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First Marburg virus outbreak in Equatorial Guinea; what should we do to prevent future occurrence?

2023; Wolters Kluwer; Volume: 6; Issue: 5 Linguagem: Inglês

10.1097/gh9.0000000000000322

2576-3342

Malik Olatunde Oduoye, Abubakar Nazir, Awais Nazir, Karim Arif Karim, Salma Mohsen Sakr, Thierno Amadou Bah, Mahammed Khan Suheb, Dattatreya Mukherjee, Aymar Akilimali, Faridah Opeyemi Amin,

Disaster Response and Management

Introduction The outbreak of Marburg hemorrhagic fever poses a significant threat to the public’s health and a call for emergency response in sub-Saharan Africa, especially in Equatorial Guinea. The World Health Organization (WHO) described the Marburg virus (MARV) as one of the most significant viruses1. This virus has been categorized as a pathogen of group 4 risk1. Case fatalities range from 24.0% to 88.0% in most sub-Saharan African countries, Equatorial Guinea inclusive. This shows its deadly nature and the necessity for wider information2. Being the first time, Equatorial Guinea is experiencing the outbreak of MARV in its country, the government and the people are lacking the preventive measures against MARV in the country, posing a serious public health issue to the government and the people of Equatorial Guinea. Despite the WHO, on June 8, 2023, declaring that MARV in Equatorial Guinea has ended with no new cases reported till date, more outbreaks of the disease in Equatorial Guinea, including other neighboring countries and the world at large, can still occur. This necessitates the aim of this present article. Historical perspective The filovirus, which is the virus that causes MARV, is thought to have fruit bats of the Pteropodidae family as natural hosts in Africa1. Like Ebola, Marburg is a member of the same virus family that exhibits similar symptoms, spreads among people, and has a high mortality rate. MARV can affect both humans and non-human primates3. African historians discovered that the first instance of MARV originated in 1967 in Uganda when a laboratory staff was working with imported African green monkeys from Uganda simultaneously in laboratories in Germany and Serbia2. Subsequent reports of solitary instances and MARV outbreaks were reported in other African countries, such as Zimbabwe in 1975, Kenya in 1980 and 1987, the Democratic Republic of the Congo in 1994 and from 1998 to 2000, Angola in 2005, and in Uganda again in the year 20071. In the year 1975, South Africa also reported outbreaks of MARV caused by the importation of infected patients from Zimbabwe. A laboratory accident was also reported in Russia1,3. After the initial case of MARV, many other outbreaks occurred around the world, especially a reoccurrence in Africa, such as in Uganda, Angola, Congo, and Kenya1. Forty-five years later after the first incident case of MARV was reported, Ghana and Guinea reported their first case of the disease in July 2012 and 2021, respectively, where one case was discovered4. However, on July 7, 2022, the Ghanaian Ministry of Health reported 2 incidences of MARV in the Ashanti Region5. This means that the Ghanaians and the Guineans suffered from MARV amidst the coronavirus disease 2019 pandemic during those years, posing serious public health challenges for both countries. Situation of Marburg virus in Equatorial Guinea The first outbreak of MARV in Equatorial Guinea was reported on Monday, February 13, 2023, where the WHO through the health authorities in Equatorial Guinea confirmed the first case of MARV in the country6. One confirmed case of MARV as of February 14, 2023, and 20 suspected cases, including 9 fatalities in 2 districts of the country—Eastern Kie Ntem Province, close to the Cameroonian and Gabonese borders6. This was confirmed through the samples sent to the Institute Pasteur reference laboratory in Senegal by the health authorities of Equatorial Guinea through the support of the WHO, with reported symptoms like fever, fatigue and blood-stained vomit, and diarrhea6. Recent updates on March 27, 2023 have it that at least 4 cases of MARV have been detected in the city of Bata with a total population of around 200, 000 people, linking to several neighboring countries like Gabon (381 km distance), Ghana (1019 km distance), Burundi (2415 km distance), and Tanzania (3158 km distance)7,8. According to the WHO, out of the 9 laboratory-confirmed cases detected in Equatorial Guinea, 7 of them have died, whereas the other 2 are currently receiving treatment. Also, the