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Two fatal cases of Marburg virus disease (MVD) have been reported in Ashanti Region, Ghana. On June 28, 2022, these cases were reported to health authorities as suspected cases of viral hemorrhagic fever (VHF) and tested positive for Marburg virus on July 1, 2022. Only one MVD outbreak has been previously reported in West Africa, and this is the first time that MVD has been notified in Ghana. An MVD outbreak can pose a serious threat to public health, as it is serious and often fatal.
Description of the outbreak
On June 28, 2022, two suspected cases of viral haemorrhagic fever (VHF) were reported to health authorities in Ashanti Region, Ghana (Figure 1). This region is located in the middle belt of Ghana and is the most populous region in the country.
The first case was a 26-year-old man who was an agricultural worker in Adansi North District, Ashanti Region, with a history of travel to the Western Region. Before the onset of symptoms on June 24, he arrived from the western region to the Ashanti region. He sought care at a hospital on June 26 and died on June 27. The case was transported and buried in the Sawla-Tuna-Kalba district, Savannah region, which borders Burkina Faso and Ivory Coast. The burial took place before the results of laboratory tests for MVD were available.
The second case was a 51-year-old man who was a farm worker in Bekwai township, Ashanti region. He sought care at the same hospital as the first case on June 28, but died the same day.
Both cases presented with fever, malaise, bleeding from the nose and mouth, and subconjunctival bleeding (bleeding from the blood vessels of the eyes). Blood samples were collected on June 27 for the first case and June 28 for the second case and sent to the Noguchi Memorial Institute of Medicine Research (NMIMR) for analysis. On July 1, both cases tested positive for Marburg virus by reverse transcriptase-polymerase chain reaction (RT-PCR). On July 12, samples collected from the two cases were sent to the Pasteur Institute in Dakar, Senegal (IPD), which confirmed the NMIMR results on July 14, 2022.
Figure 1. Region of the two confirmed cases of Marburg virus disease reported in Ghana, as of 20 July 2022
The source of infection is unknown. Preliminary investigations have shown that none of these cases had a history of contact with dead animals, sick people or animals and had not attended any social gatherings within three weeks of the onset of symptoms. Although both cases were farmers, they worked in different locations and have not been found to be epidemiologically linked. However, both cases came from communities living in a forest environment.
A cumulative number 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 and monitored daily for 21 days. On July 20, all contacts completed their follow-up period. These contacts included health workers and immediate family members of the cases. One contact reported some symptoms, but a blood sample that was collected tested negative for NMIMR on July 7. All other contacts reported being in good health during the follow-up period.
MVD is an epidemic-prone disease associated with high case fatality rates (CFR; 24-88%). In the early course of the disease, the clinical diagnosis of MVD is difficult to distinguish from many other tropical febrile illnesses due to similarities in clinical symptoms. Other VHFs need to be excluded, particularly Ebola virus disease, as well as malaria, typhoid fever, leptospirosis, rickettsial infections, and plague. Human infection with MVD can result from prolonged exposure to mines or caves inhabited by colonies of Rousettus bats. Marburg virus is spread through person-to-person transmission through direct contact (via broken skin or mucous membranes) with blood, secretions, organs, or other bodily fluids of infected people, and with surfaces and materials ( eg, bedding, clothing) contaminated with these fluids.
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 improve survival. A range of potential treatments are being evaluated, including blood products, immunotherapies, and pharmacotherapies.
The risk of this outbreak is high at the national level, moderate at the regional level, and low at the global level. The notification of two confirmed cases of MVD with a CFR of 100% (2/2) raises concern. The epidemiological investigation has not yet identified the source of this outbreak, highlighting the need to intensify community surveillance.
There is a risk that this outbreak could spread to neighboring countries because the first case traveled from the western region before the onset of symptoms. The western region shares a border with Côte d’Ivoire, and this may present a risk of cross-border transmission if more cases continue to be reported or affect other areas. Furthermore, the first case was not safely buried in the Savannah region, which also borders the Ivory Coast and Burkina Faso. Therefore, the WHO has assessed the risk of this outbreak as high at the national level, moderate at the regional level, and low at the global level.
Community engagement activities should be carried out in the three identified regions in Ghana (Ashanti, Savannah and Western regions) with a particular focus on providing adequate information and support for the population to implement measures to prevent further transmission, avoid stigmatization within the community, and encourage early presentation to treatment centers and other necessary outbreak containment measures, including safe burials.
It is also important to raise awareness of the risk factors for MVD infection and the protective measures that people can take to reduce human exposure to the virus. Key public health communication messages include:
Reduce the risk of person-to-person transmission in the community from direct or close contact with infected patients, particularly with their body 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. You should wash your hands regularly after visiting sick family members in the hospital, as well as after caring for sick patients at home. Reduce the risk of bat-to-human transmission. Handle wildlife with gloves and other suitable protective clothing. Cook animal products (blood and meat) thoroughly before consuming and avoid consuming raw meat. During work, research activities, or sightseeing visits to mines or caves inhabited by colonies of fruit bats, wear gloves and other suitable protective clothing, including masks.
Outbreak containment measures need to continue and be strengthened in all three regions of Ghana. These measures include:
Maintain and build trust with communities Expand surveillance activities (active case finding, contact monitoring, and investigation) Test all suspected MVD cases in a timely manner Ensure adequate infection prevention and control measures are implemented when providing care to suspected, probable and confirmed cases patients Early isolation and care of suspected and confirmed cases, if possible, in designated health facilities with trained health workers and adequate IPC measures. Carry out the safe and dignified burial of deceased persons who are probable or confirmed cases of MVD.
Transmission of Marburg virus has been previously reported in healthcare settings when appropriate infection prevention and control (IPC) measures were not implemented. IPC measures to reduce the risk of transmission in health care include:
Establish an IPC working group in the health zone to ensure the implementation of infection prevention and control activities. Ensure healthcare workers receive information on MVD (standard and transmission-based precautions), including an emphasis on safe injection practices. treated in health facilities.
Based on the current risk assessment, the WHO advises against any travel and trade restrictions to Ghana.