BioEd Online

Health-monitoring experts are coming under fire for their response to a mysterious and fatal outbreak of respiratory disease in northeastern Brazil in March. News of the outbreak, which began on 10 March, only reached the international community on 4 June, when a translation of a local news article was published on the international ProMED mailing list, a service for disseminating information about outbreaks. Four posts on ProMED's Latin American list in Portuguese had appeared the week before.

The 2003 outbreak of severe acute respiratory syndrome (SARS) stressed the importance of using modern communications to at least alert the world to any unusual suspected disease outbreaks.

The Brazilian outbreak was eventually declared a false alert, but that has not stopped health-monitoring officials coming under fire. "Brazil's capacity for outbreak monitoring and response leaves much to be desired," one Brazil-based US official, who declined to be named, told news@nature.com.

Waiting game

When contacted on 6 June, World Health Organization (WHO) spokeswoman Maria Cheng said that the organization's Geneva headquarters had received no information. She said that WHO experts are still awaiting information from the Pan American Health Organization (PAHO), the WHO's Latin America office. "Unfortunately, I don't have any more information about this mystery illness right now," she said.

The same day, Donna Eberwine-Villagrán, a PAHO spokeswomen, said they didn't have any information either, but had asked their Brazil office, while pointing to the first report on the Brazilian Ministry of Health's website, a post dated 29 May as "The latest info we know of 'officially'". On 7 June, Daniel Epstein, a spokesman for the PAHO Brazil office, said it too could not furnish further details, as it was waiting on the Brazilian government for information.

The ProMED report, titled 'Mysterious disease keeps Health Department on alert' cited an unknown disease, referred to as 'idiopathic haemorrhagic pneumonia', that had been suspected in 24 cases, and killed seven of nine confirmed cases (an 80% mortality rate) in the state of Rio Grande do Norte. Symptoms include high fever, respiratory difficulties and bleeding from airways.

Local health official Luiz Jacintho da Silva has confirmed that the scare was a false alarm. Rio Grande do Norte is affected by respiratory syncytial virus (RSV) and seasonal flu, and the initial diagnosis of haemorrhagic pneumonia is now thought to have been "severe, and lethal, cases of either RSV or influenza", he says, with the symptoms compounded in many cases by malnutrition, sickle-cell anaemia or asthma.

Response time

Samples were also tested for the deadly avian flu strain H5N1 at the Evandro Chagas Institute in Belém, part of a WHO flu lab network, even though avian flu has not yet been reported in Brazil, says da Silva. At the same time, he adds, the speed of the outbreak response was complicated by the impact of decentralization on the chain of command, a problem that has been blamed for Indonesia's poor response to avian flu outbreaks.

"The problem with the outbreak investigation is that, as Brazil is a federation, states have to ask for help from the Ministry of Health before an investigation is done," says da Silva. However, federal surveillance has improved recently, he adds, but it "is still problematic in Brazil, at least for respiratory diseases." It's only recently that this has received attention, he says. "Coordination is still in need of improvement."

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