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RABIES, CANINE, HUMAN - ANGOLA (03): LUANDA
*********************************************
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 18 Feb 2009
Source: Independent Online [edited]
<http://www.iol.co.za/index.php?set_id=1 ... 115C704815>


The number of children killed from rabies in Luanda rose to 69 on
Wednesday [18 Feb 2009], up from 50 last month, prompting authorities
to launch a new drive to round up hundreds of stray dogs in Angola's
capital city. The Health Ministry said health workers were rounding
up hundreds of strays in Luanda to counter the deadly virus that is
transmitted to humans through the bite of an infected animal. Almost
a 1000 dogs have already been collected since the rabies outbreak
began in November [2008]. Those that test positive for rabies are
killed; the others are released. "This is a tragedy because despite
all the efforts to control the rabies outbreak, things aren't getting
any better," Luis Bernardino, the director of Luanda's largest
children's hospital, told Reuters.

Children aged between 3 and 10 have been the main victims, as they
cannot protect themselves from dogs. Bernardino said the children are
usually from poor districts surrounding Luanda's urban core, where
thousands of stray dogs roam. Authorities in Luanda carried out a
city-wide vaccination campaign last month [January 2009] in which 100
000 animals -- dogs, cats and monkeys -- were inoculated in a city
that is home to more than 1/3rd of Angola's 16.5-million-strong
population. But this has failed to prevent the rabies death toll
among children from climbing in a country that already has one of the
worst infant mortality rates in the world. Two out of every 5
children die before reaching the age of 5, according to the United Nations.

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

[The effort to control urban rabies in the Angolan capital by a
combination of killing rabies-virus-infected feral dogs and
vaccination of urban dogs, cats and monkeys has had little impact on
the number of young children dying as a result of rabies virus
infection. A more sustained effort to control rabies by these means
will have to be implemented in combination with a more effective
education effort to inform the population of the hazard of rabies.

The HealthMap/ProMED-mail interactive map of Angola showing the
location of Luanda in the north of the country can be accessed at:
<http://healthmap.org/promed/en?v=-12.3,17.5,5>.
- Mod.CP]

MENINGITIS, MENINGOCOCCAL - UGANDA (04)
***************************************
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: Thu 19 Feb 2009
Source: The New Vision [edited]
<http://www.newvision.co.ug/PA/8/16/672024>


The health ministry has contained the meningitis outbreak in the country.
"We are on top of the situation. No new cases have been reported since 28
Jan [2009]," said Dr Sam Zaramba, the director general of health services.
He said there was increased awareness about the disease in the affected
areas, which saw many people receive treatment and vaccination.

The outbreak hit the country in December [2008]. Uganda is one of the
countries in the African meningitis belt. The epidemic that started in
Hoima and Arua districts also spread to Masindi, Adjumani and Moyo. By 3
Feb 2009, 336 people had been affected, while 42 had died.

Last month [January 2009], the ministry delivered drugs and financial
support to the affected areas. Dr Nathan Kenya Mugisha, the director for
clinical services, said the ministry and the World Health Organization had
vaccinated people aged between 2 and 30 years in the affected districts.
"This age group is more vulnerable to meningitis and our assessment teams
continue doing their work. We have also advised people to avoid congestion
especially in the affected districts," Mugisha said. "We allowed the
schools in the affected districts to open for the new academic year because
our assessment teams have reported no new cases. This is also one of the
signs that we are managing the epidemic," he added.

Meningitis is an inflammation of the meninges, the lining surrounding the
brain and spinal cord. The disease is caused by bacteria and is transmitted
through contact with the respiratory or throat secretions from an infected
person.

Last year [2008], the country also suffered cholera, botulism, Ebola,
Marburg, typhoid, measles, and hepatitis E outbreaks. While presenting the
status report on major disease outbreaks to Parliament last week [9-13 Feb
2009], health state minister Richard Nduhura said all the diseases had been
controlled, save for hepatitis E.

[byline: Anthony Bugembe]

--
communicated by:
ProMED-mail
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[It is heartening to hear that the meningococcal meningitis epidemic in
Uganda has waned. Controlling meningitis epidemics consists of early
detection of clinical cases, prompt case management, limiting social
gatherings -- for example, by closing schools in an attempt to diminish
transmission of _Neisseria meningitidis_, and meningococcal vaccination of
the people living in the epidemic area.

Meningococcal meningitis epidemics in the "African meningitis belt" when
studied in Mali usually begin soon after the onset of dusty dry weather,
diminish about 8 weeks later and end on average about another 8 weeks later
(<http://medicine.plosjournals.org/perlse ... ed.0020006>).
Similar meningococcal meningitis epidemic curves were found in 2006 in
Gulu, Uganda
(<http://www.who.int/hac/crises/uga/sitre ... 0March.pdf>),
and now in the current Ugandan epidemic, which the above news report says
began in December 2008.

A map of Uganda showing the affected districts can be found at
<http://www.un.org/Depts/Cartographic/ma ... uganda.pdf> and a map of
the African bacterial meningitis belt can be found at
<http://www.medic8.com/images/map4-9.gif>. The HealthMap/ProMED-mail
interactive map of Uganda is available at
<http://healthmap.org/promed/en?g=443351 ... 7,33.083,6>. - Mod.ML]

RABIES, CANINE, HUMAN - ANGOLA (04): LUANDA
**********************************************
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: 22 Feb 2008
From: ProMED-mail <promed@promedmail.org>


In ProMED-mail post 20090219.0694, with the above referenced title,
the 1st paragraph appeared as follows:

"The number of children killed from rabies in Luanda rose to 69 on
Wednesday [18 Feb 2009], up from 50 last month, prompting authorities
to launch a new drive to round up hundreds of stray dogs in Angola's
capital city. The Health Ministry said health workers were rounding
up hundreds of strays in Luanda to counter the deadly virus that is
transmitted to humans through the bite of an infected animal. Almost
1000 dogs have already been collected since the rabies outbreak began
in November [2008]. Those that test positive for rabies are killed;
the others are released. "This is a tragedy because despite all the
efforts to control the rabies outbreak, things aren't getting any
better," Luis Bernardino, the director of Luanda's largest children's
hospital, told Reuters."

The paragraph above is very misleading. Although there is a test for
rabies in humans, the equivalent test is not available in dogs or
other animals or is not available with any degree of reliability.
Testing for rabies in dogs can be conducted only on central nervous
system (CNS) tissue removed from the cranium. Therefore, ProMED-mail
would like to point out that this means it can be done only when the
animal is dead.

A much better approach to controlling the rabies outbreak is to
vaccinate dogs. A good vaccination program safeguards people and
preserves the animals. It has been shown repeatedly in many countries
that mass killing of dogs does not decrease the incidence of rabies.
Successful canine vaccination programs have been implemented in a
wide variety of developing, resource-strapped countries such as
Nigeria and the Philippines, so it can be done. Moreover, it is
highly cost effective. The best way to decrease the incidence of
rabies in humans and to stop outbreaks is through vaccination of
urban dogs.

