Sundowner …

One evening sitting on the deck overlooking Lango Bai, drink in hand, the conversation turned to the extraordinary perils of my homeland. This was a theme already explored by Leon Varley in Zimbabwe and encountered again on the TV in a Johannesburg hotel. Everyone, it seems, is aware that Australia is home to the world’s most poisonous snakes and deadliest spiders. A swim entails the risk of Great White Sharks, marine stingers, crocodile attack, blue-ringed octopus and killer stingrays. Less well known are the stinging trees that when touched cause pain that recurs for months on contact with water. It takes courage to be an Australian, it’s a miracle any of us grew up.

It’s much safer sitting here on this deck, isn’t it?

Walking through the bai earlier my socks got wet. They have been hanging outside my little thatched hut all afternoon. I slapped a fly or two whilst we were walking, nasty little bite. Is that a mosquito now that the sun has gone? Slap … no appears to have been just a beatle.

Fortunately the last paragraph was a flight of fancy. No one leaves wet socks or any clothing out to dry. That would be an open invitation for the Mango Fly to lay its eggs. The larvae appear in two or three days and can penetrate intact skin. An itchy and later painful swelling follows, the little maggot lives happily in your flesh until maturity then it finds its way out, metamorphoses into a fly and heads off to find some more damp washing.

The day biting flies could be the vector of a number of other nasty problems. The tsetse fly has a most unpleasant bite and they tend to hunt in packs. Bad enough for that reason alone but worse still they may spread sleeping sickness. The agent is a trypanosome, a single celled organism, that when injected in the sub-cutaneous tissue …

moves into the lymphatic system, leading to a characteristic swelling of the lymph glands called Winterbottom’s sign. The infection progresses into the blood stream and eventually crosses into the central nervous system and invades the brain leading to extreme lethargy and eventually to death.

If diagnosed early sleeping sickness can be cured relatively easily these days. But the biting fly may have been carrying filaria instead producing a disease called Loa loa …

Some patients develop lymphatic dysfunction causing lymphedema. Episodic angioedema (Calabar swellings) in the arms and legs, caused by immune reactions are common. Calabar swellings are 3-10 cm in surface non erythematous and not pitting. When chronic, they can form cyst-like enlargements of the connective tissue around the sheaths of muscletendons, becoming very painful when moved. The swellings may last for 1–3 days, and may be accompanied by localized urticaria (skin eruptions) and pruritus (itching). They reappear at referent locations at irregular time intervals. Subconjunctival migration of an adult worm to the eyes can also occur frequently, and this is the reason Loa loa is also called the “African eye worm.” The passage over the eyeball can be sensed, but it usually takes less than 15 minutes.

Eosinophilia is often prominent in filarial infections. Dead worms may cause chronic abscesses …

In the human host, Loa loa larvae migrate to the subcutaneous tissue where they mature to adult worms in approximately one year, but sometimes up to four years. Adult worms migrate in the subcutaneous tissues at a speed less than 1cm/min, mating and producing more microfilaria. The adult worms can live up to 17 years in the human host.

It is better not to slap any creepy crawly it might just be a Blister Beatle …

They squash easily and … emit cantharidin. Blisters and slight irritation will appear quite soon after contact with cantharidin. RESIST the temptation to rub or scratch AT ALL COSTS as this will spread the problem. Fullblown blisters will develop, accompanied by inflammation and an aching pain as the poison penetrates deeper.

The liquid from the blisters will itself cause new blisters if allowed to come in contact with fresh skin!

And the mosquito, of course, is the most dangerous animal in Africa. Children under five are especially vulnerable to malaria. The WHO tells us that somewhere in Africa a child dies every 30 seconds.

In the Congo McGee wore long-sleeved shirts and long pants, all his clothing was soaked in permethrin prior to leaving home. DEET was spread on exposed skin. He took his Malarone every day and slept under a mosquito net whenever one was available. His flesh may well have been rendered unfit for human consumption but he actually doesn’t give a shit for the welfare of anyone wishing to eat him.

