Tanapox

This is tanapox, photographed in Zaire, now the Democratic Republic of the Congo. While sampling animals for monkeypox virus, I also collected mosquitoes along the banks of the Zaire River in the town of Lisala, where tanapox was seen. The theory was that the tanapox reservoir rested in small mammals (possibly monkeys) and mosquitoes were the vectors.

Tanapox was first described in the late '50s along the Tana River in Kenya, where several hundred people were afflicted. It is found throughout tropical Africa, but is rarely seen. The virus can be cultured only in monkey and human tissue. A near identical disease is found in laboratory monkeys.

Like monkeypox, tanapox is a zoonosis, meaning that it is transmitted from an animal host. It is a double-stranded DNA poxvirus that starts with a fever, followed by a single hard nodule, usually on the extremities. Sometimes there are a few lesions, with a maximum of a dozen. Fortunately, patient recovery and resolution of the lesion(s) is the outcome. Tanapox occurs in males and females, of all ages and is not readily transmitted between people.

Only five cases of tanapox have been seen in the United States. Three of these came from contact with a laboratory animal, and one was a traveler from Sierra Leone. The most recent case was a 21 year-old college student who cared for orphaned chimpanzees for two months at a sanctuary in the Republic of the Congo. She exhibited a fever, swollen lymph glands and a lesion on an elbow and leg. She was first treated for malaria and then a local doctor attempted to aspirate material from a nodule, but it was solid.

Two weeks later, she returned to the states, where tanapox was suggested as a tentative diagnosis, which was confirmed by polymerase-chain-reaction (PCR).

Photo by World Health Organization

Tropical Agriculture and Monkeypox

Showing behemoth tree skeletons left behind after felling and torching a patch of forest, this photograph illustrates "slash and burn" agriculture. The ash enriched soils support a diverse harvest of corn, peanuts, manioc, yams, beans, okra, peppers, squash, amaranth, and bananas.

One of the interesting facts about monkeypox was that the primary cases were mostly children between five and ten years of age. This is the age of boys too young to hunt who accompanied their sisters and the village women to the fields to work. Besides planting, weeding, chopping firewood and harvesting, they also protected the crop from marauding pests, such as baboons and wild pigs.

To occupy their time, and because they were hungry, the young boys would learn life skills by hunting the small mammals, mostly rodents that lived in the vicinity. Mostly, the captures were made by the clever use of snares, traps, and nets. The catch would be butchered, cooked, and eaten out in the field by the boys and girls. The agricultural areas seemed to be the interface between some animal host carrying the monkeypox virus and humans. What was this animal host?

Photo by D. Messinger

Truck Stuck

Traveling the "bush" for six months, stopping in remote villages to conduct research on monkeypox, meant that one needed to carry all needed supplies and equipment, including a portable short-wave radio to keep in touch with the World Health Office in the capital. Negotiating impassible roads in the center of Zaire (now the Democratic Republic of the Congo) meant that the equipment included metal skids, shovels, an electric wench, and a chainsaw for situations.

The top photograph shows the Toyota high-centering in a sandy road in Bandundu. Digging, putting grass, skids, or other traction under the wheels or using the "come-along" were all options. Often, when the ruts were very deep, the best tactic was to strike out across the virgin savanna on a parallel track. The unbroken grass provided good traction for a new road, but, over time, the ruts would get deeper and more eroded, until that, too, was abandoned for another path. In some places, there would be a dozen side-by-side roads, wandering and twisting through the savanna, in various stages of wear. It was a challenge to chose the best road.

The middle picture shows where we fell through a small bridge over a stream. Here, it was impossible to extricate ourselves, so after a few hours, we managed to signal our distress to a village, a few miles distant. The villagers were all to happy to enjoy the excitement of a passing vehicle, busted through a rotten spot on their bridge. Joking and laughing at their fortune, they picked up the truck's rear end and placed it back on better timbers.

