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Marburg can be an exceptionally deadly virus. An outbreak in Rwanda is being managed with “unprecedented” success, public health experts say. In this photo from a Marburg outbreak in Kenya in 2014, a medical worker in protective gear carries a meal to a man being quarantined in an isolation tent after coming into contact with a virus carrier.

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Ben Curtis/AP

The Marburg virus is notorious for its ability to kill. In previous outbreaks, up to 9 out of 10 patients died from the disease. And there are no approved vaccines or medications.

This was the grim situation in Rwanda just over a month ago, when officials made the announcement no one wants to make: The country was in the middle of its first Marburg outbreak.

Now those same Rwandan officials have better news to share. Remarkably better.

“We have a mortality rate of 22.7% – probably one of the lowest ever recorded [for a Marburg outbreak]” said Yvan Buterathe Rwandan Minister of State for Health at a press conference hosted by the Africa Centers for Disease Control and Prevention on Thursday.

There is more encouraging news: Two of the Marburg patients who experienced multi-organ failure and were on life support have now been extubated – their breathing tubes were successfully removed – and have recovered from the virus.

“We believe this is the first time that Marburg virus patients have been extubated in Africa,” said Tedros Adhanom Ghebreyesus, director-general of the World Health Organization. “These patients would have died in previous outbreaks.”

The number of new cases in Rwanda has also fallen dramatically, from several per day to just 4 in the last two weeks, bringing the total from this outbreak to 66 Marburg patients and 15 deaths.

“It is not yet time to declare victory, but we believe we are on the right track,” Butera said. Public health experts are already using words like “remarkable,” “unprecedented,” and “very, very encouraging” to characterize the response.

How was Rwanda – an African country with around 14 million inhabitants – able to achieve this success? And what can other countries learn from Rwanda’s response?

The basics are mastered really well

Rwanda is known for the horrific genocide of 1994 – one of the worst in modern times. Since then, the country has taken a different path. In 20 years, life expectancy increased by 20 years from 47.5 years in 2000 to 67.5 years in 2021 – about double the increases observed across the continent. And Rwanda has spent decades building a robust health system.

“The healthcare infrastructure, the healthcare providers in Rwanda – they are really, really great,” says Craig SpencerEmergency physician and professor at Brown University School of Public Health. Spencer specializes in global health issues and has closely followed the outbreak in Rwanda.

There are well-run hospitals and well-trained nurses and doctors, he says. There are laboratories that can quickly perform diagnostic tests. Personal protective equipment is available for medical staff.

For this outbreak, there was the know-how and infrastructure to set up Marburg's own treatment facility. This was a boon for other patients and medical staff and prevented exposure to the virus – which passes from bats to humans and can be transmitted through bodily fluids such as blood, sweat and diarrhea.

And although there are no approved medications to treat Marburg, patients in Rwanda have received good supportive care for all their symptoms – such as the intravenous fluids that are important for symptoms such as high fever, nausea, vomiting and diarrhea.

This is in stark contrast to the reactions in previous Marburg scenarios. For example, in the Democratic Republic of Congo – next to Rwanda – there was an outbreak between 1998 and 2000. Dr. Daniel Bausch, a professor at the London School of Hygiene and Tropical Medicine and an expert in tropical diseases such as Marburg, provided care during this outbreak. He says what the country's health centers could offer patients was rudimentary at best.

“We called it a care center or a treatment center, but in reality it was a separate mud hut where people were housed. We didn’t really have anything at our disposal,” he remembers. “People were lucky that they were given acetaminophen or Tylenol and some fluids to drink if they managed to get away without nausea and vomiting.”

This outbreak had a case fatality rate of 83% with 154 cases and 128 deaths.

In the world 18 recorded Marburg outbreaksThe mortality rate varies considerably. Several small outbreaks had mortality rates below 30%, but the largest outbreak – in Angola in 2004 and 2005 – had a mortality rate of 90%, with 252 cases and 227 deaths.

Rwanda’s “more modern medical centers” are making a big difference, says Bausch.

Get to the patient in no time

It wasn't just the quality of care that made the difference. It is also the speed at which patients receive care.

As soon as the outbreak began, Rwandan officials launched a major operation to trace the contacts of those infected and monitor the health of over 1,000 family members, friends, health care workers and other vulnerable people. They also began door-to-door surveillance in neighborhoods where exposure may have occurred.