One note of caution should be thoroughly understood, though. While
there have been highly successful campaigns in a wide variety of
countries, there have also been multiple situations in which
seroprevalence studies on urban dog populations have shown inadequate
protection after vaccination. So while vaccination campaigns can
work, they must be implemented effectively under the local conditions
and with appropriate supporting tactics, such as community education
and stray dog control. - Mods.TG,MHJ,AS,TD,PC.

LASSA FEVER - NIGERIA (02)
************************
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: Tue 24 Feb 2009
Source: This Day, via Naijablog [edited]
<http://naijablog.blogspot.com/2009/02/l ... n-fct.html>


The Federal Capital Territory (FCT) Administration has announced that
there is currently an outbreak of the deadly Lassa Fever within the
FCT and neighbouring Nassarrawa state. The disease has already
claimed 8 lives in 3 weeks, and over 93 cases have been confirmed.

Lassa fever is a very deadly disease that can spread quickly within a
short period of time. It initially has malaria type symptoms and so
is easily mistaken for malaria and under-treated early. It is,
however, very critical to catch it in the very early stages. This is
a highly contagious disease that is transmitted traditionally by rat
urine/feces contamination of food, drink and household items/goods.
It is also transmitted via body fluids and appears to be airborne in
the current form in Abuja.

Symptoms include fever, general fatigue and weakness, headache, sore
throat, chest pain, nausea, vomiting, diarrhea, cough, abdominal
pain, and red spots. In advanced/severe cases, it may lead to a
swollen face, bleeding from orifices (eyes, mouth, nose, genitalia),
low blood pressure, etc.

The good news is that the necessary steps to curb the growing
epidemic are being taken by the FCT Health & Human Services
Secretariat, the Federal Ministry of Health and the World Health
Organization. So there is no need to panic.

Wash all foods; cook all meats thoroughly; store all drink in sealed
containers; keep your house and surroundings as free as possible from
anything that will attract and/or harbor rats. As soon as you suspect
Lassa fever, or if you have persistent fever that does not respond to
standard malaria treatment, report to the nearest FCT Health Centre.
The FCTA is setting up an emergency quarantine facility. You may
reach the FCT Health & Human Services Secretariat at 09-3141098 or
08033138538.

--
Communicated by:
ProMED-mail Rapporteur A-Lan Banks

[Concern has been expressed previously about the increase in the
number of Lassa fever cases in Nigeria during the past year. The
figures of 8 deaths and 83 cases within a period of 3 weeks are very
significant, since about 80 percent of human Lassa fever virus
infections are asymptomatic. Those affected suffer multi-system
disease when the virus affects several organs in the body, such as
the liver, spleen, and kidneys. The incubation period of Lassa fever
ranges from 6-21 days. The current increase in cases of Lassa fever
in some parts of Nigeria may be a consequence of increased abundance
of the vector (the multimammate rat) or some other factor resulting
in increased contact between humans and rodents, promoting the spread
of the disease in the human population.

The HealthMap/ProMED-mail interactive map of Nigeria is available at
<http://healthmap.org/promed/en?v=9.6,6.1,6>,
and a map of the states of Nigeria showing the locations of the FCT
and the adjacent state of Nassarrawa is available at:
<http://www.waado.org/nigerdelta/Maps/Ni ... tates.html>.
- Mod.CP]

Uganda - Meningokokken-Meningitis
02.03.2009

Der Ausbruch im Nordwesten des Landes, bei dem bis Anfang Februar mehr als 3.300 Personen erkrankten und 42 Personen verstarben, scheint unter Kontrolle zu sein. Nach Angaben des Gesundheitsministeriums wurden in den letzten Wochen keine weiteren Erkrankungsfälle registriert. Betroffen waren die Distrikte (Arua, Hoima und Masindi). Während der Trockenzeit (Dezember-April) kommt es in den Ländern des „Afrikanischen Meningitisgürtel“ regelmäßig zu Meningokokken-Epidemien. Impfschutz beachten. / Quelle: crm

UNDIAGNOSED DEATHS - ZAMBIA: (CENTRAL) REQUEST FOR INFORMATION
**************************************************************
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<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: Fri 27 Feb 2009
Source: AllAfrica, Times of Zambia, report [edited]
<http://allafrica.com/stories/200902270587.html>


Zambia: mystery illness needs quick identification
--------------------------------------------------
The mysterious illness that has hit the people of Chisomo area in
Serenje District [Central Province] needs to be quickly identified
and contained to curb further loss of life among the villagers. Since
Wednesday [25 Feb 2009] when 9 people died as the strange disease
broke out, the death toll has quickly risen to 11 and could climb
even further if the problem was not identified.

This may explain the panic that the disease has spread among the
residents of Chisomo, who are reportedly running away from medical
authorities investigating the killer disease. Be that as it may, it
will not help these important investigations if the people of Chisomo
do not cooperate with those tasked to address their problem.

It appears that the people of Chisomo may be running away from the
health authorities out of ignorance and there is need to step up
publicity on the importance of cooperating with the probe team. The
office of the district commissioner in Serenje can help address this
problem by mobilising opinion leaders such as teachers, pastors,
and traditional leaders to educate the people about the
investigation. The mobilisation of local opinion leaders needs to be
done as a matter of urgency because any further delays may result in
more deaths. The local leaders have a duty to help in the
sensitisation of the community and ensure that villagers there
co-operate with the medical staff.

The staff on the ground have already ruled out cholera and we hope
that those studying the samples will expedite the process and
identify the disease. From the reports, the disease may spread
further as it appears to be highly infectious and kills quickly. The
fact that 11 people have died within a matter of days in itself
renders the problem in Serenje an emergency and hopefully the
ministry of health will move in quickly. It is also hoped that
movement to and from the area will be strictly monitored to avoid the
spread of the disease.

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

[From the scanty description of the illness above, it is difficult to
develop any differential diagnosis. The exclusion of cholera suggests
that disease is probably not food or water-borne. Any disease
occurring in central Africa that is inducing panic in a rural
population, and apparently highly lethal, could be attributed to one
of several viral hemorrhagic fevers (although in the present case
hemorrhagic symptoms are not specifically mentioned). The Serenje
district of Zambia is close to the border with DR Congo (see
<http://www.lib.utexas.edu/maps/africa/zambia_pol01.jpg>), hence
Ebola or Marburg fevers are remote possibilities. Recently an
initially undiagnosed disease affecting several patients in South
Africa, but contracted in Zambia, was caused by a previously unknown
arenavirus (see ProMED-mail archive references below). Further
information is awaited.