Where was I? I was knee deep in the water, cooling off, taking pictures, and laughing at the absurdity of it all. I suspected that the villagers may had actually set up the bridge as a truck trap. There were so few vehicles passing in this area -- only a couple a month -- that perhaps this was the local taxation. Being Zaire, it was not out of bounds for Zairians to go to extraordinary lengths for a few dollars.

The last image is of the "one that didn't make it." Mungbau, the driver had to stop and get his picture taken by the upside down cab and trailer of what must have been a horrific accident. Usually, the metal from abandoned trucks was pulled off and recycled, but this area was too remote for such piracy.

Photos by: D. Messinger

Dancing with Bats

I always like the top photo, because it looks like I am doing some kind of barefoot water ballet. Instead, Moseli, a nurse, and I were mist-netting for bats. I was a volunteer in the Peace Corps, on loan to the World Health Organization (WHO). We were trying to determine the wild animal reservoir for the virus that caused monkeypox in Zaire (now the Democratic Republic of the Congo).

The mist net was so fine, that it was nearly invisible to the eye, and was typically strung across streams, which were used by many species of bats as highways (as opposed to dense forests, where there were many impediments to flights). A mist net could be bunched up into the size of a fist, and it was easily torn by the captured bats, which we extricated with care.

The bottom photo is Moseli holding a male hammer-headed bat, the largest bat in Africa. The males, weighing up to one pound, are twice the size of the females. They are sexually dimorphic, with males having large square heads, and a huge larynx that extends into the thorax, displacing the lungs and heart. The voice box is used to produce the loud calls to attract females.

Hammer-headed bats meet at "leks," or mating arenas, for copulation. The males gather first, in small groups, where they spread out and establish their territory. They call loudly, with honking, croaking squawks. The females follow the sounds that can be heard from a great distance and come to the lek to select their mate.

Lekking (from Swedish "to play") is a promiscuous mating system that is either classical, where visual cues are used, like the tail display of peafowl or exploded, where the attractant is vocal, such as that of the hammer-headed bat.

Trappping Rats Around a Village

The focus of the search for the wild animal reservoir of monkeypox was on rodents that lived around the villages and in the nearby agricultural fields. Mungbau, the chauffeur, is seen with the live traps that we loaned out to the village youth to set in the surrounding area. They were given in batches of ten to fifteen traps per trapper.

Mungbau, (with the supervision of the team's pet genet), is checking each trap to make sure that they are in order before they are handed out. The traps were numbered to help track them. The local hunters were easy to train, and we paid them for their knowledge of the forest and the wildlife via the catch they brought in each day.

The villagers used their own bait and knew how to mount traps high up in trees, along waterways, around trails, and in brush piles. They had a much higher catch than we could have realized if we had done the work ourselves. The rats were identified, euthanized, and processed for their organs and blood for identification of monkeypox virus and antibodies.

Photo by D. Messinger

Monkeypox Office at Night

In this photo, I am preparing the notes from the day's work, during a long field trip in Zaire (now the Democratic Republic of the Congo) to study human habits in relationship to the rodents found around the villages and agricultural areas. Because there was no electricity where I worked, lighting was limited to kerosene lanterns.

The large notebook mapped out the location of nests, and distance from a point along a transect, of the rope squirrels that we were studying. Due to many variables, the time spent in an single location was too short to learn actual density of the squirrels, but this was a quick way to get relative density indications for various areas that I studied.

The folding table belonged to our team and was the "office." This photo was taken outdoors, in front of the main house of the village chief. Like other local activities such as cooking, relaxing, working, and visiting, my study was not done in a hut. Mud huts were primarily for sleeping and for escaping the torrential equatorial rains.

One of the things not seen was my audience. The people -- adults, kids, and assorted dogs and chickens hung around to see what I was doing. They would quietly talk, work, or play and keep me company, partially as a favor. In the culture, being alone was anathema. And I was a stranger, doing strange, and unfathomable things, that would be talked about for years. I always had onlooking eyes, even here in the soft nighttime air under the stars.

