Fatal Links to Ebola Uganda Super Spreader Increase
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Recombinomics Commentary
December 6, 2007
Government of Uganda and U.S. Centers for Disease Control and Prevention have confirmed 51 cases of suspected hemorrhagic fever, reported in Bundibugyo, Kabarole and Mbarara Districts since September 2007, as Ebola.
The most recently reported three cases, of whom one has died, were recorded in Kabarole’s Fort Portal and Mbarara, and referred to the Ebola Isolation Unit in Bundibugyo.
Health authorities have identified three clusters of infection, each originating from different sites by relative proximity. However, as the most recently identified case was not from the original areas of contamination, investigations are ongoing to determine if there has been an additional outbreak. Two isolation units have been established in Bundibugyo’s Kikywa Health Centre IV (8 cases) and district hospital (9 cases), managed with MSF Switzerland's support. A third centre was established in Kampala's Mulago Hospital (2 cases), managed with MSF Spain support.
The above comments, from a UNICEF report (http://www.reliefweb.int/rw/RWB.NSF/db900SID/DPAL-79MK8G/$File/Full_Report.pdf) dated December 5, 2007 indicate there has been significant spread of Ebola in Uganda (see satellite map (http://maps.google.com/maps/ms?ie=UTF8&hl=en&msa=0&t=h&om=0&msid=106484775090296685271.000440a9f060622a05059&ll=1.274309,32.124023&spn=4.93011,7.086182&z=7)). Earlier reports had described the death (http://www.recombinomics.com/News/12040704/Ebola_Kampala.html) of Dr Jonah Kule, 41M, in Mulago Hospital in Kampala, but the above report indicates there are two confirmed cases in the capital. Similarly, there are also confirmed cases in Fort Portal and Mbarara, also signaling significant spread from the epicenter in Bundibugyo.
Media reports indicate the number of suspected cases has now topped 100, but patients are avoiding admission into hospitals, in part because of the number of fatal infections in health care workers (http://www.recombinomics.com/News/12050703/Ebola_HCW_5.html). Therefore, the number of patients silently infected with Ebola may be increasing and the virus may be spreading via fleeing patients.
These complications will impact the number of confirmed or suspect patients and hamper contact tracing. Media reports indicate the number of contacts under observation has increased to 330.
Media Links (http://www.flutrackers.com/forum/showthread.php?t=42832)
Recombinomics Presentations (http://www.recombinomics.com/presentations.html)
Recombinomics Publications (http://www.recombinomics.com/publications.html)
Recombinomics Paper at Nature Precedings (http://precedings.nature.com/tags/Recombination)
http://www.recombinomics.com/News/12060702/Ebola_Uganda_Spread_Confirmed.html
The previous thread on Ebola from Dr Niman is here (http://www.flutrackers.com/forum/showthread.php?t=43149)
Recombinomics Commentary
December 6, 2007
a team of epidemiologists from Kampala was reported to be heading to eastern Uganda to investigate reports that Ms Olive Mukite, the district information officer of Sironko died yesterday of suspected Ebola infection at Mbale referral hospital.
This follows reports of alert cases in Mbarara, Kabarole, Mubende and Kanungu; where 20-year-old Ivan Asimwe died yesterday.
The above comments raise concerns that Ebola has spread across the southern Uganda (see satellite map (http://maps.google.com/maps/ms?ie=UTF8&hl=en&msa=0&t=h&om=0&msid=106484775090296685271.000440a9f060622a05059&ll=1.274309,32.124023&spn=4.93011,7.086182&z=7)). The list represents most of the major cities in southern Uganda and extends from the western to eastern borders. The deaths of two of the suspect cases increases the likelihood these cases will be confirmed Ebola infections. Confirmed cases (http://www.recombinomics.com/News/12060702/Ebola_Uganda_Spread_Confirmed.html) have already been reported in Kampala (http://www.recombinomics.com/News/12040704/Ebola_Kampala.html). The neighboring countries of the Democratic Republic of the Congo, Rwanda, Tanzania, and Kenya have announced monitoring of border crossings.
Earlier reports confirmed that the suspect cases in south western Uganda were infected with Ebola and raised concerns that the spread had been extensive. The species (http://www.recombinomics.com/News/12020701/Ebola_Recombination_Uganda.html) involved is new and symptoms are not typical of earlier Ebola outbreaks.
