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Potential threats of Marburg virus in the Sub-Saharan African region: bridging the gaps

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

10.1097/gh9.0000000000000339

2576-3342

Malik Olatunde Oduoye, Abulkathir Mujtaba, Ikshwaki Kaushik, Gospel O. Ibezim, Tirth Dave, Mohammed Dheyaa Marsool Marsool, Danisha Kumar, Ayodeji R. Ogunleye, Binish Javed, Rita N. Ajirenike, Karim A. Karim, Shahzad A. Panhwar,

Disaster Response and Management

Dear Editor, Despite global efforts to curtail the Marburg virus (MARV) spread, the virus remains a global health threat in most parts of the world, especially in the Sub-Saharan African (SSA) region1–10. MARV, like the Ebola virus, is a negative-stranded RNA virus that belongs to the order: Mononegavirales, family: Filoviridae, and genus: Marburgvirus1. Marburg virus disease (MVD) causes hemorrhagic fever just like other viral hemorrhagic fevers (VHFs) known in the world1. The incubation period of the Marburg virus is estimated to be 2–21 days11, typically 5–10 days, and is likely related to the infectious dose and route12. Observed symptoms can range from mild to fatal, with no documented asymptomatic cases. Most result in severe illness with jaundice, pancreatitis, delirium, shock, liver failure, massive hemorrhaging, and multiorgan failure (Fig. 1)[13]. Early symptoms are abrupt and nonspecific. Consequently, a misdiagnosis may be of malaria, influenza, typhoid disease, or another viral hemorrhagic disease, such as Ebola or Lassa. The symptoms initially include high fever, chills, odynophagia, malaise, headache, myalgia, and arthralgia, followed by abdominal pain, nausea, vomiting, diarrhea, and/or pharyngitis8,13.Figure 1: The pathological manifestations of the Marburg virus in human beings.Historically, the Marburg infection is identified as an exceedingly irresistible and regularly lethal pathogen that has a place in the family Filoviridae, which also incorporates the Ebola infection8. MVD, to begin with, was distinguished in August 1967 when an episode happened in Marburg, Germany, among research facility laborers exposed to African green monkeys contaminated with the infection8. Since that point, the infection has caused a few episodes in Africa, resulting in critical illness and mortality6. After its identification, the occurrence of MVD in SSA has exhibited occasional patterns6,8. The epidemiological evidence suggests a correlation between increased morbidity and mortality rates and the occurrence of these disease outbreaks. Significantly, the documented ratios of case fatalities have exhibited a spectrum, ranging from 23% to an assemblage of 90% (Table 1). Table 1 - Marburg virus disease outbreaks in Africa: number of confirmed cases (number of fatal cases/% case fatality). Year Country – Region Number of cases Number of fatal cases/% case fatality 1975 South Africa – Johannesburg 3 1/33% 1980 Kenya – Nairobi 2 1/50% 1987 Kenya – Kitum Cave 1 1/100% 1988–2000 Democratic Republic of the Congo – Durba 154 128/83% 2004–2005 Angola – Uige 374 329/88% 2007 Uganda – Kitaka Mine 4 2/50% 2008 Uganda – Maragambo Forest 2 1/50% 2012 Uganda – Ibanda, Kabale, Kamwenge, Mbarara, Kampala 15 4/27% 2014 Uganda – Kambala 1 1/100% 2017 Uganda – Kween 3 3/100% 2021 Guinea – Gueckedou 1 1/100% 2023 Equatorial Guinea – Litoral Province, Kie-Ntem Province, Wele-Nzas and Centro Sur Province 14 9/64% Tanzania – Kagera region 8 5/62% MVD causes serious illness, with case fatality rates revealed to be as high as 80–90% in the world, including the Sub-Saharan region2. Over the past few decades, the Sub-Saharan areas have experienced several epidemics of the Marburg virus, including Ebola, bubonic plague, HIV/AIDS, meningitis, cholera, etc3–5. Sadly, from 2021 to 2023, there was another outbreak of MARV in SSA countries such as Ghana, Tanzania, the Equatorial Republic of Guinea, the Democratic Republic of Congo, etc., posing more global threats to the Sub-Saharan region and the international communities1,6,7. Threats like limited awareness, knowledge, attitude, and perception of MARV among the Sub-Saharan populations, especially those living in the epidemic zones where the community dwellers still consume the infected vector (the Egyptian Fruit bat). Other problems include a lack of political will by the African governments to put lasting solutions to the outbreaks of MARV in the Sub-Saharan region, misdiagnoses of MARV by the healthcare providers in SSA countries, limited diagnostic kits and treatment facilities in the country, economic crises, conflicts with other infectious diseases like COVID-19, cholera, typhoid, meningitis, etc1–6. Indeed, the advancement of technology in travel has made the world feel smaller and more interconnected, akin to a ‘global village.’ The ease and speed of travel have allowed people and goods to move across borders and continents with unprecedented efficiency. However, this interconnectedness also means that when one part is affected, it can potentially put other parts at high risk, including the transmission of infections. The transmission of the Marburg virus into Germany and then the USA was all linked to international travel, particularly to endemic areas14–17. Hence, considering the propensity of the Marburg virus for outbreak coupled with its high case fatality rate of nearly 100%, which translated to the Marburg virus’s ability to kill at least 9 out of 10 people that got infected, one could probably put Marburg virus as the next pandemic just like its cousin, the Ebola virus. Another incidence in the Netherlands occurred on 10 July 2008, when Marburg hemorrhagic fever was confirmed in a Dutch patient who had recently vacationed in Uganda14. Like the Ebola virus, the Marburg virus, due to its high fatality rates, low virion counts required