Marburg virus disease in Rwanda: an observational study of the first 10 days of outbreak response, clinical interventions, and outcomes

Abstract

Background

Marburg virus disease (MVD) is a highly fatal hemorrhagic fever with fatality rates between 33 and 88% in sub-Saharan Africa. Rwanda reported its first MVD outbreak on September 27, 2024. This study assessed Rwanda’s response to its first MVD outbreak, focusing on identifying critical success factors and areas for improvement during the initial 10 days after outbreak declaration.

Methods

This observational study analyzed publicly available data from daily screenings and outbreak reports provided by the Rwanda Ministry of Health and Rwanda Biomedical Center between September 27 and October 7, 2024. The study examined confirmed cases, deaths, testing rates, and recoveries, including healthcare response measures. Data was collected from checkpoints and passenger screening at entry points, with information aggregated into Rwanda’s Health System.

Results

By October 7, 2024, Rwanda reported 56 confirmed MVD cases, including 12 deaths and 8 recoveries. Daily screening began on October 3rd, and by October 7th, 2387 individuals were tested, with a positivity rate of 2.3%. Healthcare workers accounted for over 70% of confirmed cases. No new deaths were reported from October 4 (day 7) until October 7th (day 10), though the first 2–3 days after outbreak declaration were critical, with 6 deaths occurring during this period. Rwanda’s response included increased testing, early detection, intensive care management, experimental therapeutics (monoclonal antibodies and remdesivir), and comprehensive contact tracing.

Conclusions

Analysis of the first 10 days of Rwanda’s MVD outbreak provides valuable insights into effective outbreak response, highlighting the importance of early interventions, healthcare worker protection, enhanced testing, and international collaboration. Early detection and intensive management of cases, including advanced critical care and strong laboratory infrastructure, are essential to reduce early mortality. These findings emphasize the need to strengthen healthcare systems by establishing rapid preparedness and response mechanisms before outbreaks occur and fostering international partnerships to enhance outbreak management and control.

Background

Marburg virus disease (MVD) is a rare and deadly viral hemorrhagic fever caused by virus from the Filoviridae family, similar to Ebola, that presents severe health risks to humans and may carry a high fatality rate ranging between 24% (observed in the 1967 outbreak in Germany) and 88% in different settings. Caused by a single-stranded RNA virus from the Filoviridae family, MVD has an incubation period of 2 to 21 days [1]. Despite the severity of this disease, progress toward evidence-based management of the disease and outbreak control has been limited worldwide. Management in this context refers to both the clinical treatment of patients and the systematic response to outbreaks, including containment, surveillance, and mitigation strategies, as well as setting up treatment centers with innovative treatment and diagnostic systems [2, 3]. However, these resources have not yet been fully rolled out in this context [4, 5]. The rarity, severity, and rapid spread of past MVD outbreaks have hindered timely diagnosis, comprehensive treatment center setups, and the implementation of clinical trials necessary to establish definitive efficacy for vaccines and treatments.

MVD was first identified in 1967, with the initial outbreak occurring in Germany. Since then, there have been an additional 16 outbreaks globally, in countries, including Yugoslavia, South Africa, Kenya [2], the Democratic Republic of THE Congo, Angola, USA (ex: Uganda), Uganda (4 times), Netherland (ex: Uganda), Guinea, Ghana, Equatorial Guinea, and Tanzania; these frequent outbreaks in Uganda and Kenya highlight the disease’s ability to emerge in new areas due to improved detection, but not necessarily because the disease emerges in previously unaffected regions. Detection in countries where MVD had not been previously reported indicates the wide geographical scope of potential emergence and highlights the improved ability of countries to detect the virus [6–8]. In the past decade, six outbreaks have been reported, including four in the past 4 years, reflecting an increase in the frequency of MVD outbreaks. The largest MVD outbreaks occurred in Angola (374 cases in 2005) and the DRC (154 cases from 1998 to 2000) [8, 9].