The expanded geographical reach compounds problems linked to the high number of fatal infections (http://www.recombinomics.com/News/12060701/Ebola_HCW_Concern.html) in health care workers (http://www.recombinomics.com/News/12020702/Ebola_Uganda_HCW.html). Some workers had left because of compensation issues, and more may leave because of safety concerns due to lack of PPE’s. Similarly, patients are being discharged from hospitals and suspect cases are fleeing.
More detail on these suspect cases would be useful.
Media Links (http://www.flutrackers.com/forum/showthread.php?t=42832)
Recombinomics Presentations (http://www.recombinomics.com/presentations.html)
Recombinomics Publications (http://www.recombinomics.com/publications.html)
Recombinomics Paper at Nature Precedings (http://precedings.nature.com/tags/Recombination)
http://www.recombinomics.com/News/12060703/Ebola_Uganda_Spread_East.html
Recombinomics Commentary
December 12, 2007
One of the deaths today was the 20-something daughter of Jeremiah Muhindo. She had been fairly stable, and we had hoped she would pull through.
The above comments (http://paradoxuganda.blogspot.com/2007/12/ebola-bundibugyo-tuesday-night-numbers.html) describe another (http://www.recombinomics.com/News/12090701/Ebola_Super_Fatal_Links.html)fatal Ebola infection linked to Jeremiah Muhindo. He had visited a number of early Ebola infections and was briefly hospitalized at the Bundibuyo hospital. He was the first case to die, on November 24. Afew days later a number of health care workers at the hospital developed symptoms and at least four had died (http://www.recombinomics.com/News/12050703/Ebola_HCW_5.html), around December 4, including his primary doctor, Jonah Kule (http://www.recombinomics.com/News/12040704/Ebola_Kampala.html). In addition, six direct contacts (his mother, brother, wife, daughter, and two friends) were hospitalized. Media reports indicate his brother, daughter, and one friend ahs died in the past few days.
The above clustering of hospitalized and fatal cases is similar to clusters in the SARS outbreak linked to super spreaders (http://www.recombinomics.com/News/12070705/Ebola_Super.html). Analysis of SARS CoV sequences indicated the index case for the international spread, who had also seen patients prior to becoming ill, was infected with multiple variants, which may have contributed to the super spreader status of the index case, as well as contacts who spread SARS CoV to contacts, including health care workers in Hong Kong, Singapore, Hanoi, and Toronto.
Sequences from Ebola isoaltes from this cluster would be useful.
Media Links (http://www.flutrackers.com/forum/showthread.php?t=42832)
Recombinomics Presentations (http://www.recombinomics.com/presentations.html)
Recombinomics Publications (http://www.recombinomics.com/publications.html)
Recombinomics Paper at Nature Precedings (http://precedings.nature.com/tags/Recombination)
http://www.recombinomics.com/News/12120703/Ebola_Super_Another.html
Recombinomics Commentary
December 7, 2007
Admitted at Bundibugyo: 15, including Dr. Sessanga whose sister just came to our house looking for Scott because he’s no longer responsive; the matron (head nurse); the nurse who was working in the isolation unit Fred; a clinical officer named Joshua Kule; and an ophthalmic assistant. Among the other patients are six direct contacts (mother, brother, wife, daughter and two friends) of Muhindo Jeremiah who died just over a week ago.
one death this morning 5 am, another contact of Jeremiah Muhindo, who seems to have been very infectious.
Friday November 23 is the day Jonah believed himself to have been infected. That was the day he and Scott examined Jeremiah Muhindo. In between two of the times they saw the patient together, Jonah went in alone and arranged a face mask of oxygen onto the dying man, hoping to provide some relief or comfort. He was not wearing gloves because he could not find any at the hospital at that moment, and he felt that his friend needed the oxygen. That was his greatest exposure.
The above comments are from a blog of two physicians in Uganda here (http://paradoxuganda.blogspot.com/2007/12/ebola-bundibugyo-sunday-facts.html), here (http://paradoxuganda.blogspot.com/2007/12/ebola-in-bundibugyo-tues-day-6.html), and here (http://paradoxuganda.blogspot.com/2007/12/bundibugyo-where-tears-never-run-dry.html). The repeated mention of the same patient, Jeremiah Muhundo, in association with multiple suspect / confirmed cases, raises the possibility of a super-spreader. Several of the above cases, including four health care workers (http://www.recombinomics.com/News/12050703/Ebola_HCW_5.html), died within 24 hours of each other, raising concerns that they were infected by a common source.
