An epidemic at a glance
Two Marburg virus (MVD) deaths have been reported from the Ashanti region of Ghana. On June 28, 2022, these cases were reported to health authorities as suspected viral hemorrhagic fever (VHF) cases, and on July 1, 2022, they tested positive for Marburg virus. An outbreak of MVD has only been reported previously in West Africa, and this is the first time MVD has been reported in Ghana. Outbreaks of MVD can pose a serious threat to public health because it is severe and often fatal.
Description of the disease
On June 28, 2022, two suspected cases of viral hemorrhagic fever (VHF) were reported to health authorities in the Ashanti region of Ghana (Figure 1). This region is located in the middle belt of Ghana and is the most populated region in the country.
The first case was a 26-year-old man, a farm worker in Adansi North District, Ashanti Region, with a history of travel to the Western Region. He arrived in the Ashanti region from the Western Region on June 24 before the onset of symptoms. He returned to the hospital on June 26 and died on June 27. The body was transported and buried in the Savla-Tuna-Kalba district in the Savannah region, bordering Burkina Faso and Côte d’Ivoire. The autopsy was performed prior to the results of laboratory tests for MVD.
The second case was a 51-year-old man working on a farm in Bekwai Municipality, Ashanti Region. He first visited the hospital on June 28, but died the same day.
Both cases presented with fever, general malaise, bleeding from the nose and mouth, and conjunctival hemorrhages (bleeding of blood vessels in the eye). Blood samples were taken for the first case on June 27 and for the second case on June 28 and sent to the Noguchi Memorial Medical Research Institute (NMIMR) for testing. On July 1, both cases tested positive for Marburg virus by reverse transcriptase polymerase chain reaction (RT-PCR). On July 12, samples collected from both cases were sent to the Institut Pasteur (IPD) in Dakar, Senegal, which confirmed the NMIMR results on July 14, 2022.
Figure 1. Area of two confirmed cases of Marburg virus in Ghana as of 20 July 2022
The source of the infection is unknown. Preliminary investigations show that none of these cases had contact with dead animals, sick people or animals, and had not attended any public gatherings within three weeks of the onset of symptoms. Although both were farmers, they worked in different places and no epidemiological link was found between them. However, both cases came from communities living in forest environments.
A total of 108 people (50 from the Ashanti region, 48 from the Savannah region and 10 from the Western region) were identified as contacts of the two cases, all of whom were self-quarantined for 21 days and monitored daily. On July 20, all contacts completed their next period. These contacts included health care workers and close family members of cases. One contact reported some symptoms, but a blood sample collected on July 7 was found to be negative at NMIMR. All other contacts were reported to be in good health at follow-up.
Epidemiology of disease
MVD is an epidemic disease associated with a high case fatality rate (CFR; 24–88%). In the early years of the disease, the clinical diagnosis of MVD is difficult to differentiate from many other tropical fevers due to the similarity of clinical symptoms. Other VHFs, in particular, Ebola virus disease, as well as malaria, typhoid fever, leptospirosis, rickettsial infections and plague should be excluded. Human MVD infection can result from prolonged exposure to mines or caves inhabited by Rousettus bat colonies. Marburg virus is spread from person to person (through broken skin or mucous membranes) through blood, secretions, organs, or other body fluids of infected people, as well as contaminated surfaces and materials (eg, bedding, clothing). these are liquids.
Although there are no approved vaccines or antiviral treatments to treat the virus, supportive care—rehydration with oral or intravenous fluids and treatment of specific symptoms—can improve survival. A number of potential treatments are being evaluated, including blood products, immune therapy, and drug therapy.
The risk of this epidemic is high at the national level, moderate at the regional level, and low at the global level. The report of two confirmed cases of MVD with CFR 100% (2/2) is of concern. Epidemiological investigation has not yet identified the source of this outbreak, which indicates the need for increased public surveillance.
There is a risk that the outbreak could spread to neighboring countries, as the first case came from the Western region before the onset of symptoms. The western region shares a border with Côte d’Ivoire, and if more cases continue to be reported or affect other regions, this could pose a risk of cross-border transmission. Additionally, the first case was not safely buried in the Savannah region, bordering Ivory Coast and Burkina Faso. Therefore, the WHO assessed the risk of this epidemic as high at the national level, moderate at the regional level and low at the global level.
Community involvement activities should be carried out in three identified regions in Ghana (Ashanti, Savannah and Western Regions), with special emphasis on providing adequate information and prevention of further transmission to the population, avoiding stigmatization in the community, and early referral to treatment centers and other necessary outbreaks. encourage containment measures, including safe burials.
It is also important to raise awareness about the risk factors for MVD infection and the protective measures people can take to reduce their exposure to the virus. Key public health messages include:
- Minimize the risk of person-to-person transmission in the community through direct or close contact with infected patients, especially with their bodily fluids. Close physical contact with Marburg patients should be avoided. Gloves and appropriate personal protective equipment should be worn when caring for sick patients at home. After visiting sick relatives in the hospital, as well as after caring for sick people at home, hands should be washed regularly.
- Reducing the risk of bat-to-human transmission. Handle wildlife with gloves and other appropriate protective clothing. Cook animal products (blood and meat) thoroughly before consumption and avoid raw meat. Wear gloves and other appropriate protective clothing, including masks, when visiting mines or caves with colonies of fruit bats on work, research, or tourist trips.
In the three regions of Ghana, measures to contain the outbreak must be continued and strengthened. These measures include:
- Maintaining and building trust with communities
- Expand surveillance activities (active case tracing, contact tracing and investigation)
- Timely inspection of all suspicious cases of the Ministry of Internal Affairs
- Ensure adequate infection prevention and control measures are implemented during care of suspected, probable and confirmed patients
- Early isolation and care of suspected and confirmed cases, if possible, by trained medical personnel in specialized medical facilities and adequate IPC measures.
- Safe and dignified burial of those who have died with probable or confirmed cases of MIA.
Outbreaks of Marburg virus have previously been reported when infection prevention and control (IPC) measures were not implemented in health care facilities. IPC measures to reduce the risk of infection in healthcare include:
- Establishment of an IPC working group in the health zone to ensure the implementation of infection prevention and control measures
- Ensure healthcare providers are trained in MVD (standard and transmission-based precautions), including an emphasis on safe injection practices
- Ensure minimum WASH and isolation requirements and capacity are met in healthcare facilities.
Based on the current risk assessment, WHO advises against travel and trade restrictions to Ghana.