The 2024 outbreak in Rwanda represents a unique case in understanding the dynamics of MVD outbreaks in resource-limited settings. While it mounted a comprehensive response, the outbreak highlighted critical gaps in preparedness. The country would have been better equipped if international agencies had leveraged insights from prior MVD outbreaks, particularly those in neighboring regions, to enhance surveillance and response mechanisms, such as the establishment of a regional surveillance system with robust diagnostic systems and platforms to detect early and treat confirmed cases. Moreover, early deployment of clinical protocols tailored to resource-limited settings, access to trained healthcare workers, and the provision of personal protective equipment (PPE) could have mitigated initial challenges. Additionally, efforts to foster cross-border collaborations and data-sharing initiatives would significantly enhance outbreak management strategies.

Without proactive and coordinated global actions, future MVD outbreaks may pose severe risks to public health systems, particularly in non-endemic regions. Prioritizing investments in public health infrastructure, fostering international collaboration, and promoting early detection mechanisms are critical steps to building resilience and mitigating the impact of emerging zoonotic diseases. By prioritizing research, strengthening public health infrastructure globally, and fostering international collaboration, future preparedness and response efforts can be improved, ultimately saving lives and preventing further outbreaks.

This study uniquely highlights the role of rapid mobilization, healthcare infrastructure, and international collaboration in mitigating an emerging health crisis. Focusing on the first 10 days of the outbreak, this study provides rare insights into the early dynamics of outbreak management, including healthcare worker vulnerabilities, the effectiveness of early detection protocols, and the complexities of deploying experimental treatments and vaccines. These findings contribute to a broader understanding of how both previously affected and at-risk countries can strengthen their outbreak preparedness and response frameworks, ultimately enhancing global health security [10].

Methods

Study design and setting

This observational study analyzed the first 10 days of the MVD outbreak using publicly available data provided by the Rwanda MoH through its official website and social media platforms. The data, collected from daily screenings during Rwanda’s MVD outbreak, spans from September 27, 2024, when the first case was confirmed, to October 7, 2024, 10 days after the declaration of MVD in Rwanda. The study utilized all daily reported data from Rwanda, where healthcare workers were primarily affected, as well as contact tracing, departing passengers, and designated checkpoints located primarily in other high-risk areas such as transportation hubs and border posts within affected areas. These checkpoints focused on screening departing passengers for symptoms of Marburg virus disease (MVD) to prevent further spread to unaffected regions.

Data collection

The daily screenings were conducted by designated healthcare workers from the Rwanda MoH and Rwanda Biomedical Center (RBC). Screening efforts focused exclusively on departing passengers through the following channels: (1) designated checkpoints in affected areas, located at healthcare facilities, border posts, and other high-traffic zones; and (2) online symptom screening questionnaires completed by departing passengers. For international departures, the screenings aimed to prevent cross-border transmission of Marburg Virus Disease (MVD) to neighboring countries and beyond, aligning with regional and global containment efforts. Trained healthcare workers followed standardized screening protocols to collect data. The screening process involved checking temperatures with non-contact infrared thermometers, administering a symptom questionnaire that covered key MVD symptoms such as high fever, severe headache, muscle aches, fatigue, vomiting, bloody diarrhea, petechiae, and assessing travel history and potential exposure or any contact with a person who tested positive for MVD. To address representativeness, the screening sites were chosen based on contact tracing that included both urban and rural settings, with targeted mass screening based on potentially exposed patients with positive case definitions of MVD, thus ensuring comprehensive demographic coverage. This design minimized geographic bias and captured diverse population groups while improving the efficiency of MVD mass testing.

Data management and quality control

The data used in this study were sourced from publicly available reports from the Rwanda Ministry of Health and the Rwanda Biomedical Centre. While these sources are authoritative, potential limitations include incomplete reporting due to the fast-evolving nature of the outbreak and possible delays in data consolidation at the national level. Accuracy may also have been impacted by challenges in data collection, given the complexity of data collection during an outbreak such as this MVD. To mitigate these biases, the study focused on data that had been cross-validated by multiple sources, including international partners such as the WHO and CDC. To ensure accuracy and reliability, quality control measures were implemented, including double data entry and daily quality checks by two trained data entry clerks. Additionally, data validation was performed by cross-referencing reported cases with health facility reports and surveillance bulletins from WHO regional databases to ensure consistency and completeness. This acknowledgment strengthens transparency and emphasizes the study’s reliance on the most robust data available at the time.

