On 10 July 2008, the WHO Regional Office for Europe was informed by the national International Health Regulations Focal Point of the Netherlands of a case of Marburg hemorrhagic fever (MHF) in a Dutch tourist who visited Uganda. The woman returned to the Netherlands on 28 June in good health. The first symptoms (fever, chills) occurred on 2 July and she was admitted to hospital on 5 July. Rapid clinical deterioration with liver failure and severe hemorrhaging occurred on 7 July. The patient died on 11 July 2008. Marburg virus infection has been laboratory confirmed by the Bernhard Nocht Institute in Hamburg, Germany.

This event constitutes a reminder for the need for awareness among clinicians for unusual health events. Dutch health authorities have adopted an exemplary approach to manage this event. A heightened degree of awareness as well as close communication between clinicians and public health professionals enables early detection and adequate management of rare events with potentially serious clinical and public health consequences both locally and internationally.

The 40-year-old woman travelled in Uganda from 5-28 June, 2008, and entered caves on two occasions. The first cave was visited on 16 June at Fort Portal. No bats were seen in this cave. She was reportedly exposed to fruit bats during a visit to the “python cave” in the Maramagambo Forest between Queen Elisabeth Park and Kabale on 19 June. This cave is thought to harbour bat species that have been found to carry filoviruses in other locations in sub-Saharan Africa. Filoviruses cause two types of viral hemorrhagic fever: Marburg and Ebola. A large bat population was seen in the cave and the woman is reported to have had direct contact with one bat.

Contact tracing and temperature monitoring have been initiated for approximately 100 unprotected contacts with a history of possible exposure to the case after 2 July.

Although further epidemiological investigation is needed to exclude other possible sites of exposure to MHF virus, as a precaution Dutch authorities have alerted the tour operator to avoid visits to the caves until further information is available.

No citizens of other countries were involved in this trip except for a local tour guide, but the cave in the Maramagambo Forrest is known to be a tourist attraction. No measures were taken with respect to the passengers on the flight from Uganda as the flight occurred four days before the onset of symptoms in the patient.

WHO has informed the Ministry of Health Uganda which will take appropriate steps nationally to investigate these events, and WHO has recommended that the MoH advise all residents and travellers to avoid entering caves with bat populations.