On August 1, 2021, a patient was treated at a clinic in a small village in the southern province of Gekedou in Guinea, West Africa. He had fever, headache, fatigue, abdominal pain and bleeding gums, and tested negative for malaria. Despite receiving supportive care, he died of haemorrhagic fever the next day.
Do the symptoms look familiar? Yes, “Ebola” is the first word that pops into many people’s minds when it comes to hemorrhagic fevers in Africa. But the Ebola test was negative, and further results showed it was guinea’s first case of the Marburg Virus.
Marburg virus, formerly known as Marburg haemorrhagic fever, is one of the most dangerous viruses known. There have been previous outbreaks of the virus in other European and African countries with Case Fatality rates averaging 50 per cent and as high as 90 per cent during the outbreak in Angola in 2005. In contrast, the CFR of COVID-19 in most countries in the world is less than 10%, and it can reach 0.7% in China [1].
The marburg case emerged less than two months after the end of the Ebola outbreak in Guinea. The emergence of yet another high-mortality epidemic is raising alarm bells not only in Guinea and neighboring countries, but also in the nerves of health workers around the world who have been strained by COVID-19. The August case, however, received little public attention or even heard of.
Why has this new, high-risk infectious disease emerged so quietly in the context of COVID-19? Does this reflect Africa’s success or inadequate, attention or neglect?
Let’s start with the Marburg virus itself.
What is Marburg virus?
Marburg virus is named after marburg, Germany, where it was first discovered. In 1967, a simultaneous outbreak of haemorrhagic fever in Germany was traced to a laboratory in Marburg, Germany: infected green monkeys had been imported from Uganda to develop a polio vaccine. But inadequate safeguards led to the infection of laboratory workers and their contacts, resulting in an epidemic that eventually infected 31 people and killed seven.
Marburg virus to Germany’s African green monkeys Cercopithecus aethiops | Flikr, Celso FLORES/CC BY – SA, 2.0 (https://creativecommons.org/licenses/by/2.0/)
The virus, which has symptoms and spreads in a manner similar to Ebola, spreads from person to person through bodily fluids, including blood, saliva and vomit, and has an incubation period of two to 21 days. Symptoms range from severe fever, headache, diarrhoea, abdominal pain and vomiting to severe bleeding in multiple areas, confusion and even shock and death. The period from onset to death is usually 8-9 days, and the patients are severely damaged, and their appearance is even described as “devil” [2].
In fact, both viruses belong to the same filovirus family of single-stranded RNA proteins that appeared within nine years of each other. Both viruses are zoonotic and cause severe hemorrhagic fever in humans, monkeys, gorillas and other primates. It’s just that they trigger different immune mechanisms in patients, with Ebola being a bit more virulent.
Marburg virus (right) and the ebola virus (left) with filamentous virus, volume have different | in reference [3]
In September 2021, Researcher Ifeanyi Nsofor from EpiAFRIC and The Aspen Institute expressed concern in an interview with The Lancet Microbe: “The marburg virus case in Guinea in early August was found in the same area as ebola outbreaks in 2021 and 2014, suggesting that too close human-wildlife interaction had an impact, allowing some zoonoses like hemorrhagic fevers to jump from animals to humans.” [4]
Ebola and marburg outbreak in Africa and possible host fruit bats (Africa) (1967-2014), the geographical distribution of | in reference [5]
The twin dilemmas of fighting epidemics in Africa
Human-to-human transmission begins when the virus jumps from host animals to humans. The worst outbreak in decades, in Angola in 2004-05, killed more than 300 people a year, and the causes of Africa’s high mortality and spread are far more complex than the virus itself.
- The plight of health care
In the face of extremely dangerous virus, health care workers must also wear full body protective clothing in extreme heat, just put on and take off for more than an hour. What is even more painful is that they are well aware that there is little cure for the disease [6]. According to a recent conference report by the Mo Ibrahim Foundation (MIF) [7], Africa has an average of only 135.2 hospital beds and 35.4 doctors per 100,000 people, while for low-income countries the figures can be as low as “67.4” and “9.6”.
