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Marburg disease is a potentially very deadly virus. Rwanda's outbreak has been an “unprecedented” success, public health experts say. In this photo from the 2014 Marburg disease outbreak in Kenya, a medical worker in a protective suit brings food to a man who is isolated in an isolation tent after coming into contact with a carrier of the virus.

Ben Curtis/Associated Press

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Ben Curtis/Associated Press

Marburg virus is famous for its lethality. In past outbreaks, as many as 9 out of 10 patients died from the disease. And there are no approved vaccines or treatments.

That was the dire situation in Rwanda just over a month ago when the authorities made an announcement that no one wanted to make. The country was in the midst of its first infectious disease outbreak in the state of Marburg.

Now, the same Rwandan officials are sharing better news. It's gotten much better.

“Our case fatality rate is 22.7%, probably the lowest ever recorded. [for a Marburg outbreak],” said Dr. Ivan ButeraRwanda's Minister of State for Health said Thursday at a press conference hosted by the African Centers for Disease Control and Prevention.

There is even more encouraging news. Two of the Marburg patients who experienced multiple organ failure and were placed on life support have now been extubated, their breathing tubes successfully removed and they have recovered from the virus.

“We believe this is the first time a Marburg virus patient has been extubated in Africa,” said World Health Organization Director-General Tedros Adhanom Ghebreyesus. “These patients would have died in previous outbreaks.”

The number of new infections in Rwanda has also fallen dramatically, from several a day to just four reported in the past two weeks, bringing the total number of Marburg cases and deaths from this outbreak to 66. There were 15 people.

“It's not yet time to declare victory, but I think we're heading in the right direction,” Butera said. Public health experts are already using words like “remarkable,” “unprecedented” and “very encouraging” to characterize the response.

How did Rwanda, an African country of approximately 14 million people, achieve this success? And what can other countries learn from its response?

doing the basic things well

Rwanda is known for its horrific 1994 genocide, one of the worst in modern times. Since then, the country has taken a different path. Average life expectancy has increased over the past 20 years 20 years From 47.5 years in 2000 to 67.5 years in 2021, almost double the increase seen across the continent. And Rwanda has spent decades building a strong health system.

“The health infrastructure in Rwanda, the health care providers, is really, really great,” he says. Dr. Craig Spenceran emergency physician and professor at Brown University School of Public Health. Spencer specializes in global health issues and has been closely monitoring the outbreak in Rwanda.

He says there are well-run hospitals with well-trained nurses and doctors. There are laboratories that can perform diagnostic tests quickly. There is personal protective equipment for healthcare workers.

For this outbreak, we had the know-how and infrastructure to set up another treatment facility in Marburg. This was a benefit to other patients and medical staff, preventing them from being exposed to the virus. The virus can be transmitted from bats to humans through body fluids such as blood, sweat and diarrhea.

And although there is no approved treatment for Marburg disease, patients in Rwanda do not receive adequate supportive care for all symptoms, including intravenous fluids, which are essential for symptoms such as high fever, nausea, vomiting, and diarrhea. Masu.

This is in stark contrast to the reaction under the Marburg scenario in the past. For example, Rwanda's neighbor, the Democratic Republic of the Congo, experienced an outbreak between 1998 and 2000. Dr. Daniel BauschA distinguished professor at the London School of Hygiene and Tropical Medicine and an expert on tropical diseases such as Marburg disease, he provided treatment during this outbreak. He says what the country's health centers were able to offer patients was rudimentary at best.

“We called it a care center or a treatment center, but it was actually a separate mud hut that people could be put in. There was nothing really available to them,” he recalls. “Those who were able to take paracetamol, Tylenol and hydration were lucky if they were able to prevent nausea and vomiting.”

The outbreak resulted in 154 infections and 128 deaths, for a case fatality rate of 83%.

in the world 18 Marburg disease outbreaks have been recordedmortality rates vary widely. Several smaller outbreaks had case fatality rates of less than 30%, but the largest outbreak in Angola in 2004 and 2005 had a case fatality rate of 90% and resulted in 252 infected and 227 deaths. died.

Rwanda's “more modern health centers” will make a big difference, Bausch said.

Unstable response to patients

It wasn't just the quality of care that made a difference. It's also the speed at which patients receive treatment.