Variables

Key variables analyzed included the daily number of individuals screened and cumulative tests conducted across all screening channels, as well as the number of new confirmed cases reported each day and the total cumulative cases. Additionally, data on the number of isolated and treated cases, daily and cumulative deaths, and the number of recoveries, both new and cumulative, were closely monitored. These variables provided a comprehensive overview of the outbreak’s progression and the effectiveness of the response efforts.

Case management and contact tracing

All confirmed cases were isolated and treated in dedicated treatment centers. Symptomatic cases with or without confirmed contact were also isolated and tested. Contact tracing focused on identifying individuals with direct or indirect exposure to confirmed cases and involved tracking these individuals over 21 days, recording symptom onset, and ensuring timely testing. Contact tracing was ongoing, with over 300 contacts under follow-up as of October 7, 2024.

Data analysis

Data analysis was performed utilizing the Python programming language. Descriptive statistics were employed to summarize the daily incidence of new cases, recoveries, and screening efforts. A time series analysis was conducted to discern trends within the data, particularly focusing on the temporal progression of new cases, recoveries, and deaths. Furthermore, bar plots were utilized to represent daily counts, enabling the identification of peaks and troughs within the outbreak timeline. Interpolated line plots, specifically designed for cumulative metrics, were employed to evaluate the long-term progression of the outbreak, thereby providing a comprehensive understanding of its evolution.

Ethical considerations

This study analyzed publicly available, de-identified data from the Rwanda Biomedical Centre’s Marburg Virus Disease outbreak response, with approval from the Ministry of Health/RBC, and individual consent was waived per Rwanda National Ethics Committee guidelines for secondary use of public health emergency data.

Limitations

This study’s limitations stem primarily from its reliance on shared data, which may be subject to delays. The absence of individual-level data limits the depth of analysis. Following the Data Privacy and Protection (DPP) law in the country, data used was drawn from the Rwanda Biomedical Centre website, indicating new patients, positivity rate, recovery, deaths, etc. The dynamic nature of the outbreak and the need to update the community present some advantages and challenges. The population in Rwanda and outside of the country could monitor cases, deaths, and recoveries without any delay. The challenges are related to having publicly available data in real time, potential bias to data consistency due to over-testing, and the severity of Marburg virus disease (MVD) that could have led to over-reporting any similar cases within common symptoms such as malaria. Despite these constraints, the study provides valuable insights into Rwanda’s early MVD outbreak response, contributing to the understanding of outbreak dynamics and informing future public health interventions.

Results

The study period spans from 28th September to 7th October 2024, during which 56 confirmed cases were detected, 12 deaths were reported, and 8 patients recovered. Additionally, 2387 individuals were screened during this period. The results of the MVD outbreak in the first 10 days (here referred to as phase 1 of this outbreak) offer an overall analysis of the MVD outbreak epidemiology and country response.

The results also revealed significant developments in case numbers, screening efforts, and patient outcomes. Data includes daily and cumulative metrics for screening, confirmed cases, deaths, and recoveries, offering a comprehensive view of the outbreak’s progression over the 10 days.

The systemic response included general screening at the entry points and high-traffic zones, contact tracing, screening, and care confirmation that commenced on October 3, 2024, with daily screening and data sharing. A total of 1009 individuals were initially screened. By October 7, the cumulative number of screened individuals had reached 2387. The individuals screened comprised both suspected cases, symptomatic contact cases, and asymptomatic individuals passing through designated checkpoints, including healthcare facilities, border posts, and high-traffic zones. The rationale for screening included early identification of potential cases, particularly among those with recent travel history to affected regions, contacts with confirmed or suspected MVD cases, or those presenting with symptoms such as fever, fatigue, and hemorrhagic manifestations. This rapid scaling of screening capacity, particularly at entry points, high-traffic zones, and transit centers, demonstrated Rwanda’s commitment to early detection and containment, a key strategy for preventing widespread transmission.

Daily confirmed cases showed fluctuations, with the highest spikes observed on October 2 and October 7, each recording 7 new cases. The cumulative number of confirmed cases rose from 26 on September 28 to 56 by October 7. This upward trend emphasized the importance of implementing targeted contact tracing and isolation protocols to manage emerging cases swiftly and break chains of transmission, as illustrated in Fig. 1.

Fig. 1.

