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20 December 2024

Situation at a glance

On 20 December 2024, after two consecutive incubation periods (total of 42 days) since the second negative PCR test was conducted on 7 November for the last confirmed Marburg case, and without a new confirmed case reported, the Ministry of Health of Rwanda declared the end of the Marburg virus disease (MVD) outbreak, as per the WHO recommendations. The outbreak had been declared on 27 September 2024. As of 19 December 2024, 66 confirmed cases,15 deaths with a case fatality ratio (CFR) of 23%, and 51 recovered cases have been reported. The last confirmed case was reported on 30 October 2024. WHO through its country office and development partners provided technical and financial support to the government to contain this outbreak. The risk of re-emergence of MVD still remains even after the official declaration of the end of the outbreak, linked to viral persistence in body fluids (mostly semen) of recovered patients and the animal reservoir in the country. WHO encourages maintaining early case detection and care capacities in addition to sustaining the ability to quickly respond, also underscoring the importance of the recovered patient program, psychosocial support, and continued risk communication and community engagement.

Description of the situation

Since the last Disease Outbreak News on this event was published on 13 November 2024, no new confirmed cases of Marburg virus disease (MVD) have been reported in Rwanda. As of 19 December 2024, 66 confirmed cases, including 15 deaths (CFR 23%), and 51 recovered cases have been reported. Among the confirmed cases, 68% are males, and 46% are adults between 30 and 39 years of age. Health workers from two health facilities in Kigali account for almost 78% of all confirmed cases. Most cases are reported from the three districts of Kigali city, namely Gasabo, Kicukiro and Nyarugenge.

The highest number of confirmed cases (61) were reported in the first three epidemiological weeks (week 39-41, from 23 September to 13 October) of the outbreak. This was followed by a sharp decline, with three or less cases reported between epidemiological week 42 (14 to 20 October) and 44 (28 October to 3 November). The last confirmed case was reported on 30 October and the last death on 14 October 2024.

As of 6 December 2024, 7874 Marburg virus tests had been conducted at the Rwanda Biomedical Center.

On 8 November 2024, the recommended 42-day countdown to declare the end of the outbreak commenced, following two consecutive PCR negative tests from the last confirmed MVD case on 7 November. The 42-day countdown period is twice the maximum incubation period for Marburg virus infections, since the last potential exposure to the last reported case. The last confirmed case was reported on 30 October and the last death on 14 October 2024.

On 20 December 2024, after completion of two consecutive incubation periods (total of 42 days) without a new confirmed case being reported, the Ministry of Health of Rwanda declared the end of the outbreak.

Figure 1. Marburg virus disease cases by week of reporting in Rwanda, as of 19 December 2024, (n=66)

MVD Rwanda epi curve

Epidemiology

MVD is a highly virulent disease that can cause severe disease and is clinically similar to Ebola disease (EBOD). MVD and EBOD are caused by orthoebolaviruses and orthomarburgviruses, members of the Filoviridae family (filovirus). This includes Ebola virus and Marburg virus. People are infected after prolonged exposure to mines or caves inhabited by Rousettus fruit bat colonies, a type of fruit bat, that can carry the Marburg virus.  Marburg virus then spreads between people via direct contact (through broken skin or mucous membranes) with the blood, secretions, organs or other bodily fluids of infected people, and with surfaces and materials (e.g. bedding, clothing) contaminated with these fluids. Health workers have previously been infected while treating patients with suspected or confirmed MVD. Burial ceremonies that involve direct contact with the body of the deceased can also contribute to the transmission of Marburg virus.

The incubation period varies from two to 21 days. Illness caused by Marburg virus begins abruptly, with high fever, severe headache and severe malaise. Severe watery diarrhoea, abdominal pain and cramping, nausea and vomiting can begin on the third day. Although not all cases present with haemorrhagic signs, severe haemorrhagic manifestations may appear between five and seven days from symptoms onset, and fatal cases usually have some form of bleeding, often from multiple areas. In fatal cases, death occurs most often between eight and nine days after symptom onset, usually preceded by severe blood loss and shock. There is currently no approved treatment or vaccine for MVD. Some candidate vaccines and therapeutics are currently under investigation.

