As African countries baulk at One Health requirements in the draft Pandemic Agreement being negotiated in Geneva, Rwanda’s success in containing its Marburg outbreak underscores the essential role of international partnerships and a strong health system in containing human-animal outbreaks

KIGALI, Rwanda – The Egyptian fruit bats look like innocuous little furry grey umbrellas hanging upside down in Tunnel 12 of the Gamico Mine – yet one of them transmitted deadly Marburg Virus Disease to a miner not long ago, causing an outbreak that effectively shut down the country’s economy for weeks.

“There are about 10,000 bats roosting in the tunnel,” says Dr Edson Rwagasore, head of public health surveillance and emergency preparedness and response at the Rwanda Biomedical Centre (RBC), the implementation arm of the country’s health ministry.

Gamico Mining Company has dug a series of tunnels into the hillside to enable miners to extract tin ore, and the 27-year-old index case was infected in Tunnel 12 after coming into contact with the virus – likely shed in the faeces of a bat.

Although the index patient was initially misdiagnosed with malaria which has very similar initial symptoms, once Marburg was diagnosed, the Rwandan Health Ministry and the RBC swung into action.

“We worked to ensure no future bat-to-human spillovers,” said Rwagasore. “Our key interventions were to create a buffer between the bats and humans, conduct regular testing of bats and work on understanding transmission better.”

The buffer inside Tunnel 12 is a locked door separating bats from humans. The bats can exit the tunnel through a hole in the roof that has been fenced off to ensure no humans can get close. 

When Rwagasore unlocks the door, the bats squeak – and so do a few journalists – but luckily they fly away from us. 

GPS trackers have been attached to some bats to map their movements and weekly tests of bats’ blood, saliva and faeces check for Marburg. Bats are a reservoir for the virus, shedding it at certain times of the year: January to March and August and September, explained Rwagasore.

“We have mapped six other high-risk mining sites and established similar interventions. We have either established buffers or closed the sites,” said Rwagasore, adding that the health ministry encourages people to avoid bats not attack them.

Dominic Kayrgre, Gamico Mine’s safety officer, said that their 1,600 miners were issued with basic PPE and educated to avoid bats but allowed to keep working once the buffers were in place.

The Gamico Clinic, the on-site health facility that caters for miners and their families, has also been upgraded and can identify everyone with a fever and potential Marburg symptoms as soon as possible and link them to care.

Remarkably, the index patient survived, although his wife, newborn baby, healthcare workers who treated them and other contacts did not. In all, 66 people were infected during the outbreak and 15 died, a case fatality rate of 22.7% – the lowest ever recorded.

International partnerships

Rwagasore, the Rwandan Health Ministry and international experts concur that partnerships across the country, region and globe and the country’s strong primary healthcare system were essential in containing the outbreak.

Health Minister Dr Sabin Nsanzimana stressed the importance of a One Health approach involving experts on human and animal health and the environment. 

Assistance from the World Health Organization (WHO) and other international experts experienced in zoonotic spillover of diseases from animals to humans was invaluable in helping to identify and contain the outbreak, Rwagasore said.

The US-based Sabine Vaccine Institute sent its investigational vaccines to Rwanda for an open-label study, which was also key in ensuring a low fatality rate. Rwanda also used the antiviral drug, remdesivir, to treat those infected.

Strong healthcare system

Nsanzimana also described his country’s efforts as  “an opportunity for us to expand our preparedness capabilities.”

A week after the first case had been confirmed, community health workers fanned out in at-risk communities, going door-to-door to “check anyone who had symptoms of fever and diarrhoea,” said Rwagasore.

Contacts of those infected were found, tested and isolated if infected.

WHO Director-General Dr Tedros Adhanom Ghebreyesus, who visited the country at the end of the outbreak, praised the level of Rwanda’s critical care for patients as well as how the country deployed high-level leadership to address the viral haemorrhagic fever, which often kills over 80% of those infected.

Two of the Marburg patients “experienced all of the symptoms of Marburg, including multiple organ failure, but they were put on life support, they were successfully intubated and extubated, and are now recovering,” Tedros told a media briefing in Rwanda on Sunday.

“We believe this is the first time patients with Marburg virus have been extubated in Africa. These patients would have died in previous outbreaks.”

Intubation involves inserting a tube through a patient’s nose or mouth into their windpipe (trachea) to help them breathe and extubation is when the tube is removed.

Essential ‘One Health’ approach

Despite Rwanda presenting a first-class case study of the importance of the One Health approach to contain outbreaks, several African countries are reportedly against measures in the pandemic agreement that stipulate how such an approach should be implemented.

According to Article 5 of the draft agreement, currently being negotiated by WHO member states in Geneva, member states “shall promote a One Health approach for pandemic prevention, preparedness and response” that is “coherent, integrated, coordinated and collaborative among all relevant organizations, sectors and actors”.

While stressing that whatever is undertaken is appropriate to countries’ national laws and circumstances, the draft “encourages” member states “to identify and address the drivers of pandemics and the emergence and re-emergence of infectious disease at the human-animal-environment interface”.

This involves  implementing and reviewing national policies and strategies to reflect a One Health approach, including community engagement and training for workers who are “at the human, animal and environmental interface”.

African countries in particular are reportedly reluctant to sign on for anything that might cost them extra money or result in sanctions should they fail to employ these to contain outbreaks.

In the past, the WHO and other international partners could be counted on to assist in outbreaks. However, the US contributes 25% of the WHO’s emergency budget which will be lost when the US exits the global body next January.

In addition, valuable support to contain pandemics supported by the US Agency for International Development (USAID) has also been lost since the Trump Administration closed the agency.

Over the past weekend, the African Union agev the go-ahead for an African Epidemics Fund to be administered by the Africa CDC to fundraise to address outbreaks on the continent. The previous US administration had pledged $500 million to Africa CDC but this is in jeopardy under the Trump Administration.

Image Credits: Kerry Cullinan.