Marburg virus disease and current protective guidance

To: Ohio EMS providers, EMS agencies, and EMS medical directors

From: Carol A. Cunningham, M.D., FAAEM, FAEMS, State Medical Director

RE: Marburg virus disease and current protective guidance

The Centers for Disease Control and Prevention (CDC) noted an outbreak of Marburg virus disease in October 2024 that was isolated within the Republic of Rwanda. Currently, the mandatory 42-day countdown period is underway to monitor for any additional cases. The last patient was discharged on November 9, 2024. If no additional cases are detected, the outbreak will officially be declared over on approximately December 21, 2024.

Although there have been no reported cases in the United States at this time, the CDC, in partnership with the U.S. Department of Homeland Security, has been screening and isolating healthcare providers who have worked in their clinics in addition to establishing designated airports as points of entry for travelers entering the country from Rwanda. Enhanced public health screening processes have been implemented for all air travelers entering the United States who have been in Rwanda in the previous 21 days. As a part of this process, travelers are monitored for symptoms and assessed by a CDC medical officer as needed.

Marburg virus disease (MVD) is extremely rare, and the risk in the United States remains extremely low. The Marburg virus causes a highly fatal viral hemorrhagic fever for which there is no treatment other than supportive measures and currently, there is no approved vaccine. The symptoms of the disease are:

• Fever
• Fatigue
• Gastrointestinal symptoms
• Headache
• Muscle and joint pain
• Loss of appetite
• Uncontrolled bleeding

The Marburg virus is spread by direct contact of broken skin or mucous membranes with a living or deceased human or animal infected with the virus, infected body fluids, or contaminated surfaces or objects (e.g., needles, clothing). Body fluids capable of transmission of this virus include amniotic fluid, blood, breast milk, feces, saliva, semen, sweat, and vomit. MVD is not spread via airborne transmission.

While Marburg virus disease is rare, the simple step of acquiring a travel history with a link to Rwanda is imperative for both patient care and protection of the EMS provider with the additional PPE measures. During triage, patients who are exhibiting the symptoms cited above should only be deemed at risk for MVD if they have been in an area with an active outbreak in Rwanda within the past 21 days or if they report one or more of the following epidemiologically compatible risk factors, as cited by the CDC, within 21 days of onset of symptoms:

• Had direct contact with a symptomatic person with suspected or confirmed MVD, or with any objects contaminated by their body fluids.
• Experienced a breach in infection prevention and control precautions that resulted in the potential for contact with body fluids of a patient with suspected or confirmed MVD.
• Participated in any of the following activities while in an area with an active MVD outbreak:
  • Contact with someone who was sick or died or with any objects contaminated by their body fluids.
  • Attended or participated in funeral rituals, including preparing bodies for funeral or burial.
  • Visited or worked in a healthcare facility or laboratory.
  • Contact with cave-dwelling bats or non-human primates.
  • Worked or spent time in a mine or cave.

With regards to personal protective equipment, the CDC recommends that all items of PPE, with the exception of powered air purifying respirators (PAPRs), be single-use (disposable). For stable patients, the recommended PPE is as follows:

• Facemask
• Full face shield
• Two pairs of gloves with the outer glove with an extended cuff
• Fluid-resistant gown that extends at least to the mid-calf or fluid-resistant coveralls without an extended hood

For unstable patients and patients with bleeding, vomiting, or diarrhea, the additional items of PPE that should be donned are:

• PAPR or a fit-tested N-95 respirator
• Boot covers
• Impermeable apron worn over the gown or coveralls

Prior to transport, the receiving facility should be notified as soon as possible to facilitate their preparation to accept and provide care to the patient and to minimize contamination of others and the facility. The driver compartment of the transport vehicle should be separated from the patient compartment with fresh air introduced into both compartments, and exhaust fans adjusted to high in the patient compartment. The driver should consider wearing an N-95 respirator. The interior of the patient compartment should be draped to prevent contamination and, if possible, a surgical mask and an impervious sheet or fluid-resistant coveralls should be placed on the patient. The administration of anti-emetics is recommended to prevent the risk of exposure from vomiting. The number of EMS providers should be limited to what is necessary during the transport while all others should maintain a distance of 6 feet or more from the patient. Doffing of PPE should be deferred until the patient transport has been completed

The Ohio Department of Health should be notified of any suspected or confirmed cases of Marburg virus disease as soon as possible as they maintain a list of tertiary care hospitals, within and outside of Ohio, that are prepared and capable to provide specialized care to patients with highly infectious contagious diseases. In addition, there is a network of contracted EMS and medical transportation agencies with vehicle assets and personnel specifically trained in the management of patients with highly contagious infectious diseases during interfacility transports. The availability of these resources is extremely valuable to all EMS agencies and healthcare facilities. If it is anticipated that these specialized resources may be needed, notify the Ohio Department of Health at (614) 722-7221, the Ohio Emergency Management Agency at (614) 889-7150, or your local county department of health or emergency management agency.

As we enter the holiday season, there will be a marked increase in people traveling all over the world to reunite with family and to trek to vacation destinations. There will undoubtedly be numerous requests for emergency medical services for people experiencing flu-like symptoms.

EMS providers are often the first medical responders to identify trends in signs and symptoms and obtain critical information that ultimately saves lives. As stated previously, Marburg virus disease is rare. The simple step of acquiring a travel history with a link to Rwanda is imperative for both patient care and protection of the EMS provider with the additional PPE measures. For patients with or without a link to Rwanda, please continue to wear the appropriate PPE for all patient encounters and continue to use carbon monoxide detectors in the homes and buildings you enter to prevent holiday season tragedies.

Have a wonderful and safe Thanksgiving and thank you for your dedicated service to the residents and visitors of Ohio!

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