The HealthMap/ProMED-mail interactive map of Zambia can be accessed at
<http://healthmap.org/promed/en?g=918296 ... 3,30.667,5>. - Mod.CP]

Meningococcal disease in Nigeria - update
04.03.2009 - WHO

The Ministry of Health of the Federal Republic of Nigeria has reported 5 323 suspected cases of meningococcal disease including 333 deaths (case-fatality rate: 6.3%) from 1 January to 22 February 2009. Suspected cases have been reported from 22 of 37 states. So far 89 Local Government Area's (LGA) across 12 states have crossed the alert or the epidemic threshold. In the last week alone, 1 817 suspected cases including 105 deaths (case-fatality rate: 5.8%) have been reported, with 28 LGAS crossing the epidemic threshold, and 29 the alert threshold.

Cerebrospinal fluid specimens collected from Gombe, Jigawa, Kano and Katsina states have tested positive for Neisseria meningitidis serogroup A by latex test and/or culture. The International Coordinating Group (ICG) on Vaccine Provision for Epidemic Meningitis Control has approved the release of 1,010,000 doses of polysaccharide vaccine for mass vaccination campaigns in affected LGAs of Jigawa and Katsina states. Immunization campaigns will be implemented by Federal and National Ministry of Health with the support of WHO and partners, including the European Commission Humanitarian Aid Department (ECHO), Médecins sans Frontières and UNICEF.

Given the large population at risk, the early start of epidemics, and current moderate global vaccine levels, a sound vaccination strategy is of particular importance. WHO is supporting the Federal and National Ministry of Health in the assessment of vaccine needs. WHO is also providing technical and material support to the Ministry of Health to strengthen epidemiological and laboratory surveillance, including provision of laboratory confirmation supplies.

LASSA FEVER - NIGERIA (03)
**************************
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: Thu 5 Mar 2009
Source: AllAfrica, This Day (Nigeria) report [abbreviated & edited]
<http://allafrica.com/stories/200903050024.html>


Health Minister Babatunde Osotimehin said Lassa fever had [caused] 12
cases with 5 deaths within 2 weeks. He said: "Much more worrisome is
the danger that the outbreak poses to health workers. Do far, 4
health staff working in the National Hospital, Abuja who were taking
care of one of the Lassa fever cases have also fallen ill and the
laboratory investigations have confirmed they are infected with Lassa
fever [virus].

"Within the last 2 weeks, we have recorded 13 cases with 6 deaths
(CFR of 42 percent). 4 health staff working in the National Hospital,
Abuja, who were taking care of one of the Lassa fever cases have also
fallen ill and laboratory investigations have confirmed they are
infected with the Lassa virus." The minister has therefore directed
that Ribavirin, a specific antiviral drug for Lassa fever, be given
to Federal Capital Territory (FCT) Health Department and health
facilities in FCT and its environs for prompt and adequate treatment
of cases and contacts.

He also advised that people should [avoid] having contact with rats
by putting food in rat-proof containers, keeping their homes clean to
discourage rats from entering, and setting traps in and around homes
to help reduce rat population, among others. "The Federal Ministry of
Health is striving to create awareness and give appropriate
information to prevent the spread of the disease. The ministry
wants the general public and parents in particular to know the
symptoms," he said.

Yesterday [4 Mar 2009], the Senate urged the Federal, State, and Local
Governments to set machinery in motion to check the spread of Lassa
fever. This was consequent upon a motion sponsored by Senator Abubakar
Sodangi (PDP, Nasarawa West) and 10 other senators. Sodangi said Lassa
fever was a dangerous communicable disease.

Deputy Minority Leader, Senator Olorunnimbe Mamora (AC, Lagos East),
who is a medical doctor, said Lassa fever was not caused by eating
rats [large field rats are a tasty morsel in Nigeria. - Mod.JW], but
a virus carried by rats.

[Byline: George Oji, Sufuyan Ojeifo, Dayo Thomas, Segun Awofadeji]

--
Communicated by:
ProMED-mail Rapporteur A-Lan Banks

[Undoubtedly a serious epidemic of Lassa fever is occurring in the
Federal Capital Territory and adjacent regions, but the precise number
of cases and fatalities is difficult to determine. The figures cited
in the report above differ from those given in the previous report;
see 'Lassa fever - Nigeria (02) 20090225.0788'. The most significant
additional circumstance is the occurrence of nosocomial transmission
in a healthcare setting.

The HealthMap/ProMED-mail interactive map of Nigeria is available at
<http://healthmap.org/promed/en?v=9.6,6.1,6>,
and a map of the states of Nigeria showing the locations of the FCT
and the adjacent state of Nasarawa is available at
<http://www.waado.org/nigerdelta/Maps/Ni ... tates.html>. - Mod.CP]

LASSA FEVER - NIGERIA (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: 5 Mar 2009
Source: IRIN, Humanitarian News and Analysis [edited]
<http://www.irinnews.org/Report.aspx?ReportId=83309>


Nigerian health officials are working to contain a resurgence of Lassa
fever, a highly infectious disease that has killed at least 8 people
in the past month (February 2009]. The World Health Organization (WHO)
said over 93 cases of the virus [infection] had been confirmed in the
capital Abuja and neighboring Nasarawa state since December [2008].

At the Irrua Specialist Teaching Hospital in Edo state, confirmed
cases rose by 60 percent from December 2008 to January 2009. "That is
a major increase, and, furthermore, these are just the cases we hear
about in hospital," Marguerite Lamunu, WHO Lassa fever expert, told
IRIN. "In reality, there will probably be many more cases and deaths
in the community, plus the disease is spreading from state to state."

Lassa fever is an acute viral hemorrhagic condition transmitted
through contact with the urine or feces of rodents, especially rats
and shrews. It was 1st discovered in 1969 in the town of Lassa in
northern Nigeria's Borno state. Lassa fever can also be transmitted
through direct contact with the bodily fluids and feces of an
infected person or through airborne particles, according to Osi-Ogbu.

"We have an epidemic on our hands," Ogugua Osi-Ogbu, head of Lassa
fever prevention and care at the National Hospital in Abuja (NHA),
told IRIN. The disease, which has an incubation period of one to 3
weeks, has become endemic in parts of West Africa, where it kills at
least 5000 people each year among 300 000 to 500 000 cases, according
to WHO. The illness is especially severe late in pregnancy, killing
the fetus and/or the mother in more than 80 percent of cases.

The Nigerian Federal Ministry of Health has alerted all 36 state
Health Ministries, directing them to step up public awareness
campaigns on preventing Lassa fever. "We have embarked on a rigorous
campaign on the radio to sensitize our people on the dangers of Lassa
fever, how it is contracted and effective measures to avoid
infection," Kano State Health Commissioner Aisha Isyaku Kiru told
IRIN. "We are specifically calling on the people to observe and
improve community hygiene through proper refuse disposal to
discourage rats from taking refuge, and keeping food and drinking
water in containers not accessible to rats," Kiru said.

According to residents, many ethnic groups consume rodents,
especially rats, hedgehogs and badgers. Undergrowth is often burned
to smoke out rodents for ''bush meat," as it is known locally,
driving the animals to take shelter in homes, thereby increasing the
risk of Lassa fever infection. "Rodents are a source of meat to many
of our people and the government needs to ban their consumption to
effectively contain Lassa fever spread," said Bernard Ayorchia, a
private medical doctor in the central Nigerian city of Makurdi.