As soon as the outbreak began, Rwandan authorities launched a massive operation to trace the contacts of infected people, tracing the health status of more than 1,000 family members, friends, health workers, and other people at risk. was monitored. They also began door-to-door surveillance in areas where there may have been exposure.

And they carried out a large number of tests, in particular more than 6,000 tests on healthcare workers, who account for 80% of Marburg patients in this outbreak.

Spencer said many of these capabilities were built during the coronavirus pandemic and could be deployed quickly. “We have medical workers in Rwanda who can actually get tested within hours of this outbreak being declared,” said Spencer, who has been working with Médecins Sans Frontières to treat Ebola patients. says. “[Rwanda’s testing is] It was really amazing in terms of the response. ”

This surveillance and testing “allowed us to quickly detect cases and provide treatment at the very early stages of the disease,” Butera explains. He said caring for patients before they became seriously ill likely contributed to lower mortality rates.

Adoption of vaccines and therapeutics

Rwanda's speed carried over into other anti-Marburg operations.

“Everything I witnessed was really rapid,” said the WHO's Ghebreyesus, who visited Rwanda last week and said what he saw there was “very, very encouraging.”

There is no approved vaccine or treatment for Marburg, but Rwanda moved quickly to provide vaccines and treatments to people at the epicenter of the outbreak.

“I cannot imagine another scenario where the state launches an investigation just a week after confirming this outbreak. [] “Domestic vaccines are already being provided to frontline health care workers,” Spencer said, adding that administration began the same day they arrived in the country. The nonprofit Sabin Vaccine Institute provided the vaccine, which was developed with significant support from the U.S. government.

“I rarely use the word unprecedented in the global health response,” said Spencer, who said the speed was “unprecedented.”

The vaccine itself is still being developed. Tests have shown it to be safe, but we don't know if it actually works. Nevertheless, Rwanda has decided to vaccinate those at risk in the hope that it will help.

The officials also decided to administer the vaccine without conducting a randomized controlled trial in which some recipients were given a placebo. Some in the international scientific community say this is a missed opportunity to start learning whether a vaccine is effective, but acknowledge that rolling out trials would be much more complex and time-consuming. Furthermore, it is unlikely that enough data will be available to make a judgment based on the scale of the spread of infection.

Did the vaccine help stop the spread or reduce mortality? It's impossible to know, Bausch said. He points out that the first Marburg disease outbreak, recorded in 1967 in Marburg, Germany and then Yugoslavia, had a 23% mortality rate with proper symptomatic treatment alone.

On the other hand, in Rwanda, next vaccination It will go to groups at risk, including miners who are near the flying foxes that can infest the state of Marburg. Vaccination efforts will be randomized.

In addition to the vaccine, Rwanda very quickly began administering two drugs to patients: an antiviral drug called remdesivir and a monoclonal antibody. Like vaccines, they hoped these treatments would help, although they have not yet been approved for Marburg disease.

Early stumbling blocks, course correction

In addition to speed and quality patient care, there is another, less glamorous, but equally important aspect of defeating Marburg disease and other viruses, Bausch said. It's infection control. Basically, it is to prevent patients in Marburg from infecting others. This means staff at hospitals are taking precautions such as wearing gowns, masks and double gloves. In public places, that could mean disinfecting shared items such as motorcycle helmets, or setting up hand-washing stations in public places, as Rwanda has done.

Rwanda stumbled early on with its infection control measures. That's because it took several weeks to diagnose the illness in the individual believed to be the first patient in the outbreak, and the first known Marburg patient in the country.

The person likely contracted the virus from exposure to fruit bats in a mining cave, and also had severe malaria. Clinicians did not determine that Mr. Marburg was also present until other people around the patient began to become ill. As a result, many healthcare workers became infected before infection control measures improved.

Meanwhile, in Rwanda, infection control improved rapidly once authorities, as well as health facilities, understood what they were dealing with. Several cases have been confirmed in the mining community associated with the first patient. Surveillance therefore needs to ensure these people are covered, says Rob Holden, WHO's Marburg incident manager.

“As we move forward, we will continue to fine-tune, improve and enhance all of our surveillance systems, contact follow-up and investigations, taking every step possible,” he says. “If we don't let our guard down, I think we're going to see some nasty surprises with this outbreak and it's going to have a very long tail.”

Spencer agrees. But he's optimistic. He said Rwanda's strong health infrastructure and rapid response are helping protect other parts of the world from a larger Marburg disease outbreak.