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UNDIAGNOSED FATALITIES - SOUTH AFRICA ex ZAMBIA (05)
****************************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: Wed 8 Oct 2008
Source: allAfrica.com, The Times of Zambia (Ndola) [edited]
<http://allafrica.com/stories/200810080538.html>


Zambia: It's not Ebola!
-----------------------
The woman from Zambia who died in South Africa from a mysterious
disease was in fact afflicted by cerebral edema and multi-organ
failure, putting to rest suspicions that she was hit by the deadly
Ebola [haemorrhagic fever virus], experts have confirmed. 5 experts
who carried out the investigations on 2 of the 4 deceased people
revealed that the woman could have died from suspected viral
infection from a tick bite that she incurred in Lusaka. Experts from
Specialty Emergency Services (SES) Corpmed Medical Centre (CMC) and
Wilderness Safari said that the 1st victim of the disease, that had
so far claimed 4 lives, owned horses and attended polo matches in Lusaka.

The woman is known to have walked barefoot most of the time and
travelled within Africa frequently without seeking medical attention.
Between 6-8 Sep 2008, she attended a wedding in South Africa where
she might have had food poisoning along with 6 others all of whom had
developed diarrheoa, vomiting and headache. On 10 Sep 2008 she
developed rash, fever and chest congestion and was attended to by a
doctor at Care for Business Clinic, who told her that she had flu and
sent her home. The victim was flown to South Africa on 12 Sep 2008
after her condition deteriorated as she had seizures. She died on 14 Sep 2008.

Most of the people she came in contact with, including her family, 2
doctors and employees at CMC had not shown any symptoms of the
disease. But a paramedic who had spent time with her during her
seizure also died from multi-organ failure on 1 Oct 2008, almost 2
weeks after the meeting. He died at Morningside Hospital after being
flown there.

The 3rd victim was a nurse based at the clinic who had attended to
the 1st patient.

The 4th one, a cleaner at the same health institution, died in the
Charlotte Maxeke Johannesburg Academic Hospital.

Health Permanent Secretary, Simon Miti said in an interview yesterday
[7 Oct 2008] that the health authorities in the country [Zambia] had
been put on high alert against any symptoms similar to those that
afflicted the 4 dead people. Dr Miti said no such cases had been
reported from the health institutions anywhere in the country and
health officers were watching the situation. He said that apart from
putting health institutions on high alert, authorities had also
deployed officers at ports of entry to monitor the situation for
symptoms of the disease. He said that all the tests conducted in
South Africa on the deceased people were negative to the initial
suspicions and that the disease remained a mystery. "We still have no
trace of the disease in Zambia and, therefore, the nation should be
calm," he said.

Yesterday, the South African media reported that a 51-year-old woman
was on Monday [6 Oct 2008] admitted to the Chris Hani Baragwanath
Hospital in Johannesburg with symptoms of the unknown disease. The
Independent Online (IOL) reported that the hospital authorities
could, however, not say whether the woman was related to the 4 earlier victims.

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[This Zambian account of the events preceding the 4 fatalities does
not emphasize the occurrence of significant haemorrhage, and no cases
of haemorrhagic fever have been recorded in Zambia prior to or
subsequent to the illness of the index case. The index case fell ill
2-4 days after returning from a visit to South Africa and could have
contracted her illness there rather than in Zambia. The final results
of laboratory testing in South Africa are still pending.

The HealthMap/ProMED-mail interactive map of Zambia, showing the
location of Lusaka, can be accessed at
<http://healthmap.org/promed?v=-14,27.8,5>. - Mod.CP]

UNDIAGNOSED ILLNESS - DEMOCRATIC REPUBLIC OF THE CONGO: KASAI
OCCIDENTAL, EBOLA SUSPECTED, REQUEST FOR INFORMATION
*******************************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: 9 Oct 2008
Source: All Africa / La Prosperite [Trans. by Mod.MPP, edited]
<http://fr.allafrica.com/stories/200810090718.html>


Outbreaks of Ebola fever in Kasai Occidental - Dr. Eugenie Misenga
criticizes the consumption of primates
---------------------------------------------------------------------------------------------------------
1st the factor considered dangerous by Mrs. Dr. Eugenie Misenga, the
origin of the resurgence of Ebola haemorrhagic fever in the province
of Kasai Occidental, is linked to the consumption of some animal
species that feed in the rain forest in particular, monkeys from the
race of primates such as the Bonobo.

To this effect, Dr. Eugenie Misenga, the Medical Director of the
Hospital Center of Kananga, criticized the consumption of these
animals as they are often carriers of Ebola viral fever which the
only treatment available is symptomatic.

A total of 6 suspected cases were identified and taken to the
Hospital Center of Kananga for treatment by Dr. Eugenie Misenga. The
suspected cases are in good health for the moment.

Against all odds, Dr. Eugenie apologized to the population of Kasanga
who like to eat the game meat from monkeys. "Whether the monkey meat
is fresh or is smoked the risk of the presence of the vector [virus]
responsible for Ebola hemorrhagic fever is imminent," said Dr. Eugenie.

It is in this perspective that she thinks to put a mechanism for
information to prevent the constant danger which threatens the
population of Kasai Occidental in general and the population of
Kananga in particular.

Taking into account the fact that there are some suspected cases [of
Ebola hemorrhagic fever] admitted to the [Hospital Center], it should
be noted that the Kananga hospital complex lacks a bit of
everything. It is abnormal for a teaching hospital that receives
several suspected cases [of Ebola hemorrhagic fever]. There is no
potable water, let alone electricity and essential drugs.

In addition, one notes a state of advanced deterioration of the
hospital, which dates back to 1954.

However, Dr. Eugenie Misenga said that the Kananga hospital complex
[treats] an average of 1000 patients per month. Among these, 600 are
outpatients, only 300 patients are admitted [to the hospital] and 100
women are admitted for [obstetric] deliveries, according to a
dispatch received by our [La Prosperite] editorial staff.

The hospital situation [report] indicates a low utilization of public
health services despite a large increasing demography in recent
years, with the population of the town of Kananga reaching the
threshhold of 1 200 000 inhabitants.

The medical director, facing the inconvenience pointed out that
national and international opinion should remember there were 2
natural disasters that had shaken the Kasai Occidental in 2007. There
was a rail accident in Kakenge and the outbreak of of Ebola
haemorrhagic fever in Kapungu village, located 200 km [124 miles]
from Kananga city. These 2 events occurred while the hospital had no
medicines available for urgent interventions.

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[The above newswire mentions 6 suspected cases of Ebola hemorrhagic
fever presently admitted to the hospital in Kananga, the provincial
capital of Kasai Occidental in the Democratic Republic of the Congo,
not far from where there have been prior outbreaks of Ebola
hemorrhagic fever in the past (see references below). No clinical
symptoms of the cases are given, nor is there mention of any
fatalities at present, making it very difficult to comment on
possible diagnoses to be considered. In addition, information of the
localities of origin of the cases is not given.

That being said, it is an area in which there have been outbreaks of
serious infectious diseases in the past few years, including the
viral hemorrhagic fevers, monkeypox and pneumonic plague (see below).
The advisory to avoid eating primate meat, a practice that has been
associated with transmission of the viral hemorrhagic fevers in
Africa, leads one to suspect that the clinical picture includes
hemorrhagic manifestations.

More information from knowledgeable sources would be greatly appreciated.

For a map of the Democratic Republic of the Congo, see
<http://www.lib.utexas.edu/maps/africa/c ... _pol98.jpg>. For
a detailed map of Kasai Occidental, see
<http://www.reliefweb.int/rw/fullMaps_Af ... penElement>.
The identified districts are where the 2007 outbreak of Ebola
hemorrhagic fever occurred. - Mod.MPP]

Unknown disease in South Africa and Zambia
10.10.2008 - WHO

On 12 September, an office employee at a safari tour company living and working in Zambia underwent medical evacuation to South Africa with an as-yet unknown disease. The patient died in a Johannesburg hospital on 14 September.

On 27 September, the paramedic who cared for the index case during her evacuation to South Africa was admitted to hospital in Johannesburg where he died on 2 October. In addition, a nurse who cared for the index case in South Africa died on 5 October in Johannesburg.

Laboratory analysis has been conducted in South Africa at the Special Pathogens Unit, National Institute for Communicable Diseases (NICD) of the National Health Laboratory Service. Samples have, so far, tested negative for a series of viral haemorrhagic fevers and other common infectious disease pathogens. Tests to identify the pathogen continue at the NICD in South Africa and further testing will be performed at the Special Pathogens and Infectious Disease Pathology branches of the Centers for Disease Control and Prevention (CDC), Atlanta, United States. CDC and NICD are technical partners in the Global Outbreak Alert and Response Network (GOARN ).

