At least three people have been confirmed dead in Johannesburg, South Africa, in an outbreak of what officials believe to be contagious hemorrhagic fever.

Almost one month ago, Zambian tourism operator Cecilia van Deventer was airlifted to a private hospital in Johannesburg, where she died of what health officials say is likely to be Crimean-Congo fever.

Since then, the unconfirmed illness has claimed at least two more lives, that of a paramedic who accompanied van Deventer from Zambia, and a nurse who attended to her during her stay at the hospital. Health officials are on high alert.

Crimean-Congo hemorrhagic fever was first reported in South Africa in 1981, and since then the country has usually experienced up to 10 cases annually, not all of which resulted in death, according to Dr Lucille Blumberg of South Africa's National Institute for Communicable Diseases (NICD).
Confirmation as to whether Congo fever is the cause of the recent deaths is expected late next week when the NICD delivers the findings of laboratory tests, according to Gauteng provincial health department spokesperson, Zanele Mngadi.

"It may be something else, although there are not a lot of diseases that present like this - transmission in a health care setting, high mortality and a clinical picture that would contain some bleeding," Blumberg said.

Uncontrolled bleeding from the mouth, nose or genitals are among the symptoms of Congo fever. It has a mortality rate of 30 percent, with death usually occurring in the second week of illness, according to the World Health Organisation.

Hospital spokesperson Melinda Pelser said the recent death of a cleaner was unrelated to the virus, but the provincial health department has not ruled out the possibility of hemorrhagic fever.

Infection control key

Meanwhile, health professionals working in provincial hospitals, mortuaries and ambulances have been put on high alert for patients presenting with symptoms of the fever, which initially include chills and severe muscle pains.

The NICD's Blumberg said people usually contracted the virus from tick bites or contact with the bodily fluids of infected livestock, but it could spread quickly once those infected were admitted into health care settings, especially where infection control was poor.

Pelser said doctors at the private hospital in Johannesburg had quickly identified possible cases of hemorrhagic fever and had implemented proper infection control procedures, including placing the patients in isolation wards.

She said the clinic's staff and their families were being monitored for symptoms, and two family members of the nurse who had died - although asymptomatic - had been admitted for observation.

Congo-Crimea, like Ebola, is a viral hemorrhagic fever that resides in an animal host, but is less virulent than its headline-grabbing relation. Treatment is primarily supportive, and recovery is slow.

IRIN 

A tropical flesh-eating disease, Buruli ulcer, is spreading across West Africa and has infected at least 40,000 people leaving them with bloody infected wounds and swollen skin ulcers, which at their worst, require surgery or amputation, according to the World Health Organization (WHO).

The disease has been reported in 30 countries around the world, mostly in poor, rural, tropical communities that live near water. In West Africa, according to WHO 2006 statistics, Ivory Coast has reported 24,000 cases, Ghana reported 11,000, and Benin has 7,000 confirmed cases.

Despite a 10-year global WHO-backed Buruli ulcer research initiative, researchers still do not know how the disease is spread, and whether water-born insects are to blame, as suggested by early research.

Even though the same bacteria family causes both Buruli ulcers and tuberculosis, Buruli ulcer disease receives far less international attention and remains one of the world’s most overlooked diseases, according to WHO.

‘I thought it was witchcraft’

A woman, who gives her name as Agnes, says it has been five years since she was diagnosed with Buruli ulcer disease. She lives in Agbanou, a rural town 60km from Benin’s economic hub, Cotonou. She told IRIN before her infection, she spent most her time working in marshlands.

“At the beginning, I felt pain everywhere, and then the skin on my feet hurt even more and started to change colours. Then I saw open wounds. I thought it was witchcraft, which is why I did not think to go to the hospital. Instead, I turned to a traditional healer,” said Agnes.
When her condition worsened, and the healer could not treat her deepening wounds, Agnes says she went to the hospital where doctors told her she had Buruli ulcer disease.

