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This could be almost anything, including several causes at once.
Although this is a ProMED post, the original source is somewhat dubious and has made errant reports in the past.
Archive Number 20110713.2121
Published Date 13-JUL-2011
Subject PRO/AH/EDR> Undiagnosed febrile child fatalities - Congo DR: (ET) RFI
UNDIAGNOSED FEBRILE CHILD FATALITIES - CONGO DR: (EQUATEUR), REQUEST
FOR INFORMATION
************************************************** **********************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>
Date: Sat 9 Jul 2011
From: James Wilson <jim.wilson@praecipiointernational.org> [edited]
We have been tracking reports of pediatric fatalities from reliable
ground sources who have been present in DRC for many years in Gemena,
NW Equateur Province, DRC.
The area from which cases have been reported include Gemena and east
towards Karawa (as far as 80 km and 300 km west and east of Gemena,
respectively).
The reporting peaked in April and May 2011, but fatalities and
medical infrastructure strain reportedly continue.
The medical infrastructure reports "grid" level strain, with several
wards "full," with patients to include children in intensive care
(with ICU overload) at Gemena General Hospital.
The clinical presentation includes high fever (38-40.4 C), vomiting,
anemia, occasional diarrhea, dehydration, death within 2-5 days;
sources deny abdominal pain, rash, hemorrhage, or jaundice.
Epidemiological features known so far are beyond the above; reports
on the ground (without formal epi investigation) indicate they are
seeing more pediatric fatalities than they have seen at least in the
last 3 years [and this is the 1st such "alarm" we have seen from this
area from usually calm and reliable sources]. Suspected etiologies
include falciparum malaria and typhoid, among others.
Additional information/direct quote from the source: "In the case of
my friend, he personally had the same blood type as his one-year-old
son, and could give him blood. There are no blood banks here and
basically no refrigeration available. This morning, I saw my friend
who came home from the hospital to wash up then to return. He said
that the ICU is full of little children, so full that there are
children out on the walkways. This morning before 8 AM, he said 4
children died in the ward where his son is. All have similar symptoms.
When he went back, he saw another child die. In addition, I know of 2
other deaths of children from contact with other friends here. Of
course, many people do not take their children in for medical care
because they cannot afford it, or they try using smaller clinics. So
the number of deaths is much higher. At a hospital 80 km east of here
at Karawa, they have higher than normal child death rates right now as
well. In May 2011 in one church in one week, 20 child deaths were
reported, all with the symptoms listed.
Local medical people are making some contacts with the national
health service, but there is some feeling that because of upcoming
national elections in November 2011, either other things take priority
or some problems are downplayed.
Local people are suspicious of a recent polio vaccine program. Two of
the 3 doses have been administered, and many of the children who have
died of course also received the vaccine. There is enough suspicion
that there is a significant risk that people will not let their
children receive the 3rd dose in the series.
Local hospitals have also had a large number of positive tests for
typhoid.
This has been discussed by doctors in the province. Local WHO offices
are aware of these issues, but they have not sponsored a special
study. No national office has done studies. There are no suggested
treatments other than what local staff try.
As far as I know, no extensive tests have been done recently about
water quality or other possible public health risks.
Other people have voiced concerns about: Increases in Chinese
products in local markets; lead or other metal poisoning; viruses
targeting children. However, the ordinary person tends to put the
blame on the oral polio vaccination program.
One missionary reported hearing reports of increased deaths of goats
in the area, perhaps with fever and anemia as well. The goat deaths
are real. The symptoms are unconfirmed and have not been studied as
far as I know."
--
James M. Wilson V, MD
Executive Director
Praecipio International
Washington-Houston-Port au Prince
<jim.wilson@praecipiointernational.org>
[ProMED thanks Dr James M. Wilson for alerting us to this outbreak.
We agree that falciparum malaria would be high up on the list of
suspected infections; however, the NW Equateur province is
hyper-endemic for perennial transmission, and malaria usually does not
cause outbreaks under such conditions. Anemia is an unspecific symptom
in many severe infections but would be particularly severe in
malaria.
ProMED reported an outbreak of hepatitis E from the same area of DRC
in 2006, and even though jaundice is not reported, this is a
possibility, although a contamination of water sources over a large
area at the same time is difficult to explain.
Typhoid is another cause which could be waterborne, but the
geographical distribution over several hundred km makes it less
likely, as each location would have its own water source, and not all
water sources would be contaminated at the same time.
Measles seems to be excluded, as it always is followed by a
characteristic rash in a high proportion of cases, and monkeypox is
also unlikely without the typical vesicles and pustules on the skin.
The lack of bleeding should exclude haemorrhagic fevers with a high
probability, including yellow fever.
Tick-borne infections like the rickettsiae and _Borrelia recurrentis_
usually do not come in large outbreaks.
Dengue fever would be a possibility, although more haemorrhagic cases
would be expected with such a high mortality.
Trypanosomiasis would be expected to give more cases in adults.
It is stated in the report that the local inhabitants blame the polio
immunization campaign. This is highly unlikely and should be
relatively easy to investigate. It is most unfortunate if the polio
vaccine receives the blame, and this needs urgent attention from the
organization which supplied or administered the vaccine.
The other concerns raised are increases in Chinese products in local
markets and lead or other metal poisoning. Indeed, the melamine
scandal caused a lot of concern worldwide over contaminated food. The
main symptom of melamine poisoning was impaired kidney function, and
fever was also reported. We have no information on kidney function in
this report. The symptoms point to an infection, but food poisoning is
difficult to rule out without a detailed epidemiological
investigation.
ProMED will be interested in further information and will follow the
outbreak closely.
