Quality patient care, community engagement key to tackling Marburg disease – ET HealthWorld

Quality patient care, community engagement key to tackling Marburg disease

New Delhi: In light of the recent outbreak of the Marburg virus in Equatorial Guinea, after at least nine people died from Marburg virus-induced hemorrhagic fever, the World Health Organisation (WHO) announced an emergency meeting on February 14, 2023, to outline research priorities towards the newly identified outbreak and discuss therapy plus vaccine candidates. The health agency confirmed the epidemic after samples from Equatorial Guinea were sent to a lab in Senegal that confirmed the diagnosis.

The masses may not be familiar with this rare virus, however, people will be surprised to know that the Marburg virus has been around since 1967, named after the town of Marburg, Germany, where it was detected for the very first time.

For those unfamiliar with the Marburg virus, it is a highly dangerous pathogen that can cause severe fever, often accompanied by bleeding and organ failure, leading to a fatal illness in infected humans, and is a part of the filovirus family that also includes the Ebola virus.

Causative agent, mode of transmission of Marburg virus

Just like COVID-19, Marburg virus disease (MVD) is also a zoonotic disease, caused by Rousettus aegyptiacus, or fruit bats of the Pteropodidae family, who are considered to be natural hosts of the Marburg virus. WHO states that human MVD infection results from prolonged exposure to mines or caves inhabited by these fruit bat colonies.

Back in 1967, two large outbreaks occurred simultaneously in Marburg and Frankfurt in Germany, and Belgrade, Serbia, which allowed the initial recognition of the disease. The outbreak was associated with laboratory work using African green monkeys imported from Uganda.

However, the virus spreads among the masses through human-to-human transmission, via direct contact with the blood, secretions, organs or other bodily fluids of infected people through broken skin or mucous membranes, and with surfaces and materials contaminated with these fluids. This has proven extremely problematic for healthcare workers who have frequently been infected while treating patients with suspected or confirmed MVD, due to the lack of infection control precautions during close contact with infected patients. Additionally, healthcare workers often contract the virus through contaminated injection equipment or through needle-stick injuries, which can lead to severe disease, rapid deterioration, and, possibly, a higher fatality rate.

Burial ceremonies that involve direct contact with the body of the infected patient can also contribute to the transmission of Marburg.

What are the symptoms of MVD?

MVD has an average case fatality ratio of up to 50 per cent, which can vary between 24 per cent to 88 per cent depending on virus strain and quality of patient care, WHO informed through their website.

On its website, the UN health agency mentions that the illness caused by the Marburg virus begins abruptly, with high fever, severe headache and severe malaise, with the incubation period of the virus generally varying from two days to 21 days. Many patients have been reported to develop severe hemorrhagic symptoms within seven days.

Muscle aches and pains are common features. Severe watery diarrhoea, abdominal pain and cramping, nausea and vomiting can also begin on the third day and persist for a week. At this stage, the patients appear ghastly accompanied by extreme lethargy. A non-itchy rash is also a common feature noted in most patients between two to seven days after the onset of symptoms.

In the case of fatal debilitations, patients are usually plagued with some form of bleeding, often from multiple areas. Fresh blood in vomitus and faeces is often accompanied by bleeding from the nose, gums, and genitalia, along with spontaneous bleeding at venipuncture sites. During the severe phase of the illness, patients showcase sustained high fevers, and neurological symptoms such as confusion, irritability, aggression, and orchitis, which is the inflammation of one or both testicles.

In fatal cases, death occurs most often between eight and nine days after symptoms onset, usually preceded by severe blood loss and shock.

It can be difficult to clinically distinguish MVD from other infectious diseases such as malaria, typhoid fever, shigellosis, meningitis and other viral haemorrhagic fevers. The diagnostic measures undertaken to confirm that a patient’s symptoms are being caused by the Marburg virus include antibody-capture enzyme-linked immunosorbent assay, antigen-capture detection tests, serum neutralisation test, RT-PCR assay, electron microscopy, and virus isolation by cell culture.

Is there any vaccine or treatment against the Marburg virus?

Unfortunately, due to the scarce cases that occur rarely around the world, MVD has not yet received the appropriate focus from the global healthcare industry to manufacture an appropriate response. As of now, there are no licensed vaccines or antiviral treatments approved to neutralise the Marburg virus.

