HEALTH NOTES

VHF isolation area

Ebola has been confirmed by the Ministry of Health of Uganda. The viral hemorrhagic fever is primarily contained in the northern Gulu District. As of November 14, 2000, at least 336 cases, including 117 fatalities, have been reported. Ebola is one of the deadliest human diseases and its gruesome killing process inspires great fear. It essentially liquefies its victims from within, breaking down the linings of their blood vessels and organs and causing some to bleed from every orifice.

After giving birth in Gulu Hospital, Rose Akello died from Ebola on September 20. Gulu Hospital is a sprawling complex of beige concrete buildings with rusting tin roofs, in Gulu, a town of 150,000 about 225 miles north of the capital, Kampala. After three nursing students died at Lacor Hospital (the larger and better-equipped of Gulu's hospitals), doctors rushed blood samples to a high-security laboratory, the National Institute of Virology, in Johannesburg, South Africa. It was confirmed to be Ebola on October 14. The Ebola outbreak in Gulu is Uganda's first, although an outbreak of the Marburg virus, similar to Ebola, killed 22 people in the eastern part of Uganda in 1977.

Medical epidemiologists and virologists from around the world are assisting the Ugandan Ministry of Health in breaking the chain of disease transmission. The World Health Organization (WHO), in conjunction with its partners in the Global Outbreak Alert and Response Network, are working with the Ugandan authorities. Personnel and supplies have arrived from the United States Centers for Disease Control and Prevention (CDC), Istituto Superiore di Sanità (ISS) Italy, Médecins sans Frontières (MSF) International ( the French-based "Doctors without Borders"), and Epicentre, France. Several individuals have had experience in treating Ebola and Marburg outbreaks in Africa.

Discovered in 1976, Ebola is the most dreaded of the viral hemorrhagic fevers in humans and nonhuman primates (monkeys and chimpanzees). The first known outbreak, in the village of Yambuku, northern Democratic Republic of the Congo (DRC, then called Zaire), killed at least 280 people, while a simultaneous outbreak in southern Sudan left 117 dead. A 1995 outbreak in the Congolese city of Kikwit killed 244. More than one-fourth of all the victims were healthcare workers. Immediately the DRC Ministry of Health, the CDC and the WHO developed practical recommendations for carrying out viral hemorrhagic fever (VHF) isolation precautions in rural health facilities in Africa. This important manual, entitled Infection Control for Viral Haemorrhagic Fevers In the African Health Care Setting (Contrôle de l'Infection en Cas de Fièvre Hemorragique Viralé), teaches how to recognize cases of viral hemorrhagic fever, such as Ebola HF, and prevent further hospital-based disease transmission by using locally available materials and few financial resources.

Ebola cases have also been recorded in the Ivory Coast and Gabon. The virus can be transmitted by the simplest contact (a simple handshake) with infected persons or their bodily fluids, such as mucus, saliva, blood, secretions, organs or semen, or by contact with objects (e.g., needles) contaminated with the virus. Four days after exposure, flu-like symptoms set in and Ebola resembles malaria, causing fever, headache and muscle pain. Then the virus attacks internal organs, causing the victims to "bleed out" through their nose, mouth, rectum, genitals and even eyes. Between 80%-90% of Ebola victims die within two weeks of infection. Usually Ebola kills its victims faster than it can spread, burning out before it can reach too far. No vaccine or antiviral medication is available for treatment of Ebola hemorrhagic fever.

The center of the outbreak of the deadly Ebola virus is under quarantine and officials will use force to prevent anyone from leaving the area. The rapid response team from WHO Headquarters—paid for by the governments of Germany, Ireland, Italy and Japan—brought boxes of protective garments, gloves and a washing machine. Resembling a Hollywood movie, experts clad in biologically-secure space suits battle to stop the spread of a deadly disease in a remote community. Ebola was the subject of the American fictional film "Outbreak" in 1995, loosely based on Richard Preston's bestseller, The Hot Zone (1994), that recounted how the virus turned up in research monkeys in Reston, Virginia.

Hospitals tend to be the locus of Ebola outbreaks, because the disease is easily passed through bodily fluids to caregivers. Ebola may also be spreading by the intimate funerals that are customary in Uganda. The first nursing student who died of Ebola is assumed to have caught it from an unidentified patient. But Matthew Lukwiya, the chief physician at Lacor Hospital in Gulu, said the two fellow students might have been infected at her funeral. The high ratio of female victims—more than 2 to 1—might be explained by the traditional role women play in caring for the sick and preparing bodies for burial.

