Marburg virus is notorious for its lethal potential. In previous outbreaks, the mortality rate has soared as high as 90%. The shocking fact remains that there are currently no approved vaccines or medications to combat this virus.
Just over a month ago, Rwanda’s health officials faced the horrifying reality of announcing the country’s very first Marburg outbreak. The announcement sent shockwaves throughout the region, as even the slightest hint of a Marburg outbreak is generally met with escalating fear.
Now, the same officials have drastically different news to report. Their battle against this deadly virus has yielded remarkably positive outcomes.
“We are at a case fatality rate of 22.7% — probably among the lowest ever recorded [for a Marburg outbreak],” announced Dr. Yvan Butera, the Rwandan Minister of State for Health, during a press conference organized by the Africa Centers for Disease Control and Prevention.
Other signs of hope also emerged: Two critically ill Marburg patients, who had faced multiple organ failure and were placed on life support, have now successfully had their breathing tubes removed and are on the path to recovery from the virus.
Furthermore, new cases in Rwanda have significantly decreased, plummeting from several reported daily infections to just four cases in the last two weeks. This reduction brings the total count for this outbreak to 66 patients affected by Marburg and 15 fatalities.
“It’s not yet time to declare victory, but we think we are headed in a good direction,” Butera remarked. Experts in public health have already begun using terms like “remarkable,” “unprecedented,” and “very, very encouraging” to describe the incredibly effective response to the outbreak.
So, what enabled Rwanda, a nation of approximately 14 million people, to achieve such groundbreaking success? What lessons can other nations take from Rwanda’s adept handling of the Marburg outbreak?
Doing the Basics Really Well
Rwanda’s history is marred by the horrific events of the 1994 genocide, which inflicted deep scars. However, the country has remarkably reinvented itself since then. Over 20 years, life expectancy has notably risen from 47.5 years in 2000 to 67.5 years by 2021 — a stark contrast to improvements seen across the continent. This progress has been accompanied by decades of investment in building a robust health-care infrastructure.
“The health infrastructure and the healthcare providers in Rwanda — they are truly exceptional,” says Dr. Craig Spencer, an emergency physician and professor at Brown University School of Public Health. The capabilities of Rwandan hospitals, combined with well-trained nurses and doctors, have been instrumental in managing this crisis.
The country boasts modern laboratories capable of conducting rapid diagnostic testing. Medical workers have readily available personal protective equipment, which has been critical in dealing with infectious diseases. For this particular outbreak, Rwanda efficiently established a dedicated Marburg treatment facility, which has protected both patients and healthcare staff from potential exposure to the virus — which is primarily transmitted from bats to humans and can spread through bodily fluids.
Even in the absence of approved specific treatments for Marburg, patients in Rwanda have benefited from excellent supportive care, addressing symptoms prevalent in viruses like this — such as critical IV fluids for managing escalating fevers, nausea, vomiting, and diarrhea.
This efficient approach highlights a stark contrast to the responses seen during past Marburg outbreaks. For instance, in the Democratic Republic of Congo — Rwanda’s neighbor — a devastating outbreak occurred from 1998 to 2000. During that time, Dr. Daniel Bausch, an expert in tropical diseases, noted that the healthcare facilities provided only minimal support to patients.
“Although we called it a care center or treatment center, in reality, it was merely a separate mud hut where individuals were quarantined. Our available resources were extremely limited,” he recalls. Those unfortunate enough to fall ill often received nothing more than paracetamol or Tylenol and a few fluids if they could manage to consume them given their condition.
That outbreak recorded a staggering 83% fatality rate, with 154 cases and 128 deaths among patients.
In the world’s 18 reported Marburg outbreaks, the mortality rates have varied widely. While some smaller outbreaks experienced fatality rates below 30%, the largest and most catastrophic outbreak occurred in Angola from 2004 to 2005, witnessing a shocking 90% mortality rate with 252 cases and 227 deaths recorded.
Rwanda’s more advanced healthcare facilities have made a significant difference, as emphasized by Bausch.
Getting to Patients Lickety-Split
The rapid response time in attending to patients has further contributed to Rwanda’s success. Immediately upon identifying the outbreak, Rwandan officials launched a comprehensive effort to trace contacts of infected individuals, meticulously monitoring more than 1,000 family members, health workers, friends, and those potentially exposed.
Additionally, officials undertook extensive door-to-door surveillance in neighborhoods that may have been affected by the outbreak. Their efforts included thorough testing, culminating in over 6,000 tests, especially among healthcare workers, who comprised a staggering 80% of the Marburg patients in this scenario.
Spencer indicated that much of this efficient infrastructure developed in response to the COVID-19 pandemic, allowing for rapid deployment of capabilities. “In Rwanda, healthcare providers could administer tests within hours of the outbreak being declared,” notes Spencer, who has notably worked with Doctors Without Borders in treating Ebola patients. “[Rwanda’s testing capabilities are] undeniably remarkable in the context of this health crisis.”
This robust system of surveillance and testing enabled officials to identify cases swiftly and administer treatments during the very early stages of the illness, says Butera. By providing care to patients before their conditions became critical, Rwanda effectively helped reduce the mortality rate.
Embracing Experimental Vaccines and Medications
Rwanda’s speed of response extended to other vital measures against the Marburg virus.
“My experience in Rwanda has been characterized by remarkable expediency,” remarked WHO’s Ghebreyesus, who had visited the country last week. He proclaimed the progress observed as “very, very encouraging.”