Seventeen outbreaks of MVD have previously been reported globally. The most recent outbreaks were reported in Equatorial Guinea and the United Republic of Tanzania between February and June 2023. Additional countries that previously reported outbreaks of MVD in the African Region include Angola, the Democratic Republic of the Congo, Ghana, Guinea, Kenya, South Africa, and Uganda.

Public health response

  • The Government of Rwanda coordinated the response with support from WHO and partners.
  • A surge team from WHO deployed to support the in-country response across the functions of incident management, epidemiology, health operations, case management, infection prevention and control, laboratory, health logistics, therapeutics and vaccines research, and partner coordination.
  • WHO and partners supported the Ministry of Health (MoH) in conducting training of trainers and follow-up cascade training to district hospitals and health centers in the country for surveillance, IPC, case management, points of entry and border health, WASH, risk communication and community engagement and other response areas.
  • WHO and partners (US CDC) supported MOH in revising the MVD case definition.
  • WHO supported the MVD treatment center with direct support from clinical experts in infectious disease, critical care and nursing as well as health logistics and WASH expertise.
  • WHO supported the national case management pillar to collect standardized patient level data based on WHO electronic case report form from the WHO Global Clinical Platform and making descriptive reports of case management responses to outbreak.
  • WHO and partners (USAID, US CDC, and Africa CDC) supported diagnostic testing for MVD in Rwanda through the provision of laboratory supplies and technical support. WHO was continuously engaged with its viral hemorrhagic fever collaborating centers and other reference laboratories and partners to support the assessment of diagnostics test performance and ensuring technical support continues regarding MVD testing.
  • WHO supported the Government in establishing a programme for recovered patients, by sharing technical guidance and protocols for establishing a national programme and supporting the Rwanda MOH) implementation effort.
  • WHO and partners supported the MoH in updating and validating key national guidance and SOPs, including for IPC and surveillance activities (including mortality surveillance)
  • WHO and partners (IOM, Africa CDC) supported in building capacity at the points of entry (POE) through the national surveillance training program and needs assessment visit at 11 priority POEs across the country bordering DRC, Uganda, Tanzania and Burundi.
  • WHO provided technical advice to public health authorities in Rwanda and at-risk countries on the implementation of evidence-informed and risk-based health measures; the strengthening of detection, reporting and management capacities at points of entry and across borders; and travel advice.
  • WHO published interim guidance on the Considerations for border health and points of entry for filovirus disease outbreaks, which applies to but is not limited to the recently ended MVD outbreak in Rwanda.
  • WHO also published a statement advising against any travel restrictions and against any trade restrictions with Rwanda in the context of the recently ended MVD outbreak.
  • WHO continues to provide support in surrounding countries to assess the readiness of healthcare facilities, points of entry and border communities within surrounding countries and specifically risk mapping for areas bordering Rwanda.
  • WHO published the interim guidance on risk communication and community engagement for Marburg virus disease outbreaks on 10 December 2024.

WHO risk assessment

With 66 confirmed cases reported, this is the third largest MVD outbreak reported to date, with almost 80% of confirmed cases reported among health workers. Healthcare-associated infections (also known as nosocomial infections) of this disease can lead to further spread if not controlled early. In compliance with WHO recommendations, the criteria to declare the end of an outbreak after two maximum incubation periods (42 days) was observed with no new confirmed or probable case of MVD detected.

Based on the outbreak investigation which included record review in health facilities, review of epidemiological data, serology and genomic sequencing, as well as environmental and animal testing, the source of the outbreak is reported to be of zoonotic origin, linked to exposure in a cave inhabited by fruit bats.[1] Surveillance in miners working in the caves was put in place to detect any new cases.

