Guidance

Marburg virus disease: origins, reservoirs, transmission and guidelines

Marburg virus is one of two viruses of the Filovirus family which, along with Ebola virus, can cause a severe and fatal haemorrhagic fever (VHF).

Marburg virus is one of two viruses belonging to the Filovirus family. Along with Ebola virus, Marburg virus causes a severe and highly fatal haemorrhagic fever called Marburg virus disease which is clinically almost indistinguishable from Ebola virus disease.

Marburg virus affects both humans and non-human primates.

The disease was first recognised in 1967, when outbreaks of haemorrhagic fever occurred simultaneously in laboratories in Marburg and Frankfurt in Germany, and Belgrade in Yugoslavia. A total of 31 people became ill, including 25 laboratory workers, and medical personnel and a family member who had cared for them. The laboratory workers all had contact with the blood, organs or cell-cultures from a batch of imported African green monkeys from north-western Uganda.

It is generally accepted that Marburg virus is a zoonotic (animal borne) virus. Fruit bats (Rousettus aegyptii) are considered the natural host of the virus. Monkeys are susceptible to Marburg virus infection but are not considered the reservoir hosts as they die rapidly once infected.

Epidemiology

Recorded cases of Marburg virus disease are rare.

Outbreaks and sporadic cases have been reported in Angola, Democratic Republic of Congo, Kenya, and South Africa (in a person who had recently travelled to Zimbabwe).

The largest outbreak on record to date occurred in 2005 in Angola, and involved 374 cases, including 329 deaths.

Two unrelated sporadic cases occurred during 2008 following visits to the “python cave” in the Maramagambo Forest in western Uganda; this cave is home to a large colony of Egyptian fruit bats. Both people became ill after return to their home country; one in the Netherlands and one in the USA.

The most recent outbreak was in 2012 in southwestern Uganda.

See Ebola and Marburg haemorrhagic fevers: outbreaks and case locations.

Recorded outbreaks to 2012

Year(s) Country Apparent or suspected origin Reported number of cases Reported number of deaths (%) Outbreak setting
1967 Germany and Yugoslavia Uganda 31 7 (22%) Simultaneous outbreaks occurred in laboratory workers who had handled imported African green monkeys.
1975 Johannesburg, South Africa Zimbabwe 3 1 (33%) A young man who had recently travelled through Zimbabwe was admitted to hospital in Johannesburg and later died. Infection transmitted to his travelling companion and a nurse, both of whom recovered.
1980 Kenya Kenya 2 1 (50%) A male patient with a recent travel history including a visit to Kitum Cave in Kenya’s Mount Elgon National Park. The doctor who attempted resuscitation became infected but recovered.
1987 Kenya Kenya 1 1 (100%) A fatal case occurred in a 15 year old Danish boy who had been in Kenya for 1 month. He had visited Kitum Cave in Mouth Elgon National Park.
1998 - 2000 Democratic Republic of Congo (DRC) Durba (DRC) 154 128 (83%) The first large outbreak of Marburg under natural conditions. Majority in young male workers at a mine in Durba, cases also detected in neighbouring village, and among family members.
2004 - 2005 Angola Uige (Angola) 374 329 (88%) Largest outbreak on record. Cases reported in 5 provinces, the majority in Uige. Significant number of healthcare workers and family members affected. Cultural practices, civil unrest and weakened healthcare systems hampered control.
2007 Uganda Kitaka mine 4 2 (50%) Mine workers in western Kamwenge province.
2008 (Jan) USA Python cave Uganda 1 0 A tourist who had visited this cave, reknowned for its thousands of bats, became unwell after returning to the USA.
2008 (July) Netherlands Python cave Uganda 1 1 A tourist who had visited the same cave.
2012 Uganda southwestern Uganda 20 9 4 districts (Kabale, Ibanda, Mbarara, and Kampala)
TOTAL ** ** 590 478 (82%)  

Symptoms

The incubation period of Marburg haemorrhagic fever is 3 to 10 days.

The onset of illness is sudden, with:

  • severe headache
  • malaise
  • high fever
  • progressive and rapid debilitation

By about the third day symptoms include:

  • watery diarrhoea
  • abdominal pain
  • cramping
  • nausea
  • vomiting

Symptoms become increasingly severe, and many patients develop severe haemorrhagic fever after 5 to 7 days.

Fatal cases usually have bleeding, which is often from multiple sites.

Many of the symptoms of Marburg haemorrhagic fever are similar to those of other infectious diseases, such as malaria or typhoid. Diagnosis of the disease may be difficult.

Transmission

The initial infection in any outbreak occurs through exposure in mines or caves inhabited by Rousettus bat colonies.

Subsequent transmission of virus from person to person requires close contact with an infected patient. Blood or other bodily fluids (faeces, vomit, urine, saliva and respiratory secretions) contains a high concentration of virus, particularly when these fluids contain blood.

Contact with blood or other bodily fluids transmits the virus.

Sexual transmission of the virus can occur, and Marburg virus may remain in semen for up to 7 weeks after clinical recovery.

Transmission of the virus via contaminated injection equipment or needle-stick injuries is associated with more severe disease.

Close contact with the body or body fluids of people who have died of Marburg, during preparation for burial, is a recognised source of infection.

Diagnosis

In the UK, Public Health England (PHE) has specialised laboratory facilities to provide a definitive diagnosis at PHE Porton.

RT-PCR for nucleic acid detection, virus isolation or antibody detection methods can diagnose Marburg virus disease.

Treatment

There is no specific treatment available for Marburg virus disease. Patients receive supportive therapy, including:

  • balancing fluids and electrolytes
  • maintaining oxygen status and blood pressure
  • replacing lost blood and clotting factors

UK guidelines

The UK has specialist guidance on the management (including infection control) of patients with viral haemorrhagic fevers including Marburg virus disease.

It provides advice on how to comprehensively assess, rapidly diagnose and safely manage patients suspected of being infected, within the NHS, to ensure the protection of public health.

Prevention and control

There is no vaccine for Marburg virus disease.

Measures for prevention of secondary transmission of Marburg virus are similar to those used for other haemorrhagic fever viruses, and focus on avoiding contact with infected bodily fluids.

See ACDP algorithm and guidance on management of patients.

To avoid person to person transmission of Marburg virus, healthcare workers must take great care when nursing patients, to avoid contact with infected bodily fluids.

Patients should be isolated, and heathcare workers must use strict barrier nursing techniques including wearing masks, gloves and gowns.

Invasive procedures are a particular risk and infection control is essential for:

  • placing of intravenous lines
  • handling blood and secretions
  • inserting catheters
  • using suction devices

Hospital staff require their own individual gowns, gloves, masks and goggles. Staff must disinfect non-disposable protective equipment properly before re-use.

Other infection control measures include proper use, disinfection, and disposal of instruments and equipment used in caring for patients.

Those people who have died of Marburg virus infection should be promptly and safely buried.