Clinical features common to the three patients initially include fever, headache, diarrhoea and myalgia developing into rash and hepatatic dysfunction, followed by rapid deterioration and death. Bleeding was not a marked clinical feature (NICD report (.pdf)).

There are no further known symptomatic cases, either in Zambia or in South Africa. 121 known contacts of the fatal cases are being traced in South Africa and 23 in Zambia.

WHO and its partners are actively supporting the investigation at provincial and national levels. Epidemiologists from the WHO African Regional Office have arrived to assist both countries, and personal protective equipment (PPE) and sampling equipment are en route to Lusaka. WHO is also providing support to the Ministries of Health of the two countries with epidemiological investigations, active case finding and follow-up of contacts.

While the investigations and follow-up of contacts continue, there have been no new cases since the last death on 4 October. There is no indication at this point of the need for any restriction of travel to or from Zambia or South Africa and no special measures are required for passengers arriving from these countries.

WHO African Regional Office is providing updated information to the WHO Country Offices in the neighbouring countries.

Sambia - Unklare Todesfälle
10.10.2008

Am 12. September 2008 wurde eine 36 Jahre alte Frau mit einer schweren fieberhaften Allgemeininfektion aus Sambia nach Südafrika ausgeflogen und in Johannesburg stationär versorgt. Sie starb zwei Tage später. In der Folge verstarben ein sambischer Sanitäter, der die Patientin auf dem Flug begleitet hatte und am 05.10.08 auch eine Krankenschwester der Klinik in Johannesburg, wo die Patientin betreut wurde. In den letzten Tagen wurden 121 Kontaktpersonen nachbeobachtet, ohne dass weitere Symptome auftraten. Ein hämorrhagisches Fieber ist mittlerweile ausgeschlossen worden, der Verdacht fokussiert sich auf ein zeckenübertragenes Virus. Von einer weiteren Übertragung wird nicht ausgegangen. / Quelle: crm

GELBFIEBER - AFRICA (10): CENTRAL AFRICAN REPUBLIC, REQUEST FOR INFORMATION
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A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: 10 Oct 2008
Source: African Press Agency [edited]
<http://www.apanews.net/apa.php?page=sho ... icle=77467>


Central African Republic-Fever-Outbreak
---------------------------------------
A yellow fever outbreak is rocking the Boda
sub-prefecture mainly in the Ngotto village, in
south-western Central African Republic (CAR),
sources confirmed here Friday [10 Oct 2008]. The
minister of Public Health, Population and AIDS
Control, Faustin Ntelnoumbi confirmed the
outbreak in a press release issued in the capital.

The statement urged all the population in general
and particularly those in areas at risk to
quickly evacuate to the relevant care facilities
anyone showing symptoms highly suggestive of
yellow fever: sudden fever attack with jaundice
and bleeding eyes, gums and nose. Such symptoms
occur in the 2 weeks following the appearance of
the 1st symptoms of this hemorrhagic viral
disease transmitted to men through bites by
mosquito "_Aedes Aegypti_" which is infested by
the "amaril [yellow fever] virus."

"_Aedes Aegypti_" lives in gallery forests and in
areas surrounded by thick savannahs crossed by
streams filled with [monkeys, the natural host
of] the amaril [yellow fever] virus.

In its statement, the Health ministry urged the
international community to provide the support
necessary to the ongoing efforts in order to stop
the epidemic and provide its expertise to tighten
the monitoring of the yellow fever and any other
potentially epidemic diseases across the country.
According to the statement, a yellow fever case
was reported in the Boda sub-prefecture on [22
Aug 2008] in a 32-year-old male patient. The
Pasteur Institute in Bangui and the one in Dakar
where the blood sample taken on the patient was
sent confirmed the initial diagnosis.

On the other hand, no new case has been diagnosed
following additional samples taken in the Boda
village as part of an investigation conducted by
the epidemiological surveillance department in the Public Health ministry.

The findings of the tests made at the Pasteur
Institute in Bangui show however that the patient is positive.

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[From the above newswire, there is a report of a
single case of yellow fever (YF) confirmed in the
Central African Republic (CAR) with date of onset
22 Aug 2008. While no other cases have been
laboratory confirmed in that area, the wording of
the above newswire seems to suggest there may be
other clinically suspected cases. Ngotto village
is to the southwest of Boda, which is to the
southwest of the capital city, Bangui. (see map
links provided below). While Boda is served by a
"major" road, Ngotto village is served a
secondary road. This moderator worked in the CAR
a number of years ago, and the terrain once one
heads outside of the capital city is one of dense
forested areas filled with flora and fauna of the
region, with a large population of primates
living in close proximity to small villages.
Primate and other forest game meat was commonly
eaten in both the rural as well as urban zones.

Earlier this year (2008), there were 2 confirmed
cases of YF in Bozoum sub-prefecture, Ouham-Pende
Prefecture, approximately 250 kms to the
northwest of Boda prefecture (see Yellow fever -
Africa (03): Central African Republic 20080521.1681).

While the newswire is mentioning the _Aedes
Agyptus_ as a key vector of the disease in the
CAR, it is the vector that is seen more commonly
in the urban yellow fever outbreaks and not in
the sylvatic outbreaks. Mutebi J-P and Barrett
ADT describe 3 cycles of YF transmission in
Africa (see Mutebi J-P, Barrett ADT. The
epidemiology of yellow fever in Africa. Microbes
and Infections. November 2002. 4(14):1459-1468):

"1. The jungle cycle: In African forests, the
virus is principally maintained by transmission
among monkeys and small mammals by the mosquito
Aedes africanus (.Haddow AJ, Smithburn KC, Dick
GWA, Kitchen SF, Lumsden WHR. Implication of the
mosquito _Aedes (Stegomyia) africanus_ Theobald
in forest cycle of yellow fever in Uganda. Ann.
Trop. M. 1948. 42:218­223.). _Ae. africanus_ is a
forest mosquito that breeds primarily in
treeholes and is only found in the jungles of
tropical Africa. The jungle cycle is very similar
to that in South America, but in South America
the principal mosquito vectors are primarily in 2
mosquito genera, _Hemagogus_ and
_Sabethes_ (Shannon RC, Whitman L, Franca M.
Yellow fever virus in jungle mosquitoes. Science.
1938. 88:110­111]. Sporadic human cases in the
form of focal outbreaks are typical, and large
epidemics involving thousands of people are rare.

"2. The intermediate cycle: The intermediate
cycle involves several mosquito species,
including _Aedes luteocephalus_, _Aedes
furcifer_, _Aedes metallicus_, _Aedes opok_,
_Aedes taylori_, _Aedes vittatus_ and members of
the _Aedes simpsoni_ complex (Germain M, Francy
DB, Monath TP, Ferrara L, Bryan J, Salaun J, Heme
G, Renaudet J, Adam C, Digoutte JP, Yellow fever
in Gambia, 1978­1979: entomological aspects and
epidemiological correlations. Am. J. Trop. Med.
Hyg. 1981. 29:929­940). The intermediate
transmission cycle is usually in areas with some
human activity, such as small village
settlements, communal herding areas and farmland.
The intermediate transmission cycle has only been
described in the moist savanna of Africa, and to
date, no such cycle has been described in the
Americas. Due to the increased potential for
transmission to humans, the potential for large YF epidemics is very high.

"3. The urban cycle: In the urban cycle, the
virus is transmitted from human to human by the
mosquito _Ae. aegypti_. This is the most deadly
form of disease transmission, potentially involving thousands of human cases."

ProMED-mail would greatly appreciate more
information from knowledgeable sources on the
current situation of yellow fever transmission in the CAR.

For detailed maps of the Central African Republic, see
<http://www.un.org/Depts/Cartographic/ma ... le/car.pdf> and
<http://www.lib.utexas.edu/maps/africa/c ... _pol01.jpg>.
Boda is approximately 100 kms (60 miles) to the
southwest of the capital, Bangui. While 60 miles
may not seem a far distance, see
<http://www.multimap.com/world/CF> for an
interactive map of the Central African Republic
which, when one zooms in the map, one can see the
sparse road network in the country thereby
increasing the difficulties in transport and communication.

