n 27 September 2024, Rwanda’s Health Ministry confirmed the country’s first ever Marburg virus outbreak. It was a distressing national moment: a filovirus like Ebola, Marburg is lethal with fatality rates of up to 88%. Symptoms are dreadful, including intense feverishness, acute headaches, vomiting and bleeding from the eyes, gums and elsewhere – “bad news wrapped up in protein” as Nobel Laureate biologist Peter Medawar put it in 1974.
Six weeks later, on 15 November 2024, Rwanda’s Minister of Health Dr Sabin Nsanzimana, announced the discharge of the last of the Marburg patients. The virus sadly caused 15 early deaths, but of the 66 cases, 55 patients recovered.
He noted that it had been 48 days since the first case was reported, two weeks since the last new case and a month without further fatalities. If no new infections arise 42 days after the last case tests negative, the outbreak will be declared over by December 21.
It is an admirable achievement by any measure. In a context where the recent US presidential election and the controversial cabinet and agency nominations drive the news cycle, it is important to heighten the visibility of Rwanda’s achievement, of how a lower-middle-income country in mid Africa managed to contain an outbreak caused by one of the world’s most feared high-consequence pathogens.
What happened in Rwanda is captured by Louis Pasteur’s famous aphorism that “chance favours the prepared mind” or, as in this instance, the prepared response system.
In 2008, when Nelson Mandela hosted Nobel Laureate David Baltimore to give a science lecture on the origins of HIV, Baltimore travelled to South Africa via Rwanda at the invitation of President Paul Kagame where he was asked — far-sightedly — to give the country’s leaders advice on how to ground development in science.
In 2018 Rwanda was one of the first countries to conduct the World Health Organization’s Joint Evaluation Exercises in pandemic preparedness and response, which assessed the most critical gaps in their human and animal health systems and prioritised opportunities for enhanced preparedness, detection and response within the framework established by the 2005 International Health Regulations.
A National Action Plan for Health Security, a roadmap to strengthen the International Health Regulations’ core capacities, followed the Joint Evaluation Exercises. The Rwandan government, through its Ministry of Health and Rwanda Biomedical Centre, worked tirelessly to tick all the points by ensuring the readiness and the resilience of the system for any outbreak. The implementation was smooth and ready.
Rapid response
When Covid-19 hit, Rwanda responded quickly. The authorities imposed a six-week lockdown and introduced contact tracing and other interventions — 82% of the population received at least one dose of a Covid-19 vaccine.
The Australian think tank the Lowy Institute ranked 98 countries for their Covid-19 response and found that smaller populations and capable institutions were the most important factors in managing the global pandemic. Rwanda was the only African country in the top 10 achievers.
Rwanda therefore had been working hard over the long haul to upscale their preparedness. The hospital-based surveillance system gave an alert that triggered the national public health institute — the Rwanda Biomedical Centre — to detect the Marburg virus, which in turn switched on contact tracing, diagnostics and case management.
Co-infection with malaria (Marburg/Ebola share symptoms with malaria) slowed down detection of the first case. However, diagnostics were quickly scaled up and 7,408 tests were administered with a focus on healthcare workers who suffered 80% of the infections.
Epidemiologists ultimately traced the first case back to a 27-year-old mining cave worker. He was exposed to the reservoir of Marburg virus, the fruit bat Rousettus, and subsequently infected his pregnant wife who was admitted to the King Faisal Hospital’s ICU in Kigali.
In the following days, many healthcare workers were infected and fell ill. Rwanda has a sizeable and growing mining industry, and is a major exporter of the so-called 3Ts — tin, tantalum, tungsten — and increasingly gold. Some of the mines are close to Rwanda’s extensive network of 52 caves, some 2km long, many of which have large bat colonies.
At King Faisal and the rapidly deployed Marburg Treatment Centre at Baho International Hospital, patients received prompt intensive care support; use of high flow nasal canula; and intravenous fluids to manage high fever, nausea, vomiting and diarrhoea. Intubation and life support were provided to patients experiencing multiple organ failure. Two Marburg patients were extubated i.e. taken off life support, the first time in Africa.
Infection control measures were implemented in hospitals, including personal protective gear distributed to all health workers. Rwandan officials monitored the health of more than 1,000 community members and engaged in door-to-door surveillance in exposed neighbourhoods.
