How Rwanda's Health System Stopped Marburg in Its Tracks

Megan Hall: 00:03

Welcome to Humans in Public Health. I'm Megan Hall.

In the past few years, the field of public health has become more visible than ever before, but it's always played a crucial role in our daily lives. Each month, we talk to someone who makes this work possible. Today, Craig Spencer

episode in early November of: 2024

Craig is a professor at Brown University and an expert on infectious diseases like Marburg. He’s been advising the U.S.’s response to this outbreak. And he knows about these types of viruses firsthand. He’s spent over a decade treating infected patients around the world.

ght have heard of him back in: 2014

So we invited Craig into the studio to tell us about this Marburg outbreak, and what it can teach us.

Megan Hall: 01:20

So what is the Marburg virus? For people who haven't heard of it before? Can you give us a little background?

Craig Spencer: 01:26

Sure, the Marburg virus is a small virus that's in the same family as Ebola and causes very similar symptoms as Ebola. We don't hear about Marburg outbreaks all that much, and they tend to not get all that big, which is why most people don't hear about them. But when someone like myself or people working in infectious disease, hears about them, our ears perk up and we get really worried, because they can be really nasty.

Megan Hall: 01:50

And when you say really nasty, what does that mean?

Craig Spencer: 01:52

Well, I think most people remember from a decade ago what Ebola is like, It's mostly a disease of compassion, and that people taking care of loved ones or health care workers, for example, people in close contact to body fluids are at high risk, and if they get infected, they can have pretty uncomfortable symptoms, fever, vomiting, diarrhea. And with Ebola, your likelihood of dying is probably a coin flip. And with Marburg, up until now, there haven't been that many known outbreaks, but in the ones that we've had, it's been anywhere between 25 to 88% so probably somewhere in between as well, meaning that if you get infected, you know, there's a 50/50, chance that you're not going to make it

Megan Hall: 02:34

And Marburg has been around for a while, right? It was first discovered in the late 60s, is that right?

Craig Spencer: 02:41

That is correct. And Marburg virus is named after Marburg, Germany, the location of one of the labs where it was first found in 1967. Since then, there have been, you know, a handful of outbreaks, kind of all over the world. Most of them occur in Central Africa, where this Egyptian fruit bat lives, which is known to be the reservoir of Marburg. This is something that basically, when someone comes in contact with the guano or the droppings of this Egyptian fruit bat that may have virus in it, they can infect themselves, and then they can pass it on to other people, especially people who come in close contact with them when they're infectious.

Megan Hall: 03:21

So, can you give me a big picture description of what's happening in Rwanda right now?

Craig Spencer: 03:25

Yeah, absolutely so at the end of September, Rwanda alerted the world that it had discovered an outbreak of Marburg, and initially there was some confusion and concern. But what we ended up finding is that for the past few weeks before this alert Marburg spreading primarily in the west of the country, related to miners that were working in mines where they were exposed to this specific bat they had Marburg. This ended up showing up in the capital Kigali

Megan Hall: 03:53

The fact that this outbreak showed up in Kigali, was alarming. Kigali is a city of 1.7 million people, and as the capital of Rwanda, it’s well connected to the rest of the world.

Craig: 04:05

Normally with Ebola and Marburg. We get really worried when this happens in capital cities, because capital cities provide a lot of fuel for outbreaks to spread, and they have been really difficult historically, to kind of do contact tracing and to control viruses.

Megan Hall: 04:19

But this time, things played out differently. Craig’s worries about Marburg spreading uncontrolled in Kigali, haven’t panned out.

Craig Spencer: 04:28

Once this outbreak was kind of really identified, the health care institutions themselves, as well as the Rwanda Ministry of Health really jumped into action to try to get this outbreak under control and prevent it from getting any bigger and spreading any further.

Megan Hall: 04:42

In the month after Rwanda discovered this outbreak, they identified more than 50 people who’d caught Marburg. And about a quarter of those people have died.

But the spread of the disease has really slowed down. The number of new cases being identified each week has fallen to the single digits.

Craig Spencer: 05:01

What we've seen here in Rwanda is that there was probably maybe a three to four week interval between when the first case happened and when it was detected. Once it was detected, at the end of September, it was announced openly, transparently to the world, and the Ministry of Health jumped into action, and within days, you had training programs at all hospitals. You had triage protocols to make sure that people coming in with symptoms consistent with Marburg got tested and isolated. You had personal protective equipment and all the things that are really needed to keep healthcare workers safe as well, and you had international assistance coming in, in the form of the United States and others donating the supplies, but also some of the medical countermeasures, the vaccines and the treatments that are hopefully going to help in this outbreak.

Megan Hall: 05:53

And am I hearing that there's even an experimental vaccine that's already been developed?

