A Deadly Echo: The Return of Marburg to East Africa

Even before we could contain the Mpox virus, which the Africa Centers for Disease Control and Prevention (Africa CDC) reports has led to over 77,800 cases and 1,321 deaths by the end of 2024, East Africa now faces another threat: the Marburg virus. This virus has gained traction due to its resurgence in Tanzania, rekindling memories of the COVID-19 pandemic we faced a few years ago. During that time, Tanzania faced criticism for not sharing infection data and overlooking preventive measures, raising concerns about the country’s preparedness to manage this current outbreak.

A CLOSE RELATIVE OF EBOLA

First identified in 1967, the Marburg virus—although less wellknown than Ebola—belongs to the same family of viruses and has caused some of the most severe viral outbreaks in history. Marburg virus disease (MVD) is classified as a rare but highly lethal viral haemorrhagic fever, with case fatality rates reaching as high as 88%, according to the World Health Organization (WHO). However, timely and effective medical care can significantly reduce this rate.

Unlike many respiratory viruses, MVD is not easily transmissible. Historically, outbreaks of MVD have been sporadic and are often linked to zoonotic transmission from animals to humans. However, the WHO reported that in 2008, two independent cases of human infection occurred in travellers who visited a cave inhabited by colonies of Rousettus aegyptiacus bats in Uganda.

Once humans contract the virus through direct exposure, it can then spread from person to person through direct contact with bodily fluids such as blood, saliva, urine, vomit, and other secretions from infected individuals. Contaminated surfaces and materials can also serve as pathways for transmission.

With an incubation period varying from 2 to 21 days, individuals infected with the Marburg virus commonly experience a range of symptoms, which include fever, chills, headaches, muscle pain, rashes, chest pain, sore throats, diarrhoea, vomiting, stomach pain, and, in severe cases, unexplained bleeding or bruising.

TANZANIA MARBURG ALERT

Its recent emergence in Tanzania has raised eyebrows, with the WHO issuing an alert on January 15, 2024, and Tanzanian authorities officially declaring the outbreak on January 20, 2024. As of January 28, the Ministry of Health had confirmed two cases of MVD, both of which resulted in fatalities. Additionally, there have been eight probable deaths, 64 suspected cases, and 281 contacts being monitored for symptoms of the disease in the Kagera region. This current outbreak follows a previous incident in March 2023, whereby nine cases and six fatalities were reported.

Due to Kagera’s cross-border movement and trade, the WHO has warned about the high risk of spreading disease to neighbouring countries, including Rwanda, Uganda, and Burundi. Although no cases have been reported in Kenya, the Kenyan government has activated its disease response systems at all entry points, particularly in counties that border Tanzania. Some of these measures include enhancing surveillance and screening of travellers, increasing laboratory testing capacity, public risk communication, and strengthening infection prevention and control protocols.

RWANDA’S MARBURG EXPERIENCE

Tanzania is not the first East African country to encounter a Marburg outbreak along its borders. Rwanda has faced similar challenges, with the Rwandan Ministry of Health confirming the country’s first outbreak of Marburg virus disease on September 27, 2024. Within just three days, by September 30, the number of confirmed cases surged to 29, with 10 reported fatalities and over 297 contacts, including healthcare workers, placed under close monitoring.

During the epidemic at two facilities in Kigali, 66 individuals became ill, and 15 fatalities were recorded. Investigations into the outbreak’s origin indicated that fruit bats in a mining cave were responsible, highlighting the zoonotic nature of the virus. In response, the Centers for Disease Control and Prevention (CDC) and the WHO quickly provided technical assistance and support for infection prevention measures. Their coordinated efforts were effective, and after 42 consecutive days without new cases, Rwanda declared the outbreak over on December 20, 2024.

INSIDE RWANDA’S MARBURG RESPONSE

Before the virus was effectively controlled in 2024, Rwanda implemented several measures to curb its spread. A significant initiative was the establishment of a pool of Rapidly Deployable Experts (RDE) through the East African Community (EAC) Secretariat. The WHO and other partners funded this effort to ensure that experts could be swiftly dispatched to affected areas. Moreover, the Secretariat played a vital role in enhancing risk and crisis communication and set up 43 Water, Sanitation, and Hygiene (WASH) facilities along border areas.

