Ground zero account

HERE is the chronological report of events as I was best able to assimilate the information.

22 JULY: Cecilia and Linda van Rensburg went to the Lower Zambezi game lodge for a walk.

Game lodge manager Linda Bennett has had a few staff members who have subsequently been assessed, but found to have flu with no worrying signs.

AUGUST: A polo cross tournament brought horses over from DRC. Cecilia participated in that tournament. It is possible that a tick could have been brought in in this way. Cecilia is keen on horses and regularly gets tick bites. She also sustained an injury to her foot.

On September 4 Cecilia developed flu-like symptoms.

SEPTEMBER 6-8: Cecilia and some friends attended a wedding in South Africa, and many people at the wedding developed diarrhoea and vomiting. All the others recovered fully.

SEPTEMBER 9-11: Cecilia continued to deteriorate and her sister, Magda, took her to see numerous doctors at hospitals in Lusaka.

On September 9 a doctor diagnosed sepsis and gave her a cephalosporin. On September 10 the antibiotic was stopped because a doctor noticed a rash and decided it was a drug reaction. On September 11 another doctor made the diagnosis of sepsis, then meningitis. Antibiotics were recommenced. She was admitted to hospital where her SpO2 [amount of oxygen carried by red blood cells in the blood] was reported by the nurse to be below 70 percent during the night. She was not intubated at that time.

SEPTEMBER 12: Magda found out about the low SpO2 and decided to call Special Emergency Services. Hannes [Els] was the paramedic on duty and took her to the Trust Hospital.

Cecilia had a generalised convulsion shortly after arriving at the Trust Hospital. Hannes then called me as the SES ICU consultant to assist him with this critically ill patient. She was intubated by the Trust anaesthetist.

Shortly after the intubation I arrived and did her transfer to Johannesburg. She was sedated and ventilated for the transfer.

Her clinical condition revealed septic shock with severe perfusion deficit, hypotension, ARDS [acute respiratory distress syndrome], clinically with SpO2 95 percent on 100 percent O2. The right lung was more consolidated than the left with diffuse crackles. She had an eschar [nechrotic tissue] and laceration on her left foot, a diffuse vasculitic rash which blanched on compression. There were no red or purple spots on the body caused by a minor haemorrhage, but she had a haemorrhagic pharyngitis. There was no significant swelling of glands. Neuro exam was not possible due to the recent seizure and subsequent anaesthesia.

She was resuscitated with IV fluids and loaded with Flagyl, Gent, Ceftriaxone and Ampicillin en-route. Her flight was uneventful.

She continued to pass urine into the catheter throughout the flight. On arrival in Morningside ICU, Dr Sewlall found her to be completely unresponsive, and a CT scan revealed extensive cerebral oedema. She developed rapidly progressive multi-organ failure.

SEPTEMBER 13: Cecilia died.

SEPTEMBER 14: Hannes started to develop flu-like symptoms.

SEPTEMBER 16: Hannes flew a patient out of the Congo with pilot Angus Mathi. Angus has no symptoms, nor does his wife or child. We have no reports in Congo of any infection as a result of this flight.

Angus works for Star of Africa and flies twice a week to Congo. H e has been quarantined in Congo and needs a letter from CDC to confirm safety for him to fly .

SEPTEMBER 17-25: Hannes continued to deteriorate at home. His wife remains symptom free. Lee-Anne Robinson [his neighbour] was visiting to do physio on Hannes' son. She had no physical contact with him at all. I know of no other contacts during his illness.

SEPTEMBER 25: Lee-Anne develops flu-like illness

SEPTEMBER 26: Her colleague, Conrad, decided that she was sick enough to warrant evacuation.

SEPTEMBER 26-28: Lee-Anne has a 40°C fever.

SEPTEMBER 27: Hannes was flown out to Johannesburg's Morningside hospital, also under the care of Dr Sewlall. I have no records of this flight.

SEPTEMBER 27-28: Hannes has progressive multi-organ failure

SEPTEMBER 29: Respiratory failure. Intubated and ventilated. Lee-Anne reports that she has drunk six litres of water, more than usual with poor urine output. She was quarantined at her home while we tried to plan where to send her.

OCTOBER 2: New set of bloods were taken from Lee-Anne as she was feeling a lot better.

OCTOBER 3: I receive news via Dr Mead that a young Lebanese boy was evacuated and is now presenting with similar deterioration at some hospital in Lebanon.

Lee-Anne says she feels well and wants to visit her family on Kushiya farm.

Linda Van Rensburg, her husband, Charles, and baby are all examined by Dr Mead and cleared.

COMMENTS AND CONCERNS: I was sure that the incubation period was less than 10 days, but we have now been informed that the time of contact of the ICU nurse in South Africa was 14 days from contact to first symptoms, then 13 days to point of rapid deterioration. The disease appears to take about 14 days from onset to mortality. Patients are still able to function well until three 3 days before they die.

This flu-like symptom is identical to the viral flu that is common in the community at this time. The only keys we have identified at this time are a vasculitic rash (at about 7 days) or petechiae (late) and a fever - 39°C.

Clearly, if the Lebanese boy was not a contact of the others we have a very serious problem.

I have informed the polo cross events people to ensure that horses are dipped and special precautions against ticks are taken.

Oranmore-Brown runs the Mercy Flyers NGO in Zambia