recombinant, and the new virus may have increased its ability to transmit and kill.