For the HealthMap/ProMED interactive map with
links to recent ProMED-mail postings on events in
the CAR and neighboring areas, see
<http://healthmap.org/promed?v=6.6,20.5,5>. - Mod.MPP]

UNDIAGNOSED FATALITIES - SOUTH AFRICA ex ZAMBIA (07): ARENAVIRUS
***********************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: 12 Oct 2008
Source: The Mercury [edited]
<http://www.themercury.co.za/?fSectionId ... 513C975048>


The mystery viral hemorrhagic fever which killed 3 people in South
Africa has been provisionally identified as an arenavirus, the
National Institute for Communicable Diseases [NICD] and the
Department of Health said on Sunday [12 Oct 2008].

"The causative agent of the disease may be a rodent-born arenavirus
related to the Lassa fever virus of West Africa," NICD's Dr Lucille
Blumberg said at the Charlotte Maxexe Johannesburg Academic Hospital.

She said tests done by the NICD and the Centers for Disease Control
[CDC] in Atlanta, USA indicated that the disease seemed to be a kind
of arenavirus. The World Health Organisation has also been providing
technical assistance.

Arenaviruses cause chronic infections in multimammatic mice, a kind
of wild mouse, which excrete the virus in their urine, which can then
contaminate human food or house dust.

Viruses similar to the Lassa fever virus have been found in rodents
in Africa, but other than in West Africa have not been found to cause
diseases in humans.

She said there was no indication arenaviruses that could cause
disease in humans were present in South African rodents.

Blumberg said further tests still needed to be done. "It needs to be
determined whether it is a previously unrecognized member of the
arenaviruses and what its distribution is," she said.

The NICD's Robert Swanepoel said there were viruses of this family in
Southern Africa but that this could be an undiscovered kind. "Not
every country has been thoroughly searched," he said. He said the
kind of rodents that carried the virus were not generally found in
urban areas. "They are out there but attracted (to human dwellings)
if there is inadequate waste disposal." Crop disposal and animal feed
also sometimes attracted them, he said. He said the kinds of viruses
could range from causing mild fevers to being lethal. There were only
3 cases to work with for the kind of arenavirus now discovered, but
"it looks like it is very lethal," he said.

Head of the NICD's Special Pathogens Unit, Dr Janusz T Paweska, said
the arenavirus diagnosis came about after a number of tests.
[Biopsies] conducted on the last 2 victims in which infected tissues,
skin, liver and muscles were tested were critically important in
making a diagnosis. A blood sample obtained in Zambia from the 1st
victim also confirmed test results.

He said doctors were now waiting for the virus to grow in cell
culture to conduct further tests to identify what strain it was.

Gauteng health MEC [Brian Hlongwa?] said the 1st victim of the virus
was [a] 36-year-old [woman], who was airlifted from Zambia to the
Morningside Medi Clinic in Sandton on [12 Sep 2008] in a critical condition.

She is known to have lived in a smallholding on the outskirts of
Lusaka where she kept 3 horses, although the exact point of
contamination has never been discovered.

She fell ill on [8 Sep 2008] and was treated in 3 different hospitals
in Lusaka. Once in South Africa, she was treated for tick bite fever
and other potential infections but died 2 days later. She was not
tested for viral hemorrhagic fever.

On [27 Sep 2008], a Zambian paramedic who accompanied her into the
country was admitted to the hospital with similar flu-like symptoms,
fever and a skin rash, and viral hemorrhagic fever was queried.

He developed diarrhea, severe headaches, nausea and vomiting, and
although he initially seemed to respond to treatment, he died on [2
Oct 2008] at the clinic.

A 3rd victim of the virus was a nurse from Morningside Medi-Clinic
who attended [the 1st case]. She became ill with fever 18 days after
[the woman from Zambia] was admitted to the hospital, and consulted a
general practitioner, receiving intravenous therapy. She was then
referred to Robinson Hospital in Randfontein and was later
transferred due to a bedding shortage to Sir Albert Clinic. There,
she was treated for a suspected case of meningitis. Her condition
deteriorated, and she died last Sunday [5 Oct 2008].

A 4th person, a [37-year-old female] contract cleaner working at
Morningside Medi-clinic, died in Charlotte Maxeke Academic hospital.
Earlier this week, the health department said her death was not
related to viral hemorrhagic fever.

On Sunday [12 Oct 2008?], Blumberg said a female nurse and a male
paramedic were currently in isolation after they were in contact with
the deceased.

The paramedic had contact with [the 1st case, the female from
Zambia], and after developing flu-like symptoms and a fever was
admitted to Flora clinic. He was subsequently transferred to
Morningside Medi-clinic and diagnosed with kidney stones. On Sunday
[12 Oct 2008], Blumberg said it was "less likely" he had the virus.

The 2nd person in isolation is a nurse who had contact with a
paramedic that died [the 2nd patient, the male paramedic that
accompanied the 1st patient to South Africa]. She has developed
symptoms similar to the 3 deceased and is receiving anti-viral
medication called ribavirin. The department of health said she was
presently stable. Blumberg said she is "highly suspect" to have
contracted the virus and could not say further how her condition was
likely to progress.

This week, 3 other people who had been hospitalized after contact
with the deceased were discharged. On Friday morning [10 Oct 2008],
the 11-year-old son of the nursing sister who died [case number 3]
and his 23-year-old nanny were discharged [presumably discharged from
quarantine].

A cleaning supervisor at Morningside Medi-Clinic who had been
admitted to the Chris Hani Baragwanath Hospital on Monday [6 Oct
2008] with symptoms of viral hemorrhagic fever was also released. On
Sunday [12 Oct 2008], Hlongwa said she was currently "well."

All 3 continued to be monitored as part of the disease surveillance
system currently tracking 151 people who had contact with the deceased.

Blumberg said arenaviruses could cause a disease which spreads from
human to human through contact fluids. In hospital settings, special
precautions were needed when nursing patients.

People in contact with those who have contracted the virus must be
monitored for 21 days following their last contact with the patient.
Their body temperature is monitored, and those who develop fever or
illness are admitted to an isolation ward in the hospital.

Blumberg said there was a drug which showed promising results in
treating patients if their illness is recognized early.

Those who have been in contact with patients but are well do not
spread infection.

On Sunday [12 Oct 2008], Gauteng health MEC Brian Hlongwa said the
diagnosis of the virus was a step forward. "We are now a step further
because we know specifically what we are dealing with." However, it
was still vital to conduct more tests to find out what kind of
arenavirus it was, he said.

Director General Thami Mseleku cautioned South Africans not to now
fear that every mouse that came their way contained the virus.

Since the virus 1st broke out, medical officials have been at pains
to emphasize that the general public is not at risk, as only people
who were in direct contact with the bodily fluids of a person who had
a confirmed case of the virus could be infected.

--
Communicated by:
HealthMap Alert via
ProMED-mail <promed@promedmail.org>

[According to the above newswire, there has been a "preliminary"
identification of an arenavirus in specimens from the initial 3
fatalities felt to be associated in this cluster. Apparently, the
virus was identified in infected tissue of the 2nd and 3rd case (the
paramedic accompanying the 1st case during the medical transfer from
Zambia to South Africa and a nursing sister who cared for the 1st
case while hospitalized in South Africa) and further identified
through testing of blood from the original case (the 37-year-old
woman from Zambia. We await further information on this from official sources.

Former viral disease moderator Prof. Charles H. Calisher had the
following to add: "There are at least 23 recognized arenaviruses
(family _Arenaviridae_, genus _Arenavirus_). The conventional
phylogeny of these viruses distinguishes "Old World" from "New World"
arenaviruses, i.e., based on geographic distribution. As are the
hantaviruses, each arenavirus is principally associated with rodents
of a single or a very few species, thus the basis for their
geographic distributions. An unusual exception may be Tacaribe
virus, which has been isolated from bats and mosquitoes. Most New
World arenaviruses are not known to cause human illnesses but others
cause severe illnesses: Machupo virus (Bolivian hemorrhagic fever),
Junin virus (Argentine hemorrhagic fever), Guanarito virus
(Venezuelan hemorrhagic fever), Sabia virus (Brazilian hemorrhagic
fever), and Chapare virus.

Lassa virus has been shown to cause severe, often fatal, hemorrhagic
fevers in human in a wide area of West Africa. It is now recognized
that this virus causes numerous illnesses each year. It will be
enlightening when we have news of the identity of the viruses causing
these illnesses in Zambia, and now in South Africa. The
investigations are in the hands of the world's most competent people
for such studies, Dr. Robert Swanepoel of South Africa's National
Institute for Communicable Diseases and collaborating investigators
at the U.S. Centers for Disease Control and Prevention. Therefore,
definitive information regarding whether this is a hitherto
unrecognized arenavirus or a variant of a recognized arenavirus
should be forthcoming relatively soon. Meanwhile, clinical practices
to control further spread should suffice."

