April 21, 2023
NCCID Disease Debriefs provide Canadian public health practitioners and clinicians with up-to-date reviews of essential information on prominent infectious diseases for Canadian public health practice. While not a formal literature review, information is gathered from key sources including the Public Health Agency of Canada (PHAC), the USA Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO) and peer reviewed literature.
This disease debrief was prepared by Shyama Nanayakkara and Zeeshan Qadar. Questions, comments, and suggestions regarding this disease brief are most welcome and can be sent to nccid@manitoba.ca.
What are Disease Debriefs? To find out more about how information is collected, see our page dedicated to the Disease Debriefs.
Questions Addressed in this debrief:
- What are important characteristics of the Marburg virus disease?
- What is happening with current outbreaks of Marburg virus disease?
- What is the current risk for Canadians from Marburg virus disease?
- What measures should be taken for a suspected Marburg virus disease case or contact?
What are important characteristics of the Marburg virus disease?
Cause
Marburg virus is the causative agent of Marburg virus disease (MVD) formerly known as Marburg haemorrhagic fever. Marburg virus belongs to Filoviridae family of virus, the same family that causes Ebola virus. The Filoviruses are enveloped in a lipid (fatty) membrane and appear in several shapes. Each virion (complete, infective form of a virus) contains one molecule of single-stranded, negative-sense RNA.
MVD is a zoonotic infection, transmitted from animals to humans. It is a highly virulent disease that causes hemorrhagic fever with an 88% fatality rate. The virus can spread by human-to-human contact with blood, body fluids and by contact with infected body fluid objects.
PHAC: Marburg virus disease – Canada.ca
CDC: Marburg (Marburg Virus Disease)
Signs, Symptoms and Severity
The incubation period runs between 2 – 21 days, and the symptom onset is sudden and advances quickly. The initial symptoms of Marburg virus disease include fever, chills, headache, and muscle pain. However, the progressive symptoms include rashes on the chest, back, and stomach, nausea, vomiting and diarrhea, jaundiced, severe weight loss, swelling and pain in the stomach area, hemorrhaging (bleeding from inside/or outside the body), and delirium (possible restlessness and incoherent speech).
A maculopapular rash that is most noticeable on the trunk (chest, back, and stomach) may appear around the fifth day following the start of symptoms.
Within seven days, many patients experience severe hemorrhagic manifestations, and in fatal cases, there is typically bleeding, frequently from several locations. Bleeding from the nose, gums, and vagina frequently accompany fresh blood in vomitus and feces. At the sites of venepuncture, spontaneous bleeding can be especially serious. Throughout the illness’s severe stage, patients have had ongoing, high fevers. The central nervous system’s involvement can lead to confusion, irritability, and aggression. In the late phase (15 days), orchitis (testicular inflammation) has occasionally been reported.
Symptoms of Marburg virus disease are similar to those of other viral hemorrhagic fevers, such as Ebola disease, and other infectious diseases such as malaria or typhoid. Diagnosis can be difficult, especially if only a single case is involved.
PHAC: Marburg virus disease – Symptoms
CDC: Signs and Symptoms | Marburg (Marburg Virus Disease)
Diagnosis
Due to similarity of signs and symptoms from viral hemorrhagic fever and other infectious disease (malaria, typhoid, and dengue) it is difficult to clinically diagnose Marburg virus disease. However, it can be diagnosed based on travel history, symptoms, and laboratory testing.
Antigen-capture enzyme-linked immunosorbent assay (ELISA) testing, polymerase chain reaction (PCR), and IgM-capture ELISA can be used to confirm a case of MVD within a few days of symptom onset. Serum naturalization tests can also be used for diagnosis.
Laboratory testing on all patient samples must be done under the strictest biological containment measures due to the significant biohazard risk they pose. All biological samples must be transported both domestically and internationally using the triple packaging system.
Virus cultures for Marburg viruses should not be attempted outside of the biosafety level 4 containment laboratories at the National Microbiology Laboratory (NML). For diagnostic or confirmatory services for Marburg viruses, liaise with the provincial public health laboratory of your jurisdiction. The provincial public health laboratory should coordinate with the NML Operations Centre Director at 1-866-262-8433.
For diagnostic or confirmatory services for Marburg viruses, liaise with the provincial public health laboratory of your jurisdiction.
The NML Operations Centre Director will:
- work with the requesting provincial or territorial jurisdiction to activate the Emergency Response Assistance Plan
- connect you with the appropriate subject matter expert if you require assistance with:
- sample requirements
- sample packaging
- sample shipping conditions
- the shipping process
Further clarification or more information may be requested from the patient’s clinician to optimize delivery of requested laboratory services.
