Transforming health systems in crisis: innovative infrastructure adaptations for Marburg outbreak response in Biharamulo, Kagera, Tanzania

Introduction Marburg virus disease (MVD) is a highly fatal viral haemorrhagic fever (VHF), like Ebola, in the filoviridae family with a fatality rate that can reach as high as 88%.1 2 To curb the MVD outbreak, a rapid coordinated emergency response alongside stringent infection prevention and control (IPC) measures is required. MVD outbreaks have occurred sporadically in specific regions since the disease was first identified in 1967 during outbreaks in Marburg, Germany and Yugoslavia, linked to infected monkeys imported from Uganda.3 Subsequent outbreaks have been reported in the Democratic Republic of Congo,4 Angola,5 Uganda6 7 and, most recently, Equatorial Guinea in 2023 and Rwanda in 2024. The absence of specific antiviral treatments or approved vaccines further exacerbates its devastating impact. On 21 March 2023, Tanzania experienced its first MVD outbreak in the Kagera region, located in the northwestern part of the country. The outbreak was triggered by a cluster of illnesses and deaths in Bukoba district, which were confirmed as MVD through laboratory testing. The outbreak lasted for 72 days, ending on 1 June 20238 9 and six patients died. The second outbreak in Tanzania occurred in the same region but in a different district (Biharamulo) on 20 January 2025.10 VHF treatment units play a crucial role in responding to these outbreaks by providing a safe environment for optimal patient care and reducing transmission risks through the isolation and treatment of infectious patients in a bio safe healthcare facility.11 The need for a designated treatment unit closer to areas of transmission has been emphasised to enhance the quality of care for patients and mitigate possible transmission risks; this has been termed decentralisation. While the advances in clinical care of MVD have significantly evolved and are well documented,12 the health system and infrastructure modifications of healthcare facilities during the outbreaks have been rarely addressed. In response to the MVD outbreak in Tanzania in 2025, a Marburg treatment unit (MTU) was rapidly established within an existing district hospital building constructed in 2018 to enhance outbreak management. All patients accessing healthcare in the hospital were transferred to other nearby facilities to continue with medical care, a critical intervention to prevent human-to-human transmission, which is the predominant form of MVD transmission. The facility was strategically repurposed into a dedicated MTU, with a structured layout designed to optimise patient management and IPC to meet the standards for the highly infectious disease treatment unit (IDTU).13 The MTU was organised into multiple treatment zones, effectively separating suspected and confirmed cases while implementing strict protocols to minimise viral transmission, cross contamination and observe biosecurity measures. The design emphasised controlled circulation, clear demarcation between high-risk and low-risk zones, and efficient management of personnel, patients, personal protective equipment (PPE), IPC and medical supplies and waste. This paper highlights the approaches adapted in the transformation of the Biharamulo district hospital facility into a treatment unit for MVD response, detailing its structural modifications, biosecurity and IPC strategies, and overall impact on the safety of frontline healthcare workers (HCWs), outbreak containment and patient outcomes. This article aims to document innovative solutions used in transforming an existing hospital into an MTU and to share such best practices for adapting healthcare infrastructure in resource-limited settings for future outbreaks of highly infectious diseases. Study design This is real-time operational research conducted at MTU in Biharamulo, Tanzania, a facility rapidly adapted from an existing hospital structure established in 2018. A comprehensive data collection approach was employed, incorporating observational assessments, facility design analysis and clinical data review. Study setting Tanzania is a country of 67 million people, with 26 geopolitical regions and 139 districts. Kagera region is one of the 26 regions and is in the north-western part of Tanzania, bordering Uganda in the north, Rwanda and Burundi in the west. Biharamulo district is one of the eight districts of the Kagera region of Tanzania with 457 114 population.14 It is bordered to the north by Karagwe district and Muleba district, to the east and south by Geita Region, to the west by Ngara District and to the southwest by the Kigoma Region. Its administrative seat is Biharamulo town. Biharamulo Game Reserve is located within the borders of the district. Biharamulo has 17 wards and the outbreak occurred only in Ruziba ward in which one village was affected. figure 1.