If the etiologic agent is in fact an arenavirus, ribavirin is
presently used for the treatment of Lassa fever. this moderator would
like to thank Prof. C.J. Peters, an leading authority on
arenaviruses, for kindly providing the references listed below on
treatment modalities used for arenavirus infection.

References.
1. Barry, M., M. Russi, L. Armstrong, D. Geller, R. Tesh, L. Dembry,
J. P. Gonzalez, A. S. Khan, and C. J. Peters. 1995. Brief report:
treatment of a laboratory-acquired Sabia virus infection.[see
comment]. New England Journal of Medicine 333:294-296.
2. Enria, D. A., A. M. Briggiler, S. Levis, D. Vallejos, J. I.
Maiztegui, and P. G. Canonico. 1987. Tolerance and antiviral effect
of ribavirin in patients with Argentine hemorrhagic fever. Antiviral
Research 7:353-359.
3. Jahrling, P. B., R. A. Hesse, G. A. Eddy, K. M. Johnson, R. T.
Callis, and E. L. Stephen. 1980. Lassa virus infection of rhesus
monkeys: pathogenesis and treatment with ribavirin. Journal of
Infectious Diseases 141:580-589.
4. Kilgore, P. E., T. G. Ksiazek, P. E. Rollin, J. N. Mills, M. R.
Villagra, M. J. Montenegro, M. A. Costales, L. C. Paredes, and C. J.
Peters. 1997. Treatment of Bolivian hemorrhagic fever with
intravenous ribavirin. Clinical Infectious Diseases 24:718-722.
5. McCormick, J. B., I. J. King, P. A. Webb, C. L. Scribner, R. B.
Craven, K. M. Johnson, L. H. Elliott, and R. Belmont-Williams. 1986.
Lassa fever. Effective therapy with ribavirin. New England Journal of
Medicine 314:20-26.
6. Peters CJ. 2002. Arenaviruses, p. 949-969. In Richman DD, Whitely
RJ, and Hayden FG (eds.), Clinical Virology. ASM Press, Washington, DC.
7. Peters CJ, Zaki SR, and Rollin PE. 1997. Viral hemorrhagic fevers,
p. 10.l-10.26. In Mandell GL and Fekety R (eds.), Atlas of Infectious
Diseases, Vol. 8. Current Medicine, Philadelphia.
- Mod.MPP]

New virus from Arenaviridae family in South Africa and Zambia - Update
13.10.2008 - WHO

The results of tests conducted at the Special Pathogens Unit, National Institute for Communicable Diseases (NICD) of the National Health Laboratory Service in Johannesburg, and at the Special Pathogens and Infectious Disease Pathology branches of the Centers for Disease Control in Atlanta, USA, provide preliminary evidence that the causative agent of the disease which has resulted in the recent deaths of 3 people from Zambia and South Africa, is a virus from the Arenaviridae family.

Analysis continues at the NICD and CDC in order to characterize this virus more fully. CDC and NICD are technical partners in the Global Outbreak Alert and Response Network (GOARN).

Meanwhile, a new case has been confirmed by PCR in South Africa. A nurse who had close contact with an earlier case has become ill, and has been admitted to hospital. Contacts have been identified and are being followed-up.

WHO and its GOARN partners continue to support the Ministries of Health of the two countries in various facets of the outbreak investigation, including laboratory diagnosis, investigations, active case finding and follow-up of contacts.

CHOLERA, DIARRHEA & DYSENTERY UPDATE 2008 (40)
**********************************************
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<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

In this update:
Africa
[1] Cholera - Guinea-Bissau
[2] Cholera - Sudan (Northern Bahra el-Ghazal)
[3] Cholera - Benin (Bourgou)
[4] Cholera - Zimbabwe (Mashonaland West)
[5] Cholera - Mozambique (Niassa)
[6] Cholera - Tanzania (Rukwa)
[7] Cholera - Uganda (Kampala)

******
[1] Cholera - Guinea-Bissau
Date: Tue 14 Oct 2008
Source: UN Integrated Regional Information Networks (IRIN) report [edited]
<http://www.irinnews.org/Report.aspx?ReportId=80887>


The cholera epidemic is still out of control across Guinea-Bissau,
with the number of cases doubling in the past 3 weeks, bringing the
total number of people stricken to 10 476 as of 9 Oct 2008.

There have been 312 new infections in the past 2 days, according to
the UN Children's Fund (UNICEF), and 181 people have died from the disease.

"The epidemic is not under control. I don't want to be alarmist, but
we haven't reached the peak and there are still new cases every day,"
Daniel Remartinez, emergency coordinator for Medecins Sans Frontieres
(MSF) Spain, told IRIN from the capital Bissau.

At 7143, Bissau still has the highest number of cases, followed by
Biombo in western Guinea-Bissau with 1405 cases, and the Bijagos
islands, 60 km (37.3 mi) off the coast of the capital, with 441
infections. Most of the Bijagos infections have been contracted in
the past few weeks, according to Agostino Betunda, co-director of the
Centre for Epidemiology in Bissau.

One in 10 people stricken by cholera are dying from it in the region
of Quinara, which neighbors the capital, and one in 9 in Bafata in
central Guinea-Bissau, due in part to a lack of available treatment,
according to Betunda.

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[A map of Guinea-Bissau showing the mentioned areas can be found at
<http://www.un.org/Depts/Cartographic/ma ... ineabi.pdf>. - Mod.LL]

******
[2] Cholera - Sudan (Northern Bahra el-Ghazal)
Date: Tue 14 Oct 2008
Source: UN Office for the Coordination of Humanitarian Affairs
(OCHA), ReliefWeb, Miraya FM report [edited]
<http://www.reliefweb.int/rw/rwb.nsf/db9 ... enDocument>


The Commissioner of Aweil East County Cirelo Diing Aher said at least
25 people died of cholera in Tiitchok Mareeng area.

Speaking to Miraya-FM from the state government headquarters in Aweil
town on Monday [13 Oct 2008], the Aweil East county commissioner said
that citizens of Toich Area have been displaced by floods forcing
them to over crowd some highlands in the area where acute watery
diarrhea is now in progress.

Cases of cholera were first discovered in the Aweil North and West
counties in July 2008 before it spread to Aweil town.

Over 2-dozen deaths in Aweil East indicate the huge toll the disease
is having in Northern Bahra el-Ghazal State.

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[The area mentioned can be found on a map in South Sudan bordering
Southern Darfur at
<http://www.un.org/Depts/Cartographic/ma ... /sudan.pdf>. - Mod.LL]

******
[3] Cholera - Benin (Bourgou)
Date: Thu 9 Oct 2008
Source: UN Office for the Coordination of Humanitarian Affairs
(OCHA), ReliefWeb, Int Fed of Red Cross and Red Crescent Societies
(IFRC) report [edited]
<http://www.reliefweb.int/rw/rwb.nsf/db9 ... enDocument>


Since the last week of September 2008, cases of cholera have been
reported in Malanville and Karimana in the northern part of Benin.
According to the Red Cross of Benin, about 90 cases were referred to
health centres in the 2 districts. By 2 Oct 2008, the epidemic has
spread to other northern districts of Djougou and Bassilla with over
600 cases reported in the affected communities, according to the Red Cross.

No deaths have been reported. Reported cases are increasing, and if
the epidemic is not quickly controlled it could potentially spread to
other neighboring communities. The district of Karimana is recording
the highest number of cases thus far. Health officials in the
locality have been deployed in the district to give medical
assistance to affected persons. The Red Cross volunteers deployed in
the affected communities could only carry out sensitization on good
hygiene practice in a few accessible areas.

A similar outbreak was reported during the month of August 2008 in
Cotonou, the commercial capital of Benin.

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[The areas in involved are in Bourgou, in the north of the country
and can be found at
<http://www.mapsofworld.com/benin/maps/benin-map.jpg>. - Mod.LL]

******
[4] Cholera - Zimbabwe (Mashonaland West)
Date: Thu 9 Oct 2008
Source: Afrique en Ligne [edited]
<http://www.afriquenligne.fr/fresh-chole ... 13511.html>


A fresh outbreak of cholera has killed 3 people in northern Zimbabwe,
health officials said Thursday [9 Oct 2008]. The country has been hit
by a spate of cholera outbreaks in different regions, including areas
around the capital, Harare. Two weeks ago, 3 people were killed by
cholera and hundreds of others hospitalized around Harare.