Schools and hospital visits were suspended and the number of people who could attend Marburg funerals was restricted. Even with relatively prompt detection, most of the deaths were of exposed healthcare workers.
The WHO supplied 12,000 personal protective items, sufficient to run the specially built 50-bed Marburg Treatment Centre with its clinical isolation units for 30 days. A joint WHO and Rwandan Ministry of Health infection prevention and control team trained 520 healthcare workers in infection control and prevention.
Gilead Sciences, a global biopharmaceutical company that revolutionised HIV treatment and prevention, donated 5,100 vials of remdesivir, a broad-spectrum antiviral medication previously used to treat Covid-19, as an emergency treatment measure.
With support from the United States’ Biomedical Advanced Research and Development Authority, Mapp Biopharmaceutical deployed a monoclonal antibody MBP091 that targets the Marburg virus. Almost all the initial doses were given to healthcare workers.
‘Ring vaccination’ strategy
The Sabin Vaccine Institute donated more than 1,700 doses of an investigational Marburg Phase II clinical trial vaccine (manufactured by the company ReiThera) to administer to high-risk groups, including healthcare workers, mine workers (exposed to virus-carrying bats in caves in mining districts), and individuals in contact with confirmed cases. Half received the vaccine immediately, and the other half 21 days later to align with the end of the disease’s incubation period. The “ring vaccination” strategy was deployed.
Marburg vaccine efforts must be seen against the background of a major effort under way to establish Rwanda as one of Africa’s leading vaccine manufacturers. BioNTech opened its first modular messenger mRNA vaccine manufacturing facilities in Kigali in April 2024.
The Coalition for Epidemic Preparedness Innovation landed its 100 Day Mission there, working with IQVIA (clinical trials), Ginkgo BioWorks (wastewater surveillance), the Rwanda Biomedical Centre and the Rwanda Development Board on end-to-end vaccine manufacturing prospects.
Regionally, Africa Centres for Disease Control and Prevention dispatched a team of experts on 29 September to aid response efforts. In collaboration with Rwanda’s neighbours — Burundi, Uganda, Tanzania and the Democratic Republic of the Congo — Africa Centres for Disease Control and Prevention provided guidance on regional surveillance and containment strategies.
It cautioned against using travel bans and movement restrictions targeted at African countries as inconsistent with international health guidelines that undermine public health responses, deepen economic challenges, ignite inequities and prompt mistrust.
Instead, what is required is the harmonisation of regional and global policies when an outbreak like this occurs.
Finally, there is the critical asset of leadership, with President Paul Kagame and his cabinet members, and Dr Sabin Nsanzimana, an epidemiologist and former director-general of the Rwanda Biomedical Centre, in command of the effort.
WHO Director-General Tedros Ghebreyesus praised Rwanda for its response, noting that “leadership from the highest levels of government is essential in any outbreak response, and that’s what we see here in Rwanda”. To symbolise Rwanda’s partnership with the continent-wide public health technical support agency the Africa Centres for Disease Control and Prevention, Dr Nsanzimana held his press briefings jointly with its director-general, Dr Jean Kaseya.
Even so, we can do even better, and we must learn much more. Rwanda’s response was exceptional, but it wasn’t perfect. Disease detection could have been much faster. The virus spread in the hospital before being picked up.
We need to get on top of the ecology and migration patterns of the bat carrying Marburg and other viruses, and better understand the impact of rising temperatures, altered rainfall patterns and habitat loss due to mining and human incursions that drive bats to new areas in search of food and shelter.
Climate affects food availability and causes nutritional stress, disrupts hibernation and breeding patterns, and droughts and floods can drive bats closer to human settlements, all opportunities for greater viral transmission. Upscaled surveillance of the pathogens, the disease and the ecology of bats can create a knowledge base for better interventions.
It is not a stretch to say that the world — including the developed world — can learn a great deal from Rwanda. This is the true meaning of global health, an exchange of knowledge, expertise and best practice between North and South, not one-way traffic from North to South. DM
Wilmot James is a Professor at the School of Public Health and Senior Advisor; Craig Spencer a Professor in the School of Public Health; Anne Wang a Research Assistant; and Bentley Holt Assistant Director of Communications and Outreach at the Pandemic Centre, Brown University, Providence, Rhode Island, USA.
Edson Rwagasore is the Division Manager of Public Health Surveillance and Emergency Preparedness and Response, Rwanda Biomedical Centre, Kigali.