Although this is a ProMED post, the original source is somewhat dubious and has made errant reports in the past.
Archive Number 20110713.2121
Published Date 13-JUL-2011
Subject PRO/AH/EDR> Undiagnosed febrile child fatalities - Congo DR: (ET) RFI
UNDIAGNOSED FEBRILE CHILD FATALITIES - CONGO DR: (EQUATEUR), REQUEST
FOR INFORMATION
************************************************** **********************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>
Date: Sat 9 Jul 2011
From: James Wilson <jim.wilson@praecipiointernational.org> [edited]
We have been tracking reports of pediatric fatalities from reliable
ground sources who have been present in DRC for many years in Gemena,
NW Equateur Province, DRC.
The area from which cases have been reported include Gemena and east
towards Karawa (as far as 80 km and 300 km west and east of Gemena,
respectively).
The reporting peaked in April and May 2011, but fatalities and
medical infrastructure strain reportedly continue.
The medical infrastructure reports "grid" level strain, with several
wards "full," with patients to include children in intensive care
(with ICU overload) at Gemena General Hospital.
The clinical presentation includes high fever (38-40.4 C), vomiting,
anemia, occasional diarrhea, dehydration, death within 2-5 days;
sources deny abdominal pain, rash, hemorrhage, or jaundice.
Epidemiological features known so far are beyond the above; reports
on the ground (without formal epi investigation) indicate they are
seeing more pediatric fatalities than they have seen at least in the
last 3 years [and this is the 1st such "alarm" we have seen from this
area from usually calm and reliable sources]. Suspected etiologies
include falciparum malaria and typhoid, among others.
Additional information/direct quote from the source: "In the case of
my friend, he personally had the same blood type as his one-year-old
son, and could give him blood. There are no blood banks here and
basically no refrigeration available. This morning, I saw my friend
who came home from the hospital to wash up then to return. He said
that the ICU is full of little children, so full that there are
children out on the walkways. This morning before 8 AM, he said 4
children died in the ward where his son is. All have similar symptoms.
When he went back, he saw another child die. In addition, I know of 2
other deaths of children from contact with other friends here. Of
course, many people do not take their children in for medical care
because they cannot afford it, or they try using smaller clinics. So
the number of deaths is much higher. At a hospital 80 km east of here
at Karawa, they have higher than normal child death rates right now as
well. In May 2011 in one church in one week, 20 child deaths were
reported, all with the symptoms listed.
Local medical people are making some contacts with the national
health service, but there is some feeling that because of upcoming
national elections in November 2011, either other things take priority
or some problems are downplayed.
Local people are suspicious of a recent polio vaccine program. Two of
the 3 doses have been administered, and many of the children who have
died of course also received the vaccine. There is enough suspicion
that there is a significant risk that people will not let their
children receive the 3rd dose in the series.
Local hospitals have also had a large number of positive tests for
typhoid.
This has been discussed by doctors in the province. Local WHO offices
are aware of these issues, but they have not sponsored a special
study. No national office has done studies. There are no suggested
treatments other than what local staff try.
As far as I know, no extensive tests have been done recently about
water quality or other possible public health risks.
Other people have voiced concerns about: Increases in Chinese
products in local markets; lead or other metal poisoning; viruses
targeting children. However, the ordinary person tends to put the
blame on the oral polio vaccination program.
One missionary reported hearing reports of increased deaths of goats
in the area, perhaps with fever and anemia as well. The goat deaths
are real. The symptoms are unconfirmed and have not been studied as
far as I know."
--
James M. Wilson V, MD
Executive Director
Praecipio International
Washington-Houston-Port au Prince
<jim.wilson@praecipiointernational.org>
[ProMED thanks Dr James M. Wilson for alerting us to this outbreak.
We agree that falciparum malaria would be high up on the list of
suspected infections; however, the NW Equateur province is
hyper-endemic for perennial transmission, and malaria usually does not
cause outbreaks under such conditions. Anemia is an unspecific symptom
in many severe infections but would be particularly severe in
malaria.
ProMED reported an outbreak of hepatitis E from the same area of DRC
in 2006, and even though jaundice is not reported, this is a
possibility, although a contamination of water sources over a large
area at the same time is difficult to explain.
Typhoid is another cause which could be waterborne, but the
geographical distribution over several hundred km makes it less
likely, as each location would have its own water source, and not all
water sources would be contaminated at the same time.
Measles seems to be excluded, as it always is followed by a
characteristic rash in a high proportion of cases, and monkeypox is
also unlikely without the typical vesicles and pustules on the skin.
The lack of bleeding should exclude haemorrhagic fevers with a high
probability, including yellow fever.
Tick-borne infections like the rickettsiae and _Borrelia recurrentis_
usually do not come in large outbreaks.
Dengue fever would be a possibility, although more haemorrhagic cases
would be expected with such a high mortality.
Trypanosomiasis would be expected to give more cases in adults.
It is stated in the report that the local inhabitants blame the polio
immunization campaign. This is highly unlikely and should be
relatively easy to investigate. It is most unfortunate if the polio
vaccine receives the blame, and this needs urgent attention from the
organization which supplied or administered the vaccine.
The other concerns raised are increases in Chinese products in local
markets and lead or other metal poisoning. Indeed, the melamine
scandal caused a lot of concern worldwide over contaminated food. The
main symptom of melamine poisoning was impaired kidney function, and
fever was also reported. We have no information on kidney function in
this report. The symptoms point to an infection, but food poisoning is
difficult to rule out without a detailed epidemiological
investigation.
ProMED will be interested in further information and will follow the
outbreak closely.
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