But health officials said the latest cases were in the northern towns
of Chinhoyi and Kariba, where scores of other people were left hospitalized.

Poor sanitation, including non-functional sewerage facilities, is
blamed for the outbreaks of cholera.

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[Chinhoyi and Kariba are in Mashonaland West as can be seen on a map
at <http://www.un.org/Depts/Cartographic/ma ... mbabwe.pdf>. - Mod.LL]

******
[5] Cholera - Mozambique (Niassa)
Date: Thu 9 Oct 2008
Source: AllAfrica, Agencia de Informacao de Mocambique (Maputo) report [edited]
<http://allafrica.com/stories/200810090105.html>


A cholera outbreak in the town of Cuamba, in the northern Mozambican
province of Niassa, has killed 12 of the 277 people diagnosed with
the disease so far, according to a report in Wednesday's [8 Oct 2008]
issue of the Maputo daily "Noticias."

Laisson Daniel, director of the Cuamba district health services, said
that the main cause of the cholera outbreak is the poor supply of
drinking water in the town, together with poor hygiene habits. The
outbreak began in late August 2008, and this is the 1st time that
Cuamba has been struck by cholera outside of the rainy season.

The town is going through a serious water crisis. "In the few rivers
where one can still find some water, it is highly contaminated, but
this is the only alternative for the residents, because the wells
have completely dried up," said Daniel.

An average of 7 people suffering from cholera are being admitted to
the Cuamba Rural Hospital every day, which the authorities regard as
a very high figure.

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

Niassa in the north-central part of the country borders on Tanzania.
It can be found on a map at
<http://www.un.org/Depts/Cartographic/ma ... zambiq.pdf>. - Mod.LL]

******
[6] Cholera - Tanzania (Rukwa)
Date: Wed 8 Oct 2008
Source: IOL (Independent Online, South Africa) [edited]
<http://www.iol.co.za/index.php?set_id=1 ... 849C886386>


Officials said on Wednesday [8 Oct 2008] 4 people died of cholera and
70 more have been admitted to health centres following a fresh
outbreak in southern Tanzania. The 1st death was reported a week ago
in the southwestern Rukwa region, Mpanda District Commissioner
Thobias Sijabaje said.

"A patient believed to have been infected by cholera died on 30 Sep
2008 at Milala Chongo village. His relatives took the body and there
are fears that they did not take necessary precautions before the
burial," he said.

The disease has since spread to several parts of the district and
more than 70 patients have been admitted to different health centres, he said.

An outbreak in northern Tanzania killed at least 13 people in September [2008].

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[Rukwa province is in southwestern Tanzania, bordering on Zambia. It
can be found on a map at
<http://www.un.org/Depts/Cartographic/ma ... nzania.pdf>. - Mod.LL]

******
[7] Cholera - Uganda (Kampala)
Date: Tue 7 Oct 2008
Source: New Vision [edited]
<http://www.newvision.co.ug/D/8/13/653524>


So far, 40 cases of cholera have been reported in Kinawataka, a
Kampala suburb since the disease break out last month [September
2008]. Dr Joseph Senzoga yesterday [6 Oct 2008] said 8 victims were
undergoing treatment at the Mulago Hospital cholera isolation camp.
"We have not registered any deaths at the camp," he said.

Three people, including a 5-year-old child, died at the beginning of
September 2008, while the 4th victim died at the end of the month.
Cholera usually hits the city suburbs during rainy seasons. The most
prone areas are Kawempe, Kisenyi, Kamwokya, and Kalerwe.

[Byline: Florence Nakaayi]

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[Kampala is in southern Uganda and its location can be found on a map
at <http://www.un.org/Depts/Cartographic/ma ... uganda.pdf>. - Mod.LL]

HEPATITIS E VIRUS - UGANDA (10): (PADER)
****************************************
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International Society for Infectious Diseases
<http://www.isid.org>

Date: Tue 14 Oct 2008
Source: UN Office for the Coordination of Humanitarian Affairs
(OCHA), Integrated Regional Information Networks (IRIN) News [edited]
<http://www.irinnews.org/report.aspx?ReportID=80886>


Uganda: hepatitis E spreads, IDPs [internally displaced persons] most
vulnerable
----------------------------------------------------------------------
As of Mon 13 Oct 2008 hepatitis E is on the increase in Uganda's
northern district of Pader, where it has claimed scores of lives and
infected thousands in the past year, officials said.

Since May [2008], there have been 55 new infections and 7 deaths in
Pader, according to Angelo Luganya, a health official in Pader. "More
cases are being received in health units in villages and there is
need for urgent attention to check on the disease that is on the
rise," he told IRIN. Since 2007, the viral disease has infected up to
8000 people in neighbouring Kitgum district alone, and killed 129.
The disease has since spread to the districts of Pader, Gulu,
Adjumani, and Amuru.

Hepatitis E is transmitted mainly by drinking contaminated water or
eating contaminated food. Charles Kurua, the Pader deputy
commissioner, said the majority of those infected in the district
were internally displaced persons (IDPs).

"There is need for intervention by local government and health
partners to curb the spread of the disease," said Kurua, who is also
a member of the hepatitis E taskforce in the district, adding that
the number of those being infected was rising daily. Poor sanitation
has contributed to the spread of the disease, with some IDPs lacking
pit latrines and others drinking unsafe water from unprotected
sources, leaving them prone to infection, Kurua said. "Our people are
living under unhygienic conditions in IDP camps and areas of return
in villages that leave them more vulnerable to diseases such as
hepatitis E and cholera," he said. "If they [IDPs] keep on staying in
the camps, more would die from the diseases."

The infected were being treated at Kalongo, the main hospital in the
district, as well as in health centres in Pader, Acholi Bur, Pajule,
and Patongo areas. Kurua said the taskforce was being frustrated by a
lack of adequate resources, making it hard for its members to reach
all the communities living in Pader. He said efforts were underway to
drill boreholes in all resettlement areas to avoid outbreaks of
sanitation-related diseases.

Alfred Akena, a local leader in Pader, said the situation was
worrying because in most of the villages IDPs are returning to do not
have adequate functional health centres. "A number of parishes have
not been able to get health centres within their reach due to a
collaboration gap between the parish development committees and the
district, this is dangerous when we get outbreak of diseases," he
said. Moreover, Akena said, people in the neighbouring district of
Kotido also risk infection of hepatitis E following an influx of
Karimojong people looking for food and water. At least 346 Karimojong
women and children have crossed into Pader district and settled in
the sub-counties of Adilang, Lapono, Paimol, Kalongo, and Parabongo,
adjacent to Abim and Kotido districts.

--
Communicated by:
ProMED-mail Rapporteur Brent Barrett

[A map Uganda showing the district of Pader lying south of Kitgum and
east of Gulu can be accessed at
<http://www.ugandatravelguide.com/uganda-map.html>.

The hepatitis E outbreak in Uganda is far from contained and is
spreading further south from Kitgum district into Pader district.
Partly as a consequence of movement of IDPs (internally displaced
persons) deeper into the country. And now Kotido district to the east
of Pader is threatened by another movement of IDPs.

The causes of the outbreak, contaminated water sources and inadequate
provision of sanitation, are well understood, but administrative and
resource problems have yet to be overcome.

A comprehensive account of all aspects of hepatitis E disease and its
control can be accessed at
<http://www.who.int/mediacentre/factsheets/fs280/en/>. - Mod.CP]

FOODBORNE ILLNESS, FATALITY - BOTSWANA: (SOUTHERN)
****************************************
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ProMED-mail is a program of the
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<http://www.isid.org>

Date: Thu 16 Oct 2008
Source: All Africa, Mmegi/The Reporter (Gaborone) report [edited]
<http://allafrica.com/stories/200810160131.html>


In a shocking case of food poisoning in Kanye, a child is said to
have died, whilst about a hundred were admitted to Kanye Seventh Day
Adventist (SDA) Hospital.

According to Kanye deputy officer commanding, superintendent Obonyeng
Kelebeng, a 9-year-old girl died last weekend [11-12 Oct 2008] after
eating food at a funeral in Selokolela, a settlement several
kilometers west of Kanye. He said that the girl was dead upon arrival
at Athlone Hospital in Lobatse.

Kanye SDA Hospital deputy matron, Keabitsa Ramantele, said that they
received patients from the settlement who were complaining of
diarrhea and vomiting last Sunday [12 Oct 2008]. She said they all
reported that they had eaten samp and meat at a funeral in Selokolela.