Temporal trends in the progression of MVD in Rwanda. Panel a shows the daily number of individuals screened for MVD, while panel b presents the daily confirmed cases. Panel c tracks the cumulative screened cases, and panel d illustrates the cumulative confirmed cases

The data on mortality and recoveries in Fig. 2 shows that daily deaths due to MVD were recorded consistently up until October 4, after which no new deaths were reported. A peak of 6 deaths occurred on September 28, with the total rising to 12 by October 7. Daily recoveries began to be documented on October 3, with the cumulative total reaching 8 by October 7. The cessation of new deaths after October 4 (day 7), coupled with the increasing number of recoveries, underscores the critical role of combined interventions including systemic response, early clinical case management, and experimental therapies, such as Remdesivir, and introduction to advanced critical care management to severely ill patients in reducing mortality rates and improving patient outcomes [11]. This strategy was uniquely implemented in Rwanda, underscoring the significant public health impact of these interventions during the early days of the outbreak declaration, which played a crucial role in containing the spread.

Fig. 2.

Temporal trends in the progression of MVD outcomes in Rwanda. Panel a displays the daily number of deaths due to MVD, while panel b presents the daily recoveries. Panel c tracks the cumulative deaths, and d illustrates the cumulative recoveries

The daily progression of new cases, deaths, and recoveries showed variation throughout the observation period. New cases peaked on October 2 and October 7, with 7 cases confirmed on each day. Daily deaths occurred between September 28 and October 4, but no further fatalities were reported after that, based on the 10 days of analysis. Daily recoveries started on October 3, and by October 7, 8 individuals had recovered, as shown in Fig. 3. Many patients were still admitted to the treatment center and could not be used to calculate the updated case fatality rate.

Fig. 3.

Daily new cases, deaths, and recoveries of MVD in Rwanda over 10 days

Discussion

The findings reveal a marked increase in Marburg virus disease (MVD) cases between September 27 th and October 7 th, 2024. Initial reports documented 26 confirmed cases with 6 deaths, predominantly among healthcare workers. By October 7 th, the outbreak had escalated to 56 confirmed cases, with 12 deaths, 8 recoveries, and 36 patients still admitted to treatment centers. The rise in cases was primarily attributed to amplification events in healthcare facilities during the early phase of the outbreak. Unrecognized cases were admitted without isolation protocols, facilitating the transmission of the virus. The primary route of transmission was through direct contact with bodily fluids, such as blood, saliva, vomit, and sweat, from infected individuals. Secondary transmission occurred via contaminated medical equipment and surfaces.

Healthcare workers were disproportionately affected, comprising over 70% of the initial cases. Factors contributing to these amplification events included performing of high-risk procedures on MVD before the recognition of the origin of the outbreak, such as cardiopulmonary resuscitation (CPR), advanced airway management (intubation), peripheral and central vascular access performed on MVD patients prior to the identification of the Marburg virus (MARV) as source of the outbreak and with insufficient use of personal protective equipment (PPE) during these initial stages of the outbreak. These delays in implementing infection prevention and control (IPC) measures, and overcrowded treatment centers, including intensive care units (ICU), have increased the risk of exposure to infected bodily fluids among personnel of those units. To address these challenges, the Rwanda MoH rapidly implemented the following: (1) firstly early detection and clinical management that comprised of strengthened IPC measures, including comprehensive training for healthcare workers, the establishment of dedicated isolation wards, deployment of sufficient PPE with adherence monitoring, and rigorous sterilization of medical equipment and surfaces, management of ill patients and separation of suspected and confirmed cases. (2) Systematically deployed trained surveillance teams across countries for contact tracing and targeted points of screening, mass communication that significantly curtailed healthcare-associated transmissions. Lastly (3), the implementation of clinical research during the outbreak with treatments that were promising to cure MVD was crucial to reducing the CFR of MVD in Rwanda [10].