Another hurdle in tackling Lassa in Nigeria is the lack of
laboratories. Only 2 facilities, in the southern states of Lagos and
Edo, are equipped to diagnose the illness. Initial symptoms, which
include headache, sore throat, muscle pain, chest pain, nausea,
vomiting, diarrhea and coughing, are similar to those of malaria,
which can also make diagnosing Lassa fever difficult, according to
the WHO. Severe cases may progress to bleeding from the mouth, nose,
vagina or gastrointestinal tract. In late stages, seizures, shock,
tremors and coma can occur.

"The government must urgently provide laboratories for diagnosing
Lassa fever in all parts of the country," said NHA's Osi-Ogbu. "Early
detection of the virus and a prompt response are key in saving the
life of an infected person."

WHO plans in the coming days to send an evaluation team to affected
states in Nigeria to assess the scale of the outbreak.

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

[It is clear from the reaction of the Nigerian healthcare authorities
that the epidemic of Lassa fever is continuing to spread, but its
true extent is difficult to assess. The estimated figure of at least
8 fatalities and 93 confirmed cases has not changed since the
previous report from Nigeria on 24 Feb 2009. It is stated also that
the epidemic is spreading beyond the Federal Capital Territory (FCT)
and Nasarawa, but the other states now affected are not named. The
emphasis of the report concerns rodent control, but it would be
relevant also to determine the extent of person-to-person
transmission of infection in the development of the epidemic and to
provide appropriate advice.

The HealthMap/ProMED-mail interactive map of Nigeria is available at
<http://healthmap.org/promed/en?v=9.6,6.1,6>,
and a map of the states of Nigeria showing the locations of the FCT,
in the center (red), the adjacent state of Nasarawa (orange), and Edo
state (in SW, red) is available at:
<http://www.cladiya.com/07MNIAsite/image ... p-prov.gif>
- Mod.CP/JW]

HEPATITIS E VIRUS - UGANDA: (PADER)
***********************************
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<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: Mon 9 Mar 2009
Source: The Daily Monitor (Uganda) [edited]
<http://www.monitor.co.ug/artman/publish ... 1220.shtml>


At least 12 new cases of hepatitis E virus have been reported in
Pader District, a top official of a taskforce instituted to eliminate
the disease in the district has confirmed. Mr Charles Kulwa told the
Daily Monitor on Friday [6 Mar 2009] the outbreak was first reported
on 21 Feb 2009. "There are 12 persons that are suspected to have
hepatitis E, according to their symptoms," he said. Mr Kulwa said the
affected persons are from Pajule in Kibong village were 5 cases have
been reported; 2 other cases were in Payimol; 2 in Acholi bur; Lapul
village had 2; and one person in Awere. All the cases are of school children.

He added that they are not leaving anything to chance in the fight
against the epidemic. "The task force, is on the ground to sensitise
people on hygiene in their areas of return [resettlement?] and in the
camps," Mr Kulwa said. Sanitation in the district is worrying as only
22 per cent of the families have toilets. The rest ease themselves in
bushes and this explains the continued contamination of water points
in the district.

Hepatitis E is a waterborne disease. The health inspector in charge
of Aruu County, Ms Ruth Among, said blood samples where taken to
Kampala on Thursday [5 Mar 2009] for tests. "While we are waiting for
the results from the samples, we are treating these people because
they have all the symptoms of persons with hepatitis E," she said.
The disease has found a safe ground in northern Uganda. In the 1st 4
weeks of this year [2009], Kitgum District had 53 cases.

The cumulative number of hepatitis E cases to date [9 Mar 2009]
stands at 128 since the epidemic was first reported on 21 May 2008.

[By Cissy Makumbi]

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

[In its weekly update on epidemics released on 6 Mar 2009, the
Ministry of Health Uganda reported a total of 12 new cases of
hepatitis E in Pader district during the 9th epidemiological week.
This brings the cumulative case count in Pader district to 118 cases
(10 cases excluded since they were already line listed in the
neighboring district of Kitgum) with 7 deaths and a case fatality
rate of 5.9 per cent since the outbreak started on 21 May 2008. The
majority of the cases have been reported from Pader TC, Atanga
sub-county, Acholi bur sub-county, Kilak sub-county, Pajule
sub-county, Paimol, and Laguti sub-counties. Most of these are
bordering Kitgum district, which is the epicenter of the hepatitis E
outbreak in Northern Uganda. The District Task Force is coordinating
the rolling out of interventions to improve sanitation and hygiene
practices, access to safe water including safe water chain. - Mod.JFW.

A map of the administrative districts of Uganda showing Pader to the
south of Kitgum, in the north of the country, can be accessed at
<http://www.un.org/Depts/Cartographic/ma ... uganda.pdf>.
The HealthMap/ProMED-mail interactive map of Uganda is available at
<http://healthmap.org/r/005N>. - Mod.CP]

CHOLERA, DIARRHEA & DYSENTERY UPDATE 2009 (16)
**********************************************
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<http://www.promedmail.org>
ProMED-mail is a program of the
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In this update:
Africa
[1] Cholera - Zimbabwe: WHO
[2] Cholera - South Africa
[3] Cholera - Somalia (Middle Shabelle)
[4] Cholera - Kenya (Eastern Province), Ethiopia (Oromia Region)
[5] Cholera - Zambia (Central Province)
[6] Cholera - Botswana


******
[1] Cholera - Zimbabwe: WHO
Date: Sun 8 Mar 2009
Source: UN Office for Coordination of Humanitarian Affairs (OCHA),
ReliefWeb, Government of Zimbabwe; WHO report [edited]
<http://reliefweb.int/rw/rwb.nsf/db900SI ... c=1&cc=zwe>


Zimbabwe: daily cholera update and alerts, 8 Mar 2009
-----------------------------------------------------
Highlights of the day:
- 255 cases and 2 deaths added today (in comparison 631 cases and 18
deaths yesterday [7 Mar 2009])
- 32.2 percent of the districts affected have reported today (19 out
of 59 affected districts)
- 90.3 percent of districts reported to be affected (56 districts out of 62)
- cumulative institutional case fatality rate 1.8 percent
- daily institutional case fatality rate 0.4 percent

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

[In the 25 reporting days since the last ProMED-mail posting, the
total number of cases reported in the full report has increased by 16
013 from 73 105 to 89 018 and the total fatality count has increased
by 498 from 3513 to break the 4000 barrier at 4011. This corresponds
to a daily increase in cases of 640 and in deaths of 20. The
horrendous outbreak continues to spread to new areas and the overall
case fatality rate, reflecting the overall poor conditions in the
country, although decreasing slightly remains very high at 4.5 per
cent. The full report can be found at
<http://reliefweb.int/rw/rwb.nsf/db900si ... report.pdf>

An up-to-date map of the epidemic can be found at
<http://reliefweb.int/rw/fullMaps_Af.nsf ... penElement>

A map of Zimbabwe with provinces can be found at
<http://www.un.org/Depts/Cartographic/ma ... mbabwe.pdf>.
The HealthMap/ProMED-mail interactive map of Zimbabwe is available at
<http://healthmap.org/promed/en?v=-19,29.9,6>. - Mod.LL]

******
[2] Cholera - South Africa
Date: Mon 9 Mar 2009
Source: Agence France-Presse (AFP) [edited]
<http://www.google.com/hostednews/afp/ar ... nxkaRGodHA>


A cholera outbreak in South Africa is being brought under control
after 59 people died and more than 12 000 were infected since
November 2008, the health department said on Monday [9 Mar 2009].