Ramantele said that so far they have received about 98 patients from
Selokolela. "Yesterday [15 Oct 2008] we consulted and sent back some
of them home, while we had 30 whom we hospitalized overnight," she
said. She said that because the hospital was already overcrowded,
they had to refer 13 patients, also suffering from food poisoning, to
Athlone hospital in Lobatse, which is 45 km (28 mi) from Kanye.

[Byline: Ephraim Keoreng]

--
Communicated by:
HealthMap Alerts via ProMED-mail
<promed@promedmail.org>

[The etiology of the illness here cannot be easily surmised from the
information given without an approximate incubation from the meal to
the onset of symptoms, whether fever was present or not, and how long
the illness lasted. Bacterial, viral, protozoan, enteric toxins, as
well as toxic chemicals can be considered.

Samp (<http://en.wikipedia.org/wiki/Samp>) is dried corn kernels that
have been chopped until broken but not as fine as mealie-meal or
mealie rice. The coating around the kernel loosens and is removed
during the pounding and stamping process. It can be served with beef,
lamb, poultry, and in stuffings.

Kanye is in Botswana's Southern province and can be found on the map at
<http://www.mapsofworld.com/botswana/map ... na-map.jpg>.
The location of the country in southern Africa can be seen at
<http://www.un.org/Depts/Cartographic/ma ... africa.pdf>
and the HealthMap/ProMED-mail interactive map at
<http://healthmap.org/promed?g=933685&v=-21.983,25.35,5>. - Mod.LL]

HEPATITIS E VIRUS - UGANDA (11): (KITGUM)
*****************************************
A ProMED-mail post
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<http://www.isid.org>

Date: Thu 16 Oct 2008
Source: The New Vision, Uganda [edited]
<http://www.newvision.co.ug/D/8/16/654882>


Kitgum gets 64 new cases of hepatitis E
---------------------------------------
Sixty-four new cases of the deadly hepatitis E virus were reported
this week in Kitgum district. This, however, is a reduction in the
infections from 90 cases reported the previous week. According to the
Ministry of Health, the disease is receding. The ministry said the
cumulative number of hepatitis [E] infections now stands at 8617.

Only one new death was reported in Lokung sub-county in the week,
which brings the cumulative deaths to 127 in 41 weeks. "On the whole,
the trend of the hepatitis E outbreak continues to recede in all the
sub-counties of Kitgum district," a statement from the ministry
stated. Layamo sub-county had 15 of the new cases, while Agoro and
Padibe reported 10 each. Kitgum Town Council had 6, Mucwini had 5,
while Lagoro and Paloga reported 4 each. Madi Opei, Kitgum Matidi,
and Namukora reported 2 cases each, while Lokung, Akwang, Omiya
Anyima, and Amida reported one case each. The statement said Layamo,
Agoro, Padibe, and Kitgum town council had registered the highest
number of cases.

The disease, which is spread through consumption of food and fluids
contaminated with infected faecal matter, broke out in October last
year [2007]. The most affected were people living in camps for the
internally displaced and those returning to their villages after the
LRA [Lord's Resistance Army] insurgency.

The disease's long incubation period had been responsible for its
spread, according to the Minister of Health, Dr Stephen Mallinga. He
said recently that the heavy rains in Kitgum had increased
transmission of the disease because people returning from camps had
limited safe drinking water. The problem was compounded by lack of
pit latrines, with people easing themselves in bushes from where the
virus found its way into the water sources. According to Mallinga,
there was need for the water ministry to sink more boreholes. He said
the Min Health was working with UNICEF (UN Children's Fund) and the
World Health Organisation (WHO) to provide better services in the region.

[Byline: Anne Mugisa)

--
Communicated by:
ProMED-mail Rapporteur Brent Barrett

[Although the outbreak of hepatitis E infection in the Kitgum
district of Uganda may be beginning to decline, the number of new
cases is substantial, bringing the overall total in the Kitgum
district to 8617. Heavy rainfall, movement of internally displaced
persons (IDPs), and the consequences of internal strife are combining
to frustrate the efforts of the Ugandan authorities to provide
adequate sanitation and sources of clean water in this district of Uganda.

A map of Uganda showing the location of Kitgum district in the north
of the country can be accessed at:
<http://www.lib.utexas.edu/maps/africa/u ... l_2005.jpg>
The HealthMap/ProMED-mail interactive map of Uganda is available at
<http://healthmap.org/promed?g=443346&v=1.5,36,5>. - Mod.CP]

UNDIAGNOSED FATALITIES - SOUTH AFRICA ex ZAMBIA (09): ARENAVIRUS
****************************************************************
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<http://www.isid.org>

Date: Thu 16 Oct 2008
Source: Eurosurveillance, Volume 13, Issue 42 [edited]
<http://www.eurosurveillance.org/ViewArt ... leId=19008>


Unknown disease in South Africa identified as arenavirus infection
------------------------------------------------------------------

Introduction
---------------
On 12 Sep 2008, a tourist guide organising safari
trips, residing in Lusaka, Zambia, was evacuated
in a critical condition to Johannesburg, South
Africa. She was admitted to a clinic where she
died on 14 Sep 2008 about 10 days after the onset
of symptoms. The symptoms included a prodromal
phase with fever, myalgia, vomiting, diarrhoea,
followed by rash, liver dysfunction and
convulsions [1]. Cerebral oedema was detected on
scan examination. No laboratory specimen was available for investigation.

The paramedic who had cared for the index case
during her evacuation to Johannesburg developed
prodromal symptoms similar to the index case. He
was hospitalised on 27 Sep 2008. His condition
deteriorated and he died on 2 Oct 2008. An
intensive care unit nurse who cared for the index
case in Johannesburg developed similar flu-like
symptoms and was hospitalised on 1 Oct 2008. Her
condition deteriorated on 4 Oct 2008 and she died
on 5 Oct 2008 of acute respiratory distress
syndrome. In both cases, the incubation period is
estimated to have been about one week. On 13 Oct
2008, the World Health Organization (WHO) posted
a Web site update informing about a 4th case
affecting a nurse who had been in contact with the paramedic [2].

On 12 Oct 2008, the National Institute for
Communicable Diseases (NICD) in South Africa
provided preliminary evidence that the causative
agent of the disease was a virus from the family
_ Arenaviridae_ [3]. Specimens were shipped to
the United States Centers for Disease Control and
Prevention (CDC) in Atlanta for additional investigations.

Arenavirus taxonomy
------------------------
Arenaviruses are enveloped viruses (about 120 nm
diameter) with a bi-segmented negative strand RNA
genome. The typical image in electronic
microscopy showing grainy ribosomal particles
("arena" in Latin) inside the virions gave the
name to this family of viruses. The prototype is
Lymphocytic Choriomeningitis virus (LCMV),
isolated in 1933 in North America from a human
case with aseptic meningitis. Cases caused by
LCMV occur worldwide. Other arenaviruses causing
hemorrhagic fevers were reported in South
America, causing sporadic cases or limited
outbreaks: Junin virus in 1958 in Argentina,
Machupo virus in 1963 in Bolivia, Guanarito virus
in 1990-1991 in Venezuela, Sabia virus in 1990 in
Brazil and more recently Chapare virus in 2004 in
Bolivia [4]. In West Africa, Lassa virus was
identified in Nigeria in 1969. It causes
thousands of cases each year in Sierra Leone,
Liberia, Guinea and Nigeria. However, only
limited data are available to assess the real
incidence of Lassa fever in Africa.

Clinical symptoms of arenavirus infections, treatment and vaccine
-----------------------------------------------------------------
2 types of clinical presentations are described:
neurological and haemorrhagic fever. However,
asymptomatic arenavirus infection may be
frequent. The incubation period is about 10 days
(3-21 days). LCMV causes aseptic meningitis or
meningoencephalitis with an overall case fatality
<1 percent. Foetal infections can result in
congenital abnormalities or death. Transmission
of arenaviruses via organ transplantation has
been documented; immunosuppressed recipient
patients can develop fatal haemorrhagic
fever-like disease [5,6]. The Lassa viral
haemorrhagic fever usually presents as a
non-specific illness with symptoms including
fever, headache, dizziness, asthenia, sore
throat, pharyngitis, cough, retrosternal and
abdominal pain, and vomiting. In severe forms,
facial oedema is associated with haemorrhagic
conjunctivitis, moderate bleeding (from nose,
gums, vagina, etc.) and exanthema. Neurological
signs may develop and progress to confusion,
convulsion, coma and death. Severe prognosis is
associated with a high viraemia, elevated
aspartate aminotransferase (AST) liver enzymes,
bleeding, encephalitis and oedema. There is a
very high risk of foetal mortality in pregnant
women during the 3rd trimester of pregnancy. Case
fatality rates range from 5 to 20 percent for
hospitalised cases. Clinical symptoms of
infection by arenaviruses in South America are
similar to those described for Lassa fever in Africa.