The repeated mention of the same patient raises concerns that he was a super spreader, leading to infection of multiple contacts. More information on the direct contacts would be useful.
Super spreaders were implicated in the transmission of SARS coronavirus, and the above linkages raise questions about the new strain of Ebola, which is likely to be a recombinant. In the SARS outbreak, sequences of isolates from the same super spreader suggested co-infections and recombination contributed to the multiple linked infections. Although the case fatality rate of this new Ebola strain may be lower than that of prior strains, confirmed or alert cases (http://www.recombinomics.com/News/12060703/Ebola_Uganda_Spread_East.html) throughout Uganda (see satellite map (http://maps.google.com/maps/ms?ie=UTF8&hl=en&msa=0&msid=106484775090296685271.000440a9f060622a05059&ll=1.208406,31.992188&spn=9.10699,17.29248&t=h&z=6&om=0)), suggest that transmission may be more efficient than seen for prior strains, resulting in a large geographical reach.
Media Links (http://www.flutrackers.com/forum/showthread.php?t=42832)
Recombinomics Presentations (http://www.recombinomics.com/presentations.html)
Recombinomics Publications (http://www.recombinomics.com/publications.html)
Recombinomics Paper at Nature Precedings (http://precedings.nature.com/tags/Recombination)
http://www.recombinomics.com/News/12070705/Ebola_Super.html
Recombinomics Commentary
December 7, 2007
MPs yesterday unanimously asked the government to immediately declare a State-of-emergency over the rapidly spreading Ebola epidemic and impose quarantine on already affected areas in western Uganda.
"We need to take radical measures if we are to save our people from this deadly virus," Theodore Ssekikubo, the MP for Rwemiyaga constituency in Ssembabule district, said.
In the afternoon plenary session dominated by the Ebola debate, most MPs called on the government not to drag its feet when people are dying in the countryside.
"Ebola is a serious disease and the government must declare all affected areas a no-go area.
The above comments call for a state of emergency in western Uganda, but recent reports suggest the disease may have already spread (http://www.recombinomics.com/News/12060702/Ebola_Uganda_Spread_Confirmed.html)to the eastern border (http://www.recombinomics.com/News/12060703/Ebola_Uganda_Spread_East.html) and cover most of southern Uganda (see satellite map (http://maps.google.com/maps/ms?ie=UTF8&hl=en&msa=0&t=h&om=0&msid=106484775090296685271.000440a9f060622a05059&ll=-0.087891,32.124023&spn=4.525185,9.283447&z=7)).
Most of the cases are in and around Bundibugyo, but the confirmed and suspect cases have led to monitoring of border crossings by the Democratic Republic of the Congo, Rwanda, Tanzania, and Kenya.
The recent deaths of health care workers (http://www.recombinomics.com/News/12050703/Ebola_HCW_5.html) have emptied the hospitals of both patients and health care workers. The fleeing patients could spread the virus, which appears to be readily transmitted. Over 330 contacts are being monitored, but patient avoidance of hospitals will create additional contact tracing problems.
More information on the sequence of the new strain, which is likely a recombinant (http://www.recombinomics.com/News/12020701/Ebola_Recombination_Uganda.html), and further confirmation of suspect cases will be useful.
Media Links (http://www.flutrackers.com/forum/showthread.php?t=42832)
Recombinomics Presentations (http://www.recombinomics.com/presentations.html)
Recombinomics Publications (http://www.recombinomics.com/publications.html)
Recombinomics Paper at Nature Precedings (http://precedings.nature.com/tags/Recombination)
http://www.recombinomics.com/News/12070701/Ebola_Uganda_Emergency.html
Recombinomics Commentary
December 9, 2007
The Ebola death toll climbed to 25 after three people succumbed to the deadly virus on Friday evening. Two patients died in Bundibugyo Hospital, while a third one exhibiting symptoms of Ebola passed away in Kabarole Hospital in Fort Portal.
