By Denise
Grady
The New York Times
Tuesday 26 April 2005
Uíge, Angola - Traditional healers
here say their grandmothers knew of a bleeding disease similar
to the
current epidemic of hemorrhagic fever that has killed 244 of
the 266
people who have contracted it. The grandmothers even had a
treatment
for the sickness, the healers told Dr. Boris I. Pavlin of the
Centers
for Disease Control and Prevention. But the remedy has been
lost. The
old disease was called kifumbe, the word in the Kikongo
language for
murder.
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Killer's Progress: Marburg viruses, above, are
in the family that includes Ebola. They kill
the white
blood cells essential to fighting off
infections.
(Photo: The NYT) |
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But
kifumbe did not seem to be contagious.
And so, Dr. Pavlin said, though he did not doubt it was real,
it was
probably not the same as the disease in Uíge today. The
current
disease, caused by the Marburg virus, is contagious. Like the
Ebola
virus, to which it is closely related, it is spread by bodily
fluids
like blood, vomit and saliva.
No one can say for sure what kifumbe
(pronounced key-FOOM-bay) was, and in some ways the Marburg
virus is
almost as mysterious. More than a month has passed since it
was identified
as the cause of the deadly outbreak here - the largest Marburg
epidemic
on record - but some of the most basic questions about the
epidemic
have yet to be answered. How and when did this rare virus get
here?
Why have so many victims been children? And how could so many
have become
infected before the disease was recognized?
The high death rate, over 90
percent,
is also puzzling, but it is too soon to tell whether the rate
is really
that high. In past outbreaks, mortality has been lower. In
Uíge,
milder cases may be going unrecognized.
"It is easier to count the dead
people,"
said Dr. Pierre Rollin, a physician in the special pathogens
branch
of the C.D.C. "The numbers in the beginning don't mean
anything."
Viral hemorrhagic fevers, a handful
of diseases found only in Africa and South America, are among
the most
frightening of all illnesses. Ebola and Marburg, limited to
Africa,
are the only members of a family known as filoviruses, and
they are
as bad as these diseases get. The viruses sabotage the body's
defenses
by invading and eventually killing the white blood cells that
are essential
to fighting off infections.
Three to 9 days after exposure, the
illness comes on suddenly, with a fever and a pounding
headache, and
swiftly progresses to vomiting and diarrhea. The virus also
attacks
vital organs like the liver, spleen and pancreas, and
ultimately spreads
just about everywhere in the body. About half the patients
bleed under
the skin and from the mouth, nose, intestines and other
openings.
There is no vaccine or treatment,
and
victims can be dead in a week, usually from shock and
plummeting blood
pressure caused by fluid leaking out of blood vessels. Death
rates have
been 80 percent to 90 percent for Ebola, and 30 percent to 90
percent
for Marburg.
People can catch the virus from
animals
- primates and possibly bats - and the disease can spread
easily from
person to person in those who come into contact with bodily
fluids from
patients. But little is known about the cause of human
outbreaks or
the animal reservoirs where the virus must live between them.
The international experts who have
rushed to Angola have been so busy trying to contain the
epidemic that
they have had no time to trace its origins. Ultimately,
though, finding
the source of the disease may help health authorities to
prevent future
outbreaks.
"We can do that once the situation
here is better under control," said Dr. Thomas Grein of the
World Health
Organization. One possibility is that the disease came from
monkeys,
which are hunted and eaten in Africa. The animals can harbor
the Marburg
virus, though they get sick and die from it just as people do.
People
who eat cooked monkey meat are not necessarily at risk, since
heat destroys
the virus. But those who hunt and butcher the animals and
handle the
raw meat run a high risk of infection if the animal was sick.
What remains puzzling, though, is
why
so many children have been infected. Early in the epidemic,
scores of
babies and children younger than 5 died, and they accounted
for a majority
of the cases. Now, children make up 30 to 40 percent of the
cases, still
an unusually high percentage.
The Marburg virus does not spread
through
the air, and people do not start transmitting it until they
are sick;
even then, direct contact with bodily fluids is required.
Some researchers suspect that what
spread the disease so quickly was contaminated medical
equipment, like
needles, syringes or intravenous lines. If that occurred,
where it occurred
is anyone's guess.
Somehow, somewhere, "I think they
were
getting IV Marburg," said Dr. Pierre Formenty, a virologist
with the
W.H.O.
Some health officials have blamed
the
provincial hospital. But Dr. Enzo Pisani, who has worked in
Angola for
seven years for an Italian charity, Doctors With Africa,
insisted that
only disposable needles were used there and discarded, never
reused.