Ribavirin has been shown to be an effective
treatment for Lassa fever, especially when
started within the first 6 days of illness [7,8].
There is currently no vaccine for Lassa fever but
several candidates are under development studies
with successful trials in primates [9]. One
available vaccine is licensed in Argentina for Junin virus.


Reservoir of arenavirus and transmission
----------------------------------------
Arenaviruses are associated with rodents, their
natural hosts. Some of these viruses can be
transmitted to humans by contact with faeces,
urine, blood or saliva of infected rodents or
with dust containing infective particles. In
South America, Machupo and Junin viruses were
identified in _Calomys_ sp. rodent, and Guanarito
virus was found in a Sigmodon cotton rat [10]. In
West Africa, _Mastomys natalensis_ (a
peridomestic rodent) is the reservoir of Lassa
virus. Its geographic distribution is much wider
in sub-Saharan Africa that the presently known
area of Lassa transmission [11]. Other
arenaviruses such as Mopeia virus in Mozambique
had been isolated from rodents without evidence of disease in humans [10].

Fatal nosocomial and laboratory infections by
arenaviruses have been reported. Contamination
occurs via direct contact with body fluids or via
droplets. Since the 1970s special procedures for
handling these viruses (now categorised as class
4 agents) have been put in place, including the
building of dedicated biosafety laboratories
(BSL-4), with containment equipment for all
activities involving the virus, infectious or
potentially infectious body fluids or tissues.

Conclusion
----------
In the cluster reported here, 4 cases have been
identified including an index case and 3 cases of
subsequent nosocomial transmission among health
workers. The clinical presentation was consistent
with neurological symptoms of arenavirus
infection. As the incubation period for
arenaviruses is up to 3 weeks, secondary cases
may still be identified as part of the follow-up
of contacts established in response to this event.

The professional activities of the index case
could have favoured possible exposure to rodent
excreta in a rural area. This is the 1st
identification of an arenavirus causing human
disease in a southern African country. Further
laboratory investigation will allow
characterisation of the virus associated with
this outbreak and its relation with the existing
Lassa virus present in West Africa. Since 1969,
at least 24 cases of Lassa fever are known to
have been exported outside Africa, including 16
cases imported to Europe [12,13]. However, in
none of these cases has secondary transmission
resulted in a symptomatic disease.

(Acknowledgements: We gratefully acknowledge the
openness, the collaboration and the information
provided by the National Institute for
Communicable Diseases in South Africa, as well as
the International and Tropical Department of the
French Institute for Public Health Surveillance
(Institut de veille sanitaire, InVS).

[Reported by: H Zeller, K Leitmeyer, C Varela
Santos, D Coulombier. European Centre for Disease
Prevention and Control (ECDC), Stockholm, Sweden]

References
--------------
1. National Institute for Communicable Diseases
(NICD). Outbreak of an acute disease, ex-Zambia.
Communicable Diseases Communique volume 7 alert
1; October 2008. Available from:
<http://www.nicd.ac.za/pubs/communique/2 ... lert01.pdf>.

2. WHO Web site: <http://www.who.int/csr/don/2008_10_13/en/index.html>.

3. ProMED-mail. Undiagnosed fatalities - S.
Africa ex Zambia (7): arenavirus. Archive Number
20081012.3234. 12 October 2008. Available from:
<http://www.promedmail.org/pls/otn/f?p=2 ... 00%2C74346>.

4. Delgado S, Erickson BR, Agudo R, Blair PJ,
Vallejo E, Albari­o CG, et al. Chapare virus, a
newly discovered arenavirus isolated from a fatal
hemorrhagic fever case in Bolivia. PLoS Pathog. 2008;4 (4):e1000047.

5. Brief report: Lymphocytic choriomeningitis
virus transmitted through solid organ
transplantation - Massachusetts, 2008. MMWR Morb
Mortal Wkly Rep. 2008 Jul 25;57(29):799-801.

6. Palacios G, Druce J, Du L, Tran T, Birch C,
Briese T, et al. A new arenavirus in a cluster of
fatal transplant-associated diseases. N Engl J Med. 2008;358(10):991-998.

7. McCormick JB, King IJ, Webb PA, Scribner CL,
Craven RB, Johnson KM, et al. Lassa fever.
Effective therapy with ribavirin. N Engl J Med. 1986;314(1):20-6.

8. World Health Organization. Lassa fever - fact
sheet. April 2005. Available
from:<http://www.who.int/mediacentre/factsheets/fs179/en/>

9. Lukashevich IS, Carrion R Jr, Salvato MS,
Mansfield K, Brasky K, Zapata J, Cairo C,
Goicochea M, Hoosien GE, Ticer A, Bryant J, Davis
H, Hammamieh R, Mayda M, Jett M, Patterson J.
Safety, immunogenicity, and efficacy of the ML29
reassortant vaccine for Lassa fever in small
non-human primates. Vaccine. 2008 Sep 26;26(41):5246-54.

10. Charrel RN, de Lamballerie X. Arenaviruses
other than Lassa virus. Antiviral Res. 2003 Jan;57(1-2):89-100.

11. Fichet-Calvet E, Lecompte E, Koivogui L,
Soropogui B, DorZ A, Kourouma F, et al.
Fluctuation of abundance and Lassa virus
prevalence in Mastomys natalensis in Guinea, West
Africa. Vector Borne Zoonotic Dis. 2007;7(2):119-128.

12. Macher AM, Wolfe MS. Historical Lassa fever
reports and 30-year clinical update. Emerg Infect Dis. 2006 May;12(5):835-7.

13. Unit for Surveillance and Communication,
Unit for Preparedness and Response, Editorial
team. E-alert 24 July: Case of Lassa fever
imported into Germany from Sierra Leone. Euro
Surveill. 2006;11 (30):pii=3008. Available from:
<http://www.eurosurveillance.org/ViewArt ... cleId=3008>.

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[This is a comprehensive account of the outbreak
of a novel arenavirus infection in Southern
Africa. Some confusion remains concerning the
location of exposure of the index case and the
existence of a clinical sample from the index case.

With regard to the taxonomy of the arenaviruses
it should be noted that the Old World
arenaviruses (LCMV and the African viruses) are
phylogenetically distinct from the New World
arenaviruses. While similarities exist in genomic
organization, structure and clinical disease
caused by pathogenic Old World and New World
arenaviruses these pathogens use different
primary receptors. The Old World arenaviruses
employ alpha-dystroglycan, a cellular receptor
for proteins of the extracellular matrix, and the
human pathogenic New World arenaviruses use the
cellular cargo receptor transferrin receptor 1.

While the New World arenavirus Junin virus enters
cells via clathrin-dependent endocytosis,
evidence occurred for clathrin- independent entry
of the prototypic Old World arenavirus
lymphocytic choriomeningitis virus. Upon
internalization, arenaviruses are delivered to
the endosome, where pH-dependent membrane fusion
is mediated by the envelope glycoprotein (GP).
While arenavirus GPs share characteristics with
class I fusion GPs of other enveloped viruses,
unusual mechanistic features of GP-mediated
membrane fusion have recently been discovered for
arenaviruses with important implications for
viral entry (see: Cell entry by human pathogenic
arenaviruses. Rojek JM, Kunz S. Cell Microbiol.
2008 Apr;10(4): 828-35. Epub 2007 Dec 21). - Mod.CP]

MALARIA - NIGERIA: (KATSINA), REQUEST FOR INFORMATION
***************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: Sun 19 Oct 2008
Source: Press TV [edited]
<http://www.presstv.ir/detail.aspx?id=72 ... =351020505>


An outbreak of malaria in northern Nigeria's Katsina state has taken
401 lives in the last 4 weeks, local health officials have said.

"In the last 28 days, 401 people have died of malaria, which has
become endemic in the state," said Halliru Idris, director of public
health in the state's health ministry.

He added that the death toll could be much higher because it only
includes those who died in hospitals, excluding those who might have
died at home.