By October 7 th, 2387 tests had been conducted, achieving a positivity rate of 2.3%. The effectiveness of these measures was not based solely on the number of tests conducted but, on the outcomes, achieved, including a targeted testing approach that focused on high-risk groups, such as close contacts and symptomatic individuals, ensuring resources were directed toward those most likely to transmit the virus. The low positivity rate reflected the success of early identification and isolation efforts. Early case identification allowed timely isolation and treatment, preventing further transmission. Testing also supported contact tracing by confirming or ruling out infection among identified contacts, enabling effective interruption of transmission chains. Additionally, rapid testing excluded non-infected individuals, minimizing unnecessary quarantines, and optimizing healthcare resources. These efforts underscore the importance of targeted testing strategies in outbreak management. Rwanda’s experience highlights the need for a balance between scaling up laboratory capacity and ensuring testing efforts are strategically focused to achieve meaningful outcomes.

The amplification events and rapid case rise in Rwanda highlight the critical need for early IPC implementation in healthcare facilities, particularly during the initial phases of an outbreak. Surveillance and testing systems must focus on targeted approaches to maximize their effectiveness in identifying cases, supporting contact tracing, and preventing secondary transmission. Rwanda’s proactive measures provide valuable lessons for strengthening outbreak response and preparedness globally.

Case fatality rate and disease severity

In comparison to other documented Marburg virus outbreaks, by October 7, 2024, Rwanda reported 56 confirmed cases of MVD, including 12 deaths and 8 recoveries, with the remainder still under treatment. The case fatality rate (CFR) was calculated using the recommended definition of the WHO, stating that it is the percentage of people who have contracted the disease who die from it. The CFR is influenced by various factors, including early case identification, the timely initiation of treatment, and the quality of clinical care as well as the quality of case management to capture different aspects of the outbreak. When considering all 56 confirmed cases, the CFR was 21.4%, providing an overview of the outbreak’s total impact at the time of reporting. By the end of the outbreak, a total of 66 confirmed cases were detected, among them 15 died, resulting in a CFR of 23%. 42 consecutive days without new cases, following the discharge of the last confirmed patient in Rwanda [8].

Rwanda’s success in managing the outbreak can be attributed to specific interventions. Extensive contact tracing and early detection played a critical role in reducing disease severity by ensuring that cases were identified and isolated before severe progression. On average, the time from symptom onset to hospital admission was reduced to two days, and testing turnaround time was under 24 h, enabling timely treatment. Early isolation and patient management, including access to intensive care resources such as mechanical ventilation and hemodialysis, played a critical role in reducing fatalities. The deployment of experimental therapies, including Remdesivir and monoclonal antibodies (MBP-091), was a pivotal component of Rwanda’s response to the MVD outbreak [11, 12]. These treatments were administered as part of a phase 3 clinical trial protocol, demonstrating Rwanda’s proactive approach to using investigational therapies during the outbreak. s. However, it is important to acknowledge the investigational status of these therapies and the limitations in existing efficacy data. Remdesivir and MBP-091 were utilized based on preclinical and limited clinical data suggesting potential antiviral activity. Their deployment was informed by international guidance and expert opinion but lacked robust Phase 3 trial data. Of the 12 patients treated with these therapies, 5 recovered, resulting in a survival rate of 41%, while 7 unfortunately died, leading to a mortality rate of 58%, which suggests potential benefits of the treatments, but further research is required. However, the absence of control groups and the small sample size necessitate caution in interpreting these outcomes. In addition to clinical limitations, the use of experimental therapies presented ethical and operational challenges. Ensuring informed consent, equitable access, and proper administration in resource-constrained settings required significant coordination. These challenges highlight the need for further research to establish the efficacy and safety of these treatments in the context of MVD. While experimental therapies provided an additional tool in Rwanda’s outbreak response, their investigational nature underscores the importance of accelerating research and development for approved treatments for viral hemorrhagic fevers.

Advanced supportive care provided in Rwanda’s intensive care units (ICUs) also contributed significantly to better outcomes. The ICUs were equipped with mechanical ventilation, hemodialysis, and dedicated IPC teams, allowing for optimal management of critically ill patients. “Phase 1” refers to the early phase of the disease when symptoms are less severe and organ failure has not yet occurred, underscoring the importance of early medical intervention.