Dr. Pisani said the many small for-profit clinics that dot
Uíge,
run by people with little or no medical training, were more
likely to
blame.
He said the neighborhood clinics,
which
are completely unregulated, were often the first stop for
parents with
sick children, and provided shots and various intravenous
treatments
for malaria and other fevers. To save money, he said, they may
have
reused needles.
In recent days, health experts
visiting
the houses of infected people found that they were being
treated at
home with shots and intravenous medicines. This could help
spread the
disease within households, Mr. Daigle said.
In past Ebola outbreaks in other
African
nations, hospitals and clinics sometimes acted like
distribution centers
for the virus: in some, patients were admitted for malaria and
then
caught Ebola and died.
"Every time you have a hospital, you
have amplification," said Dr. Rollin.
Hospitals in Africa are crowded,
another
ideal condition for spreading infections. Most do not provide
meals
or much attention from nurses, and family members must feed
and care
for the patient. Often, the entire family stays at the
hospital.
The province was ill equipped to
deal
with the spread of the disease, as it is to fight more common
diseases,
like malaria, dysentery and yellow fever, that are endemic
here.
Sickness and death are so common in
children here that doctors say the illness caused by the
Marburg virus,
which starts with fever and headache like many other tropical
diseases,
might at first have simply been mistaken for something else.
"Here, every day, if three children
die and not four, you are very, very happy," Dr. Pisani said.
Nor is it easy for Uíge to receive
international aid. The province is 190 miles northeast of the
capital,
Luanda, a 12-hour drive along an unpaved road through a region
so heavily
planted with land mines during 27 years of civil war that
travelers
are told never to drive off the road, not even onto the
shoulder to
pass another vehicle.
Only buildings with their own
generators
have electricity - and even then, only when there is fuel and
the machines
are working. Cellphones abound, but there is no running water.
Windows
have no screens.
If this outbreak is stopped,
scientists
will still be left with a major question: where does the virus
lurk
between outbreaks?
It must have a natural host in some
animal, but one that is not known for Marburg or Ebola. The
host would
have to be a species that is not wiped out by the virus. That
requirement
would rule out monkeys and apes, because when they catch
Marburg or
Ebola, they have even higher death rates than people do.
Health authorities
in Africa warn people to stay far away from the corpses of
dead primates,
because they may have died of Ebola.
Several Marburg victims in South
Africa
and Kenya had visited caves before taking ill. And in the
outbreak that
killed 128 people in Congo from 1998 to 2000, most victims
were miners.
The link to caves and mines has led scientists to suspect that
bats
carry the virus. Two victims in the 1980's had visited Kitum
Cave in
Mount Elgon National Park in Kenya. The cave is full of bats
and guano.
Dr. Daniel Bausch, an expert in
hemorrhagic
fevers at Tulane University who studied the Congo outbreak,
said that
the mine in Congo, in a region called Durba, was full of bats
of many
species. Laboratory studies by another researcher, in South
Africa,
found that bats could carry the virus for long periods without
getting
sick.
Miners could easily come in contact
with virus-laden droppings by touching floors or walls in the
mine,
and then touch their eyes or mouths and infect themselves, Dr.
Bausch
said. Primates could also become infected by sleeping in mines
or caves.
Researchers captured and tested
about
500 bats from the mine and never found the Marburg virus, Dr.
Rollin
said. But, he added, there were literally millions of bats in
the mine,
and entire species probably went untested. Sometimes, only one
species
is the principal carrier of a particular virus. The scientists
may simply
have tested the wrong species.
Although the reservoir of the
Marburg
virus has not been found, another aspect of the Congo outbreak
points
to bats, or to some other creature that inhabits mines and
caves: the
epidemic stopped when the mine became flooded and people could
no longer
enter it. But no caves or mines have been implicated in Uíge;
the
source of Marburg here remains a mystery.
Not much research money was spent on
Marburg or Ebola until recent years, when fears of
bioterrorism grew
and it became apparent that the viruses could be used for germ
warfare.
Now, drugs and vaccines are being
developed
against both viruses. Dr. Heinz Feldmann, a Canadian
researcher who
set up a lab to test for the virus in Uíge, said his research
team
had created a vaccine that protected primates against the
Marburg virus,
but had not yet published the results. The vaccine would
probably not
be given routinely, but to people at risk during an outbreak.
"We will most likely have some
options
in a couple of years," Dr. Feldmann said. Whether "they're
ever going
to be used in these poor people here in Central Africa is a
different
issue." |