And they've done a lot of testing – over 6,000 tests, particularly on healthcare workers, which included 80% of Marburg's patients in this outbreak.

Spencer says many of these capabilities were built during the COVID pandemic and could be rolled out quickly. “In Rwanda, there are providers who are able to get tested within hours of the announcement of this outbreak,” said Spencer, who has worked with Doctors Without Borders treating Ebola patients. “[Rwanda’s testing is] Absolutely remarkable in terms of the response.”

This surveillance and testing “allowed us to quickly identify cases and offer them treatments in the very, very early stages of their disease,” Butera explains. He says caring for patients before they become seriously ill has likely helped reduce mortality rates.

Experimental vaccines and medications are comprehensive

Rwanda's speed carried over into other anti-Marburg efforts.

“Everything I saw happened really quickly,” said WHO’s Ghebreyesus, who visited Rwanda last week and said what he saw was “very, very encouraging.”

While no vaccines or treatments have been approved for Marburg, Rwanda has moved quickly to provide experimental vaccines and treatments to the people at the center of the outbreak.

“I cannot imagine another scenario in which a country, after identifying this outbreak, launches an investigation just over a week later [experimental] “Vaccines are already being provided to frontline healthcare workers in the country,” Spencer said, adding that doses began being administered the same day they arrived in the country. The nonprofit Sabin Vaccine Institute provided the doses, which were developed with major support from the U.S. government.

“I rarely, very rarely use the word ‘unprecedented’ in the global health response,” says Spencer, but this speed was “unprecedented.”

The vaccine itself is still in development. Tests have shown that it is safe – but not whether it actually works. Nevertheless, Rwanda decided to vaccinate those at risk in the hope that it would help.

Those officials also chose to vaccinate without a randomized controlled trial in which some recipients receive a placebo. Some in the international scientific community say this was a missed opportunity to find out whether the vaccine is effective – although they admit it is far more complicated and slower to conduct a trial. And it was unlikely that the size of the outbreak would provide enough data to make any conclusive statements.

Have the vaccines helped stop the spread or reduce the mortality rate? You can't know that, says Bausch. He points out that in the first recorded outbreak in Marburg – in 1967 in Marburg, Germany and what was then Yugoslavia – the mortality rate was 23% with only good supportive care.

Meanwhile in Rwanda the… next round of vaccinations goes to vulnerable groups, including miners, who are in close proximity to flying foxes that can spread Marburg; that vaccination efforts are randomized.

In addition to the vaccines, Rwanda quickly began giving patients two drugs – an antiviral called remdesivir and a monoclonal antibody. As with the vaccine, they also hoped that these treatments would help, even if they are not approved for Marburg.

An early stumble, a course correction

In addition to speed and high-quality patient care, there is another, less glamorous but equally important dimension to combating Marburg and other viruses, says Bausch. It's about infection control: basically it's about ensuring that Marburg patients don't infect others. In the hospital, this means staff taking precautions such as wearing gowns, masks and double gloves. In public, this may mean disinfecting shared items such as motorcycle helmets and installing handwashing stations in public places, as Rwanda has done.

Rwanda stumbled early on when it came to infection control. That's because it took several weeks to diagnose the disease in the person believed to be the first patient in this outbreak – and the first known Marburg case in the country.

This person, who likely contracted the virus through contact with flying foxes in a mining cave, also had a severe case of malaria. Doctors didn't realize that Marburg was also present until other people around the patient began to fall ill. As a result, many healthcare workers were exposed before infection control measures were improved.

While Rwanda quickly improved its infection control as officials understood what they were dealing with – and not just in health facilities. There have been multiple cases in the mining community associated with the initial patient. Therefore, surveillance must ensure that these populations are covered, says Rob Holden, WHO incident manager for Marburg.

“As we move forward, we are fine-tuning, we are refining, we are strengthening all of our surveillance systems, our contact tracing, our investigations and we are leaving no stone unturned,” he says. “If we become more careless, I think we're going to have some nasty surprises and we're going to see this outbreak for a very long time.”

Spencer agrees. But he is optimistic. He says Rwanda's robust health infrastructure and rapid response helped protect the rest of the world from a much larger Marburg outbreak.