Comparing Rwanda’s 2024 MVD outbreak to recent outbreaks in Ghana and Tanzania highlights both shared challenges and distinct differences in outbreak dynamics and response strategies. Ghana’s 2022 outbreak was confined to a small cluster of three confirmed cases within the same household, with no reported infections among healthcare workers (HCWs). This limited transmission, attributed to swift containment efforts and a high level of community cooperation, underscores the effectiveness of early isolation and targeted contact tracing. While Rwanda’s outbreak involved broader transmission, the scale of testing and surveillance in Rwanda provided valuable insights into identifying transmission chains and preventing widespread community spread [13, 14]. In Tanzania’s 2023 outbreak, which reported 9 total cases (8 confirmed, 1 probable) with a CFR of 67%, delays in outbreak recognition could have hindered early containment. The last case in Tanzania had symptom onset 25 days after the outbreak was confirmed, reflecting the need for a higher index of suspicion and stronger early-warning systems at the healthcare facility level. Rwanda’s experience, marked by the detection of 26 cases at once during initial investigations, highlights the critical role of heightened suspicion and proactive testing protocols in managing emerging outbreaks [13, 15].

A common trend across MVD outbreaks is the disproportionate impact on healthcare workers, who often represent a significant portion of confirmed cases. In Rwanda, as of October 7, 2024, healthcare workers accounted for over 70% of confirmed cases in the initial stages, reflecting their vulnerability. By October 7, 39 out of the 56 confirmed cases were healthcare workers ​ [16]. The early stages of Rwanda’s MVD outbreak revealed significant vulnerabilities in IPC protocols, particularly in protecting healthcare workers (HCWs), who accounted for over 70% of confirmed cases initially. Amplification events, such as the admission of unrecognized cases and high-risk procedures like CPR, exposed HCWs to increased risks of infection. In response, the MoH rapidly enhanced IPC measures, introducing intensive training on viral hemorrhagic fever management, restructuring isolation protocols, and revising procedural guidelines for high-risk interventions. The deployment of IPC supervisors ensured adherence to safety protocols during critical procedures. Additionally, the country implemented routine symptom monitoring for HCWs and provided mental health support to address burnout and anxiety. These measures significantly reduced further HCW infections and underscored the importance of rapid adaptation of IPC strategies during outbreaks.

This situation contrasts with the 2022 Marburg outbreak in Ghana, which reported three confirmed cases, all from the same household, with no infections among healthcare workers. While Ghana's outbreak did not involve healthcare workers, other outbreaks, such as the 2004–2005 outbreak in Angola, provide a more relevant example. In Angola, approximately 80 healthcare workers were infected, illustrating the significant risk posed to frontline workers in the absence of stringent infection prevention and control measures [4, 14, 17, 18]. Rwanda’s experience underscores the importance of enhanced infection prevention protocols, adequate personal protective equipment, and training to protect healthcare workers during MVD outbreaks.

In addition to physical vulnerability, healthcare workers experienced heightened psychological stress due to prolonged exposure to infected patients, fear of contracting the virus, and the trauma of losing colleagues. Long working hours and insufficient mental health resources exacerbated burnout and anxiety. These findings highlight the need for mental health support, such as counseling, peer support systems, and structured debriefing sessions, to mitigate the psychological toll on frontline responders. The country has set up mental health services in Rwanda to specifically support MVD survivors while addressing their mental health challenges to maintain a resilient healthcare workforce during and after outbreaks, while facilitating a smooth return and integration to their families and communities.

Testing and surveillance

Rwanda’s robust testing and surveillance strategy was central to its early containment of the MVD outbreak. Key metrics highlight the potential positive effect of these measures. On average, symptomatic individuals were tested within 1–2 days of symptom onset, facilitating early case identification and isolation. Additionally, the testing process achieved a turnaround time of under 24 h, enabling timely intervention. By October 7, 2024, 2,387 individuals had been tested, with a positivity rate of 2.3%, demonstrating broad surveillance coverage across high-risk populations. These metrics underscore the importance of rapid testing and comprehensive surveillance in reducing transmission risks and enhancing outbreak management. The integration of digital tools for real-time data collection and the prioritization of symptomatic and high-risk individuals ensured efficient use of testing resources. These systems ensured that symptomatic individuals were promptly tested and isolated, contributing to the containment of community transmission. Lessons learned from Rwanda’s approach should inform global strategies for strengthening testing and surveillance during outbreaks [19].