health authorities in Equatorial Guinea reported that the 20 suspected cases of MARV, on February 14, 2023, are now dead7. Of recent, the WHO, on June 8, 2023, declared that MARV in Equatorial Guinea has ended with no new cases reported till date2. However, another outbreak of MARV can still occur in Equatorial Guinea if no proper measures are taken to mitigate it. Mode of transmission and clinical manifestations of Marburg virus Person-to-person transmission can happen in settings like homes or hospitals when infection control measures are less effective. Human contracts MARV through sexual interaction and direct contact with body fluids8,9. The virus penetrates the mucosa with an incubation period of 3–21 days, which differs according to the dose and route of infection1,10. General symptoms, including fever, very bad headache, and myalgia, gradually worsen during the duration of the infection’s abrupt onset and steady progression. Diffuse erythematous maculopapular rash is the earliest clinical manifestation to take place. Hemorrhagic signs like bleeding gums, petechiae, purpura, subconjunctival injection, and gastrointestinal bleeding include hematochezia and melena that appear on progression. Disturbed blood components reveal during laboratory investigation9–11. These findings represented leukopenia, thrombocytopenia, and lymphopenia. Homeostasis is also affected and leads to electrolyte imbalances like hypokalemia. Elevated liver enzymes, amylase, prothrombin time, and partial thromboplastin time indicate coagulation factors consumption, which ends by disseminated intravascular coagulopathy. Multiple organs focally necrosed by the disease’s sequelae, resulting in death. Eventually, end-organ failure and disseminated intravascular coagulopathy will be risk factors for mortality10. Global health efforts to mitigate Marburg virus in Equatorial Guinea The WHO has already deployed its team in Equatorial Guinea, along with local health care authorities, for rapid identification of cases and increased rate of investigations. Surveillance has been strengthened, and sources of transmissions are being actively identified. Educational activities have been increased at the community level to increase the masses’ knowledge about Marburg’s risks and dangers1. Marburg and Ebola have both received increasing attention in West Africa due to the past when Ebola has been common in West African countries12. Convalescent patients’ eyes and testes may continue to contain MARV. Moreover, it can be detected in the amniotic fluid, breast milk, and placenta of pregnant women. Simply said, if the virus is discovered in the blood, the person will continue to be contagious. However, there is no proof that mosquitoes or other biting arthropods can spread MARV among people. Because there has not been a recent large-scale MARV outbreak comparable in size to the Ebola Virus Disease 2014–2016 West Africa outbreak, much less is known about MARV. Clinical diagnosis of MARV might be difficult due to the similarity in the signs and symptoms to malaria, typhoid fever, dengue, or endemic viral hemorrhagic fevers like Lassa or Ebola. Hence, diagnosis during the initial phase of the outbreak is always challenging. Enzyme-linked immunosorbent assay (ELISA), polymerase chain reaction, and immunoglobulin M capture ELISA serve as the confirmatory tests. Virus isolation should always be done in high-containment laboratories. In the later course of the disease, immunoglobulin G capture ELISA may serve to be handy4. As a biosafety level-IV laboratory is required for the diagnosis of MARV, the best technology and transportation should be used so that even with a few numbers of laboratories, many samples can be tested very fast, and with all safety protocols in place, which will also serve to be very cost-effective for the Equatorial Guinean government. Being the fact that there are no current treatment measures known and no protocols in place for MARV, patient management in Equatorial Guinea should be symptomatically and supportive, such as balancing fluid, electrolyte levels, maintaining blood pressure and oxygen levels, and treating any further complications13. Asian countries are already affected by Crimean Congo hemorrhagic fever14. MARV is creating a new concern in the field of hemorrhagic diseases. Re-emerging diseases, such as coronavirus disease 2019 and monkeypox, are now showing up in the world and are difficult to treat15–17. Hence, we recommend that physicians in Equatorial Guinea should make adequate