Craig Spencer: 05:58

Yeah, I prefer to use the phrase investigational vaccine based on what we've learned over the past couple years, but absolutely so let me just give a little bit of context. For a very, very long time for a lot of these viral hemorrhagic fevers, there was no vaccines. There was no treatment. And about a decade ago, The Onion the satirical newspaper, made the joke that an Ebola vaccine is, you know, the infection of 50 white people away. And people laughed. But the reality was kind of there. The political economy of what we invest in terms of health is focused on issues in the Global North. And so for a very, very long time, there was no Ebola vaccine. There were no Ebola treatments, because there was not much of an Ebola market. Now, in 2014 that changed, and out of that, we now have FDA approved Ebola treatments. We have multiple vaccines that do a really good job of helping us control outbreaks. Similarly for Marburg, the Sabin Institute based in DC, is a non profit that has been working towards developing vaccines for diseases like this that may not have a big enough market for pharmaceutical companies, but are really, really important in terms of managing how we respond to scary disease outbreaks. And the vaccine candidate that they had prior to being used in Rwanda recently had gone through phase one. And so basically, hey, is this safe? So we had phase one data that was published, we know that it was safe, and it was in the process of going through phase two, basically, meaning, what does it do? Does it help? And what happened is the Rwandan Ministry of Health, basically, the day after the outbreak was identified, contacted the Sabin Institute and said, we would love to have access to some of these vaccines. Can we make it happen? And I hate to use the word unprecedented, because very rarely are things such, but I think in a pretty unprecedented display of speed between the time the Rwandan Ministry of Health asked the Sabin Institute for vaccines,the time that they were in country being injected into frontline healthcare workers, it was eight days.

Megan Hall: 08:10

Wow.

Craig Spencer: 08:11

Eight days. Now, we don't have great data on whether they work. We don't know, do they reduce mortality from 90% to 20%? Do the vaccines provide sterilizing immunity, meaning that it's impossible to get infected, or do they maybe make the severity of illness, you know much less for people that got vaccinated. We don't know that. But what we do know is that for people in Rwanda, for Africans to have access to one of these tools so quickly, just meant a lot for their morale.

Megan Hall: 08:45

How is their response compared to other responses in the past?

Craig Spencer: 08:49

That's a good question. And I think the response in Rwanda to Marburg is really emblematic of why we invest in global health security and why we need partners, especially partners that can do this work all over the world. If you recall, 30 years ago, Rwanda was mired in a genocide. The country was completely turned over. You know, over 800,000 people died, and in the aftermath, there has been a very dedicated process of rebuilding. There's been a lot of international investment. Much of that investment has gone into building up a strong health system. There was a lot of international support, but also internal capacity building to make sure that they could build up and have their own strong health sector. Now why is that important? It's important because once Marburg was first recognized, this was work that was done by Rwandans, in Rwanda. It was done with capacity that had been built up over the past three decades. The response was led by an incredibly strong Rwandan Ministry of Health, and they were able to use a lot of the tools and training that they picked up over the past few decades, with that outside support to lead a really strong internal response, thus keeping us all safe by containing this outbreak at its source and catching it quickly.

Megan Hall: 10:11

As we record this episode, it looks like the Marburg outbreak is nearly under control. But Craig says these types of diseases can be especially hard to stop completely.

Craig: 10:23

The end game can often be really frustrating. We saw a decade ago in West Africa during the Ebola outbreak, countries might one day declare themselves Ebola free after two incubation periods 42 days, which is kind of the standard that we say, you can call yourself Ebola free, and then the next day find a new case. Things like this happen all the time.

Megan Hall: 10:43

But in general, Rwanda’s response to the virus looks like it might be a model for other countries.

Megan Hall: 10:49

Is there a message for us in the West, you kind of referenced that Onion article that maybe in America, we kind of think that we have all of the answers, and maybe we assume that African countries are not as advanced as us. Is it important for us to pay attention to places like Rwanda that are doing it right?

Craig Spencer: 11:09

Absolutely. Look, it's been nearly five years since SARS-COVID-2 started circulating in China. And I don't know anyone that will look back on the last five years and say, the US got it right, and a lot of people will say we got a lot, a lot, a lot wrong. And that's true. There are lessons for us to learn from everywhere. Are there lessons to take away from Rwanda? Absolutely. It is that having coordinated messaging and response and rapid action and support can like, truly save lives. And even during COVID, there was a lot of experiences from places that you know we consider the Global South that actually did things really, really well, that were able to build up a sense of community or societal Trust, which is really, really helpful in terms of responding to outbreaks. There's a lot that we can learn from places, and I think recent history has shown that we don't always do this great ourselves, and so maybe it's a good time for us to start thinking about what we can learn and take from the way other countries respond to diseases like this.

Megan Hall: 12:18

So what is your message to folks in the US? Should they be worried about Marburg?

Craig Spencer: 12:23

Yeah, I don't think anyone has any reason at this point to be worried about Marburg, but I do think it's important to be tuned in, to be healthy, to be concerned and to express your concern for what happens in other places to your elected officials, for example, at a time when pandemic preparedness and response is not getting a lot of love in places like Congress. And I don't think it's reason for us to worry about a Marburg case, but it is important for us to maintain that vigilance.

Our takeaway should be that we are incredibly lucky that none of us, at this moment is realistically concerned about a case of Marburg showing up in our hospital or in our schools. And the reality is that we are lucky only because of what the international community has done over the past couple decades and what the Rwandan government has done in the same time, but also over the past couple weeks. This is a massive success for global health security, and should be a reason for us all to remember and value the support that we give as a country to other places to not only keep themselves safe, but to also keep us safe.

Megan Hall: 13:36

Great. Craig Spencer really enjoyed our conversation. Thanks for coming in.

Craig Spencer: 13:41

Thank you for having me yet again.

Megan Hall: 13:46

Dr. Craig Spencer is an emergency medicine physician and an Associate Professor of the Practice of Health Services, Policy and Practice at the Brown University School of Public Health.

Humans in Public Health is a monthly podcast brought to you by Brown University School of Public Health. This episode was produced by Nat Hardy and recorded at the podcast studio at CIC Providence.

I'm Megan Hall. Talk to you next month!