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Marburg Spread Inside and Outside Angola
April 10, 2005
>> "The hospital has been the main source of infection," said MSF emergency co-ordinator Monica De Castellarnau.
She said people infected by the virus went to the hospital where they infected doctors and nurses, who in turn infected other patients.
"We have to break that circle," she said, adding that MSF was recommending that the hospital be closed "because it was still contaminated." <<
Although the main hospital in Uige may have been the main source of Marburg infections at one time, the situation in Angola has clearly changed. The news coming out of Angola clearly lags the true spread of Marburg hemorrhagic fever, but it provides some information on where the virus was and where it might be now.
The difference between the number of cases diagnosed and the number dead identifies the most advanced hospitalized patients. Last week that number was between 5-8 and now it is up to 30 out of 213 diagnosed patients. However, only 12 of these 30 patients are in the main hospital in Uige, so clearly most of the advanced patients are now elsewhere. Two other hospitals in Uige province are also under consideration for closure, but these closings seem to be related somewhat to staffing issues. In the past several weeks, 17 health care workers have died. This total included two nurses who died last Thursday, indicating that tightened infection control and more gloves, gowns, and masks failed to prevent transmission to at least two more health care workers.
These transmissions raise the issue of airborne transmission, which increases the likelihood of transmission outside of the hospital setting. Since there are no survivors, relatives are reluctant to send sick patients to the hospital, and are hiding such patients from contact tracers. Thus, the actual number of deaths and infected contacts is not well known.
Since Marburg cases have been acknowledged in seven provinces in Angola, repeats of the situation in and around the city of Uige can be expected. Since the surrounding area probably has smaller hospitals or clinics, with poorly trained and equipped staff, new centers of transmission are likely.
This has happened in Cacuaco, a slum just outside of Luanda. On March 27 a 12 year-old patient began to hemorrhage and was transferred to the Americo Boa Vida hospital in Luanda. However, she had been admitted in Cacuaco two days earlier, so multiple transmissions were possible prior to her transfer. There was no indication the patient had ties to Uige.
A week later the scene was repeated in the same slum. This time a 22 year-old patient was admitted and was hemorrhaging badly. Transfer to Luanda was delayed because the hospital had only one ambulance. Two patients in the same slum admitted a week apart is an indication of transmission within the slum, and linked cases are not likely to be in the totals of dead or diagnosed.
Thus, the spread within Angola is accelerating at multiple transmission sites, and most of these transmissions are not being tallied or monitored. The relative ease of transmission, even at a hospital facility on alert, should fuel the spread, which will likely lead to transmission outside of Angola.
Cases are being investigated in Democratic Republic of Congo and South Africa. In South Africa there are no "confirmed" cases in part because there is no Marburg test in South Africa. Samples are shipped to the CDC in Atlanta. This leads to delays in diagnosis and potential false negatives because of added complications involved in collection and international shipment of samples.
Marburg virus is clearly flying around the world, and where it lands is largely a matter of chance.