efforts, such as mass awareness campaigns, among the populations of Equatorial Guinea for them to avoid contact with the fruit bats Rousettus aegyptiacus and already affected individuals. Similar control measures that are used for other hemorrhagic fevers should also be put into force to mitigate the spread of MARV in Equatorial Guinea. Direct physical contact should be avoided by wearing personal protective gear, and infected individuals should be placed in strict isolation. There is also an increased need for proper sterilization and disposal of needles, personal protective equipment, and patient wastes among the health care providers in Equatorial Guinea. Health care givers and family members of the ill in the country should take added precautions. Conclusion and recommendations Despite the WHO, on June 8, 2023, that Marburg virus disease in Equatorial Guinea has ended with no new cases reported till this present time after the first case2, we still believe that proper standard operating protocols should be implemented by the Equatorial Guinean government. The government should prepare a central laboratory with all the needed facilities, especially for all the primary health care centers in the country. Also, the government should provide an adequate number of medications to the affected places. Increased caution should be exercised by people traveling to Equatorial Guinea, especially to eastern Kie Ntem Province, the region most affected by the MARV. “Healthy” individuals in the country should avoid contact with people presenting with fever, chills, myalgia, rashes, sore throat, diarrhea, weakness, stomach ache, and bleeding or bruising due to unknown causes18. Overall, to mitigate future outbreaks of Equatorial Guinea, more efforts should be focused on the primary preventive measures, such as increased mass education and awareness campaigns, on the risk factors of MARV, individual protection from the virus, and what to do in case of presentation of symptoms, as well as a high index of suspicion by the clinicians in the country. Also, at each entry and exit point in Equatorial Guinea, surveillance, and control strategies should be imposed among travelers, as well as restrictions on commercial travel19. Besides, rapid detection of infection should be done immediately if there is a suspected case of MARV in the country. Travelers should avoid contact with animals (especially monkeys and bats) in markets and should also avoid frequenting places or places that seem to be contaminated with animal feces. Travelers should strictly adhere to and comply with barrier measures, such as washing their hands often with soap and water or with hydroalcoholic solutions, covering their mouth and nose, and avoiding touching their eyes frequently19. They should also practice good food safety and personal hygiene measures. These measures would serve to prevent a future pandemic or even an epidemic of MARV19. We realized that more research is needed in this field to improve the knowledge gap. As there is no treatment available, it is only with increased precaution and more awareness that Equatorial Guinea can win the battle against Marburg. Finally, the government of Equatorial Guinea through its Ministry of Public Health should collaborate and partner with the WHO, the Centre for Disease and Prevention Control, and other infectious disease experts in other neighboring countries like Nigeria, Ghana, and Rwanda, as well as other powerful nations in the world like the United Kingdom, the United States, China, etc in strengthening the health facilities and equipment in Equatorial Guinea. Such facilities would include mobile clinics and diagnosis for rapid detection of infection for close surveillance of MARV in the country. Ethical approval Not applicable. Sources of funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Author contribution M.O.O. and Abubakar Nazir: conceptualization of ideas. Abubakar Nazir, Awais Nazir, K.A.K., S.M.S., T.A.B., and M.K.S.: writing of initial draft. M.O.O.: writing, reviewing, editing, and funding acquisition. M.O.O. and D.M.: supervision. F.O.A.: data curation. K.A.K. and A.A.: administrative support. M.O.O., Abubakar Nazir, Awais Nazir., K.A.K., S.M.S., T.A.B., and M.K.S., D.M., A.A., and F.O.A.: critical review and comments and final approval. Conflicts of interest disclosure The authors declare that they have no financial conflict of interest. Research registration unique identifying number (UIN) Not applicable. Guarantor Malik Olatunde Oduoye.