OSAC Health Security Snapshot: Marburg Virus Disease in Uganda
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OSAC Health Security Snapshot: Marburg Virus Disease in Uganda Product of the Research & Information Support Center (RISC) The following is based on open-source reporting. It is designed to give a brief snapshot of a particular outbreak. October 30, 2017 Summary On October 17, the Ugandan Ministry of Health (MoH) notified the World Health Organization (WHO) of a confirmed outbreak of Marburg in Kween District, eastern Uganda (see map), near Mount Elgon National Park, which is popular with tourists. The MoH officially declared the outbreak on October 19 and subsequently responded with support from the WHO and partners, by deploying a rapid response field team within 24 hours of the confirmation. As of October 27, six cases, including three deaths, have been reported. The six cases include one probable case (a game hunter who lived near a cave with a heavy presence of bats), two confirmed cases with an epidemiological and familial link to the probable case, and three suspected cases. Contact tracing with 135 contacts and follow-up activities have been initiated. Social mobilization has been increased by the Rapid Response team working together with the District Leadership to dispel myths and misbeliefs that what is happening is due to witchcraft. School visits, airing of radio spots and talk shows, and distribution of leaflets and posters are also being carried out to inform the population. What is Breaking Out? Marburg virus disease is an emerging and highly virulent epidemic-prone disease associated with high fatality rates (23–90%), though outbreaks are rare. Marburgvirus is in the same family as Ebolavirus, both of which cause hemorrhagic fever in humans. Signs and symptoms can vary but, in general, patients present with an abrupt-onset fever, weakness, muscle and joint pains, and headache. This is often followed by gastrointestinal symptoms including abdominal discomfort, nausea, vomiting, and diarrhea. Because many of the signs and symptoms are similar to those of other infectious diseases (malaria or typhoid fever) common to the region, clinical diagnosis of the disease can be difficult. The reservoir host is the cave-dwelling African fruit bat. The virus is transmitted to people from fruit bats and spreads among humans through person-to-person and direct or indirect physical contact with infectious body fluids. Bats do not show obvious signs of illness, so it is not possible to avoid infected bats based on their outward appearance or actions. Where is it Breaking Out? There have been 12 known cases/outbreaks of Marburg between its discovery in 1967 and 2014. The contents of this (U) presentation in no way represent the policies, views, or attitudes of the United States Department of State, or the United States Government, except as otherwise noted (e.g., travel advisories, public statements). The presentation was compiled from various open sources and (U) embassy reporting. Please note that all OSAC products are for internal U.S. private sector security purposes only. Publishing or otherwise distributing OSAC-derived information in a manner inconsistent with this policy may result in the discontinuation of OSAC support. This particular outbreak is in Kween District, in eastern Uganda, a rural, mountainous area on the border with Kenya and near Mount Elgon National Park, a major tourist destination. While the remote location may slow any potential spread, it also renders the work of trained health care workers and the delivery of essential supplies and equipment difficult. Uganda has experience in managing recurring viral hemorrhagic fever outbreaks, including Marburg virus disease. Marburg cases have historically been reported among miners and travelers who visited caves inhabited by bat colonies in Uganda. The following are known Marburg outbreaks in Uganda: Year Cases Location 2014 1 Mpigi District, central Uganda (see OSAC’s Report “Marburg Virus in Uganda: Ebola-like, but Not Ebola”) 2012 15 Ibanda and Kabale districts, western Uganda 2008 2 Travelers returning to the Netherlands and USA, respectively, after visiting caves in western Uganda 2007 4 Ibanda District, western Uganda Marburg tends to occur in eastern and southern Africa; confirmed cases have occurred in Kenya, the Democratic Republic of Congo, Angola, and possibly Zimbabwe. Given the fruit bat's wide distribution and mobility, more areas are potentially at risk for outbreaks of Marburg than previously suspected. When Does it Occur? Marburg’s transmission to humans is not fully understood. Outbreaks occur when a person becomes infected after exposure to the reservoir species or a secondarily infected non-human primate, and then transmits the virus to other people in the community. Marburg virus is generally transmitted by direct physical contact between unprotected skin or mucous membranes and blood or other infected body fluids of patients either in either the acute phase of the disease or who have died from it. Who is Impacted? People at greatest risk of Marburg include family members, health care workers, or others who come into direct contact with infected patients or corpses without protective equipment; people who have come into contact or close proximity to bats; and those who have handled infected primates or carcasses. Exposure risk can be higher for travelers visiting endemic regions in Africa, including Uganda and other parts of central Africa, when they have contact with fruit bats, or enter caves or mines inhabited by fruit bats. Many previous outbreaks have started in mine workers working in bat-infested mines. Why Should I be Concerned? The high number of potential contacts in extended families, at healthcare facilities, and surrounding traditional burial ceremonies is a challenge for the response. In addition, hospitalized cases were handled in general wards without strict infection control precautions, and one suspected case refused to be hospitalized and remains at large. The close proximity of the affected area to the Kenyan border, cross-border movement between the affected district and Kenya, and the potential for transmission of the virus between colonies and to humans all increase the risk of cross-border spread. Travelers to the Mount Elgon bat caves are advised to avoid exposure to bats and contact with non-human primates and, to the extent possible, to wear gloves and protecting clothing, including masks. The WHO contends that the global risk of Marburg is low, but any hemorrhagic fever outbreak should be taken seriously and addressed quickly; the virus can spread quite rapidly once it has entered the human population, as was seen in West Africa’s 2014-2016 Ebola outbreak. 2 How do I Respond? The WHO advises against the application of any travel or trade restrictions on Uganda or the affected area based on the current information available on this event. There is no specific treatment for Marburg other than managing symptoms. Preventive measures are not well-defined. However, avoiding fruit bats and sick non-human primates in central Africa is one way to protect against infection. It is critical to increase awareness in communities and among healthcare providers of the clinical symptoms of patients with Marburg and to improve the use of diagnostic tools. Measures for prevention of secondary, or person-to-person, transmission are similar to those used for other hemorrhagic fevers, including Ebola. If a patient is either suspected or confirmed to have Marburg virus, precautions should include wearing protective gowns, gloves, and masks; placing the infected individual in isolation; and sterilizing or disposing needles, equipment, and patient excretions safely. Further, public health authorities should be notified. For More Information For additional information on global diseases and pandemic outbreaks, please contact OSAC’s Global Health and Outbreaks Analyst. For information on the security climate in Uganda, please contact OSAC’s Africa Team. Other OSAC Sources Marburg Virus in Uganda: Ebola-like, but Not Ebola Emergency Message for U.S. Citizens: Marburg Hemorrhagic Fever Confirmed in Kampala (Oct 2014) CDC Sources Marburg webpage Yellow Book: Marburg Marburg Factsheet Other Sources WHO: Marburg virus disease – Uganda 3 .