Roch Christian Johnson, director of Benin’s Program to Control Buruli ulcer disease, says unreported cases in Benin outnumber reported ones because lack of knowledge about the disease, illiteracy, poverty and traditional healing often prevent people from going to medical facilities.

Also, the disease has few noticeable symptoms at the beginning— painless swelling, no fever—according to WHO. Yet, without treatment, massive, bloody ulcers start tearing away the patient’s flesh.

Johnson says when it reaches this stage it can cost up to US$2,000 to cure the disease. Depending on how bad the ulcers are, the patient may need eight weeks of medicine, surgery, or in worst case scenario, amputation to fight the infection.

Hospital stays often last longer than three months; complications can lead to even costlier long-term disability, according to WHO.

Patient care is subsidised in part by the government and private foundations in Benin. But nevertheless, Johnson says the cost is still too much for many ulcer patients.

The average annual salary in Benin is US$570, based on 2008 World Bank figures.
Attacking the disease early

Faced with a rapidly spreading and largely unknown disease, and mounting health care costs, Benin’s government set up five testing centres throughout the country starting in 1998 to try and catch the disease early.

On average, about 80 people seek treatment or testing in these centres for Buruli ulcer every month, according to program director Johnson.

From 2003 to 2006, Johnson says health officials tested and treated 3,793 people. Out of the country’s 12 regions, eight, including the south with its 125km of open coastline, have reported infections.

The arid north has been spared.

Wiping out the disease?

Despite the fact that little is known about how the infection is spread, Johnson says he is still hopeful the disease can be controlled, “The prospects are good to progressively contain this disease in Benin. We are working with a large team of [local] researchers to learn all we can about this disease, which means, in the near future, the situation will improve. ”

Johnson says even if health officials do not know how the disease is spread, they can encourage people to get tested at government health centres, and to get treatment quickly to prevent the disease from consuming their flesh -- and finances.

WHO reports a vaccine, available in Benin, can offer some short-term protection against mycobacterium ulcerans bacteria, which causes the ulcers.

WHO’s Buruli ulcer Initiative lists as its research priorities learning how the debilitating bacteria is spread, developing a safe and effective long-term vaccine, and creating a simple, fast way to diagnose the disease.

IRIN 

Exaucée Makembi, aged three, has been very weak for three days and sleeps in the arms of her mother, Tina Nzongola, who has taken her to a health centre on the outskirts of Kinshasa.

She is suffering from malaria. The doctor prescribed water-soluble artesunate, but Nzongola complains she does not have the funds to buy it, as it costs around US$5.

Other patients lie on beds next to her - young and old - taking quinine and antibiotics because their cases, according to the nurse, are serious.

“Most of the patients we receive have malaria,” said Baby Bilo, a consultant at another health centre in the area.

The situation is repeated all over the country.

“Today, malaria is the primary cause of sickness and death in the country as it is in Africa, despite the efforts made,” said Yacouba Zina, head of the malaria project of the Global Fund to Fight AIDS, Tuberculosis and Malaria.

On average, five million cases of malaria, according to him, are registered every year throughout the country with a population of nearly 60 million.

Between 500,000 and one million people die of the disease every year.

However, according to the National Programme for the Struggle against Malaria (PNLP), some success has been noted. “Medicines have been distributed to the sick, insecticide-treated bed nets have been distributed and awareness-raising campaigns have been conducted,” explained the deputy head of the PNLP, Jean Angbalu.

Exaucée Makembi, aged three, has been very weak for three days and sleeps in the arms of her mother, Tina Nzongola, who has taken her to a health centre on the outskirts of Kinshasa.

She is suffering from malaria. The doctor prescribed water-soluble artesunate, but Nzongola complains she does not have the funds to buy it, as it costs around US$5.

Other patients lie on beds next to her - young and old - taking quinine and antibiotics because their cases, according to the nurse, are serious.

“Most of the patients we receive have malaria,” said Baby Bilo, a consultant at another health centre in the area.

The situation is repeated all over the country.

“Today, malaria is the primary cause of sickness and death in the country as it is in Africa, despite the efforts made,” said Yacouba Zina, head of the malaria project of the Global Fund to Fight AIDS, Tuberculosis and Malaria.