As doctors rush from many countries to contain Ebola, they also hope to discover the virus's "reservoir"—the place where it lives when it is not in the human body—and the way in which it "jumps" into the human community. Researchers believe that the virus resides in a host animal or insect that it does not kill, but they have not identified the host in which it lives between outbreaks, which are often years and hundreds of miles apart. People here do not eat wild animals, suspected as the source of some past Ebola outbreaks.

Therefore, researchers are studying the intersection of war and disease in Central Africa. Aid agencies routinely battle cholera, measles and other contagions that sweep through makeshift camps of families displaced by the region's half-dozen wars. At least a third of the approximately 1 million people in the district around Gulu have fled in fear of the Lord's Resistance Army, a rebel group that kidnaps local children during the night and forces them to serve as combatants or concubines.

Area residents sleep in the corridors of Lacor Hospital's compound for refuge so routinely that the hospital staff call them the "night dwellers." It is greatly feared that Ebola may have leapt from infected patients to the "night dwellers" in the weeks before doctors realized that the virus was in their midst. To date, doctors know of one such case, a local man "who died across the road," reported Dr. Lukwiya. Relatives bringing patients to the 500-bed Lacor Hospital routinely report several other deaths at home that have not been counted in the official statistics.

The same lack of security characterized an outbreak in neighboring Congo. Bonzali Katanga, M.D., suspected Ebola or its cousin, the Marburg virus, when men working an abandoned gold mine in the town of Durba began dying by the dozens in late 1998. As the government's district health officer, Bonzali continued his duty, even though anti-government rebels controlled his district. Dr. Bonzali sounded the alarm in urgent radio reports to his provincial superiors in Kisangani for 4 months. But in Congo—where only 2 of 11 provincial health inspectors have even a working vehicle—the health system barely exists. When his superiors finally arrived, they found Dr. Bonzali dead and a vial of his blood in the refrigerator. The sample contained the Marburg virus, which Bonzali had contracted treating the miners. To date, Marburg has killed 69 of the 103 infected people in Durba.

Many of the Ugandan troops now in Gulu to fight the rebels came from the northeast corner of Congo, where Durba is located. The rebel group nominally in control of that area, the Rally for Congolese Democracy, is supported by Uganda, which has soldiers stationed in Durba. Far from shutting down the gold mine, witnesses say, the soldiers and rebels have been charging admission to local men who want to try their luck. Rumors are flying high that the outbreak in Gulu came with the soldiers.

Emerging infectious diseases have increased in the world the past two decades. When antibiotics first began to treat tuberculosis and typhoid fever and vaccination first began to conquer polio, whooping cough, and diphtheria, it seemed that infectious pathogens would eventually disappear from the planet. But, as early as the 1950s, penicillin began to lose its power to cure infections caused by Staphylococcus aureus. In 1957 and 1968, new strains of influenza emerged in China and spread rapidly around the globe. During the 1970s, new diseases were identified: Legionnaires' disease, Lyme disease, toxic shock syndrome, and Ebola hemorrhagic fever. Then came HIV/AIDS and TB (including multidrug-resistant strains) reemerged.

The CDC, in a paper entitled Preventing Emerging Infectious Diseases: A Strategy for the 21st Century, expects more diseases from the following conditions:

  • global travel
  • globalization of the food supply and centralized processing of food
  • population growth, increased urbanization and crowding
  • population movements from civil wars, famines, and other man-made or natural disasters
  • irrigation, deforestation, and reforestation projects that alter the habitats of disease-carrying insects and animals
  • human behaviors, such as intravenous drug use and risky sexual behavior
  • Increased use of antimicrobial agents and pesticides, hastening the development of resistance
  • increased human contact with tropical rain forests and other wilderness habitats that are reservoirs for insects and animals that harbor unknown infectious agents.

At this time, there is no advisory recommending that people avoid travel to the outbreak area in Uganda. Everyone in Gulu District and surrounding areas in northern Uganda must take appropriate precautions to prevent infection. Avoid contact with infected people, as well as funeral rites that involve close proximity to the deceased or funeral attendees. Americans in Uganda should also register with the U.S. Embassy in Kampala to keep abreast of the situation. Futher information is available online with the CDC or the U.S. State Department. No case of Ebola in humans has ever been reported in the United States.


B i b l i o g r a p h y

CDC's Traveler's Health, National Center for Infectious Disease

CDC's Division of Viral and Rickettsial Diseases, Special Pathogens Branch

CDC Fact Sheet on Ebola Hemorrhagic Fever

Vick, Karl. "Where Disease and War Intersect," The Washington Post (October 17, 2000): A16.

WHO's Communicable Disease Surveillance and Response

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