Sampling Rats for Monkeypox

In 1986, conditions for sampling rodents for monkeypox virus in Zaire (now the Democratic Republic of the Congo) were rustic and home grown. The rats and mice were live-trapped by the villagers and brought to the World Health team every morning for processing.

The upper photograph shows me as the record-keeper and anesthetist. I had to grossly identify the species (and prepare the museum skins of questionable animals). I placed the entire live trap in the red wooden box, added the cotton balls soaked with liquid anesthetic (chloroform or halothane) and covered the top with a clipboard that was weighted down with a car jack.

After several minutes, I would remove the unconscious rodent from the cage and pin it out, belly up on a cork board for surgery, with the animal's accession number. The two nurses behind at the "surgical" table would quickly take blood by cardiac puncture, which euthanized the animal.

Two pieces each of lung, liver, spleen, and kidney were removed by surgical technique and placed in cryogenic tubes to be frozen in liquid nitrogen. The blood was spun down in a battery operated centrifuge and the serum was also frozen. All of the samples were split between Atlanta and Moscow for analysis.

Fieldwork was exhausting and difficult. I am wearing my stern, no-nonsense expression for the camera, and the ever constant gaggle of curious onlookers. We had no hotel to retire to every night, or restaurant to have dinner. Everything that we needed, we carried with us, and we truly lived off of the fat of the land.

Photo by M. Sczeniowski, WHO

Don't Mess with Me Messinger

Here I am, with the World Health Organization Toyota, studying monkeypox disease on the road in remote Zaire (now the Democratic Republic of the Congo). I am wearing my flying-geese-with-yoke-embroidery dress to present myself to the immigration officials in a regional governmental district. I usually wore flip flops (to ward off fungus), but here I must have kicked them off in favor of being barefoot.

I am also wearing my "just make my day" scowl used to face down Zairian authorities, both fake and authentic, who tried to threaten, intimidate, or coerce me into giving them something. The guns were real and there were plenty of stories of people being jailed or manhandled over trumped up charges. I don't know why, but, over the years, keeping myself out of trouble had become one of my favorite games.

In the above scenario, I gathered up my papers signed by the central government, put on my flip flops, and presented myself to the office of the local immigration official. Rarely would they see me, but they would hold my passport for "approval." I would call their bluff, saying that they had better stamp my papers and deliver them, because our team was already behind on our important health work and we needed to start immediately.

That was the beginning of a dance that was short or long, simple or complex, based on the artfulness of my dance partner, (the official), and his minions. I looked forward to the testing and refining of my techniques and in the Africa art of getting by, I believe that the officials also enjoyed the exercise.

In the end, I always won. One thing about the game was that, although the end goals were serious, everyone recognized that it was a game, and the losers were (usually) good sports.

Monkeypox Supplies

The porters were placing a metal trunk on a wooden dugout canoe, for crossing a river during flood season. The trunk was so wide that it could not be placed in the bottom of the canoe. It had to be balanced on top of the wooden sides, along with the bamboo carrying pole, and ferried across by two expert paddlers. The woven fiber basket carried a couple of chickens that were taken along, for dinners.

One of the difficulties of doing extended field work was the need to carry large sums of cash to pay the locals. I learned to take along my own insurance: a snake. For the pictured trunk, for instance, I had opened it in front of the village chief, telling him that it was the trip's bank, and then placed a snake inside, thus insuring complete compliance to the "Do not Open" request. The chief had sucked in his breath, gravely thanking me for telling him, so as to avoid any accidental accidents by the villagers.

Photo by D. Messinger

Monkeypox Field Freezer

This image highlights the juxtaposition between modern technology and the real word in central Africa. This liquid nitrogen filled, vacuum pulled tank was the ultracold "freezer" that enabled tissues to be transported from the field to the laboratory. A filled tank would last from six to eight weeks under normal conditions.