On average, five million cases of malaria, according to him, are registered every year throughout the country with a population of nearly 60 million.

Between 500,000 and one million people die of the disease every year.

However, according to the National Programme for the Struggle against Malaria (PNLP), some success has been noted. “Medicines have been distributed to the sick, insecticide-treated bed nets have been distributed and awareness-raising campaigns have been conducted,” explained the deputy head of the PNLP, Jean Angbalu.

Resistance

“There has been an upward trend in the number of malaria cases and there are also many more of the serious cases because of resistance [to certain drugs used hitherto] owing, among other things, to self-medication,” Zina said.

“And this translates into a high mortality rate among infants, owing to the resistance,” he said.

In addition, said Zina and Angbalu, the new drugs, although sold 10 times cheaper thanks to the partnership with international organisations, were not readily available to most of the population.

Nor has the distribution of bed nets been universal. According to Angbalu, only 35 health zones out of 515 were covered.

But the Global Fund programme envisages covering 120 health zones. Partners, such as the World Bank and the EU, will be able to take on others.

More could be done in terms of prevention, said Zina. Formal education on hygiene issues, or via the media, had not been carried out sufficiently, he said.

“Furthermore, the bed nets given out are insufficient, as they are distributed only to pregnant women and children under five, while other family members are left out and exposed to the disease,” he said.

“Right now, the statistics are stagnant,” he said. Between 2003 and 2008, 172,000 children between zero and five years-old died every year from malaria in Cote d’Ivoire, he said, equivalent to eight children per hour.

Some 60 percent of consultations at state-run health clinics are malaria-related, he added. At least 20 percent of pregnant women have malaria, frequently causing low birth weights among their infants.

According to the UN Development Programme in Cote d’Ivoire, the combination of poverty and high levels of malaria around the country mean 90 percent of Ivorians are at “high risk” of infection.

However health officials say they have little in the way of support to either treat or prevent infections. “Some illnesses are underfinanced,” said Magloire Kablan N’Zi, a nurse at Grand-Yapo, a village 60km outside the country’s financial centre Abidjan.

Cote d’Ivoire’s health ministry says it has made low-cost anti-malarial medicines available for 420,000 people. It has requested funds from the Global Fund to fight AIDS, Tuberculosis and Malaria to provide more medicines, bed nets and sensitisation programmes.

"An outbreak has been confirmed; it will be a big challenge to contain," Nestor Ndayimirije, Inter-Country Epidemiologist at the UN World Health Organisation's (WHO) Eastern and Southern Africa office, told IRIN.

The MoH said 59 cases had been positively identified by the Pasteur Institute of Madagascar, part of a global network devoted to medical issues and epidemiological screening in developing countries.

RVF is a viral disease that primarily affects animals but can also infect humans, so even when the disease has been removed from human populations "you still have to control the animal side," Ndayimirije explained.

RVF is usually well-established in animal populations by the time the first human cases are observed - the Ministry of Agriculture first reported cases among livestock on 9 April.

According to a WHO statement, the human cases were recorded the Alaotra Mangoro, Analamanga, Itasy, Vakinakaratra and Anosy regions in the East of the Indian Ocean island.

A call for help

In an effort to contain the outbreak, Malagasy authorities have established an inter-ministerial committee to oversee the response and have requested assistance from the WHO, the UN Food and Agricultural Organisation (FAO) and the World Organisation for Animal Health (OIE).

A joint mission of WHO, FAO and OIE representatives to support Malagasy efforts was expected to be in the country by 23 April, Ndayimirije said.

Meanwhile, Malagasy authorities have implemented control measures such as case management, surveillance, social mobilisation, provision of medicines, and prevention and strengthening of hospital infection control.

The vast majority of RVF infections in humans result from direct or indirect contact with the blood or organs of infected animals. To date, no human-to-human transmission of RVF has been documented, according to the WHO.

