Marburg virus disease is a looming threat in the Republic of Guinea

The recent outbreaks of Marburg virus disease (MVD) in West Africa (Ghana and Guinea) are a cause of global concern, exemplified by the fact that the Marburg virus was included in the WHO list of high priority pathogens in 2018 due to its potential risk of causing significant harm to public health1. The virus is a member of the Filoviridea virus family, the same as the deadly Ebola virus. Marburg virus is a zoonotic virus that spreads via contact with animals, blood, or other bodily fluids such as saliva, semen, sweat, urine, or even tears from other infected humans2. Once the MARV is inside the human body, the virus remains asymptomatic for 3–21 days with an average incubation period of 5–10 days2. Fruit bats have been identified as the hosts of the Marburg virus, from which the virus is then transmitted to humans3. Symptoms of MVD include fever, malaise, headache, nausea, vomiting, severe watery diarrhea, and a characteristic erythematous rash on the face and buttocks around day eight that spreads to the rest of the body3,4. Extensive hemorrhage in the form of ecchymosis, petechiae, bleeding from gums, mouth, other body orifices, hematemesis, and melena entail as the most concerning symptoms3. The disease progresses to cause multi organ failure and shock, which ultimately leads to death5. The roots of this lethal virus are traced back to 1976 when an unknown infectious epidemic with features of hemorrhagic fever occurred in three different cities simultaneously around the globe: Marburg, Frankfurt (Germany), and Belgrade (Yugoslavia, Serbia now)6. Numerous outbreaks have occurred since, including in Uganda, the Democratic Republic of the Congo and most recently, in 2022, in Ghana and in 2023 in Guinea7. MVD has been identified for more than 50 years; sadly, there is still paucity in the development of its treatment8 and despite improvement in standard and intensive patient care, integration of prophylactic and therapeutic treatment options for infectious diseases is generally lacking9. Significant gaps in genomics and bioinformatics capacity in national institutions have also been caused by MVD10. It is therefore urgent to look into and deal with this ongoing issue as the MVD outbreaks continue to be a threat in recent times when we are still recovering from aftermaths of COVID-19 and its newer variants. The sudden arrival of MVD in West Africa was initially unexpected, but prior ecological niche modeling revealed that the ecological traits of the West African sub-regions were comparable to those of other Marburg Virus endemic locations, indicating that the region was highly susceptible to MVD11. As of 21 March 2023, Equatorial Guinea had nine confirmed MVD cases and 20 suspected cases. The wide geographic spread of the province and unknown connections between cases suggest the possibility of undisclosed community transmission12. In Tanzania, there have been a total of eight cases in the Kagera region, resulting in a 62.5% case fatality rate (CFR), and the national-level risk is evaluated as extremely high due to the high CFR and the possibility that the outbreak would spread to other regions, as well as limited resources and the risk of surpassing existing capacity13. Ghana reported outbreak in 2022 with CFR of 66.7%14. The current epidemiological investigation has not yet identified the cause of the outbreak15. There were four Marburg virus outbreaks in Uganda in 2007, 2012, 2014, and 2017 with the CFR ranging from 27 to 100%16,17. According to the WHO, Equatorial Guinea, Ghana, Guinea, Uganda, Angola, the Democratic Republic of the Congo, Kenya, and South Africa have previously reported outbreaks of MVD https://www.who.int/news-room/fact-sheets/detail/marburg-virus-disease. In order to combat the MVD epidemic, Guinea's Ministry of Health is working with several organizations, including the WHO, United Nations Children's Fund (UNICEF), The Alliance for International Medical Action (ALIMA), the US Centers for Disease Control and Prevention (CDC), the Red Cross, the International Organization for Migration, and others. Since there are no vaccines or treatments for MVD, their collective efforts aim to prevent new cases through contact tracing, active case searching in health facilities, enhanced surveillance, risk communication, community engagement, infection prevention, and control measures18. In the fight against the MARV epidemic, Ghana's Ministry of Health is co-ordinating with partners for assistance. Co-ordination mechanisms have been developed in affected health areas in Ghana, and an Ashanti Region-designated hospital has been established15. Furthermore, WHO is bolstering community-based surveillance by giving testing reagents to the NMIMR (Noguchi Memorial Institute of Medicine Research) located at the University of Ghana in Accra, Ghana15,19. The WHO is also sending experts to Ghana before a potential outbreak to assist with disease surveillance, contact identification, and patient care planning and