THE HAEMORRHAGIC FEVER OUTBREAK IN MARIDI, WESTERN EQUATORIA, SOUTHERN SUDAN

BABIKER MOHD EL TAHIR
National Health Laboratory, Virology Department, P.O. Box 287, Khartoum, Sudan

The epidemic was brought to our attention on the 26th of September, 1976, by the Director-General for Laboratories, Khartoum. We flew to Maridi, with the idea of a highly infectious disease - probably viral - characterized by a high mortality rate (40 - 50%) especially among the hospital staff, possibly Lassa fever.

On arrival in Maridi we found a really grave situation. There were over 30 cases in three hospital wards, most of them seriously ill, a few in coma, some were recovering. A few patients were left neglected, a large number of nursing staff, in panic, did not show up for work.

We examined some of the patients. All gave the same history of sudden onset with high fever followed by severe headache, myalgia, gastro-intestinal upset (vomiting or diarrhea or both) - chest pain, cough with dryness of the throat.

All patients were given antimalarial treatment without improvement and then anti-typhoid drugs during the second week. Some of them developed haemorrhagic manifestations, such as epistaxis, haemoptysis, haematemesis, malaena leading to deterioration in their general condition and cachexia. Some patients developed signs and symptoms of general nervous system involvement going into a state of convulsions, coma and death.

The epidemic started on the 6th of August 1976, when a student from Nzara arrived in Maridi en route to Juba. He was suffering from a severe febrile disease, and becoming increasingly ill was admitted to Maridi Civil Hospital. He died a week later. His brother and nephew, after burrying him in Maridi returned to Nzara. The brother then became ill and died in Nzara, the nephew also fell sick, went to Juba for treatment, flew to Khartoum and died in Omdurman on 30th August.

Meanwhile in Maridi a nurse, a hospital cleaner and a hospital messenger all developed identical symptoms and were admitted into various wards of the Hospital. Hospital contacts of these patients, seeded the disease around Maridi town - leading to one of the most tragic hospital outbreaks that ever occurred in the recent history of Medicine.

Position	Total in Hospital	Infected	% Infected	Deaths
Doctor	2	1	50%	1
Office Personnel	11	5	45%	1
Medical Assistants	6	6	100%	5
Nurses	53	14	26%	5
Student nurses	95	39	41%	22
Cleaners	39	6	15%	2
Miscellaneous	24	5	21%	5
Total	230	76	33%	41

The outbreak started by Mid-August and ended by the last week of November. The peak was during September.

Month	Cases	Deaths
August	10	3
September	111	56
October	84	53
November	23	5
Total	228	117

We collected specimens for virological studies :

blood, throat swabs, urine, C.S.F. These were transported by air to Khartoum and then to Porton-Down, England, where the etiologic agent was isolated. The following instructions were issued as primary measures for the control of the outbreak :

1. Very strict quarantine measures and isolation of suspected cases.

2. The application of strict aseptic techniques in handling specimens for investigation.

3. Minimize the unnecessary handling of patients by either the hospital staff or their relatives.

4. The wearing of gowns, masks, gloves by all hospital staff attending these wards.

With the institution of these measures the number of cases started to drop.

It appeared then that Maridi hospital acted as an amplifier of the disease without which the disease would have died out naturally.

The disease had originated in Nzara towards the end of June 1976 in three employees of the local cotton factory. The total number of cases in Nzara was about 70 with 33 deaths (mortality 47%).

The big question still remains as to the origin of the responsible virus.