Jeanine Condo is an Adjunct Associate Professor at the University of Rwanda and Tulane University and CEO of the Centre for Impact, Innovation and Capacity Building for Health Information and Nutrition, Kigali.
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Six weeks later, on 15 November 2024, Rwanda’s Minister of Health Dr Sabin Nsanzimana, announced the discharge of the last of the Marburg patients. The virus sadly caused 15 early deaths, but of the 66 cases, 55 patients recovered.
He noted that it had been 48 days since the first case was reported, two weeks since the last new case and a month without further fatalities. If no new infections arise 42 days after the last case tests negative, the outbreak will be declared over by December 21.
It is an admirable achievement by any measure. In a context where the recent US presidential election and the controversial cabinet and agency nominations drive the news cycle, it is important to heighten the visibility of Rwanda’s achievement, of how a lower-middle-income country in mid Africa managed to contain an outbreak caused by one of the world’s most feared high-consequence pathogens.
What happened in Rwanda is captured by Louis Pasteur’s famous aphorism that “chance favours the prepared mind” or, as in this instance, the prepared response system.
In 2008, when Nelson Mandela hosted Nobel Laureate David Baltimore to give a science lecture on the origins of HIV, Baltimore travelled to South Africa via Rwanda at the invitation of President Paul Kagame where he was asked — far-sightedly — to give the country’s leaders advice on how to ground development in science.
In 2018 Rwanda was one of the first countries to conduct the World Health Organization’s Joint Evaluation Exercises in pandemic preparedness and response, which assessed the most critical gaps in their human and animal health systems and prioritised opportunities for enhanced preparedness, detection and response within the framework established by the 2005 International Health Regulations.
A National Action Plan for Health Security, a roadmap to strengthen the International Health Regulations’ core capacities, followed the Joint Evaluation Exercises. The Rwandan government, through its Ministry of Health and Rwanda Biomedical Centre, worked tirelessly to tick all the points by ensuring the readiness and the resilience of the system for any outbreak. The implementation was smooth and ready.
Rapid response
When Covid-19 hit, Rwanda responded quickly. The authorities imposed a six-week lockdown and introduced contact tracing and other interventions — 82% of the population received at least one dose of a Covid-19 vaccine.
The Australian think tank the Lowy Institute ranked 98 countries for their Covid-19 response and found that smaller populations and capable institutions were the most important factors in managing the global pandemic. Rwanda was the only African country in the top 10 achievers.
Rwanda therefore had been working hard over the long haul to upscale their preparedness. The hospital-based surveillance system gave an alert that triggered the national public health institute — the Rwanda Biomedical Centre — to detect the Marburg virus, which in turn switched on contact tracing, diagnostics and case management.
Co-infection with malaria (Marburg/Ebola share symptoms with malaria) slowed down detection of the first case. However, diagnostics were quickly scaled up and 7,408 tests were administered with a focus on healthcare workers who suffered 80% of the infections.
Epidemiologists ultimately traced the first case back to a 27-year-old mining cave worker. He was exposed to the reservoir of Marburg virus, the fruit bat Rousettus, and subsequently infected his pregnant wife who was admitted to the King Faisal Hospital’s ICU in Kigali.
In the following days, many healthcare workers were infected and fell ill. Rwanda has a sizeable and growing mining industry, and is a major exporter of the so-called 3Ts — tin, tantalum, tungsten — and increasingly gold. Some of the mines are close to Rwanda’s extensive network of 52 caves, some 2km long, many of which have large bat colonies.
At King Faisal and the rapidly deployed Marburg Treatment Centre at Baho International Hospital, patients received prompt intensive care support; use of high flow nasal canula; and intravenous fluids to manage high fever, nausea, vomiting and diarrhoea. Intubation and life support were provided to patients experiencing multiple organ failure. Two Marburg patients were extubated i.e. taken off life support, the first time in Africa.
Infection control measures were implemented in hospitals, including personal protective gear distributed to all health workers. Rwandan officials monitored the health of more than 1,000 community members and engaged in door-to-door surveillance in exposed neighbourhoods.
Schools and hospital visits were suspended and the number of people who could attend Marburg funerals was restricted. Even with relatively prompt detection, most of the deaths were of exposed healthcare workers.