Human infections have also resulted from the bites of infected mosquitoes and RVF has commonly been associated with unusually heavy rainfall and flooding. Madagascar is just coming out of a particularly wet rainy reason: earlier this year cyclones Fame and Ivan brought powerful winds, heavy rains and flooding that affected over 330,000 people, of whom 190,000 lost their homes.

"While some infected people experience no detectable symptoms, others develop flu-like fever, muscle pain, headaches, joint pain, vomiting, loss of appetite and sensitivity to light. In more severe cases patients can also experience lesions in their eyes, neurological problems, liver impairment and haemorrhagic fever symptoms, including widespread bleeding," the WHO statement said.

RVF was generally confined to Sub-Saharan Africa until outbreaks were reported in Saudi Arabia and subsequently in Yemen in 2000.

Results from three randomised controlled trials in South Africa, Kenya and Uganda, in 2006 showed that following circumcision, the incidence of HIV infection was reduced in men by more than half.

According to the new policy document, circumcision will be rolled out for males of all ages in a culturally sensitive way and in a clinically safe setting.

The programme will involve some strengthening of the health infrastructure, but according to Peter Mutie, head of communications at the National AIDS Control Council (NACC), the existing health centres are sufficiently equipped for the rollout.

"We are trying to fast track it so that by mid-2008 we can start rolling it out," Mutie told IRIN/PlusNews.

Although a handful of ethnic communities in Kenya - including the Luo, Suba and Teso in western Kenya and the Turkana in northwestern Kenya - do not practice circumcision culturally, Mutie said the government's programme would focus on the whole country.

"Most of our tribes practice circumcision as a rite of passage, but many do it traditionally, using the same blade for several boys, a practice we would like to eradicate; others don't remove the entire foreskin, which is the medical way to do it - they just cut off a bit of it," he said.

Mutie added that in order to limit resistance to the programme, social mobilisation exercises would precede the rollout, with community members being trained to educate their peers on the benefits of male circumcision.

"This is a programme that needs very careful implementation, and education is key - for instance, people need to know that it is not in any way a guarantee of protection from HIV," Mutie said. "

He stressed that traditional circumcisers would play a key role in re-educating their communities. "We cannot totally remove their role - they are useful advisers whom people look up to, so they can be taught to advise the young initiates on safe sex and other healthy practices," he added.

The news about a national policy will be good news for many NGOs and medical practitioners who have been awaiting guidance on male circumcision. Among these is Marie Stopes Kenya, which started a pilot project on male circumcision in western Kenya a year ago using World Health Organization guidelines. The organisation is part of the national male circumcision task force.

Testing the waters

"Our pilot is a free mobile outreach, where a team of five members - a doctor, clinical officer, care assistant, nurse and driver - goes into various communities and sets up camp in a room at a local medical centre or in a tent, and invites people to come or bring their children for circumcision," said George Obhai, monitoring and evaluation manager at Marie Stopes Kenya.

Before the mobile team arrives, the local hospital or clinic is contacted to conduct community mobilisation, and on the day every man getting circumcised receives counselling from a trained member of staff before the procedure is carried out.

"Interestingly, many of the ideas people have about male circumcision work in our favour, even among the Luo; for example, people believe that it improves the sexual experience and that ladies prefer circumcised men," he added.

Obhai noted that male circumcision has not been a hard sell in western Kenya because the Luo, Teso and Suba are surrounded by circumcising communities, and many of them know people who have been circumcised. The HIV prevention benefits it offers, also made the practice popular in the region.

In four districts of Nyanza Province, more than 2,700 men have volunteered for circumcision through Marie Stopes since April 2007, and the numbers are increasing every month; 80 percent of the men and boys being circumcised are from traditionally non-circumcising communities.

But this success is not uniform; among the Turkana of northwestern Kenya, an isolated and very traditional society, it has been much harder to push the circumcision agenda.

"When we took the mobile team to Turkana last year, we got two cases on one outreach day, on another day we got three cases," Obhai said. "We pulled out because we simply didn't have the financial resources to justify continuing at the time, but once we are able to set up some more mobile teams we will go back to the region."