Although, supportive care, rehydration with oral or intravenous fluids, and treatment of specific symptoms, can improve the chances of survival. Currently, monoclonal antibodies are under development, and antivirals such as remdesivir and favipiravir which have been used in clinical studies for Ebola are also being tested for treating MVD. In May 2020, the European Medicines Agency (EMA) granted marketing authorisation to Zabdeno (Ad26.ZEBOV) and Mvabea (MVA-BN-Filo) against Ebola virus disease (EVD). Experts suggest that these vaccines could also potentially protect against MVD, but their efficacy has not been proven in clinical trials yet.

However, the fight against MVD seems less bleak, as one of the major agendas of the emergency meeting undertaken by WHO after the outbreak in Equatorial Guinea was to evaluate a range of potential treatments, including blood products, immune therapies and drug therapies, as well as candidate vaccines with phase one data, to arm global health with an effective and equitable response to this debilitating disease.

Community engagement key to controlling MVD outbreaks

MVD, much like any other highly virulent infectious disease, can be managed only through a range of interventions, namely case management, surveillance and contact tracing, a good laboratory service, safe and dignified burials, and social mobilisation.

Raising awareness of risk factors and protective measures against Marburg infection should be effectively deployed in high-risk areas around the globe. Some important measures that can alleviate the risk of contracting MVD in areas prone to the Marburg virus include:

  • To reduce the risk of bat-to-human transmission, workers or tourists visiting mines or caves inhabited by fruit bat colonies must wear gloves and other appropriate protective clothing.
  • During an MVD outbreak, all animal products should be thoroughly cooked before consumption.
  • Avoid close physical contact with Marburg patients. Gloves and appropriate personal protective equipment should be worn, and regular hand washing must be employed when taking care of ill patients at home or the hospital.
  • Develop outbreak containment measures that include prompt, safe, dignified burial of the deceased.
  • Identify people who may have been in contact with someone infected with Marburg, monitor their health for 21 days, separate the healthy from the sick to prevent further spread, provide care to the confirmed patient, and maintain good hygiene and a clean environment.
  • WHO recommends that male survivors of Marburg virus disease should practice safe sex for 12 months from the onset of symptoms or until their semen tests negative twice for Marburg virus. Contact with body fluids should be avoided and washing with soap and water is recommended. During this period used condoms should be safely disposed of, to prevent contact with seminal fluids.
  • Laboratory testing on non-inactivated samples from MVD patients should be conducted under maximum biological containment conditions. All biological specimens transported nationally and internationally should use triple packaging systems.
  • Healthcare workers should always take standard precautions when caring for patients including basic hand hygiene, respiratory hygiene, use of personal protective equipment, safe injection practices, and safe and dignified burial practices.

WHO and Equatorial Guinea’s response

On February 13, 2023, Mitoha Ondo’o Ayekaba, Health Minister, Equatorial Guinea, informed that nine people had died in the country’s first outbreak of MVD. He informed that a health alert had been declared in Kie-Ntem province and the neighbouring district of Mongomo, with an impending lockdown being planned after consulting with WHO. The minister added that nine deaths occurred between January 7 and February 7, 2023. In response to these suspected cases, the small central African country quarantined more than 200 people and restricted movement in the Kie-Ntem province. Neighboring Cameroon also restricted movement along its border over concerns about the potentially fatal outbreak. The deaths have been linked to a funeral ceremony in the Kie-Ntem province’s Nsok Nsomo district, notified Ayebaka.

WHO said in a statement on the same day that in addition to the nine deaths, 16 other people in Kie-Ntem had shown suspect symptoms including fever and vomiting blood. WHO confirmed on February 14, 2023, that the Marburg virus is the cause behind these suspected cases and they aim to deploy health emergency experts in epidemiology, case management, infection prevention, laboratory, and risk communication to support the national response efforts and secure community collaboration in the outbreak control.

Further investigations are also ongoing in Equatorial Guinea, where advanced teams have been deployed in the affected districts to trace contacts, isolate, and provide medical care to people showing symptoms of the disease.

WHO also promised to facilitate the shipment of laboratory glove tents for sample testing as well as one viral haemorrhagic fever kit that includes personal protective equipment that can be used by 500 health workers.

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