The WHO supplied 12,000 personal protective items, sufficient to run the specially built 50-bed Marburg Treatment Centre with its clinical isolation units for 30 days. A joint WHO and Rwandan Ministry of Health infection prevention and control team trained 520 healthcare workers in infection control and prevention.
Gilead Sciences, a global biopharmaceutical company that revolutionised HIV treatment and prevention, donated 5,100 vials of remdesivir, a broad-spectrum antiviral medication previously used to treat Covid-19, as an emergency treatment measure.
With support from the United States’ Biomedical Advanced Research and Development Authority, Mapp Biopharmaceutical deployed a monoclonal antibody MBP091 that targets the Marburg virus. Almost all the initial doses were given to healthcare workers.
‘Ring vaccination’ strategy
The Sabin Vaccine Institute donated more than 1,700 doses of an investigational Marburg Phase II clinical trial vaccine (manufactured by the company ReiThera) to administer to high-risk groups, including healthcare workers, mine workers (exposed to virus-carrying bats in caves in mining districts), and individuals in contact with confirmed cases. Half received the vaccine immediately, and the other half 21 days later to align with the end of the disease’s incubation period. The “ring vaccination” strategy was deployed.
Marburg vaccine efforts must be seen against the background of a major effort under way to establish Rwanda as one of Africa’s leading vaccine manufacturers. BioNTech opened its first modular messenger mRNA vaccine manufacturing facilities in Kigali in April 2024.
The Coalition for Epidemic Preparedness Innovation landed its 100 Day Mission there, working with IQVIA (clinical trials), Ginkgo BioWorks (wastewater surveillance), the Rwanda Biomedical Centre and the Rwanda Development Board on end-to-end vaccine manufacturing prospects.
Regionally, Africa Centres for Disease Control and Prevention dispatched a team of experts on 29 September to aid response efforts. In collaboration with Rwanda’s neighbours — Burundi, Uganda, Tanzania and the Democratic Republic of the Congo — Africa Centres for Disease Control and Prevention provided guidance on regional surveillance and containment strategies.
It cautioned against using travel bans and movement restrictions targeted at African countries as inconsistent with international health guidelines that undermine public health responses, deepen economic challenges, ignite inequities and prompt mistrust.
Instead, what is required is the harmonisation of regional and global policies when an outbreak like this occurs.
Finally, there is the critical asset of leadership, with President Paul Kagame and his cabinet members, and Dr Sabin Nsanzimana, an epidemiologist and former director-general of the Rwanda Biomedical Centre, in command of the effort.
WHO Director-General Tedros Ghebreyesus praised Rwanda for its response, noting that “leadership from the highest levels of government is essential in any outbreak response, and that’s what we see here in Rwanda”. To symbolise Rwanda’s partnership with the continent-wide public health technical support agency the Africa Centres for Disease Control and Prevention, Dr Nsanzimana held his press briefings jointly with its director-general, Dr Jean Kaseya.
Even so, we can do even better, and we must learn much more. Rwanda’s response was exceptional, but it wasn’t perfect. Disease detection could have been much faster. The virus spread in the hospital before being picked up.
We need to get on top of the ecology and migration patterns of the bat carrying Marburg and other viruses, and better understand the impact of rising temperatures, altered rainfall patterns and habitat loss due to mining and human incursions that drive bats to new areas in search of food and shelter.
Climate affects food availability and causes nutritional stress, disrupts hibernation and breeding patterns, and droughts and floods can drive bats closer to human settlements, all opportunities for greater viral transmission. Upscaled surveillance of the pathogens, the disease and the ecology of bats can create a knowledge base for better interventions.
It is not a stretch to say that the world — including the developed world — can learn a great deal from Rwanda. This is the true meaning of global health, an exchange of knowledge, expertise and best practice between North and South, not one-way traffic from North to South. DM
Wilmot James is a Professor at the School of Public Health and Senior Advisor; Craig Spencer a Professor in the School of Public Health; Anne Wang a Research Assistant; and Bentley Holt Assistant Director of Communications and Outreach at the Pandemic Centre, Brown University, Providence, Rhode Island, USA.
Edson Rwagasore is the Division Manager of Public Health Surveillance and Emergency Preparedness and Response, Rwanda Biomedical Centre, Kigali.
Jeanine Condo is an Adjunct Associate Professor at the University of Rwanda and Tulane University and CEO of the Centre for Impact, Innovation and Capacity Building for Health Information and Nutrition, Kigali.