Assessment of the outbreak
The international response to the outbreak in Angola began one month ago, on 22 March. The features of Marburg haemorrhagic fever, and the conditions in Angola, have been an extreme test of international capacity to hold emerging diseases at bay. The outbreak in Angola is the largest and deadliest on record for this rare disease, which is presently showing a case fatality rate higher than 90%. For comparison, outbreaks of the closely related Ebola haemorrhagic fever have shown mortality rates ranging, according to the virus strain involved, from 53% to 88%. The only other large outbreak of Marburg, in the Democratic Republic of Congo from 1998 through 2000, had a case fatality of 83%.
Two factors make the rapid detection of outbreaks of Marburg haemorrhagic fever difficult: the extreme rarity of this disease and its similarity to other diseases seen in countries where deaths from infectious diseases are common. Neither the source nor the date of the initial cases in Angola can be presently identified with any certainty.
The number of cases began increasing in February and then, more dramatically, in March. On 21 March, Marburg virus was detected in patient samples sent to the Centers for Disease Control and Prevention in Atlanta (USA), and WHO assistance was requested by the Ministry of Health in Angola. The operational response began the following day. As known from extensive experience with outbreaks of other viral haemorrhagic fevers, including Ebola, outbreaks of Marburg can be brought to an end using classic public health interventions. In theory, the measures needed to end the Angolan outbreak are few in number and straightforward in nature. Rapid detection and isolation of patients, tracing and management of their close contacts, infection control in hospitals and protective clothing for staff work to interrupt chains of transmission and thus seal off opportunities for further spread.
Such straightforward measures are complicated by the distinct features of this disease. The sudden onset, dramatic symptoms, and rapid deterioration of patients, and the absence of a vaccine and effective treatment, invariably incite great anxiety in affected populations. This anxiety, in turn, can interfere with control operations, especially when communities begin hiding cases and bodies because of suspicions about the safety of hospitals.
In the current outbreak, such suspicions are understandable. Very few patients with laboratory-confirmed Marburg haemorrhagic fever have survived; most hospitalized patients have died within a day or two following admission. For affected communities, staff from the mobile teams, fully suited in protective gear, are seen as taking away relatives and loved ones who may never again be seen alive.
WHO staff in Uige have today reported further signs that community attitudes are improving, though hostility towards the mobile teams remains of concern in one area known to have recent cases and deaths. Efforts to sensitize affected communities are continuing, with local volunteers supported by Portuguese-speaking experts from Brazil and Mozambique.....