"We are seeing a very welcome decline in figures," said Thami
Mseleku, the department's director-general. Most of the cases were in
regions near the border with Zimbabwe, where more than 4000 people
have been killed by the disease. But officials said the outbreak in
South Africa could not be blamed entirely on Zimbabwe.

"Cholera started to develop in South Africa as a consequence of
general living conditions and unsafe water supplies," Health Minister
Barbara Hogan told a press briefing. Government also defended the
decision to shut down a makeshift refugee camp on the Zimbabwe border
housing thousands of asylum seekers, saying the conditions there were
appalling.

"The situation is totally untenable," said Water Minister Lindiwe
Hendricks. She said crowds at the municipal showgrounds often swelled
to 8000 in the evenings as farmworkers came to try and receive food
parcels meant for asylum seekers in the border town of Musina. Global
medical charity Doctors Without Borders had on denounced plans to
shut down the refugee camp.

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

[A map of the country of South Africa can be found at
<http://www.un.org/Depts/Cartographic/ma ... uthafr.pdf>.
The HealthMap/ProMED-mail map of South Africa is available at
<http://healthmap.org/promed/en?v=-29,25.1,5>. - Mod.LL]

******
[3] Cholera - Somalia (Middle Shabelle)
Date: Sun 8 Mar 2009
Source: AllAfrica, Shabelle Media Network (Mogadishu) report [edited]
<http://allafrica.com/stories/200903091184.html>


At least 11 people died of cholera for the last 24 hours in Qordheer
village in Rage Elle District in Middle Shabelle [Shabelle Dhexe]
Region in south-central Somalia, Shabelle's Shador Haji reported on
Sunday [8 Mar 2009]. 8 children and 3 women are confirmed dead in the village.

Sheik Ali Dhere, a resident in Rage Elle said there were people who
are now sick and need a helping hand. Qordheer village does not have
a [health] center. There is also a water shortage and drought in the area.

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

[A map of Somalia can be found at
<http://www.un.org/Depts/Cartographic/ma ... omalia.pdf>.
The HealthMap/ProMED-mail interactive map of Somalia is available at
<http://healthmap.org/promed/en?v=6.1,47.9,5>. - Mod.LL]

******
[4] Cholera - Kenya (Eastern Province), Ethiopia (Oromia Region)
Date: Thu 5 Mar 2009
Source: Kenya Broadcasting Corporation (KBC) [edited]
<http://www.kbc.co.ke/story.asp?ID=55976>


3 people have died and 46 others have been treated at Moyale District
Hospital following an outbreak of cholera. Area acting Medical
Officer of Health Dr Abdullahi Jaldesa said 5 people were currently
admitted at the hospital while the rest were treated and discharged.

Dr Jaldesa said specimens taken from the patients were examined by
the Disease Control Surveillance Unit from Embu, which confirmed the
cholera outbreak. He said the disease was first spotted across the
border in Ethiopia where 15 people have reportedly died and 108
others admitted at an emergency cholera treatment centre set up by
the Ethiopian government to contain the outbreak.

Dr Jaldesa said the most affected areas were Hellu, Biashara, and
Manyatta Burji on the outskirts of Moyale town.

[Byline: Rose Kamau]

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

[Moyale is located in the extreme northern aspect of the Eastern
Province and borders on the Oromia region of Ethiopia as seen on the
maps at <http://www.un.org/Depts/Cartographic/ma ... /kenya.pdf>
and <http://en.wikipedia.org/wiki/Regions_of_Ethiopia>. - Mod.LL]

******
[5] Cholera - Zambia (Central Province)
Date: Tue 3 Mar 2009
Source: AllAfrica, Times of Zambia report [edited]
<http://allafrica.com/stories/200903030574.html>


District Commissioner, Stanley Chibwana has said 3 more people have
died of suspected cholera in Chief Chisomo's area in Serenje,
bringing the total number to 14. Mr Chibwana said in an interview
yesterday [2 Mar 2009] the number of patients admitted to the local
clinic had also swelled to 10.

"Preliminary tests are so far pointing to cholera and we trying our
best to contain the situation to stop further deaths. Of all
admissions so far, 6 people have been discharged and we have opened
up 2 satellite camps in Kaombe and Chimbaya which shall later be
transformed into cholera bays," Mr Chibwana said.

Last Wednesday [25 Feb 2009], 9 people died after drinking suspected
contaminated water in Kaombe and Chimbaya areas in Vice-President
George Kunda's Muchinga constituency in Serenje district. Meanwhile,
the disaster management and mitigation unit (DMMU) under the office
of the vice-president has sent a helicopter to Serenje district to
help in transporting cholera patients to access medicine. Central
Province Minister, Ackimson Banda said the helicopter was meant to
access places that were not passable by road in Chief Chisomo area
where suspected cholera had broken out.

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

[Serenje is located in the Central Province of Zambia. Maps of the
country can be found at
<http://www.un.org/Depts/Cartographic/ma ... zambia.pdf> and the
HealthMap/ProMED-mail interactive map at
<http://healthmap.org/r/005Y>. - Mod.LL]

******
[6] Cholera - Botswana
Date: Mon 2 Mar 2009
Source: AllAfrica, Mmegi report [edited]
<http://allafrica.com/stories/200903030183.html>


Cholera cases have been on the rise since last December [2008]. At a
press briefing on the update on the cholera situation in Botswana,
public health director Shenaaz El-Halabi said by 15 Dec 2008, 8
suspected cholera cases were reported, 3 of which were confirmed.

She revealed that since 24 Feb 2009, 55 suspected cases of cholera
have been reported in various districts. El-Halabi said of the 55, 15
have been confirmed to be cholera and of the number, 2 deaths have
been reported at Princess Marina and Maun General hospitals. Both
fatalities, she added, are a man and woman of Zimbabwean origin.

"All confirmed cases are adults, 5 males and 10 females. The
nationalities of the confirmed cases are 2 from Botswana, a Zambian,
and 12 Zimbabweans. The 1st Motswana [the singular form of Botswana -
Mod.LL] case is originally from Zimbabwe. She has no history of
having recently left Botswana. The 2nd Motswana is from Palapye and
has also reported never being out of the country recently. Contact
tracing is ongoing for these cases and steps to trace possible source
of infection is also ongoing," she said.

