Hatching at a glance
Two fatal cases of Marburg virus disease (MVD) have been reported in Ashanti Region, Ghana. On June 28, 2022, these cases were notified to health authorities as suspected cases of viral hemorrhagic fever (VHF) and tested positive for Marburg virus on July 1, 2022. An outbreak of MVD was only reported in only once before in West Africa, and this is the first time that MVD has been notified in Ghana. An outbreak of MVD can pose a serious threat to public health because it is severe and often fatal.
Description of the outbreak
On June 28, 2022, two suspected cases of viral haemorrhagic fever (VHF) were notified to health authorities in Ashanti Region, 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 who was a farm laborer 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 was treated in a hospital on June 26 and died on June 27. The case was transported and buried in the district of Sawla-Tuna-Kalba, Savanes region, bordering Burkina Faso and Côte d’Ivoire. The burial took place before the results of lab tests for the MVD were available.
The second case was a 51-year-old man who was a farm laborer in Bekwai Municipal, Ashanti Region. He sought treatment at the same hospital as the first case on June 28 but died the same day.
Both cases presented with fever, general malaise, bleeding from the nose and mouth, and subconjunctival bleeding (bleeding from blood vessels in the eyes). Blood samples were taken 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 taken from both cases were sent to the Institut Pasteur 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 showed 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 they were not found epidemiologically linked. However, both cases came from communities living in forest environments.
A cumulative number of 108 people (50 from Ashanti Region, 48 from Savannah Region and 10 from Western Region) have been identified as contacts of the two cases, all of whom were in self-quarantine and under surveillance. daily for 21 days. On July 20, all contacts completed their follow-up period. These contacts included health workers and immediate family members of cases. A contact reported symptoms, but a blood sample taken tested negative at NMIMR on July 7. All other contacts reported being healthy during the follow-up period.
MVD is an epidemic-prone disease associated with high case fatality rates (lethality; 24-88%). Early in the illness, the clinical diagnosis of MVD is difficult to distinguish from many other tropical febrile illnesses due to similarities in clinical symptoms. Other VHFs should be excluded, especially 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. The Marburg virus is transmitted by human-to-human transmission by direct contact (through broken skin or mucous membranes) with the blood, secretions, organs or other bodily fluids of infected persons, and with surfaces and materials (eg. example, bedding, clothing) contaminated with these fluids.
Although there is no approved vaccine or antiviral treatment to treat the virus, supportive care – rehydration with oral or intravenous fluids – and treatment of specific symptoms improve survival. A range of potential treatments, including blood products, immune therapies and drug therapies, are being evaluated.
The risk of this epidemic 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 lethality of 100% (2/2) raises concern. The epidemiological investigation has not yet identified the source of this epidemic, which underlines the need to intensify community-based surveillance.
There is a risk of this outbreak spreading to other countries as the first case from the western region before symptoms appeared. The West region shares a border with Ivory Coast, which may present a risk of cross-border transmission if more cases continue to be reported or affect other areas. Additionally, the first case was not buried safely in the Savanes region which also borders Ivory Coast and Burkina Faso. Therefore, the WHO has assessed the risk of this epidemic 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) with particular emphasis on providing adequate information and support to the population to implement measures to prevent transmission, avoid stigma within the community and encourage early referral 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 individuals can take to reduce human exposure to the virus. Key public health communication messages include:
- To reduce the risk of human-to-human transmission in the community resulting from direct or close contact with infected patients, especially 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. Regular hand washing should be done after visiting sick relatives in the hospital, as well as after caring for sick patients at home.
- Reduce the risk of transmission from bats to humans. Handle wildlife with gloves and other appropriate protective clothing. Thoroughly cook animal products (blood and meat) before consuming them and avoid consuming raw meat. During work, research activities, or sightseeing in mines or caves inhabited by colonies of fruit bats, wear gloves and other appropriate protective clothing, including masks.
Epidemic containment measures should be continued and strengthened in the three regions of Ghana. These measures include:
- Maintain and build trust with communities
- Intensification of surveillance activities (active case finding, contact tracing and investigation)
- Test all suspected MVD cases in a timely manner
- Ensure that adequate infection prevention and control measures are implemented when caring for suspected, probable and confirmed patients
- Early isolate and manage suspected and confirmed cases, if possible, at designated health facilities with trained health workers and adequate IPC measures.
- Safe and dignified burial of deceased persons who are probable or confirmed cases of VDD.
Marburg virus transmission has previously been reported in healthcare settings when appropriate infection prevention and control (IPC) measures were not implemented. IPC measures to reduce the risk of transmission in healthcare settings include:
- Set up an IPC working group in the health zone to ensure the implementation of infection prevention and control activities
- Ensure that health workers are informed about MVD (standard and transmission-based precautions), with an emphasis on safe injection practices
- Ensure that minimum WASH and isolation requirements and capacities are met in health facilities.
Based on the current risk assessment, WHO advises against any travel and trade restrictions in Ghana.
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