CDC: Diagnosis | Marburg (Marburg Virus Disease)
Treatment
There is no specific treatment in the form of drug or vaccine for Marburg virus disease. But a variety of potential treatments, including immunotherapies, drug therapies, and blood products, are currently under investigation.
Clinically, patients are treated symptomatically that includes:
- supportive care in an intensive care unit
- maintenance of fluid levels and electrolytes
- maintenance of oxygen status and blood pressure
- replacement of lost body fluids, blood and/or clotting factors
- strict isolation to prevent the infection from spreading
PHAC: Marburg virus disease – Canada.ca
CDC: Treatment | Marburg (Marburg Virus Disease)
Epidemiology
Long-term contact with mines or caves where Rousettus bat colonies were present initiated human infection with the Marburg virus disease. After becoming infected, a person can contract Marburg through direct human-to-human contact (through cuts, scrapes, or ruptured mucous membranes) with the blood, secretions, organs, or other bodily fluids of an infected person, as well as with surfaces and items (like bedding and clothing) that have been contaminated with these fluids.
The disease was identified in 1967 as a result of two major outbreaks that occurred concurrently in Frankfurt in Germany, and Belgrade in Serbia. The outbreak was linked to laboratory experiments involving Ugandan monkeys. Later, outbreaks and sporadic infections have since been documented in Angola, the Democratic Republic of the Congo, Kenya, South Africa (in a person with recent travel history to Zimbabwe), and Uganda. Travellers who went to a cave in Uganda that was home to Rousettus bat colonies were involved in two separate cases that were reported in 2008.
Due to the similarity of the clinical symptoms, it can be challenging to distinguish the early stages of MVD from many other tropical febrile illnesses. It is necessary to rule out any additional viral hemorrhagic fevers, such as the Ebola virus infection, malaria, typhoid fever, leptospirosis, rickettsial infections, and plague.
An MVD outbreak has been reported in Equatorial Guinea in 2023. The recent MVD outbreak currently documented, three confirmed cases occurred in Ghana in 2022. Previous MVD outbreak reports came from Guinea (2021), Uganda (2017, 2014, 2012, 2007, Angola (2004-2005), the Democratic Republic of the Congo (1998 and 2000), Kenya (1990, 1987, 1980), and South Africa (1975).
PHAC: Pathogen Safety Data Sheet – Marburg virus
WHO: Marburg virus disease – Equatorial Guinea
CDC: Health Alert Network (HAN) – 00489 | Marburg Virus Disease
Prevention
In case of an outbreak in-depth epidemiological investigations are needed to determine the source of the outbreak.
Persons who are or have been in a region where a Marburg virus disease outbreak has occurred, are advised to take these general precautions listed below.
- Avoid direct contact with blood, saliva, vomit, urine, and other bodily fluids (e.g., semen, breast milk, sweat) of people with Marburg virus disease or unknown illnesses.
- Avoid direct contact with bodies of people who died of Marburg virus disease or unknown illnesses.
- Avoid contact with any objects, such as bedding or needles, contaminated with blood or bodily fluids.
- If you are a health care worker,
- Practice strict infection control measures. This includes isolating infected individuals and using personal protective equipment (gowns, masks, goggles, and gloves).
- Properly use and disinfect instruments and equipment used to treat or care for patients with Marburg virus disease – like needles and thermometers – before throwing them out.
- Avoid close contact with wild animals and avoid handling wild meat.
- Avoid potential carriers, both live and dead since both can spread the virus. The potential carriers of the virus include:
- monkeys
- chimpanzees
- gorillas
- fruit bats
- pigs
- duikers
Know the symptoms of Marburg virus disease and call your public health authority if they develop.
According to the Public Health Agency of Canada (PHAC) before visiting a doctor or a hospital, immediately call your public health authority if you have or if anyone in your household has:
- Any symptoms of Marburg virus disease AND
- Travelled to a Marburg virus disease affected area in the last 21 days.
Your public health authority will make appropriate arrangements for your medical assessment
CDC: Prevention | Marburg (Marburg Virus Disease)
Reporting and Surveillance
Marburg virus disease has been nationally notifiable in Canada since 2000.
The patients under investigation for Marburg virus disease should be reported immediately to local public health authorities as per the jurisdictional protocols in the Canadian provinces and territories.
Provinces and territories are required to report cases to PHAC by contacting the Health Portfolio Operations Centre (HPOC) at 1-800-545-7661.
The decision for specimen collection and testing should rely on the clinical status of the patient (compatible clinical presentation) the risk of exposure (epidemiological factors).