[Byline: Ephraim Keoreng]

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

[Maps of the southern African country of Botswana can be found at
<http://www.statistiques-mondiales.com/c ... swana2.jpg> and the
HealthMap/ProMED-mail interactive map at
<http://healthmap.org/promed/en?v=-22.2,23.8,5>. - Mod.LL]

Angola - Tollwut
10.03.2009

Der Tollwut-Ausbruch in der Hauptstadt Luanda hält weiter an. Bis Mitte Februar sind bisher 69 Personen an der Tollwut verstorben. Bei der Mehrzahl handelt es sich um Jungen die von streunenden Hunden gebissen worden sind. Die Regierung startete im Januar eine großangelegte Aktion zur Impfung bzw. Keulung von Hunden in Luanda. Bei entsprechenden Kontakten sofort einen Arzt aufsuchen, bei vorhersehbarem Risiko und längerem Aufenthalt wird eine vorbeugende Impfung empfohlen. / Quelle: crm
________________________________________

Namibia - Tollwut
10.03.2009

Aus der Hauptstadt Windhoek wird eine ungewöhnliche Häufung von Tollwut-Fällen bei Hunden gemeldet. Nach Angaben des veterinärmedizinischen Instituts erkrankten in den letzten Wochen fast 50 Hunde an der Tollwut. Eine groß angelegte Impfkampagne wurde initiiert. Nach verdächtigen Tierkontakten ist sofort ein Arzt aufzusuchen. Da eine adäquate postexpositionelle Versorgung in Afrika nicht immer gewährleistet ist, sollten Risiko-Reisende prophylaktisch geimpft sein. / Quelle: crm

RABIES, CANINE, HUMAN - ANGOLA (05): LUANDA
*********************************************
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 11 Mar 2009
Source: ReliefWeb [edited]
<http://www.reliefweb.int/rw/rwb.nsf/db9 ... YAH-7Q2S7E>


One of the most severe rabies epidemics to hit Angola has claimed the
lives of at least 93 children within 3 months in the capital, Luanda.
"The 93 children were brought to our hospital and are the only ones
we know of, so the number could be higher," said Luis Bernardino,
head of the Hospital Pediatrico David Bernardino in Luanda, the
country's largest referral hospital. "The number of cases has,
however, started declining now." He said the hospital was unable to
save any of the children, as it had run out of doses of rabies
vaccine; in some instances, the children were brought in too late.
"It is a sad moment for us," said Bernardino.

Francois Meslin, the rabies expert at the World Health Organisation
(WHO) headquarters in Geneva, said in the last severe rabies
outbreak, from 1998 to 2003 in Indonesia's Flores Island, 100 people
had died within a year. "The high number of deaths in Luanda within
the short period of time is a cause for serious concern and calls for
a thorough investigation."

Rabies is an incurable viral disease transmitted by close contact
with saliva from infected animals, usually canines or rodents. It can
be prevented by vaccination, either pre-exposure or as part of
post-exposure treatment. However, once the symptoms of the disease
develop, it is fatal in both animals and humans.

Post-exposure treatment comprises 5 doses of the vaccine and has to
start "as soon as possible" to prevent the symptoms from developing,
Meslin said. The disease attacks the respiratory, gastrointestinal
and/or central nervous systems, leading to paralysis followed by coma
and death in all cases, usually due to respiratory failure.

Luanda's large stray dog population has been identified as causing
the spread of the disease. "We have had some sporadic cases in other
provincial capitals in the country; we think the virus was brought
into Luanda and then spread through the dogs; Angolans love dogs,"
said Bernardino.

The capital was built to accommodate around 400 000 people but now
has a population of more than 4.5 million, most of whom live in
unhygienic conditions in "musseques" or slums.

The outbreak has raised concerns over the slow reaction of the
Angolan authorities. "When the 1st 10 deaths were reported in
December 2008, we alerted the authorities, but we do not have
veterinary services in the city, no kennels [to keep and observe the
animals] and vaccinate them," said Bernardino. There were also not
enough vaccines available. "I think it was probably that no one was
prepared for such a high case load," he said. A vaccination campaign
is underway. "We now also have enough vaccines in stock. The cases
have started dropping now; we have 12 cases in one week, it dropped
to 4 cases, and this week, it is down to 3," Bernardino told IRIN.

Developing countries are often unable to afford rabies treatment,
which is prohibitively expensive, said Melvin. "One dose costs about
USD 10, and 5 of those have to be administered, which makes the total
cost of treatment USD 50, which is more than what a family can earn
in a month in most developing countries." Besides the vaccine, "in
instances where the person has been heavily exposed, with multiple
bites in the head," that person also has to be given rabies
immunoglobulin to prevent death, which can cost another USD 50. "The
treatment can be a huge drain on public health services, especially
in countries where the vaccines are given free."

Melvin said there was a global shortage of the vaccines. "As there
are few registered manufacturers who meet the WHO guidelines, the
supply cannot keep up with the demand." At least 55 000 people die
from rabies every year in Asia and Africa; most of the victims are children.

[This article does not necessarily reflect the views of the United
Nations or its agencies.]

--
Communicated by:
ProMED-mail Rapporteur Brent Barrett

[The number of child deaths in this rabies outbreak in Luanda, the
capital city of Angola, has risen from 63 on 18 Feb 2009 to at least
93 known child deaths on 10 Mar 2009. The number of adult deaths is
not reported. The outbreak is now thought to be in decline, as judged
by the number of children admitted to the main referral hospital per
week. Unfortunately, none of the children admitted to hospital has
been saved due to the lack of vaccine and immunoglobulin for
post-exposure treatment, in part due to the global shortage of
vaccine and its high cost. Control of the urban dog population
remains unresolved due to the absence of appropriate veterinary
services, although adequate supplies of canine vaccine are said to be
available. Until progress is achieved in control of the dog
population, it is unlikely that there will be an early end to this outbreak.

The HealthMap/ProMED-mail interactive map of Angola showing the
location of Luanda in the north of the country can be accessed at:
<http://healthmap.org/promed/en?v=-12.3,17.5,5>. - Mod.CP]

FOOD POISONING, CASSAVA - CAMEROON, CENTRAL AFRICAN REPUBLIC
***********************************************
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 Mar 2009
Source: All Africa [edited]
<http://allafrica.com/stories/200903110496.html>


The consumption of toxic compounds with improperly prepared cassava
with high cyanogenic potential has caused disastrous consequences in
some regions of Cameroon and the Central African Republic, provoking
an outbreak of Konzo, a new disease that causes paralysis of both legs.

The French-based humanitarian NGO, Medicins Sans Frontires and the
United Nations Children Emergency Fund (UNICEF) reported the disease
in August last year [2008] in the East and Adamawa regions of Cameroon.