Geographic spread and cross-border risks

By October 7, 2024, confirmed cases of MVD were reported in health facilities located in three districts within Kigali: Nyarugenge, Kicukiro, and Gasabo. Exposure risks, however, were identified in 2 additional districts: Nyagatare and Rubavu, through contact tracing efforts [16, 19] (see Fig. 4). These exposures were attributed to the movement of patients and their close contacts before diagnosis and isolation. In response, the Rwanda MoH implemented a series of targeted measures to contain the outbreak. These included enhanced contact tracing, quarantine of exposed individuals, and community-based surveillance to identify additional cases. Screening checkpoints were established at key transportation hubs and health facilities to identify symptomatic individuals, and harmonized protocols were adopted at border points to mitigate the risk of cross-border transmission.

Fig. 4.

Districts of Rwanda: areas with confirmed Marburg virus disease cases in red

Rwanda’s proximity to neighboring East African countries with shared borders, such as Uganda and Tanzania, highlighted the importance of regional collaboration. Real-time data sharing, cross-border contact tracing, and coordinated screening protocols were essential in preventing the broader dissemination of MVD across national boundaries. This localized nature of the outbreak aligns with similar patterns observed in Ghana’s 2022 outbreak, which was largely confined to the Ashanti region [14], and Tanzania’s 2023 outbreak, which was restricted to the Kagera region [15]. The geographic spread in Rwanda highlights the success of robust surveillance systems in identifying cases and exposures early. However, the risk of cross-border transmission due to Rwanda’s proximity to other East African countries underscores the need for continued regional collaboration and rapid response to prevent wider dissemination of the virus.

Role of international collaboration during the outbreak

Rwanda’s success in managing the outbreak can largely be attributed to its robust healthcare systems and international partnerships. The US CDC and WHO provided critical support through training, expertise, and enhanced laboratory capacity [20]. This proactive engagement helped Rwanda establish effective systems for testing, treatment, and surveillance. In contrast to Ghana had only 3 confirmed cases with swift international support, demonstrating the importance of early intervention even in low-transmission scenarios [8, 14, 21, 22]. The comparison highlights the importance of timely international collaboration in managing infectious disease outbreaks. The receipt of 700 doses of an experimental vaccine on October 6, 2024, underscores Rwanda’s commitment to preparedness and its proactive approach to preventing future transmission chains. While the vaccine did not influence outcomes during the review period, its arrival signifies international collaboration and the prioritization of preventive measures in outbreak management [14]. The vaccine’s role highlights the importance of stockpiling and deploying experimental tools as part of a comprehensive outbreak preparedness strategy, ensuring rapid response capabilities in the event of future transmission risks’ impact on healthcare workers.

Call to regional and global health actors to act before the outbreak

Unfortunately, in most cases where outbreaks were declared, international and global health actors were only activated once outbreaks had already started, leaving countries with devastating consequences, including massive loss of healthcare workers and fragilizing the health system’s resiliency.

In view of the findings emerging from this analysis, the authors call for a critical and urgent call for action for regional and global health actors to rethink, reposition, and respond to current and future pandemic outbreaks. Given the rapid progression of cases and fatalities during the first few days of the outbreak, there is a pressing need for regional and global health actors to establish pre-emptive measures. This includes investing in robust surveillance systems capable of detecting anomalies before outbreak declaration, building scalable treatment facilities with advanced ICU capabilities with skilled HCWs, and fostering regional and global repositories for emergency supplies such as PPE and experimental therapies. Strengthening these systems not only improves immediate outbreak response but also enhances the resiliency of national health systems in facing future zoonotic threats. Results from this research paper suggest most of the deaths occurred during the first 3–4 days of outbreak declaration, creating room for repositioning of the pandemic fund to (1) strengthen the emergency and ICU departments at decentralized and centralized levels, (2) create an antenna for suspicion of any abnormal cases, and (3) activate country systems. All regional and global health actors should accelerate their efforts to prepare and support countries at risk of outbreak, before the outbreak, build platforms to detect suspicious cases, and support and coordinate local and regional efforts from local and primary healthcare systems to the overall national health system. National, regional, and global health actors should coordinate the data with signals, including case definitions for all potential outbreaks in the region, capable of analyzing and formulating rapid responses that are applicable and funded to equip national response command centers.

