Last week, the Global Health Security Agenda (GHSA) held its annual high-level ministerial meeting in Kampala, Uganda. The location of the meeting was significant, as it was the first time that an African country has hosted a ministerial meeting since the GHSA’s launch in 2014. It was also an opportunity for those of us in attendance to witness the signing of the Kampala Declaration, a landmark document endorsed by roughly 50 GHSA member nations reflecting their commitment to strengthen global health security.

Perhaps even more importantly, however, the meeting coincided with an ongoing Marburg outbreak, which the Ugandan Ministry of Health is working aggressively to control. The occurrence of a deadly hemorrhagic fever in Uganda at the same time that ministers of health, defense, agriculture, and finance were meeting to increase global cooperation and preparedness for infectious disease threats brought particular salience to the meeting. It also illustrated a situation that so often faces public health professionals: the need to manage multiple challenges at once. For Uganda, that meant staying on top of a significant outbreak while simultaneously hosting high-level officials from around the world. In light of this accomplishment, this week’s post will look at both the ongoing Marburg outbreak and how initiatives like the GHSA can strengthen countries’ preparedness and response capacities so that they, too, can rapidly respond to threats like Marburg.

What is Going on with Marburg in Uganda?

Marburg virus disease (MVD) is a severe, viral hemorrhagic illness, and like Ebola virus disease (EVD), MVD is caused by a filovirus. Clinically, EVD and MVD cause similar symptoms—initially high fever, headache, and muscle aches and pains are typical, followed by diarrhea and/or vomiting. On average, 50% of those infected with MVD die—but case fatality rates in past outbreaks have ranged from 24-88%. The specific viral strain and the availability of supportive care can be an important determinant in how deadly MVD is.

Uganda first reported to the WHO a confirmed case of Marburg on October 17. The initial case is suspected to have been a game hunter who died after seeking care on September 20 for a high fever, vomiting, and diarrhea. He was initially treated for malaria. As his condition deteriorated, he was transferred to a referral hospital in a neighboring district, but died that day. No biological samples were collected, and he was buried in accordance with local traditions.

The first confirmed case was the sister of the suspected initial case, who had cared for her sick brother. She was admitted on October 5 to the same local health clinic and then transferred to the same referral hospital that treated her brother. The patient died and was also buried in accordance with local traditions. Posthumous samples were collected and sent to the Uganda Virus Research Institute (UVRI), which confirmed Marburg virus infection.

On October 26, the Ugandan MOH reported an additional confirmed case: the brother of the two cases described above. According to an official report, this patient refused to cooperate with the monitoring/screening team until October 24, after he developed symptoms; he died on October 26. This brings the total case count to 9—2 confirmed, 4 suspect, and 3 probable (including the index case discussed above). The suspect cases include two healthcare workers that treated the index patient, and one of the probable cases was in the hospital bed next to the newly confirmed case. Public health investigations are currently monitoring 130 contacts for signs of the illness, including dozens of healthcare workers, that will be monitored for signs of illness, as of October 26. The WHO reports that a total of 185 contacts have been identified over the course of the investigation, as of October 24.

Successes and Challenges

The first confirmed Marburg case in this current outbreak was diagnosed at the esteemed Uganda Virus Research Institute (UVRI). UVRI has a long history of serving as a national and regional resource for laboratory diagnostics. The institute has been involved in the discovery of more than two dozen new viruses, including Zika, and it has lengthy experience testing for Marburg and other viral hemorrhagic fevers. The capability to conduct these tests was developed after a large outbreak of Ebola virus disease—the second biggest on record—that occurred in 2000. Since then, the addition of enhanced systems for rapidly collecting, transporting, and testing specimens has contributed to more timely confirmation of Ebola, Marburg, and other emerging and endemic diseases and faster containment of outbreaks, according to the Minister of Health of Uganda. Local authorities credit these methods with improving the speed with which subsequent outbreaks have been contained—with response timelines shifting from weeks/months to 1-2 days. In the current outbreak, the speed with which UVRI was able to confirm Marburg stands in stark contrast to the 2013-16 West Africa Ebola epidemic, which was not confirmed until specimens were sent to Institut Pasteur in Lyon, France months after the epidemic began. This is a testament to the value of building and sustaining in-country laboratory capacity and specimen referral networks.