Health experts and researchers say Konzo occurs abruptly within
minutes or hours in previously healthy persons whose diets consist
almost exclusively of foods from roots of bitter cassava which have
not been properly processed. General symptoms of the disease include
deafness, blindness, aggravated goiter, partial or total paralysis of
arms and cranial nerves, and acute cyanide intoxication, which
appears 4-6 hours after consumption and consists of vomiting,
collapse and, in some cases, death.

In order to overcome the outbreak of the disease in Cameroon and the
Central African Republic, the International Institute of Tropical
Agriculture (IITA) took the initiative to organize a meeting of
stakeholders at IITA-Nkolbisson last Tues 3 Mar 2009 to identify
strategic preventive measures and approaches to eliminate the
disease. Experts drawn from health and research institutions,
international NGOs, UN agencies and universities, including
representatives of partner organizations (IITA, IRAD, FAO, CRS,
PNDRT, MINADER, MINSANTE, MINRESI, UNICEF, CODAS Bertoua, SARB
Batouri, Universities of Buea, Ngaoundre and Yaound 1) brainstormed
and identified strategic preventive measures and approaches to
eliminate Konzo as well as build potential partnerships. In effect,
the meeting brought up a multi-faceted proposal including a baseline
survey and sensitization campaign, introduction of improved cassava
varieties with low cyanogenic potential, reduction in malnutrition,
and empowerment of local communities in post harvest processing
options and capacity building.

--
Communicated by:
ProMED-Mail Rapporteur Susan Baekeland

[Konzo is an epidemic paralytic disease. Outbreaks are associated
with several weeks of almost exclusive consumption of insufficiently
processed bitter cassava
<http://en.wikipedia.org/wiki/Cassava>. Often, women and children
are more prominently seen as being affected and generally more often
in remote rural areas of East and Central Africa. Konzo translates as
"bound legs." The sudden onset of paralysis (hypertonic paraparesis)
is symmetrical and permanent, but does not progress. The onset is
reported to occur within minutes to a few hours at some point
following a diet that is high in cyanide from improperly prepared
cassava. The cyanide is released from the glucosides. Normally, the
cyanide-glucosides are bound and are removed by the processing of the
cassava root. When the processing is incomplete or not done at all,
the cyanide can be released. During food shortages, war and other
severe disruptions of life in poor rural cassava-growing communities,
the population has to make shortcuts in normal processing. A number
of epidemiological studies implicate the combination of high cyanide
intake and simultaneous low intake of sulfur amino acids needed to
detoxify cyanide as the main etiological factor. Familial clustering
is observed. Epidemics typically occur in the dry season in
households living in absolute poverty that have sustained themselves
for weeks or months on bitter cassava. It is noteworthy that not one
single case of any similar type of upper motor neuron damage has been
reported from cyanide exposure without simultaneous protein
malnutrition and, even more, that no case of Konzo has yet been
reported from poor cassava eating populations in South America.

There are varieties of cassava root that do not contain the cyanide
compound. Generally, the argument for using the cyanide containing
plant is its resistance to insects, which is apparently lacking in
the varieties without cyanide.

Konzo begins abruptly, without any warning or prodromal signs. The
initial symptoms are described as tremor, cramps, a heavy feeling
and/or weakness in the legs, a tendency to fall down and difficulty
remaining upright. There is a visible hypertonic gait when walking or
running. Occasionally, there will be lower back pain, blurred vision,
speech difficulties and/or paresthesia of the legs, but they
disappear within a month. During the 1st 2 days, the majority of
patients have general muscular weakness and are confined to bed.
Hypertonicity is present from day one. Flaccid paralysis of the limbs
does not occur. Later, there is a slight partial improvement.
Finally, the affected person develops a stable hypertonic
paraparesis, which persists for the remainder of life. Although the
patient is affected physically, there is no mental impairment, and
children should continue their education.

Unfortunately for the victims, there is no good treatment once the
limbs are affected. There may be some improvement with a varied diet.
Prevention is the best means of control of these outbreaks. A more
varied diet is imperative to prevent the symptoms.

Portions of this comment were extracted from:
<http://en.wikipedia.org/wiki/Konzo> and
<http://www.itg.be/itg/distancelearning/ ... ntsp13.htm>.
- Mod.TG]

LASSA FEVER - UNITED KINGDOM ex MALI (02): FATAL
************************************************
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: Thu 12 Mar 2009
Source: Eurosurveillance edition 2009; 14(10) [edited]
<http://www.eurosurveillance.org/ViewArt ... leId=19145>


The 1st case of Lassa fever imported from Mali to the United Kingdom,
February 2009
----------------------------------------------------------------------
[Authors: S Atkin1, S Anaraki1, P Gothard2, A Walsh3, D Brown4, R
Gopal4, J Hand4, D Morgan3
1. Health Protection Agency, North East and North Central London
Health Protection Unit, London, United Kingdom
2. Hospital for Tropical Diseases, University College London
Hospitals NHS Foundation Trust, London, United Kingdom
3. Health Protection Agency, Gastrointestinal, Emerging and Zoonotic
Infections (GEZI) Department, Centre for Infections, Colindale, United Kingdom
4. Virus Reference Dept (VRD), Centre for Infections, Colindale,
United Kingdom]

In February 2009, the 12th recorded case of Lassa fever, since
surveillance records are available, was imported to the United
Kingdom (UK). This is the 2nd case to be imported to the UK in 2009
and the 1st reported case to have acquired infection in Mali. Risk
assessment of 117 UK healthcare contacts with potential direct
exposure to the patient's body fluids was undertaken. 7 contacts are
considered to be at high risk of infection and are being actively
monitored for 21 days.

Background
----------
Lassa fever is caused by an arenavirus and is an acute illness of
between one and 3 weeks duration. The incubation period is usually 7
to 12 days but may range between three and 21 days. About 80 percent
of human infections in endemic areas are asymptomatic. The overall
case fatality rate is 1 percent, although it is reported to be 15
percent-20 percent in hospitalised patients (1,2).

The natural host of Lassa virus is the multimammate rat (_Mastomys_
species), which sheds the virus in urine and droppings. Transmission
of the virus to humans usually occurs via direct or indirect contact
with rodent excreta. Person-to-person transmission occurs through
direct contact with blood, saliva, urine, faeces, or semen (1).

Lassa fever is known to be endemic in parts of West Africa, with most
cases reported from Guinea, Liberia, Sierra Leone and Nigeria. People
living in rural areas of West Africa are most at risk of Lassa fever.
Imported cases to the UK are rare and occur almost exclusively in
individuals who have worked in endemic areas in high risk occupations
such as medical or development workers (4). Although there is some
evidence of endemicity in neighbouring countries (1,3-5), this is the
1st case of imported Lassa fever from Mali into the UK.