for infection, relative stability, infective aerosol nature, and the possibility of person-to-person transmission, is thought to have the potential as a biological weapon in terrorism15,18. Thus, this has posed a significant threat to public health in SSA and the world at large. It has also been postulated that the natural reservoir for the Marburg virus remains unknown, although it is indicated to be of zoonotic origin in nature17. This has made it one of the deadliest and most dangerous viruses. Additionally, in many areas of SSA where MVD outbreaks are most likely to occur, the necessary diagnostic techniques are not readily available, which limits infection prevention measures that invariably facilitate its transmission to close relatives and healthcare providers in SSA13. To this date, the mechanisms of its transmission and treatment are not well documented, and no proven vaccine has been developed so far17,19–21. To put an end to the threats of MVD as well as the gaps, African leaders should ensure proper evaluation and control measures against MARV and their impact on the affected Sub-Saharan countries through developing strong political will in implementation research strategies in the fight against MARV, that is, working hand-in-hand with the WHO, CDC, including the international communities, infectious experts, organizations, governments, academic institutions, and pharmaceutical companies, as well as public health physicians, stakeholders, religious and traditional leaders, student organizations, etc. in order to share knowledge, resources, and expertise in the fight against MARV in Africa. Recent guidelines and recommendations by international health organizations play a significant role in guiding prevention and control strategies6. African leaders should improve public awareness and information about MARV and its transmission in SSA. This awareness can be achieved through public health campaigns, community participation, and education initiatives (either on social media platforms; Facebook, Instagram, Linkedln, etc., radio/television stations, posters, etc.) among African dwellers. We are optimistic that this strategy would assist in increasing awareness about the dangers of handling diseased animals or their bodily fluids, as well as advocating safe practices to prevent transmission. In addition to the above-described actions, African policymakers in the health sector should develop modern diagnostic tools, antiviral medicines, and vaccinations against MARV, as it has been shown to be a critical component of combating the Marburg virus threat in the world6–10. Research is being conducted to understand transmission pathways better, identify possible reservoirs or intermediate hosts, and create effective responses. Improving diagnostic capabilities is critical for detecting and responding to Marburg virus epidemics early. Rapid and reliable diagnostic testing can help identify infected patients, adopt necessary isolation measures, and begin treatment as soon as possible. African researchers should therefore focus on developing sensitive and specific diagnostic assays that can be easily deployed in resource-limited African settings where the majority of outbreaks occur, for example, in Uganda, Republic of Congo, Zimbabwe, etc6. Finally, African researchers should also put more effort into searching for effective antiviral drugs against the Marburg virus, especially antivirals that can reduce viral replication or target specific viral proteins. To establish the safety and efficacy of prospective candidates, preclinical and clinical trials are being done. Finding effective medicines is crucial for improving patient outcomes and reducing the overall burden of the disease. Our hope is that, through the efforts of African researchers, Marburg virus disease will be put to an end. We are advocating that the development of a safe and effective vaccine against the Marburg virus in SSA should be a top goal for African leaders. Studies have shown that vaccination can provide long-term protection and help avert future outbreaks of diseases in SSA1–4,6,10. Also, several vaccine alternatives, including viral vector-based vaccines and DNA-based immunizations are being studied in preclinical and clinical studies. These immunizations should, therefore, be implemented by the African leaders and health authorities in order to elicit a protective immune response against the Marburg virus, therefore avoiding or decreasing illness severity in the affected Africans22. Ethical approval Not applicable to this work. Consent Not applicable to this work. Sources of funding No funding received for this work. Author contribution M.O.O.: conceptualization; D.K.: data curation; R.N.A.: formal analysis; T.D.: funding acquisition; M.O.O. and R.N.A.: investigation; M.O.O. and B.J.: methodology; M.O.O.: project administration; All authors: resources; M.O.O. and T.D.: software; M.O.O.: supervision; All authors: validation; All authors: visualization; A.M., G.O.I., I.K., and S.A.P.: roles/writing – original draft; B.J., M.D.M.M., and M.O.O.: writing – review and editing. All authors were involved in the final approval of the manuscript. Conflicts of interest disclosure The authors have no competing interests to declare that are relevant to the content of this article. Research registration unique identifying number (UIN) Name of the registry: not applicable. Unique identifying number or registration ID: not applicable. Hyperlink to your specific registration (must be publicly accessible and will be checked): not applicable. Guarantor Malik Olatunde Oduoye; College of Medical Sciences, Ahmadu Bello University Teaching Hospital, Kaduna State, Nigeria; E-mail: [email protected] Data availability statement None. Provenance and peer review Not commissioned, externally peer-reviewed.