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All you need to know about Marburg haemorrhagic fever
Datelinehealth-Africa News
2005-05-03

Marburg haemorrhagic fever is a rare though severe and highly fatal disease.

The disease and what causes it
Marburg haemorrhagic fever is a rare though severe and highly fatal disease. It is called Haemorrhagic fever because unlike many other fever causing diseases, Marburg haemorrhagic fever is often associated with significant bleeding from multiple sites in the body during days 5 to 7 of the onset of the illness. The disease is caused by a Ribonucleic Acid (RNA) virus of the filovirus family (Marburg virus). This virus is from the same family as the one that causes Ebola haemorrhagic fever.

Filoviruses are among the most virulent pathogens known to infect humans.

Natural reservoir of the disease causing virus
Despite years of intensive investigation involving the testing of hundreds of animals, insects, and plants, no proven animal reservoir or other environmental source of the causative virus has been identified. Bats have been alleged to be reservoirs, but there are no hard evidence to support this. Monkeys are susceptible to infection but are not considered viable reservoir hosts as virtually all infected animals die too rapidly to sustain survival of the virus. Humans are not considered part of the natural transmission cycle their infection is accidental.

Transmission
Transmission of the virus from person to person requires extremely close contact with a patient. Infection results from contact with blood or other body fluids (faeces, vomitus, urine, saliva, and respiratory secretions) with high virus concentration, especially when these fluids contain blood. Transmission via infected semen can occur up to seven weeks after clinical recovery. Infection through casual contact is thought to be exceedingly rare. The low rate of transmission to persons with casual contact suggests that air borne transmission via the respiratory tract is not efficient, if it occurs at all. Transmission does not occur during the incubation period. Patients appear to be most infectious during the period of severe illness accompanied by haemorrhagic manifestations. Close contact with a severely ill patient, during care at home or in hospital, and certain burial practices are common routes of infection. Transmission via contaminated injection equipment or through needle-stick injuries is associated with more severe disease, rapid deterioration, and possibly higher death rate.

Reported outbreaks
The first reported outbreaks of this disease occurred in Marburg, Germany and in Belgrade, the former Yugoslavia in 1967. These outbreaks were linked to laboratory workers using African green monkeys (Cercopithecus aethiops) imported from Uganda. Isolated occurrences of the disease in humans were reported in South Africa (in 1975) and, Kenya (in 1980 and 1987). An outbreak in the Democratic Republic of the Congo, (DRC), (formerly Zaire) marked the first large outbreak of this disease under natural conditions. The outbreak occurred from late 1998 to 2000. It involved 154 cases, of which 128 were fatal, representing a case fatality of 83%. The majority of cases in the DRC outbreak occurred in young male workers at a gold mine in Durba, in the north-eastern part of the country. This region proved to be the major area (epicentre) of the outbreak. Cases were subsequently detected in a neighbouring village called Watsa. Family members involved in the close care of patients accounted for some cases, but secondary transmission appeared to be rare.

A more recent and ongoing outbreak has been reported in Angola. The outbreak is believed to have begun in October 2004 in Uige Province, a region that is located in north-western Angola (view map & details). As of 27 April 2005, the Angolan Ministry of Health reported a cumulative total of 275 cases, of which 255 were fatal. A case fatality of 93 percent. Most cases detected in other provinces have been linked directly to the outbreak in Uige.

Incubation period
The disease, has an incubation period of 3 9 days. Incubation period refers to the time between contact with the causative agent and the first noticeable appearance of disease related symptoms.

Clinical features
Haemorrhagic fever illness caused by Marburg virus begins abruptly, with severe headache and malaise (weakness and poor health), muscle aches and pains. A high fever usually appears on the first day of illness, followed by progressive and rapid deterioration in health. A severe watery diarrhoea, abdominal pain and cramping, nausea, and vomiting begin about the third day. Diarrhoea can persist for a week. The appearance of patients at the early period of the disease has been described as showing ghost-like drawn features, deep-set eyes, expressionless faces, and extreme weakness coupled with lack of interest (lethargy). A non-itchy rash appearing between days 2 and 7 after symptom onset could be a feature in most patients.

Many patients develop severe bleeding (haemorrhagic) manifestations between days 5 and 7. Fatal cases usually have some form of bleeding, often from multiple sites. Findings of fresh blood in vomitus and faeces are often accompanied by bleeding from the nose, gums, and vagina. Spontaneous bleeding at venipuncture sites can be particularly troublesome. During the severe phase of illness, patients have sustained high fevers and involvement of the brain can result in confusion, irritability, and aggression. Infection and tenderness in the testis (orchitis) has been reported occasionally in the late phase of disease (day 15). In fatal cases, death occurs most often between 8 and 9 days after symptom onset, usually preceded by severe blood loss and shock.

Diagnosis, Treatment and Public health control
Marburg haemorrhagic fever may be difficult to diagnose early since many of its initial symptoms are mimicked by other tropical infectious diseases including the common malaria. A high level of suspicion is required, especially if the presenting patient has a history of travel or close contact with an ill individual who has travelled or lived in regions where the disease is known to occur. There are no known preventive or curative vaccine or specific treatment for the disease. Acute care is often directed at managing the severe presenting symptoms ans stabilizing the patient body systems generally. Care is best provided in strictly enforced isolation unit with excellent attention to barrier nursing, hygiene and body fluid waste disposal.
Survival from the disease is not unknown where care is provided early. Public health control of an outbreak of Marburg haemorrhagic fever can be very challenging as the disease commonly occurs in resource-poor regions of the world, like Angola, Uganda and DRC in Africa. Early mobilization of infectious disease control personnel to the outbreak region is mandatory. These personnel may be local health ministry officials and/or from expert institutions like the WHO.

Detailed and prompt surveillance system has to be put in place to identify affected individuals, isolate and treat them as early as possible. Appropriate community sensitization, education and mass mobilization for healthy behaviours and practices need to be emphasized in affected populations. Adequate provision of supplies for acute care, barrier nursing, proper disposal of corpses and body fluids of infected patients are essential for containment of the disease. These and other population-directed (public) health measures help to bring outbreaks under control. 

(Source: Dateline health-Africa News, May 1, 2005)


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