Although there are no approved vaccines or treatments available for Marburg, Rwanda wasted no time in obtaining experimental vaccines and treatments for those at the center of the outbreak.
“It’s hard to imagine another scenario in which a country identified an outbreak and, within just over a week, introduced investigational [experimental] vaccines into the country and began administering them to frontline healthcare workers,” says Spencer, emphasizing that the emergency doses started being given on the very day they arrived. The nonprofit Sabin Vaccine Institute facilitated the provision of these doses with substantial support from the U.S. government.
“It is truly rare for me to use the term unprecedented in the context of global health response,” Spencer admitted; however, he believes the rapidity of Rwanda’s actions was indeed “unprecedented.”
Though the vaccine is still undergoing development, and while it has been deemed safe in testing, its efficacy remains unproven. Nevertheless, Rwandan health officials opted to vaccinate those at risk, driven by the hope that it would prove beneficial.
The decision to vaccinate without implementing a randomized controlled trial, where some participants receive placebos, raised debate among some international scientists who felt this was a missed opportunity to gather insights on the vaccine’s effectiveness. Yet, many acknowledged the complexity of launching such trials quickly, particularly given that the size of the outbreak might not produce sufficient data for definitive conclusions.
Determining whether the experimental vaccines helped stem the outbreak or lessen the mortality rate remains elusive, says Bausch. He recalls that during the inaugural Marburg outbreak in 1967 in Marburg, Germany, the mortality rate stood at just 23% with only supportive care provided.
Currently, in Rwanda, the next series of vaccines is set to be administered to at-risk groups, specifically targeting miners who frequently come into contact with the fruit bats responsible for spreading Marburg. This second wave of vaccination efforts will be conducted in a randomized manner.
Beyond the vaccines, Rwanda aggressively implemented two antiviral treatments — Remdesivir and a monoclonal antibody — for patients, aiming to mitigate the illness despite these treatments not receiving formal approval for Marburg.
An Early Stumble, A Course Correction
In addition to the swift, high-quality patient care provided, another critical, albeit less glamorous, aspect crucial for combating Marburg and similar viruses is infection control. Effective infection control involves stringent measures to prevent Marburg patients from transmitting the virus to others. Within healthcare facilities, this entails staff adhering to protocols such as wearing gowns, masks, and double gloves. In public spaces, measures include sanitizing shared items like motorcycle helmets and setting up handwashing stations — initiatives Rwanda has actively pursued.
Rwanda faced an initial misstep in its infection control approach, which arose due to a delay of a few weeks in diagnosing the first known patient of this outbreak, also recognized as the initial case of Marburg in the country.
This individual is believed to have contracted the virus from exposure to fruit bats in a mining cave and was also suffering from severe malaria. Clinicians did not identify the presence of Marburg until additional individuals in close proximity to this patient began falling ill. Consequently, many healthcare workers had likely been exposed to the virus before infection control measures were effectively implemented.
Once the nature of the situation became clear, Rwanda urgently enhanced its infection control measures—not just in healthcare settings, but also in the mining communities linked to the initial patient, where several additional cases emerged. Surveillance efforts must extend to these at-risk populations, emphasizes Rob Holden, WHO’s incident manager for Marburg.
“As we progress, we will continue fine-tuning, refining, and strengthening all our surveillance systems, including contact tracing and investigations. We cannot afford to leave any stone unturned,” Holden insists. “If we relax our vigilance, we may face disturbing surprises and an extended crisis related to this outbreak.”
Spencer shares this concern, albeit with a sense of cautious optimism. He concludes that Rwanda’s robust health infrastructure and swift intervention have served to safeguard not only the nation but also the global community from the potential onset of a more extensive Marburg outbreak.
Les and other means of transportation used by infected individuals. Rwanda’s swift enforcement of these infection control measures helped to minimize the potential spread of the virus.
In the immediate aftermath of the outbreak identification, there were reports of healthcare workers who had come into contact with infected patients. Recognizing this, health officials promptly quarantined contacts and monitored their health status, which was crucial in preventing further transmission. This proactive approach stands in stark contrast to the shortcomings observed in past outbreaks, where delays in isolation and contact tracing allowed viruses to spread unchecked.
Experts praised Rwanda’s commitment to relentless vigilance in infection control, which was underscored by constant training and awareness programs for healthcare workers. Health authorities conducted simulations and workshops to prepare for potential outbreaks, ensuring that medical teams were well-versed in both treatment protocols and safety measures.
Additionally, regular communication with the public played a pivotal role. Rwandan authorities engaged in transparent and ongoing discussions with communities about the dangers of the Marburg virus, modes of transmission, and preventative measures. This education and outreach helped in fostering compliance with health directives and encouraging those with symptoms to seek medical attention promptly.
Rwanda’s multi-faceted strategy—extending from robust healthcare infrastructure and rapid patient response to aggressive vaccination and stringent infection control—has yielded notable success in curbing the Marburg outbreak. As international health authorities and scientists assess Rwanda’s approach, many are hopeful that these lessons will inform future responses to outbreaks of this nature, not just in Africa, but globally.
Rwanda’s handling of the Marburg outbreak illustrates the importance of preparedness, swift action, and community engagement in containing infectious diseases. While the focus remains on the ongoing fight against Marburg, the country’s proactive measures may serve as a blueprint for others facing public health crises in the future.