In 1986 and 1987, the samples carried in these tanks were tested for evidence of monkeypox virus. They were shipped from Zaire (now the Democratic of the Congo) to the Centers for Disease Control in Atlanta and to a Moscow reference laboratory. At that time, only these two facilities were allowed to keep the smallpox virus (and conduct research on the related monkeypox virus).

In the photograph, the tank is lashed to bamboo for transport balanced on the shoulders of porters, one in front, and one behind. Now, the tank is being placed in a pirogue, a hollowed out log canoe, for a river crossing. The "rope" is local fiber and there are a pair of extra plastic sandals tied to the tank. (No one in the African jungle wore leather or closed foot gear, due to the risk of fugal infection).

The story that goes with this scene is that one of the workers went with the porters to take a filled tank back to the road, while I stayed in the village to continue the work. They were met by a villager who attacked them (for reasons not clear to me -- maybe to steal) In the fracas, the liquid nitrogen tank tipped over. As per industry standard, the tank cannot be sealed tight, so the insulated cap fits loosely in the neck.

As they related, a cloud of steam billowed up -- the escaping liquid nitrogen, at minus 320 degrees Fahrenheit. The attacker was frightened and ran off, while the porters quickly righted the tank. There was no harm done, but the incident could have turned deadly. In any case, the samples arrived in good shape halfway around, and on either side, of the world.

Photo by: D. Messinger

Monkeypox Field Work

Mungbau drove our team of three -- Zairian nurse, Zairian chauffeur, and me, a Peace Corps volunteer -- from Lisala, on the North side (the right bank) of the Zaire river to Kinshasa and beyond, by road. We traveled for six months, and lived entirely out of what we could carry in the short-bed Toyota Land Cruiser. In 1986, we were detached from the National Program of Vaccination to the World Health Organization to conduct field studies on the wild animal reservoir for the zoonotic disease called monkeypox.

We traveled light because we had to. Over half of the back of the vehicle was for our supplies, including a liquid nitrogen tank, animal live traps, tissue sampling supplies, and a battery operated centrifuge, pictured above. The centrifuge was needed to spin down the tubes for the serum that was frozen in the liquid nitrogen.

We also carried a big box of replacement parts for the truck, a chain saw, and tools. Our own supplies were limited to some kerosene lanterns, folding cots, cooking utensils, buckets, a card table, a short-wave radio with antenna, and a metal trunk full of money to pay people. The three of us each had a small duffel bag with several changes of clothes, a towel, and soap. We bought powered milk, rice, sugar, salt and coffee where we could find it along the way.

Mungbau was the most ingenious and talented mechanic I have ever known. When we were stationed working at a village, Mungbau would offer his considerable expertise to fix anything that had moving parts, especially generators, old trucks, and motorcycles. He used scrap metal, wire, and rubber. Once he jury-rigged a broken leaf spring by shoring the side up with wood chopped out of the forest and the driver was able to limp in to the next commercial center.

Monkeypox on the Wrong Side of the River

In 1986, as a Peace Corps volunteer, I was placed on "loan" to the World Health Organization (WHO) to work on a specific question: what was the wild animal reservoir of monkeypox disease? The WHO logo on the driver and passenger doors of the project's short-bed Toyota lent authority in the interior, where one survived by wits, bluff, and knowing what motivated action in a nation known for its paralysing inertia. We were three -- me, a Zairian driver, and a nurse. On the road for six months, we sampled small mammals in four widely varying sites in the country.

One time, in an extremely remote area of Bandundu, far from civilization, we came upon a river that we could not cross, because the ferry had shut down for the day. We were about half-way through our voyage from Lisala to Lodja to Kikwit to Kinshasa and then to Tshela, Bas-Zaire and back again to Kinshasa. (People who know the country will tell you that this route cannot be traveled by road, but we managed to do it.) Our cargo included hundreds of precious tissue samples from rodents that were ultrafrozen in liquid nitrogen.

