Angola

Continuing emergency response to an outbreak of Marburg fever in northern Angola

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Location of operation: AFRICA

Amount of decision: EUR 1,500,000

Decision reference number: ECHO/-AF/BUD/2005/02000

Explanatory Memorandum

1 - Rationale, needs and target population:

1.1. - Rationale:

Recurring reports of a mysterious illness killing small children in Uige province in northern Angola came to a head when two members of the health staff treating patients in Uige hospital also died of similar symptoms. Blood specimens tested at the Institut Pasteur in Dakar tested negative for viral haemorrhagic fevers, including yellow fever, West Nile, Rift Valley, lassa, dengue, Chikungunya, Crimean-Congo. However, blood specimens sent to the laboratories of the Centre for Disease Control (CDC) in Atlanta, USA, tested positive for the Marburg virus, a rare cause of viral haemorrhagic fever belonging to the same family as Ebola. The results were issued on the afternoon of 22 March, and the Government of Angola declared an outbreak on 23 March. Because many of the signs and symptoms of Marburg fever are similar to those of other infectious diseases, such as malaria which is endemic in Angola, diagnosis is extremely difficult and all suspect cases must be treated as Marburg.

By the time the diagnosis was confirmed and the outbreak officially declared on March 23rd, the overall number of cases registered in the Provincial Hospital of Uige stood at 101, with 93 deaths. As of 6th April, the number of cases had risen to 200, with 173 deaths. Whilst the province of Uige remains the primary focus of the outbreak, cases (and fatalities) have been reported in five other provinces - Cabinda, Malanje, Kwanza Norte, Kwanza Sul and Zaire - as well as in the capital, Luanda. Two other provinces, Bengo and Lunda Norte, which share internal borders with Uige, are considered to be at increased risk. There have been two deaths of small children at Matadi hospital over the border in the Democratic Republic of Congo, though these cases also originated in Uige. Though the majority of cases and fatalities are children, an increasing number of adults are also falling victim to the virus.

The outbreak has now become by far the worst ever recorded of the disease. It is also the first time that cases have been recorded in an urban environment.

According to information published by the Centre for Disease Control Special Pathogens Branch, the Marburg virus was first recognized in 1967 in laboratories in Marburg, Germany, and recorded cases are extremely rare. It is an extremely contagious and virulent disease, with a reported case fatality rate of about 25%. According to data currently available, though, the case fatality rate of the Angolan outbreak is close to 100%. Though Marburg fever is a very rare human disease, when it does occur, it has the potential to spread quickly to other people, especially health care staff and family members who care for the patient.

After almost thirty years of conflict, peace came to Angola in April 2002. The conflict left the country devastated, with the provision of social services such as basic health care absent in many cases. Though the situation is improving somewhat, the weak capacity of the health staff, coupled with extremely poor hygiene practices among the general population, contribute to both causing and compounding the spread of disease. As the number of cases has risen, an element of fear has caused many people to shun hospitals, and many suspected cases are kept at home to die. This type of behaviour obviously poses the very real threat of the virus spreading among family members. Furthermore, these deaths are not included in the official statistics, which record only hospitalized cases.

Since the outbreak was declared, a considerable international effort has been underway to try to contain it. The Ministry of Health has created a National Technical Commission with its UN and NGO partners to strengthen coordination mechanisms for logistics, epidemiology and social mobilization, to set up isolation and treatment interventions in Uige, Luanda and other locations where there are now confirmed or suspected cases. A case definition of Marburg fever has been adopted to enhance knowledge of the disease and promote accurate identification of suspected cases, and intensive training for health workers is ongoing. Over 60 international experts in various fields (epidemiology, bio-security, logistics, medical anthropologists) are now in Angola, and outbreak response teams are in the field in Uige province, Cabinda and in Luanda to provide rapid technical support for case management, intensified contract tracing and surveillance, infection control and to improve public understanding of the disease and its modes of transmission.

The outbreak has had an impact on movement into and out of Uige, and the disruption of normal commercial activities, has meant that food and other consumer prices in the city of Uige have skyrocketed. More communities, including those in other provinces that depend on Uige for trade, may face some difficulty with shortages of basic commodities.

In addition to the loss of life, family members of those infected by the virus, as well as the general population of Uige Province, have been stigmatized due to a lack of understanding of how the virus is spread and who is at risk.

1.2. - Identified needs:

Though there is no specific treatment for Marburg fever, supportive hospital therapy and barrier nursing techniques to prevent direct contact with the patient must be envisaged. Supportive hospital therapy includes the provision of strong antibiotics and IV treatments to counter dehydration, delivered in an environment where the patient is kept in strict isolation. In order to avoid cross-contamination, each patient must be provided with individual containers for clean (chlorinated) water, and blankets which must be burned after use. Barrier nursing techniques include the wearing of total protective equipment by carers, such as suits and gloves which must be burned after each patient contact, rubber boots and goggles, constant disinfection, provision of clean water (such as bladder tanks), chlorine, bleach, etc.

Epidemiological investigation is required in order to identify and eliminate the source of the outbreak, to be carried out by specialists in the disease, of which there are only a handful in the world.

Social mobilization efforts are critically important to the control of this type of outbreak, in an environment where the population is wary of hospital-related infection, and other local beliefs (linking the disease with witchcraft practices) play an important role.

Transport and logistics are crucial to the speed and efficiency of the interventions, with specialized material needing to be quickly replenished, and specialized personnel needing to be transported to where their skills are required. In view of the refusal of some overland transporters to travel to certain parts of the country affected by the outbreak, WFP is considering the reintroduction of air services to additional locations. Furthermore, transport is essential for the mobile teams carrying out active case identification and recuperation/burial of bodies, as well as for the referral in controlled conditions of suspected cases.

On 6th April 2005, in view of the increasing severity of the outbreak, the UN issued a flash funding appeal for US $ 3.503.000.

1.3. - Target population and regions concerned:

At the time of writing, the outbreak appears to be affecting the whole north-western part of Angola, with Uige Province at the epicentre. Due to the unpredictable nature of epidemics, and the rapid spread of this particular one, interventions funded from this decision may extend to other areas, even outside Angola.

1.4. - Risk assessment and possible constraints:

The rainy season, which is very heavy and long in this area of Angola (though now gradually coming to an end), may constrain the logistics aspects of this intervention. The main risk is the possible spread of the outbreak, possibly even to the bordering areas of the Democratic Republic of Congo, which are home to the same Bakongo ethnic group. In order to avoid additional constraints, the Government of Angola has eased customs and duty procedures for donor vehicles and shipments of equipment and supplies for the control of the outbreak, as well as visa formalities for specialised international staff.