Once Marburg was confirmed by health authorities in Uganda, public health authorities conducted contact tracing to identify additional individuals who may have been infected by the known cases. Conducting such investigations requires skills and expertise in field epidemiology, and Uganda’s ability to do this is aided by the existence of their robust Field Epidemiology Training Program (FETP). Uganda’s FETP is operated as a partnership between the country’s Ministry of Health and Makerere University, which provides the training. The fact that there is a strong, existing cadre of trained epidemiologists in Uganda likely expedited the speed with which contacts were identified and tracked.

Still, the Marburg outbreak also highlights important and common challenges in controlling infectious disease outbreaks: ensuring that health workers are trained to (1) recognize possible cases of highly communicable diseases, (2) know when to request appropriate tests to diagnose infection, and (3) have access to and experience in using appropriate levels of personal protective equipment so that they do not become infected while caring for patients with highly communicable diseases. Though public health authorities rapidly responded to Marburg once it was confirmed at UVRI, a failure to collect specimens from the suspected index case delayed recognition by more than a month. Even more concerning is the potential infection of two healthcare workers who treated the initial Marburg patients, underscoring the need to recognize possible cases early so that healthcare workers can protect themselves. This suggests that while the public health response to Marburg may be strong, additional work is needed to ensure that clinical communities have appropriate suspicion for high-consequence infectious diseases and the necessary resources to be able to treat patients with these conditions in a safe manner.

What is the GHSA and How Can it Help Improve Response to Outbreaks like Marburg?

The GHSA was launched by the United States in 2014 as a 5-year initiative to increase national governments’ progress towards “a world safe and secure from infectious disease threats.” Since then it has grown to a partnership of 63 countries that work collectively to improve public health capacities in 11 target areas or “action packages”:

GHSA Action Packages graphic by Benjamin J. Park, MD (US CDC) from  Antimicrobial Resistance (AMR) in Humans and the Global Health Security Agenda

GHSA Action Packages graphic by Benjamin J. Park, MD (US CDC) from Antimicrobial Resistance (AMR) in Humans and the Global Health Security Agenda

The GHSA aims to improve such capacities in countries around the world. In Uganda, for instance, GHSA funding provided by the United States helped to develop a system for text message-based reporting of suspect cases of high-consequence infectious diseases, which provides immediate notification to health authorities that a clinical specimen has been collected for testing for infections like Marburg virus. The rapidity with which Uganda was able to diagnose and act upon a Marburg outbreak once specimens were collected speaks to the importance of having strong national capacities to detect and respond to infectious disease threats.

The response so far to the Marburg outbreak in Uganda highlights the very mission of the GHSA—ensuring that all countries have the necessary infrastructure and capacity to deal with infectious diseases—as well as the considerable work that still remains. Therefore, it is welcome news that at the conclusion of last week’s GHSA Ministerial meeting, ministers and delegates issued the Kampala Declaration, which reaffirmed the GHSA’s overarching vision and included a commitment to extend the GHSA through 2024. It critical that all countries have strong public health capacities to diagnose, investigate, and contain outbreaks in order to mitigate the local, national, regional, and global risk posed by infectious diseases.


Photo: Uganda Virus Research Institute staff giving a laboratory tour during the GHSA Ministerial meeting in Kampala, Uganda.

Update: December 6, 2017 - The Minister of Health of Uganda Dr. Aceng Jane Ruth served as the Director General of Health Services at the time of publishing.

Outbreak Observatory aims to collect information on challenges and solutions associated with outbreak response and share it broadly in near-real time to allow others to learn from these experiences in order to improve global outbreak response capabilities.