Mishandled specimens from patients under investigation for Marburg virus disease are a serious risk to all, including laboratory personnel. Before accepting samples and proceeding with testing, laboratories receiving specimens from patients under investigation for Marburg virus disease should consult the Biosafety Guidelines for Laboratories Handling Specimens from Patients Under Investigation for Ebola Disease.
For diagnostic or confirmatory services for Marburg viruses, liaise with the provincial public health laboratory of your jurisdiction. The provincial public health laboratory should coordinate with the NML Operations Centre Director at 1-866-262-8433.
The NML Operations Centre Director will:
- work with the requesting provincial or territorial jurisdiction to activate the Emergency Response Assistance Plan
- connect you with the appropriate subject matter expert if you require assistance with:
- sample requirements
- sample packaging
- sample shipping conditions
- the shipping processes.
Further clarification or more information may be requested from the patient’s clinician to optimize delivery of requested laboratory services.
PHAC: Marburg virus disease-Health professionals
PHAC: Marburg virus disease-Surveillance
Case classification
Confirmed case:
A case is said to be confirmed when the patient presents clinical signs of the disease, one of the epidemiological factors mentioned below (probable case) has occurred and is positive to a PCR test performed by the NML.
- A Marburg virus disease case can only be confirmed through laboratory testing at the Agency’s National Microbiology Laboratory (NML).
Probable case:
A probable case is defined as one with clinical evidence of illness and a history within the three weeks before onset of fever of one of the following:
- travel in a specific area of a country where an outbreak of Marburg virus disease has recently occurred.
- contact with a suspect, probable or confirmed case of Marburg virus disease.
- direct contact with blood or other body fluid secretions or excretions of a person or animal with a confirmed or probable case of Marburg virus disease.
- work in a laboratory or animal facility that handles haemorrhagic fever viruses.
PHAC-Marburg virus disease-Health professionals
What is happening with current outbreaks of Marburg virus disease?
On 7 February 2023, the Ministry of Health and Social Welfare of Equatorial Guinea reported at least eight suspected MVD deaths that occurred between 7 January and 7 February 2023.
On 12 February 2023, eight blood samples were collected from contacts and sent to the Institute Pasteur in Dakar, Senegal, where one of these samples was confirmed positive for Marburg virus.
On 13 March 2023, samples from two additional individuals from Kié-Ntem province tested positive for MVD.
PHAC: Marburg virus disease in Equatorial Guinea
WHO: Marburg virus disease – Equatorial Guinea
CDC-Health Alert Network (HAN) – 00489 | Marburg Virus Disease
What is the current risk for Canadians?
There have been no confirmed cases of Marburg virus disease in Canada. If the precautionary measures are taken, there is low risk of contracting Marburg virus in a country where the disease is present. People who are in close contact with infected humans are at risk in contacting the virus which includes:
- laboratory or quarantine facility workers
- hospital staff
- family members caring for patients
- morticians and other individuals handling corpses of persons who have succumbed to Marburg virus disease
The Public Health Agency of Canada (PHAC) is working closely with its national and international partners to monitor Marburg virus disease situation globally and continue to monitor the situation on an ongoing basis.
PHAC-Marburg virus disease-Risks
Travel advisory
The Public Health Agency of Canada (PHAC) has issued a level 1 travel notice (practice travel health precaution) for Equatorial Guinea.
The Public Health Agency of Canada (PHAC) advises a high degree of caution when traveling to Tanzania.
PHAC: Marburg virus disease in Equatorial Guinea
CTC news: Marburg virus: What to know about the latest outbreak
What measures should be taken for a suspected Marburg virus disease case or contact?
If you or anyone in your household has any Marburg virus disease symptoms or have traveled to a Marburg disease affected area within the last 21 days should call public health before visiting a doctor of hospital and describe your symptoms over the phone, tell them where you have been travelling or living and mention any possible exposure risks.
The public health authority will make appropriate arrangements for your medical assessment.
Follow the instructions provided to you by your public health authority and:
- immediately separate yourself from those around you and do not have physical contact with people, household pets or other animals
- wash your hands frequently, especially after vomiting or using the toilet!
- ensure that others do not come into contact with your body fluids, including blood, vomit, saliva, sweat, urine, feces, breast milk or semen
- ensure that others do not encounter anything that may have come in contact with your body fluids, such as:
- toilet
- linens (e.g., bedding)
- clothing
- toiletries
- medical equipment (e.g., thermometer)
- other members of your household should not handle your waste or perform any cleaning and disinfecting activities in your home.
- your public health authority will give you instructions on managing contaminated waste and properly cleaning and decontaminating your home.