Medical workers in Bundibugyo said one of the victims was Enock Bwambale, brother to Jeremiah Muhindo, the very first person to die of the disease in the hospital. The other was an old woman.
The patient who died in Kabarole Hospital was admitted during the night, but died in the morning before he could be transferred to the isolation centre in Kichwamba.
The above comments detail Ebola fatalities on Friday. Once again there is a link to Jeremiah Muhindo, who died in November. Jonah Kule had adjusted Jeremiah Muhindo’s oxygen mask on November 23 and developed symptoms five days later. Jonah Kule (http://www.recombinomics.com/News/12040704/Ebola_Kampala.html) and four other health care workers (http://www.recombinomics.com/News/12050703/Ebola_HCW_5.html) died over a 24 hour period (http://www.recombinomics.com/News/12070705/Ebola_Super.html) around December 4 and several contacts of Jeremiah Muhindo were hospitalized. One of those contacts also died December 4.
The death of Jeremiah Muhindo’s brother increases the number of fatal cases linked to this index case. Initial sequence data on the Ebola species in Uganda indicated it has 75% homology with earlier strains. The bust of fatal cases liked to the above index case raises questions about additional genetic changes or the presence of co-infections in the infectious case.
More sequence information on Ebola from this cluster would be useful.
Media Links (http://www.flutrackers.com/forum/showthread.php?t=42832)
Recombinomics Presentations (http://www.recombinomics.com/presentations.html)
Recombinomics Publications (http://www.recombinomics.com/publications.html)
Recombinomics Paper at Nature Precedings (http://precedings.nature.com/tags/Recombination)
http://www.recombinomics.com/News/12090701/Ebola_Super_Fatal_Links.html
Recombinomics Commentary
December 7, 2007
Twenty two people have so far died of the fever.
"Cumulatively, we have got 101 cases of Ebola -- those who fit the case definition," Kabwa said, adding that all were in western Uganda's Bundibugyo district, except for two in Kampala, including a doctor who died.
He said 39 had been admitted to hospital in serious condition and 350 others suspected of having been exposed to the virus were being urged to stay at home.
"They are being observed because they are possible contacts with Ebola cases," Kabwa said. "They are not being confined."
The outbreak, which started in August, has sparked panic amongst officials, health workers and the public.
"A bigger Ebola bomb could explode, claiming many more lives," Bundibugyo district chairman Jackson Bambalira was quoted as saying in the state-owned New Vision daily on Friday.
The above comments provide an update on the Ebola cases in Uganda. However, these numbers are incomplete and easily misinterpreted by the popular press. Some media reports have cited a 22% case fatality rate based on the 22 deaths out of 101 diagnosed patients. However, this calculation is incorrect. It assumes that all cases that have not died will not die, and there is no data to support such an assumption. There is no cure for Ebola, so many of the recently diagnosed patients will not recover.
The above comments cite 39 patients admitted in serious condition. However, the report does not say how many diagnosed patients have fled. As the hospitals empty because of patients requesting discharge and staff absenteeism, the number of diagnosed patients who are admitted also declines because patients fear infections from the hospitals. This fear is based in part on fatal infections (http://www.recombinomics.com/News/12050703/Ebola_HCW_5.html) in health care workers. Thus, many of the diagnosed patients have no outcome (death or discharge), and have instead chosen not to be admitted. Moreover, new suspect cases are being identified across southern Uganda (http://www.recombinomics.com/News/12060703/Ebola_Uganda_Spread_East.html) (see satellite map (http://maps.google.com/maps/ms?ie=UTF8&hl=en&msa=0&t=h&om=0&msid=106484775090296685271.000440a9f060622a05059&ll=1.274309,32.124023&spn=4.93011,7.086182&z=7)), which creates additional tracking problems.
Therefore, the case fatality rate will be a very soft number until more outcomes are known, and these outcomes may not include fleeing patients, or contacts of fleeing patients.
Without details of outcomes, publication of case fatality rates is misleading.
Media Links (http://www.flutrackers.com/forum/showthread.php?t=42832)
Recombinomics Presentations (http://www.recombinomics.com/presentations.html)
Recombinomics Publications (http://www.recombinomics.com/publications.html)
Recombinomics Paper at Nature Precedings (http://precedings.nature.com/tags/Recombination)
http://www.recombinomics.com/News/12070702/Ebola_Uganda_Flee.html
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