And he made it safely back to Australia where …

 

 

A panicked populace …

So much soothing music.

Within the week I shall abandon my sheltered work station and make a foray into darkest Africa. If I make it back you will hear all about it in due course. Among the places I will be visiting is the Republic of Congo. You will remember that there are two Congos separated by the Congo River. I’m off to the smaller one to the north. The other one used to be Zaire and is now the Democratic Republic of Congo (DRC). In June 1976 a haemorrhagic fever broke out in Sudan, in August a second outbreak occurred in Zaire. The virus was later isolated and named Ebola after a river close to the site of the Zaire outbreak.

The 1976 event affected 602 people, 151 died in Sudan, 280 died in Zaire, a mortality rate of 72%.

Ebola revisited the DRC in 1995 (254 dead) and in 2003 it appeared in the Republic of Congo killing 128,a death rate of 90%. There were further cases in the DRC in 2012. There have been outbreaks in Uganda. Currently the largest outbreak of all is threatening the people of Guinea, Liberia and Sierra Leone. It has recently been contained in Nigeria.

These last countries are in west Africa, reassuringly for me, the capital of Liberia is  5,000 km by road from Brazzaville in the Republic of Congo (or a seven hour flight).

Viruses are essentially little packets of genetic material. They find their way into living cells, hijack the process of protein manufacture within the cell so that it churns out lots of copies of itself and usually packages them for export. They are obligate intracellular parasites. Therefore if they are not infecting humans full-time they need to be hiding in other organisms. The ebola viruses are a little group of closely related viruses, they contain RNA. They are lethal to primates so the reservoir is not likely to be in Gorillas or monkeys. Fruit bats and dogs are high on the list of suspects. Endothelial cells are their main target especially in the liver. These are the cells that line the inside of blood vessels.

Incubation occurs in 2 to 21 days. The first symptoms are like the flu. Fever is usually greater than 38.3 °C,  often followed by vomiting, diarrhea and abdominal pain. Shortness of breath and chest pain may occur next along with swelling, headache and confusion. In about half of cases the skin may develop a maculopapular rash (a flat red area covered with small bumps). Five or so days into the process vomiting and coughing up of blood as well as voiding blood in the feces may occur. For the majority death will follow within 16 days from the onset of symptoms. Those who survive start to show signs of recovery in the second week of the illness.

As recently as July this year Nature’s Declan Butler could tell us that Ebola does not pose a global threat.

… to become infected in the first place, a person’s mucous membranes, or an area of broken skin, must come into contact with the bodily fluids of an infected person, such as blood, urine, saliva, semen or stools, or materials contaminated with these fluids such as soiled clothing or bed linen. By contrast, respiratory pathogens such as those that cause the common cold or flu are coughed and sneezed into the air and can be contracted just by breathing or touching contaminated surfaces, such as door knobs. A pandemic flu virus can spread around the world in days or weeks and may be unstoppable whereas Ebola only causes sporadic localised outbreaks that can usually be stamped out.

Since then the disease has made it to the US and Spain and transmission has occurred in both places. Reassuring noises from the ill-prepared CDC have not prevented alarm or transmission. Indeed, given the number of affected healthcare workers in Africa and out of Africa, it seems to me that ebola has a greater capacity for spread than so far suspected.

One of the hospitals I work at has begun to prepare itself (for my return?). It issued a memorandum a week ago.The Quality, Risk and Business Manager informed us …

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A week later a quick look around the point of entry was not reassuring. There is a crowded waiting area between the front door and the first staff member, there was no personal protection equipment to hand, nor illustrated signage on how to put it on or take it off. No area had been designated for isolation nor is there an area that could be accessed without passing close to waiting patients or other staff.

Visitors to Africa or Texas can take a few precautions …

  • Avoid contact with sick people and the recently dead
  • Don’t handle bushmeat
  • Wash your hands thoroughly and often
  • Don’t pat the dogs

… and don’t lose sight of the fact that Malaria will kill more than 600,000 people this year.