There remains a risk of re-emergence of MVD even following the declaration of the end of the outbreak linked to a new spillover from interactions with the animal reservoir. The virus may also persist for an extended period in the body fluids (mostly semen) of people who recovered from the disease, underlying the importance of their participation in the recovery care program, and the support the program provides.

Based on the available information at the end of MVD outbreak in Rwanda, the risk is considered as low at the national, regional and global levels.

WHO advice

WHO encourages maintaining early detection and care capacities in addition to sustaining the ability to quickly respond after the outbreak ends. This is to make sure that if the disease re-emerges, health authorities are able to detect it immediately, prevent the disease from spreading again, and ultimately save lives.

Raising awareness of risk factors for Marburg virus infection and protective measures that individuals can take is an effective way to reduce human transmission. WHO advises the following risk reduction measures as an effective way to reduce MVD transmission in healthcare facilities and in communities:

  • Reducing the risk of bat-to-human transmission arising from prolonged exposure to mines or caves inhabited by fruit bat colonies. People visiting or working in mines or caves inhabited by fruit bat colonies should wear gloves and other appropriate protective clothing (including masks).
  • WHO encourages countries to implement a comprehensive care programme to support people who recovered from MVD with any subsequent sequelae and to enable them to access body fluid testing and to mitigate the risk of transmission through infected body fluids by adequate practices.
  • Capabilities for early detection of MVD patients should be maintained over time in settings at risk of the disease.
  • Reducing the risk of human-to-human transmission in the community arising from direct or close contact with infected patients, particularly with their body fluids. Close physical contact with MVD patients should be avoided. Patients suspected or confirmed for MVD should be isolated in a designated treatment centre for early care and to avoid transmission at home.
  • Communities affected by MVD, along with health authorities, should ensure that the population is well informed, both about the nature of the disease itself and about necessary outbreak containment measures.
  • Outbreak containment measures include safe and dignified burial of the deceased, identifying people who may have been in contact with someone infected with MVD and monitoring their health for 21 days, separating the healthy from the sick to prevent further spread and providing care to the confirmed patient and maintaining good hygiene and a clean environment need to be observed.
  • Critical infection prevention and control measures should be implemented and/or strengthened in all health care facilities, per WHO’s Infection prevention and control guideline for Ebola and Marburg disease.   Health workers caring for patients with confirmed or suspected MVD should apply transmission-based precautions in addition to: standard precautions, including appropriate use of PPE and hand hygiene according to the WHO 5 moments to avoid contact with patient’s blood and other body fluids and with contaminated surfaces and objects. Waste generated in healthcare facilities must be safely segregated, safely collected, transported, stored, treated and finally disposed. Follow the national guidelines, rules and regulations for safe waste disposal or follow the WHO’s guidelines on safe waste management
  • Patient-care activities should be undertaken in a clean and hygienic environment that facilitates practices related to the prevention and control of health-care-associated infections (HAIs) as outlined in Essential environmental health standards in health care. Safe water, adequate sanitation and hygiene infrastructure and services should be provided in healthcare facilities. For details on recommendations and improvement, follow the WASH FIT implementation Package

Based on the current risk assessment, WHO advises against any travel restrictions or any trade restrictions with Rwanda at this time. For further information, please see WHO advice for international traffic in relation to the Marburg virus disease outbreak in Rwanda.

Further information

 

[1] Yvan Butera, et al. Genomic characterization uncovers transmission dynamics of Marburg Virus in Rwanda following a single zoonotic spillover event. medRxiv 2024.11.01.24316374; doi: https://doi.org/10.1101/2024.11.01.24316374 [Preprint]

Citable reference: World Health Organization (20 December 2024). Disease Outbreak News; Marburg virus disease in Rwanda. Available at: https://www.who.int/emergencies/disease-outbreak-news/item/2024-DON548

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