It was only about 4:00 pm, but we could see both banks dotted with travelers, all seemingly resigned to spending the night on the wrong side of the water. A vehicle or two were also stranded, but in the usual Zairian way, no one was bucking the system -- there was a group of loiterers drinking at a dive with distorted music blaring from a battery powered boom box sitting on an overturned yellow plastic beer crate.

But for me, there was no way was I going to lose hours of driving. Cueing my driver to honk, I thumped loudly on the passenger side of the door as we rounded the bend and came to a dramatic stop in front of the white-washed official hut of the ferry-minders.

A crowd quickly assembled. I hollered, still beating on the WHO sign, "Hurry, hurry, get the ferry boatmen here quickly! We have to get to the other side tonight! Our vaccines will melt!"

The crowd was energized into shouting and the ferry workers soon trotted up. I showed them the liquid nitrogen tank in the back, and opened the lid to let them feel the instantly freezing vapor. "We must hurry and get across, this freezer will run out tonight and our precious medical supplies will be ruined!"

My driver and nurse played along, using the medical card that had always worked in the past. The people had never seen a liquid nitrogen tank, nor even a real freezer in this region. But the thought that lifesaving medicine would be lost convinced them to fire up the ferry and take us, and a load of lucky travelers on foot, to the other side.

As a thank-you, we passed out four WHO approved medicines that we were allowed to freely hand out to the population, as their usage was commonly understood: aspirin, multivitamins, a wormer, and an anti-malarial treatment. The crowd was delighted and roared their approval as we gunned off in the truck.

An hour and a half later, satisfied at our small feat of conquering the government officials, and still laughing at the expression of astonishment on everyone's faces at the ferry crossing, we stopped at a village for the night, and went to find the chief to ask for a place to stay. We knew that our passage would be the topic of wonder and many questions for months to come, as word would travel up and down the area about the crazy woman who carried a freezer in a tank, and how their quick action had saved the vaccines.

A New Disease?

In Zaire (now the Democratic Republic of the Congo, or DRC), I never saw an active human case of monkeypox. Monkeypox was so rare that the World Health Organization (WHO) had only investigated the clinical course and epidemiology of 300 cases during sixteen years of surveillance, most of them in Zaire.

The poster above was used to illustrate the important signs of monkeypox to African health workers. Two differences between it and smallpox was that monkeypox had pox lesions on the palms of the hands and bottoms of the feet, as well as swollen lymph glands, unlike smallpox.

This zoonotic disease (any illness that can be transmitted from animals to man -- or from man to animals), at first thought to be "new," had actually been smoldering in the African tropics for thousands of years. When smallpox was eradicated in the late '70s, the lookalike monkeypox surfaced. As a Peace Corps volunteer, my "job" with WHO was to try and find out what animals carried the virus as the wild reservoir.

Monkeypox became important to Americans in 2003 when it surfaced in pet prairie dogs that had been contaminated by a shipment of African rodents destined for the pet trade.

Photo by M. Szczeniowski, WHO

Girl with Monkeypox

This photo shows a seven-year old Zairian girl afflicted with a disease called monkeypox, two days after the onset of the rash. (She survived, and there was no scaring.) Only 400 cases of this rare disease had been described in West and Central Africa when, as a Peace Corps volunteer, I was "loaned" to the World Health Organization to lead the virus ecology team in research to learn the animal reservoir of monkeypox.

Monkeypox closely resembled smallpox, the only disease that has ever been eradicated from the face of the earth (with the exception of two research laboratories). The virus was so similiar to smallpox that the smallpox vaccination was protective against monkeypox, and clinically there were only minor differences between the two illnesses.

Smallpox had no animal reservoir, and it was passed from human to human. An aggressive worldwide vaccination program literally vaccinated a geographical ring around active cases and the disease was snuffed out, country by country, until it was eradicated in the late 1970's.

Many questions were raised about the newly described disease. Where was it coming from in the wild? How easily did it pass from one human to another? Would it cessation of the protective smallpox vaccination cause monkeypox infection to skyrocket? Most importantly, could it mutate and become a new global problem?

Photo by M. Sczeniowski, WHO