The Secretariat also improved laboratory testing capacity in the Partner States by providing diagnostic PCR kits for the Marburg and Monkeypox viruses. This enabled the deployment of mobile laboratories in key locations and the donation of essential laboratory equipment, such as sequencers. These comprehensive actions are crucial in combating the outbreak and safeguarding public health in the region.

Another important player was Gilead Sciences, Inc., which, in October 2024, with support from Rwanda’s Ministry of Health, donated 5,100 vials of remdesivir to combat the Marburg virus disease (MVD) outbreak in Rwanda. Remdesivir, which was recognised during the 2014-2015 Ebola outbreak and tested in the 2018 Ebola outbreak in the Democratic Republic of Congo, was provided as an emergency measure since there is no approved cure for MVD.

LESSONS FROM RWANDA

Drawing on Rwanda’s collaborative experiences, the Tanzanian government is working closely with the WHO and other partners to obtain technical guidance and logistical support for implementing essential outbreak management measures. These measures include disease surveillance and public awareness programmes targeting communities and healthcare personnel, concentrating on the prevention and symptoms of the Marburg virus to avert further spread.

The Africa CDC has also assembled a team of twelve public health experts, comprising epidemiologists, risk communication specialists, infection prevention and control (IPC) experts, and laboratory professionals, to provide on-the-ground assistance with surveillance, diagnostics, IPC, and community engagement. It has also allocated US$2 million to enhance immediate actions, including deploying public health specialists, increasing diagnostic capacities by procuring testing kits and equipment, and improving case management by providing training and resources to healthcare facilities.

The fight against the Marburg virus presents a global concern due to its potential for rapid international spread. Organisations such as the CDC and WHO, along with African ministries of health and local NGOs, are collaborating to enhance public health capacities. Their efforts focus on improving disease surveillance, laboratory capabilities, workforce training, and border health systems, while also strengthening outbreak response measures, including case management, infection control, and safe burial practices.

CURRENT APPROACHES TO MARBURG

According to the WHO, supportive treatment remains the primary approach for managing Marburg haemorrhagic fever. This involves maintaining hydration to combat fluid loss, balancing electrolytes to support organ function, and managing haemorrhagic complications to control bleeding. Strict barrier nursing techniques are also essential when caring for patients suspected or confirmed to have Marburg haemorrhagic fever. This includes utilising personal protective equipment (PPE) such as gowns, gloves, masks, and eye protection to prevent direct contact and ensure safety.

Preventive strategies against Marburg virus infection are still being developed, and understanding the precise transmission dynamics from wildlife to humans is an area of ongoing research. The incomplete understanding of these dynamics complicates the development of targeted interventions beyond general precautions. To minimise the risk of infection, avoid direct contact with bats and non-human primates, particularly those that appear sick or injured, and practise good hygiene, including the safe handling of bushmeat.

A PATH FORWARD

Progress in the fight against Marburg Virus Disease (MVD) offers hope for enhanced prevention and management; however, the disease presents significant challenges. One difficulty in diagnosing MVD is that its symptoms often overlap with those of other illnesses, such as malaria, typhoid fever, shigellosis, meningitis, and other viral haemorrhagic fevers. Therefore, accurate and timely diagnosis remains crucial.

The WHO has recommended several diagnostic tests to confirm Marburg Virus Disease (MVD) cases, which are vital for saving lives. These tests include the antibody-capture enzyme-linked immunosorbent assay (ELISA) for detecting antibodies, antigen-capture tests for identifying viral proteins, reverse transcription polymerase chain reaction (RT-PCR) for detecting the virus’s genetic material, electron microscopy, and virus isolation through cell culture.

Just like for Ebola, there are currently no vaccines or specific antiviral treatments for Marburg that have been approved for widespread use by regulatory bodies such as the FDA or the WHO. Nevertheless, several promising vaccine candidates and therapeutic agents are in various stages of preclinical and clinical trials. These candidates comprise vaccines based on the vesicular stomatitis virus (VSV-MARV), Vaccinia Ankara (MVA-BN-Filo), and chimpanzee adenovirus (ChAd3). Developing these vaccines is essential for controlling outbreaks and safeguarding healthcare workers at higher risk.

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