Clinical case description
-------------------------
In February 2009, a man in his 20s was admitted to University College
Hospital in London (UCLH) having been medically evacuated from Mali
with a 10-day history of fever and a diagnosis of falciparum malaria
that did not respond to treatment. He had been in a village in
southern Mali for 4 weeks, where he was working in remote rural
conditions on the border with the Ivory Coast. He had travelled
directly from the UK to Bamako, Mali and then travelled overland to
southern Mali. Although precise details of possible exposure to
rodents are not known, rodents including rats were seen regularly in
the village.

On arrival the patient was alert and able to give a clear report on
his medical history. However, he deteriorated rapidly and was
transferred to a negative pressure room in the intensive care unit.
He died of multi-organ failure later the same day. His malaria blood
film and rapid antigen test were negative and a diagnosis of Lassa
fever was confirmed the same night by PCR.

The patient was originally considered at low risk of Lassa fever
because the disease has never been reported in Mali and is thus not
considered endemic there. However, as he became more unwell his
status was upgraded. Standard universal infection control precautions
were followed and visors, but not full body protection, were worn
during the attempted resuscitation.

Virological analysis
--------------------
The diagnosis was confirmed in 2 different reverse transcription PCR
(RT-PCR) assays targeting different regions of the genome and by
sequencing of the 291 amino acids at the N-terminus of the Lassa
virus glycoprotein C (6). The detection of Lassa virus in 2 different
RT-PCRs together with the characterisation of a unique part of the
Lassa virus genomic sequence constituted a definitive diagnosis.
Further studies including virus culture are in progress, and
sequencing of the entire genome of the isolate is planned.

Phylogenetic analysis showed that the virus was distinct from other
Lassa virus strains but grouped most closely with a strain of Lassa
virus (Lassa (AV)) isolated from a case reported from Germany in 2000
(7) . The German patient had travelled through Ivory Coast, Ghana,
and Burkina Faso during the incubation period and the investigations
could not determine where he had acquired the virus. The British case
reported here had been working close to the border with Ivory Coast.
[The original text is accompanied by a figure showing the
phylogenetic relationship of the Mali virus with other African arenaviruses].

Surveillance and management of contacts
---------------------------------------
An Incident Control Team (ICT) meeting was called by UCLH early the
following day to discuss risk assessment of contacts, safe
decontamination of the environment, and management of the body. The
ICT identified 123 people who could have come into direct contact
with the Lassa virus either through contact with the case or exposure
to body fluids. Almost all of these contacts were UCLH emergency care
and laboratory staff. All UK based contacts were assigned to one of 3
categories depending upon their level of risk (no risk, low risk, or
high risk, and were managed as reported recently (8). Contacts will
be monitored for 21 days from exposure.

None of the category 3 contacts received ribavirin prophylaxis. The
evidence base for the use of ribavirin prophylaxis is limited, but
category 3 contacts were given information explaining its possible
benefits and side effects and were left to make an informed choice.

The German air ambulance crew are being followed up and managed by
German authorities, and the World Health Organization (WHO) is
supporting health authorities in Mali in conducting field
investigations and in the implementation of control measures.

Discussion
----------
In the case described here, the reported diagnosis of malaria and the
fact that Mali has not been considered endemic for Lassa fever made
the clinical diagnosis difficult. As a consequence, the initial risk
of Lassa fever was considered low. Only when the patient developed
multi-organ failure 6 hours after admission was the risk of Lassa
fever upgraded. Universal barrier precautions were used throughout,
but not the high levels of protection currently recommended for viral
haemorrhagic fevers (9). As a result, 76 hospital staff were put at
risk in the space of 8 hours, and 3 of 7 category 3 contacts were
laboratory staff. Although transmission to healthcare workers from
imported Lassa fever cases is very rare, this can cause considerable
anxiety among contacts. There is only one reported case of
transmission in a hospital setting in an industrialised country, and
this was a seroconversion without clinical illness in Germany (10).

This is the 1st Lassa virus to be characterised from Mali. The virus
is closely related to isolates from neighbouring countries and was
amplified using a widely used diagnostic PCR test (6). There is
serological evidence that Lassa virus is present in Mali (3,5), but
this is the 1st proven imported case and has implications for current
risk assessment in travellers returning from this area.

References
----------
1. World Health Organization (WHO): Lassa fever. Fact sheet No 179.
Geneva, Switzerland: WHO; 2005 April. Available from
<http://www.who.int/mediacentre/factshee ... index.html>.
[Accessed 25 Feb 2009].
2. McCormick JB, Fisher-Hoch SP: Lassa Fever. Curr Top Microbiol
Immunol. 2002;262:75-109.
3. Richmond JK, Baglole DJ: Lassa fever: epidemiology, clinical
features, and social consequences. BMJ. 2003; 327(7426): 1271-5.
[Available from <http://www.bmj.com/cgi/content/extract/327/7426/1271>.]
4. Health Protection Agency (HPA). Lassa fever - fact sheet for
health professionals. London, United Kingdom: HPA. Available from
<http://www.hpa.org.uk/webw/HPAweb&HPAwe ... 1942149574>.
[Accessed 25 Feb 2009].
5. Frame D: Surveillance of Lassa fever in missionaries stationed in
West Africa. Bull World Health Organ. 1975; 52(4-6): 593-8. [Available from
<http://whqlibdoc.who.int/bulletin/1975/ ... 93-598.pdf>.]
6. Demby AH, Chamberlain J, Brown DW, Clegg CS: Early diagnosis of
Lassa fever by reverse transcription PCR. J Clin Microbiol. 1994;
32(12): 2898-903. [Available from <http://jcm.asm.org/cgi/reprint/32/12/2898>.]
7. Guenther S, Emmerich P, Laue T, Kuehle O, Asper M, Jung A, et al:
Imported Lassa fever in Germany: molecular characterization of a new
Lassa virus strain. Emerg Infect Dis. 2000; 6(5):466-76. [Available
from <http://www.cdc.gov/ncidod/EID/vol6no5/gunther.htm>.]
8. Kitching A, Addiman S, Cathcart S, Bishop L, Krahe D, Nicholas M,
et al: A fatal case of Lassa fever in London, January 2009. Euro
Surveill. 2009;14(6):pii=19117. Available from
<http://www.eurosurveillance.org/ViewArt ... leId=19117>.
9. Advisory Committee on Dangerous Pathogens: The Management and
Control of Viral Haemorrhagic Fever. London, United Kingdom: The
Stationery Office; 1997. [summary of document available at
<http://www.dh.gov.uk/en/Publicationsand ... DH_4008120>]
10. Haas WH, Breuer T, Pfaff G, Schmitz H, Kohler P, Asper M, et al:
Imported Lassa fever in Germany: surveillance and management of
contact persons. Clin Infect Dis 2003;36(10):1254-8. [Abstract available from
<http://www.ncbi.nlm.nih.gov/pubmed/1274 ... stractPlus>.]

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

[This case confirms the presence of a unique strain of Lassa fever
virus in the region of Mali close to its southern border with Cote d'Ivoire.

The HealthMap/ProMED-mail interactive map of the West-African country
of Mali can be accessed at
<http://healthmap.org/r/006r>. - Mod.CP]