In addition, at least 17 African countries have fewer than one hospital bed for a thousand people. ICU beds are even more scarce, with an average of 3.1 beds per 100,000 people, compared with 0.53 in low-income countries. Fewer than 2,000 ventilators are available in public hospitals in 41 African countries to serve hundreds of millions of Africans, and 10 countries do not have even one.
- Trust dilemma in healthcare system
Due to limited basic health education, most ordinary Africans do not believe that the invisible virus is the cause of infection, and instead believe that hospitals are the source of infection — after all, most of the patients sent there never come out. In the grip of fear, people lose faith in the healthcare system and begin to hide patients at home rather than seek treatment, further increasing the risk of transmission. In addition, they began to regard medical staff as the culprits of disease, so they attacked medical staff and ambulance convoy, and even killed staff members [8].
Medical workers in full gear carry the bodies of marburg infected patients. And dressed in protective equipment, health care, more like a god of death arrival | in the eyes of the africans in reference [9]
Africa continues to suffer from a lack of medical resources and a lack of trust in the medical system. This is not only true in the fight against Marburg, but also profoundly affects the fight against other epidemics.
For example, if you look at the data on paper, Africa seems to be far worse off than Europe and the United States — Tanzania’s cumulative number of confirmed cases by the end of 2021 was around 30,000, and the death toll was around 700, far lower than Italy and France, which have similar populations. However, the “cure rate” of COVID-19 in Tanzania is also close to zero, and due to the lack of testing capacity, there must be a large number of “hidden” cases that are not included in the statistics. Who estimates that six out of every seven COVID-19 cases in Africa go undetected.
Map of global COVID – 19 cases (the number of cases per 100000 people) | WHO Coronavirus (COVID – 19) Dashboard
International cooperation in Africa’s spicy and sweet
- Helpful, but not panacea
Historically, efforts to aid to Africa is often a top-down isolated activities, not only decisions from far away from the continent’s institutions, the international organization or cooperation state aid to Africa is usually focused on short-term crisis management, Africa’s own independent institutions and experts are hard to establish a sustainable control system – in other words, grant “to the” fish “than to” fish “. The 2014 Ebola outbreak, for example, was not officially classified as a global health emergency until nearly 2,000 cases and nearly 1,000 deaths were reported in West Africa. Before international organizations intervened, the capacity of African countries to deal with epidemics on their own was clearly weak.
At the same time, Africa’s available resources are themselves inadequate. In the early days of COVID-19, more than 70 countries imposed restrictions on the export of medical materials, including raw materials for nucleic acid tests, and the shortage of medical supplies in Africa was not alleviated until the establishment of the African Medical Supplies Platform in June 2020. The episode clearly illustrates both the importance and fragility of multilateral cooperation and international assistance.
In addition, Africa’s public health systems may be overly dependent on outside aid, making them vulnerable to serious global problems. Before programs such as the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria were established in the mid-1990s, more than 10 million Africans had died because they lacked ready access to antiretroviral drugs.
- Having difficulties, but still trying
Faced with both material and institutional difficulties, African countries have not completely given up. Following the Ebola outbreak in West Africa in 2014-2016, the African Centers for Disease Control and Prevention (Africa CDC), established by the African Union in 2017, played an important role during the COVID-19 outbreak.
In February 2020, when the first COVID-19 case was reported in Africa, CDC Africa established the African Coronavirus Task Force (AFTCOR) to work with public health agencies. Four months later, the African Medical Supplies Platform (AMSP) was established. The African Vaccine Procurement Working Group (AVATT), established in November, has so far made 400 million doses of vaccines available to the continent [10]. So far, Nigeria’s African Center of Excellence for Infectious Disease Genomics (ACEGID) has sequenced samples from about 30 African countries and trained more than 1,300 geneticists, public health workers and officials from other countries.
