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Angola's killer epidemic

By Sharon LaFraniere and Denise Grady

Scientists say the Marburg epidemic in Uige began with just one infected person.

THE STAFF in the paediatric ward of the regional hospital in Uige, Angola, suspected something was terribly wrong as early as October, when children who had been admitted with seemingly treatable illnesses began, suddenly and wrenchingly, to die. But were those early deaths caused by the Marburg virus? If they were and had they been diagnosed at the right time, might the current epidemic have been averted? The international health experts who have descended on Angola say they cannot pinpoint exactly when the largest outbreak of the deadly virus began.

"Nobody really has a sense of where or when it started," said Dr. Thomas Grein, a medical officer in the World Health Organisation. "The widespread belief that it began in October is speculation."

But local officials in Uige, the centre of the outbreak, believe it began around that time, and then spread from the paediatric ward of the regional hospital, which has now been declared off limits.

If they are correct and there was a delay in explaining the deaths, the reason may be that in Africa, sometimes the extraordinary is buried in the ordinary.

Children die at such an astonishing pace here and for any range of horrible reasons unknown to other parts of the world that it takes much more time for health workers to piece together if something as deadly as Marburg is at work. Experts say at least 214 people have caught the virus and 194 of them have died.

Marburg is spread by contact with bodily fluids, from blood to sweat, and kills with gruesome efficiency. Victims suffer from vomiting, diarrhoea, high fever and bleeding from body orifices. Nine in 10 are dead within a week. There is no effective treatment.

When strange deaths first began to appear in October, mystified local health officials shipped samples of tissue and blood from four children to the United States. In November the Centres for Disease Control and Prevention tested them for at least three different types of hemorrhagic fever, including Marburg.

The results, which nearly all agree were accurate, came back negative. But in the cacophony of deadly diseases and other health issues that plague Africa, it remains possible that Marburg was present in Uige even then. By the end of December, at least 95 children were dead, local health workers say.

How many deaths were Marburg-related is unknown, but even by the grim standards of the continent, it was an alarming number of deaths.

It was not until February that Angolan authorities shipped more samples to the CDC in Atlanta. This time, nine of 12 came back positive for Marburg, which by then was claiming more victims by the day. In early March, the provincial health officials alerted a WHO representative that they had found 39 suspected cases of Marburg. When a larger international team arrived, the members identified more than 60 suspected cases.

Since new lab tests positively confirmed the virus on March 18, a growing number of epidemiologists, anthropologists, public health experts and emergency medical workers have descended on Uige in a race to cut off the disease.

One thing is certain, scientists say: The epidemic began with just one infected person, and was then transmitted from one person to another. That conclusion, based on finding only one strain of virus in all the samples tested, means the outbreak can be stopped if infected people are isolated.

Given the degree to which it has been contaminated, the regional hospital, which serves 500,000 people, has now been limited to furnishing an isolation ward where Doctors Without Borders, the international health charity, treats Marburg victims.

Eight paediatric nurses and the doctor in charge of the ward are dead, along with six other nurses and one other doctor, all Marburg victims. Every mattress, bedsheet and hospital uniform must be thrown out. Everything left must be disinfected.

On Monday, teams of soldiers and hospital personnel clad in bright yellow prowled the grounds, spraying grass, benches and dirt paths with a solution of diluted bleach. Afterwards, they burned their uniforms. At some point, said Dr. Gakoula Kissantou, the hospital's acting administrator, normal operations will resume. He refused to hazard a guess as to when.

But to safely treat patients again, hospital officials need to address a range of problems. They must find ways to systematically isolate high-risk patients; to equip the medical staff with masks, gloves and other protective equipment; and to enforce sanitation measures, like proper hand-washing, even when there is no running water.

Dr. Kissantou says all that could be done, with enough money. The provincial governor has promised $1 million, he said, but more support is needed. Yet the biggest challenge of all may be regaining the trust of the community after so many deaths.

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