He said 50 311 malaria cases were recorded in the state of 4.5
million people over the past 4 weeks, which he attributed to the high
rainfall recorded in this rainy season, which saw more mosquitoes
breed than usual.

Mosquitoes can transmit malaria. The government has deployed health
workers to the worst affected districts to fumigate mosquito breeding
areas and to distribute mosquito bed nets.

According to the 2008 World Health Organization's annual malaria
report, the disease struck between 35 million and 80 million Nigerians in 2006.

One million people died from malaria in 2006, most of them children under 5.

Malaria is an infectious disease transmitted by mosquitoes. Symptoms
include sharp fluctuations in body temperature, weakness, body aches,
nausea and vomiting. It can be fatal if not treated in time.

--
Communicated by:
ProMED-mail <pollack@promedmail.org>

[Malaria is endemic in Katsina State, and the WHO 2008 malaria report
<http://www.who.int/malaria/wmr2008/MAL2 ... ria-EN.pdf>
states that: "Nigeria accounts for a quarter of all malaria cases in
the WHO African Region. Transmission in the south occurs all year
round and is more seasonal in the north. Almost all cases are caused
by _P. falciparum_ but most are unconfirmed. There is no evidence of
a systematic decline in malaria burden; the upward trend in numbers
of cases and deaths is probably due to improvements in reporting.

IRS [indoor residual spraying] is not national policy. The NMCP
[National Malaria Control Program] delivered about 17 million ITN
[insecticide treated mosquito-nets] during 2005-2007 (6.6 million
LLIN [long lasting insecticide-treated nets]), enough to cover only
23 percent of the population at risk. The programme delivered 4.5
million courses of ACT [artemisinin-based combination therapy] in
2006 and 9 million in 2007, far below total requirements. Funding for
malaria control was reported to have increased from USD 17 million in
2005 to USD 60 million in 2007, provided by the government, the
Global Fund and the World Bank. This is unlikely to be sufficient to
reach national targets for prevention and cure."

Nigeria is notorious for manufacturing counterfeit drugs, and a high
number of malaria deaths in an highly endemic area could indicate
that the drugs used for treatment did not contain sufficient (if any)
active substance.

For Katsina State, see: <http://www.maplandia.com/nigeria/katsina/> - Mod.EP]

[More information on the drug resistance pattern seen in Nigeria and
in Katsina State would be greatly appreciated. - Mod.MPP]

Zentralafrikanische Republik - Gelbfieber
20.10.2008

Bei einem 32-jähriger Patient aus der Boda Provinz (SW) wurde eine Gelbfieberinfektion nachgewiesen. Weitere Fälle wurden bisher nicht diagnostiziert. Im Mai dieses Jahres wurden bereits zwei Gelbfiebererkrankungen im Westen des Landes registriert. Impfschutz beachten. / Quelle: crm
____________________________

Guinea-Bissau - Darminfektionen
20.10.2008

Risiko für Durchfallerkrankungen landesweit. Nach einer Pause von zweieinhalb Jahren gab es im Land wieder Cholera: Der seit Anfang August anhaltende Ausbruch ist weiterhin nicht unter Kontrolle. Bisher sind mehr als 10.500 Personen erkrankt, wovon 181 verstarben. Die Zahl der täglichen Neuerkrankungen ist mit ca. 150 weiterhin sehr hoch. Die Hauptstadt Bissau ist am stärksten betroffen. Guinea-Bissau erlitt mit mehr als 25.000 Erkrankungen und 400 Todesfällen in der zweiten Jahreshälfte 2005 eine der schwersten Cholera-Epidemien in seiner Geschichte. Hygiene beachten. / Quelle: crm

CHOLERA, DIARRHEA & DYSENTERY UPDATE 2008 (41)
**********************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

In this update:
Africa
[1] Cholera - DR Congo, Ethiopia, Guinea-Bissau, Niger
[2] Cholera - Somalia (Galguduud)
[3] Cholera - Zimbabwe (Mashonaland West)
[4] Cholera - Nigeria (Gombe)

******
[1] Cholera - DR Congo, Ethiopia, Guinea-Bissau, Niger
Date: Mon 20 Oct 2008
Source: UN Office for the Coordination of Humanitarian Affairs
(OCHA), ReliefWeb, World Health Organization (WHO) report [edited]
<http://www.reliefweb.int/rw/rwb.nsf/db9 ... enDocument>


Democratic Republic of the Congo (DRC)
--------------------------------------
Outbreaks of cholera are reported in several provinces: Katanga (146
new cases with 12 deaths in week 40 [week of 29 Sep 2008]), North
Kivu (95 new cases with no deaths in week 40), South Kivu (217 new
cases with 1 death in week 40). WHO and other health partners are
supporting the health authorities for the control of these outbreaks.

Ethiopia
--------
Acute watery diarrhea [= cholera] epidemics are reported in the
country. As of 5 Oct 2008, cumulative cases and deaths nationally are
3675 and 22 espectively. WHO, UNICEF (United Nations Children Fund),
and major NGOs (non-governmental organizations) are supporting the
Ministry of Health for the outbreak control.

Guinea-Bissau
-------------
The cholera outbreak is still out of control. As of week 41 [week of
6 Oct 2008], a total of 10 872 cases and 185 deaths have been
reported. The capital Bissau has the highest number of cases with
7427 cases. WHO and numerous national and international partners are
supporting the Ministry of Health to contain the outbreak.

Niger
-----
The situation is still dominated by the cholera outbreak in the
region of Tahoua and Maradi. In week 41 [week of 6 Oct 2008], the
number of cases is decreasing with 25 cases and no deaths reported
versus 84 cases and 3 deaths in week 40 [week of 29 Sep 2008]. A
total of 948 cases and 70 deaths have been reported since the
beginning of the outbreak. WHO is supporting the health authorities
to control the cholera outbreak with cholera kits and essential drugs.

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[A map of Africa showing the countries mentioned can be found at
<http://www.un.org/Depts/Cartographic/ma ... africa.pdf>. - Mod.LL]

******
[2] Cholera - Somalia (Galguduud)
Date: Tue 21 Oct 2008
Source: Press TV Iran [edited]
<http://www.presstv.ir/detail.aspx?id=72 ... =351020501>


The Press TV correspondent in South Mogadishu reported on Tuesday [21
Oct 2008] that about 15 people died of cholera in Cabudwaaq town of
the Galguduud region due to lack of clean drinking water and
medicines to treat the disease.

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[A map of Somalia showing the location of Galguduud region north and
east of Mogadishu can be found at
<http://www.un.org/Depts/Cartographic/ma ... omalia.pdf>. - Mod.LL]

******
[3] Cholera - Zimbabwe (Mashonaland West)
Date: Tue 21 Oct 2008
Source: Associated Press (AP) [edited]
<http://ap.google.com/article/ALeqM5jYaM ... QD93UT2280>


Zimbabwean health authorities say 11 people have died from cholera in
a town outside Harare in an outbreak blamed on collapsing sewer
services and the country's economic crisis.

Authorities said Tuesday [21 Oct 2008] at least 500 people have been
treated since the outbreak earlier in October 2008 in Chinhoyi, 70
miles (113 km) northwest of Harare.

Diarrhea outbreaks in impoverished towns across the country have been
blamed on water outages and other problems associated with Zimbabwe's
economic meltdown. Authorities have urged the government to stem the
discharge of sewage from broken pipes into rivers and dams.

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[Chinhoyi is located in Mashonaland West as can be seen on a map of
Zimbabwe at
<http://www.un.org/Depts/Cartographic/ma ... mbabwe.pdf>. - Mod.LL]

******
[4] Cholera - Nigeria (Gombe)
Date: Mon 20 Oct 2008
Source: AllAfrica, Leadership (Abuja) report [edited]
<http://allafrica.com/stories/200810201237.html>


Cholera and diarrhea have hit Zone 'F' preliminary games camp of the
16th Nigeria College of Education Games (NICEGA) being held at the
Federal College of Education in Gombe, with no fewer than 5
participants in serious condition.

A Leadership Sports check revealed that there were complaints about
the acute shortage of water supply, mattresses, and hostel rooms. This
is connected to the fact that the host school is in session and the
accommodation facilities are inadequate for the students and visitors.

[Byline: Vincent Ekhoragbon]

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[The state of Gombe in northeastern Nigeria can be found on a map at
<http://www.un.org/Depts/Cartographic/ma ... igeria.pdf>.

The outbreaks reported in this update can also be found on the
HealthMap/ProMED-mail interactive map at
<http://www.healthmap.org/promed>. - Mod.LL]