Researchers in Nigeria Ed ACEGID diagnostics training | acegid.org
Who and international efforts have helped African countries develop very comprehensive responses to Ebola and Marburg viruses. Considering the zoonotic characteristics of the disease, they continuously monitored the status of wild animals from the beginning of the epidemic and made a review and summary after the epidemic completely ended [11], which helped to improve the infectious disease surveillance capacity of West African countries.
Such collaboration among African countries, and between Africa and other international forces, has enabled many African countries to make full use of available resources, and has also been part of the reason for some mitigation of the COVID-19 pandemic on the African continent [12].
Who response strategy for Ebola and Marburg virus disease: preventive-alert-control-assessment
An excellent answer to the Marburg epidemic
The emergence of Marburg virus is usually accompanied by a very high mortality rate, but this outbreak has been successfully contained in the face of multiple mutations and hard-to-prevent transmission, coupled with the impact of the Novel Coronavirus: From the laboratory detection of Marburg virus in viral haemorrhagic fever in Guinea on 3 August 2021 to the declaration of the end of the outbreak on 16 September 2021, a total of only one confirmed case was reported in 44 days [13].
Within hours of the death of the first patient with the haemorrhagic fever, a team of medical professionals arrived at the scene to take oral swab samples and send them to the laboratory for rapid testing, which was confirmed by several research institutions. At the same time, 173 contacts were quickly identified and tested until WHO recommended that the outbreak be declared over.
- Quick response, international cooperation, and luck
The rapid resolution of the outbreak in Guinea was a result of the continent’s long experience fighting different infectious diseases: The successive outbreaks of Ebola virus, COVID-19 and Lassa fever have made guinea’s epidemic response activities a normal state. It is also accustomed to extensive detection of various infectious pathogens, and has isolation facilities and professional knowledge of infectious disease control, all of which contribute to the early detection and response of the epidemic [14].
Over time, significant progress has been made in Both Africa’s own public health capacity and in the approach and input of international assistance to Africa. The rapid disposal of marburg virus in Guinea in 2021 can be said to be the result of successful multilateral cooperation. The Ministry of Health of Guinea actively participated in the cooperation with the World Health Organization (WHO), the United States Centers for Disease Control (CDC), the International Medical Action Alliance (ALIMA) and other institutions, jointly took measures to trace contacts and search for cases [15], and finally achieved this exciting prevention and control result.
However, there is no denying that there is an element of “luck” in the smooth prevention and control. If close contacts happen to be infected and go undetected, could the outbreak actually cause an outbreak, adding another burden to Guinea’s fragile health system? Is it going to be like Ebola, where other continents don’t take notice until a lot of tragedy strikes? Although Public health systems in Africa have made significant progress compared to the past, this is still entirely possible, and to this day, effective drugs and vaccines for Marburg haemorrhagic fever are still being developed, and most hospitals have to focus on supportive therapies [16].
Many African countries often face special difficulties in fighting epidemics due to economic constraints, lack of medical resources, backward scientific thinking, inadequate education and even political isolation. Infectious diseases and periodic natural disasters such as floods, combined with social and political instability, make the health care system vulnerable. It’s hard to imagine how lucky we might be when the next pandemic strikes.
The future of medicine on the African continent
As noted at the beginning of this article, the Marburg virus outbreak has not been noticed by many people far from west Africa, so why do we need to see this outbreak almost invisible to the public?
After all, at a time of rapid social development and increasing mobility, the destiny of Africans cannot be easily separated from that of the rest of the world, including our own. The significance of international aid is not only to help people far away to solve their immediate problems, but to “teach people how to fish” in an appropriate way at one level and prevent problems in an appropriate way at another level, so as to achieve win-win results and achieve the best of both worlds. In the future, Africa needs to build its own health care system, and we are also keeping an eye on health care in poor parts of the world.
After all, the “good luck” of the prevention and control of Marburg virus resulted from countless efforts. This undoubtedly reminds us that we should not take any disease lightly on the road to win-win cooperation and elimination of disease for all mankind.