Marie Stopes also uses people from within the community as peer educators, and hopes to incorporate the traditional circumcisers into their programmes.

"In the past we have experienced resistance from them [traditional circumcisers], as we are perceived as trying to take away their source of income or their role in society," Obhai said. "For instance, in many areas, this coming August is a circumcising period, so we'd like to encourage them to maintain their role as counsellors and even pay them an allowance for that, but to bring the boys to the clinic for circumcision."

The pilot has been particularly successful in reaching rural populations with little access to modern medical facilities, and prisoners, who also lack access to healthcare. The social mobilisation is also being used as an entry point for education about the traditional ABC - Abstinence, Be faithful and use a Condom - prevention strategy, as well as as an avenue for promoting voluntary counselling and testing.

Marie Stopes' outreach has recorded five complications with the procedure in the year it has been operational - two adverse reactions to the anaesthetic and three post-op infections.

The organisation intends to replicate its mobile outreach across the country following the success of the Nyanza experience.

"I was so shocked and so angry with my dad for a long time," he told IRIN/PlusNews. "I immediately thought I was going to die, I had very little hope."

Gordon had been diagnosed at the age of about 10, and was put on Septrin, an antibiotic, but was never told why he had to take the medication. When he was older, his frequent sickness, as well as his step-mother's death and his father's ill health, made him suspicious about his status. His father eventually buckled under pressure from a doctor and told him.

"If I had known earlier I could have dealt with it better, but I no longer trusted him and I blamed him for giving me HIV," he said. Gordon's father passed away in March - by then the two men were on better terms.

Gordon is the author of a short book, an autobiography titled How I Discovered I was HIV-positive. He hopes the book will highlight the importance of parents letting their children know their HIV status early.

His younger brother, Graham, now aged 12, is also HIV-positive, but was told early on. "You can see that he is handling it well and he's in a support group - he'll be ok," Gordon said.

Stigma and denial

According to Goretti Nakabugo, a Ugandan counsellor with experience in dealing with young people living with HIV, the main reason parents don't disclose their children's HIV status to them is the fear that the child will be stigmatised.

"Children take late disclosure very hard, it's so sudden and they are often very ill when they find out, making it that much harder," she said.

"They are filled with anger, guilt and feel they have been denied a big role in their own lives," she added. "Disclosure is a process; it should be done in bits from the age of about eight or ten years of age, depending on the child's cognitive development."

Often, Nakabugo noted, parents are in denial about their own status, and so admitting their children's status would force them to come to terms with their own condition.

This was the case for Gordon's girlfriend, Princess Nuru, 22, who found out her status when she was 18 years old after a near-fatal illness. Her doctors told her she was HIV-positive and when she told her mother, she accused Princess of having acquired the virus sexually.

"But I knew I had never had sex before so there could only be one explanation that made sense, especially since I had been so sickly throughout my childhood," Princess said. "It was a shock to find out, but my mom's reaction made it even more terrible."

Princess's father died several years ago, and although his wife knew he had died from HIV-related causes, she only got tested recently - almost four years after Princess was diagnosed.

"She got TB last year and that's when she finally got tested and when she confirmed that she was HIV-positive," Princess added. "Now we are on good terms, she has apologised and she is on TB treatment but is still quite ill."

According to counsellor Nakabugo, the key to disclosure was to deal with stigma first. "If the parents have self-stigma then they'll pass it on to their children," she said. "Stigma leads to denial and late disclosure and late disclosure in turn leads to stigma because the child thinks he or she cannot talk about their status since it was such a big secret for so long - it's a vicious cycle."

According to the American Academy of Pediatrics, research indicates that children who know their HIV status have higher self-esteem than infected children who are unaware of their status.

"Parents who have disclosed the status to their children experience less depression than those who do not," the Academy said in its policy statement on disclosure to children and adolescents living with HIV.

"Disclosure should not only take into consideration the child's age, maturity, and the complexity of family dynamics, but the clinical context as well," the statement added. "In critically ill children, issues of dying rather than disclosure may be more appropriate to address."