Conclusions

The first 10 days of analysis of the MVD outbreak in Rwanda offer valuable insights into effective outbreak response, emphasizing the critical role of early detection and interventions, enhanced testing, and early implementation of clinical trials while collaborating with international institutions. While the CFR of 21.4% during the review period underscores the severity of the outbreak, Rwanda’s ability to scale up testing capacities, provide advanced supportive care, early implementation of clinical trials, and ensure timely isolation of cases highlights key strategies for outbreak containment. These efforts demonstrate the country’s capability to respond effectively despite limited resources, showcasing practical solutions that can be adapted globally. Rwanda’s response to its first MVD outbreak provides critical lessons for global health policy. The successful containment of the outbreak highlights the importance of proactive planning, rapid mobilization of resources, and the integration of local and international response efforts. Based on these insights, several action points are recommended for global health systems:

Enhance early detection and surveillance: invest in real-time surveillance systems and training for healthcare workers to improve the early recognition of rare diseases. Integrate digital tools and regional data-sharing platforms to support rapid decision-making during outbreaks.

Strengthen healthcare worker support: address the psychological well-being of healthcare workers by integrating mental health resources into outbreak response plans. Ensure that training on IPC is routinely updated and tailored to emerging threats.

Scale up emergency and trials preparedness: establish national and regional repositories for personal protective equipment (PPE), experimental therapies, and rapid diagnostic tools. Ensure these resources can be deployed quickly during public health emergencies.

Foster international collaboration: strengthen mechanisms for cross-border collaboration, including joint training exercises, harmonized screening protocols, and coordinated outbreak response frameworks.

Address socio-economic impacts: develop socio-economic safety nets to support affected families, communities, and healthcare workers during outbreaks. These measures should include financial assistance, psychosocial support, and programs to rebuild affected communities.

Accelerate research and development: prioritize global investment in the research and development of vaccines, treatments, and diagnostics for viral hemorrhagic fevers. Establish frameworks for the ethical and equitable deployment of experimental interventions.

Abbreviations

CFR

Case fatality rate

CDC

Centers for Disease Control and Prevention

CPR

Cardiopulmonary Resuscitation

DPP

Data Privacy and Protection

HCW

Healthcare worker

ICU

Intensive care unit

IPC

Infection Prevention and Control

MARV

Marburg virus

MoH

Ministry of Health

MVD

Marburg virus disease

PPE

Personal protective equipment

RBC

Rwanda Biomedical Center

WHO

World Health Organization

Authors’ contributions

All authors of this study affirm that they have made significant contributions to the conception, design, data analysis, interpretation, and writing of the commentary. GA, CRB, ECN, KM, PI, ZC, CM, NU, SMF, FKR, ES, ER, TT, SM, and JC played key roles in the conception and design of the study, as well as in the analysis and interpretation of the data. PI contributed to data analysis, interpretation, and manuscript revision. JC and GA critically revised the manuscript for important intellectual content, provided final approval of the version to be published, and agreed to be accountable for all aspects of the work, ensuring that any questions regarding the accuracy or integrity of the work are thoroughly investigated and resolved. All authors read and approved the final manuscript.

Authors’ Twitter Handles

Gashaija Absolomon: @gashaijaabsolom.

Emmanuel C. Nyabyenda: @nyabyendaEmman2.

Piero Irakiza: @IrakizaPiero.

Caroline Mudereri: @Carolinemudere1.

Nathalie Umutoni: @UmutoniNathalie.

Sabine F. Musange: @sabineFM.

Eric Seruyange: @seruyange1.

Theogene Twagirumugabe: @TwagirumugabeT.

Sanctus Musafiri: @musanct.

Edson Rwagasore: @edrwagasore.

Jeanine Condo: @CondoJeanine.

Funding

Not applicable.

Data availability

The data used in this study are publicly available through the Rwanda Biomedical Centre's official website (https://rbc.gov.rw/marburg/) which provides daily updates on the MVD outbreak.

Declarations

Ethics approval and consent to participate

This study analyzed publicly available, de-identified data from the Rwanda Biomedical Centre’s Marburg Virus Disease outbreak response, with approval from the Ministry of Health/RBC, and individual consent was waived per Rwanda National Ethics Committee guidelines for secondary use of public health emergency data.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.