educate people about the disease's risks and hazards20. Recent research done at National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health (NIH) showed promising results https://www.nih.gov/news-events/news-releases/marburg-vaccine-shows-promising-results-first-human-study and various therapeutic options, such as postexposure therapy using antiviral medications, monoclonal antibodies, small antiviral molecules, and viral inhibitors, have shown encouraging results as well , but still, no treatment and vaccine has been approved21. Also, implementing a One Health (OH) strategy provided a framework for a co-ordinated and effective response to zoonotic emergencies and has improved event management and a lower fatality rate of MARV22. Public health professionals and clinicians in Africa should prioritize primary prevention and control measures of MARV in order to contain the spread of the disease. With no medicines and a high mortality rate, outbreaks in the future and more pandemics remain possible23. In the absence of specific treatment, supportive treatment such as balancing fluids and electrolyte levels, maintaining oxygen and blood pressure, and replacing blood loss and clotting factors might be helpful3. According to the WHO's 2022 report, zoonotic illnesses like MARV have surged by 63% in Africa during the last 10 years. Seventy percent of these instances have been caused by deadly new viruses, placing a heavy pressure on healthcare infrastructure. Overall living standards have dropped as a result16. Three years of viral epidemics in Africa, including measles, polio, Lassa fever, dengue, and yellow fever, had already taxed the inadequate healthcare system when the COVID-19 pandemic struck24,25. Because COVID-19 was so lethal, management of it took up resources that were already scarce in the hospital system. There is a good chance that additional infectious outbreaks will not be adequately managed because of the present pandemic and another fatal Marburg virus outbreak, trapping Africa in a vicious cycle where managing infections is complicated24. The 2022 UNICEF health budget brief report documents that managing communicable diseases is already costing 6.9% of the gross domestic product (GDP) of Ghana, where the most recent MVD outbreak occurred. There is an expected fall in the healthcare budget in 2025 to 1.8% of GDP, far below the LMICs (lower middle-income countries) average allocation of 2.3% of GDP to the healthcare budget25. Along with the budget issue, there are several other difficulties in managing the MVD epidemic and thus reducing its potential to become a pandemic, such as trouble detecting MVD in its early stages due to its resemblance to the initial stages of COVID-1924. Furthermore, when considering measures to address the Marburg virus, the present circumstances also bear similarities to those encountered during the others, for example, the Ebola virus outbreak. This similarity underscores the importance of not underestimating the threat of MVD26. One significant challenge is identifying the source of the outbreak in Ghana and Equatorial Guinea. Despite ongoing investigations, the source of the epidemic remains elusive. The limited effectiveness of the surveillance system in both countries hinders the identification process, thereby increasing the potential risk of disease transmission to other areas within the community and neighboring nations25. Even freely crossing borders causes an upheaval in the risk of disease spreading to neighboring countries. Countries like Guinea are hard-pressed to access essential primary healthcare services because these countries are already dealing with a slew of epidemics other than MVD, including COVID-19, yellow fever, measles, and vaccine-derived polio24. The impact of MVD is further exacerbated by inadequate public health infrastructure, patient noncompliance, limited education, inadequate expertise, and lack of financial/personnel support, which are required to handle infectious disease outbreaks on a structural level27. Other challenges include insufficient infection prevention and control measures in the nation's health system, indicating a problem with the response capacity24. Also, sporadic cases have been reported in people who gave a travel history, like a cave inhabited by the Rousettus aegyptiacus bat colony in Uganda. That is why the risk of exposure to MVD is very high for people who visit such caves, and more people are at risk because of a lack of awareness and inadequate safety precautions such as wearing masks, gloves, and PPE28. It should be noted that addressing all these issues is vital for effective combat and control of the disease. There are certain precautions that one can take in order to prevent catching the disease and thus its spread as well. Some are listed in Table 1. Table 1 - The primary prevention and control measures for Marburg virus disease. Measure Description 1 Avoid contact with bodily fluids29 Avoid contact with blood, urine, feces, saliva, sweat, vomit, breast milk, amniotic