Africa CDC faults U.S. government over Marburg-related travel advisory to Rwanda

The director general of the Africa Centres for Disease Control and Prevention and Rwanda’s health minister on Thursday criticized the U.S. government’s decision to urge Americans to avoid travel to Rwanda because of the country’s ongoing Marburg outbreak.

Calling the travel alert a travel ban — it is not — Jean Kaseya, who heads the Africa CDC, suggested the U.S. action was counterproductive and unfair to a country that is being transparent about its efforts to quell the first confirmed Marburg outbreak within its borders.

“Rwanda is applying transparency for this outbreak. And when a country is applying transparency, the country [should not] be punished,” Kaseya said during a press conference. 

The U.S. Department of State and the Centers for Disease Control and Prevention issued Level 3 travel advisories for Rwanda on Monday in response to the Marburg outbreak, which has resulted in 58 confirmed cases and 13 deaths to date. For the second day in a row, Thursday saw no new cases or deaths reported. The number of people who have recovered has risen to 15. 

A Level 3 advisory is not a travel ban. It recommends that people consider postponing or canceling unnecessary travel to the country assigned the advisory. Both the State Department and the CDC have Level 4 advisories which they use to tell Americans they should not travel to a destination because of security concerns or disease transmission risks.

The Africa CDC issued a statement Tuesday urging countries not to assign travel restrictions to African countries fighting mpox outbreaks, or, in the case of Rwanda, Marburg. It noted that travel restrictions are in violation of the WHO’s International Health Regulations, which require countries to be transparent about disease threats they face but which also seek to shield countries dealing with outbreaks from retaliatory actions from other countries for having been transparent.

On Thursday, the WHO issued interim guidance for travel during outbreaks of filovirus diseases — Marburg is caused by a filovirus. It lays out advice for screening of people leaving an area where a filovirus outbreak is underway, and what people returning from an affected area should do if they develop symptoms within 21 days of their return. It does not mention the U.S. travel advisories.

Rwanda’s health minister, Sabin Nsanzimana, said the country is doing active exit screening, and has barred people who are contacts of confirmed cases from leaving the country while they are within the disease’s incubation period, 21 days after exposure.

“This is our International Health Regulation responsibility, that we protect our community, our population here, but also the populations of the world,” Nsanzimana said. “The faster we stop it, the better for everyone.”

Kaseya complained that the U.S. action was taken without consultation with or advance notice to Africa CDC or the Rwandan government, a move he called disrespectful. He said he complained to high-ranking U.S. officials and was given what he characterized as a “clear commitment” that in future, such a move would not be made without consultation. 

Marburg is caused by a virus that is related to those that cause Ebola. The diseases manifest and spread in similar ways, and have similarly high fatality rates. While there are two licensed vaccines for Zaire ebolavirus, there are no licensed vaccines or drugs for Marburg. 

There is, however, an experimental vaccine being developed by the Sabin Vaccine Institute that Rwanda has been using. The U.S. government shipped 700 doses of the vaccine — which is used in a one-dose regime — to Rwanda last weekend. Another 1,000 doses are set to arrive either Thursday or Friday, the Sabin Institute told STAT.

The vaccine is currently being tested for safety and immunogenicity — its ability to generate an immune response — in a Phase 2 clinical trial being conducted in Kenya and Uganda. 

The Rwandan Health Ministry’s update for Thursday said that so far 346 doses have been administered to people who were exposed to confirmed cases, particularly those working in two Kigali hospitals where the risk of exposure is deemed to be high. 

“Our aim is to save as many lives as quickly as possible and also to stop the spread,” the health minister said. “Because when it gets too far into the community, that’s the worst case scenario. … Time and speed matters a lot.” 

Nsanzimana, who said the origins of the outbreak are still being investigated, has said all the new cases that have occurred since the outbreak was declared on Sept. 27 have been among health workers or their contacts. 

The WHO has been working for several years to ready countries to be able to test experimental vaccines in situations such as this one, including developing a number of clinical trial protocols that can be pre-approved. But at present, Rwanda is using the vaccine in an open-label approach, Nsanzimana said — giving it to anyone known to have been in the path of the virus. 

One of the proposed trial designs is what’s known as a delayed ring vaccination trial, where people who were in contact with a confirmed case either get vaccinated immediately or after a delay. This is the design that was used to prove that the first approved vaccine for Zaire ebolavirus, Merck’s Ervebo, actually works. 

Nsanzimana said Rwanda may consider moving to a delayed ring vaccination approach later, but for now it is focused on vaccinating those at highest risk. “For us, saving lives matters. Delaying also has its challenges and consequences,” he said when asked about the decision.