fluid, semen, and vaginal fluids of infected individuals 2 Transfer suspected cases to healthcare system30 Any suspected case should instantly be transferred to a healthcare system for treatment and isolation instead of managing at home 3 Proceed with caution during aerosol-generating procedures31 When doing procedures that generate aerosols, proceed with utmost caution 4 Use protective gear when handling wildlife30 Use gloves and other suitable protective gear while handling wildlife 5 Use infection prevention and control measures32 Health and care providers should use IPC measures, such as conventional and transmission-based precautions when caring for patients with confirmed or suspected MVD 6 Safer sexual activities for male survivors28 Male MVD survivors must engage in safer sexual activities and maintain better personal hygiene until their semen tests Marburg virus-free twice 7 Safely dispose of infected dead bodies31 MVD infected dead bodies should be safely disposed of In conclusion, this virus can be lethal and transform into another deadly pandemic if the healthcare authorities do not take appropriate measures right now. The prevention of the Marburg virus from becoming a pandemic relies on effective regional management in Africa. Given the constant migration and travel, there is a significant risk of global spread. Therefore, increased healthcare spending at the regional level (Africa) is crucial for successfully controlling disease outbreaks and halting the problem in its tracks. To completely eradicate the Marburg virus as quickly as feasible, researchers should continue to develop more potent vaccines and other antiviral medications against MARV. While therapeutic advancements are essential, community involvement, and awareness are equally important. Since there is no one size fits all approach and case-based real-time changes must be made, actions should be taken to lower risk factors and encourage community self-prevention. Through the use of mass media and social media on a global scale, the WHO and local government bodies should make efforts for creating educational content by using collaborations with social media influencers to educate masses about safety precautions and the importance of appropriate safety precautions, such as wearing masks, gloves, and personal protective equipment (PPE) with special emphasis on increasing public awareness of coexistence of MVD with COVID-19 and other emerging varieties such as delta COVID, and the hazards associated with bat-to-human and human-to-human transmission. Organizations like the WHO should enhance co-ordination efforts in African countries regarding MVD in endemic countries and provide sustained financial support to reduce the recurrence of this lethal disease in Africa. Thus, together, nations can surmount any obstacle and construct a safer and healthier world, against MARV and ensuring a better tomorrow for everyone. By joining forces to fortify regional management, reinforce healthcare systems, propel scientific research, cultivate community involvement, and raise global consciousness of MARV, they (WHO?) have the potential to establish a global environment where the Marburg disease is effectively contained and managed. With shared commitment and unwavering resolve, nations can avert its progression into a pandemic, safeguarding the health and welfare of people across the globe. Ethics approval and consent to participle Not applicable. Consent for publication Not applicable. Sources of funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Author contribution F.J.: conceptualized the study, drafted the manuscript, and provided final approval of the version to be published, and ensured the accuracy of the work; N.B.: contributed to the study design and manuscript drafting, provided final approval of the version to be published, and verified the accuracy of the work; M.A.: wrote the original draft of the manuscript, provided final approval of the version to be published, and ensured the accuracy of the work; M.H.: contributed to the writing of the original draft, provided final approval of the version to be published, and verified the accuracy of the work; H.H.S.: contributed to the writing of the original draft, provided final approval of the version to be published, and ensured the accuracy of the work; M.O.O.: writing, review and comments, resources, software, project supervision, validation, and visualization. All authors approved the final manuscript for publication. Conflicts of interest disclosure The authors have no competing interests to declare that are relevant to the content of this article. Research registration unique identifying number (UIN) Name of the registry: not applicable. Unique identifying number or registration ID: not applicable. Hyperlink to your specific registration (must be publicly accessible and will be checked): not applicable. Guarantor Malik Olatunde Oduoye. Availability of data and material Not applicable. Provenance and peer review Not commissioned, externally peer-reviewed.