Learning Objectives
Identify the four viral families that cause hemorrhagic fevers
Recognize clinical presentation and phases of VHF disease
Explain transmission routes and why VHFs are NOT airborne
Implement enhanced PPE requirements for VHF patients
Demonstrate proper donning and doffing sequences with trained observer
Provide supportive nursing care for VHF patients
Viral Hemorrhagic Fever Overview
What are VHFs?
Viral hemorrhagic fevers are caused by RNA viruses from four distinct families. They share the ability to damage the vascular system and impair blood clotting, leading to hemorrhage, shock, and multi-organ failure.
Ebola, Marburg
Lassa, Junin, Machupo
CCHF, Rift Valley, Hantavirus
Yellow fever, Dengue
Bioterrorism Potential
The Soviet Union weaponized both Ebola and Marburg viruses. VHFs are considered high-priority bioterrorism threats due to their high mortality, potential for person-to-person spread, and ability to cause widespread panic.
Viral Hemorrhagic Fevers: Ebola in Focus
An overview of Ebola virus disease — transmission, clinical course, and the infection-control challenges that make VHFs uniquely dangerous in a healthcare setting.
Filoviruses: Ebola & Marburg
Ebola Virus Disease
Depends on strain and available care
Average 8-10 days
Central/West Africa: DRC, Guinea, Liberia, Sierra Leone, Uganda
Ervebo (rVSV-ZEBOV) - FDA approved for Zaire ebolavirus
Marburg Virus Disease
Similar presentation to Ebola
Average 5-7 days
Africa: Angola, DRC, Kenya, Uganda
Egyptian fruit bats; caves and mines are high-risk
Active Outbreak Alert: 2026 Bundibugyo Ebola Epidemic
DATA AS OF 7 OCT 2026Transmission is ongoing in the Democratic Republic of the Congo. WHO determined this epidemic a Public Health Emergency of International Concern on 17 May 2026. It is the largest outbreak of Bundibugyo virus ever recorded and the DRC's 17th Ebola outbreak. Uganda's outbreak was declared over on 27 August 2026 after 20 confirmed cases, 2 deaths and 18 recoveries.
Critical: no licensed vaccine or treatment exists for this strain
This epidemic is caused by Bundibugyo virus, not Zaire ebolavirus. The FDA-approved countermeasures covered elsewhere in this module — Ervebo, Inmazeb and Ebanga — are specific to Zaire ebolavirus and are not licensed for Bundibugyo virus disease. WHO states that evidence of cross-protection between Ebola species remains limited and inconclusive, and that Ervebo should not be used outside carefully designed research settings.
Candidates prioritized by WHO on 28 May 2026, all for use within clinical trials: monoclonal antibodies MBP134 and maftivimab and the antiviral remdesivir for treatment; oral obeldesivir for post-exposure prophylaxis; and the vaccine candidates rVSV‑Bundibugyo (IAVI) and ChAdOx1‑Bundibugyo (Oxford / Serum Institute of India).
Geographic spread
- • DRC provinces affected: Bas-Uélé, Haut-Uélé, Ituri, North Kivu, South Kivu, Sud-Ubangi, Tshopo
- • Most recent health zone: Alimbongo, North Kivu
- • Exported cases: Uganda (outbreak now closed), Kenya (1 case reported 6 Oct 2026), France (1 case, resolved); patients were also medically evacuated to Germany and the Netherlands
- • WHO risk assessment (14 Aug 2026): very high in the DRC, high in bordering countries, low for the rest of the African region and globally
United States status
- • No Ebola cases associated with this outbreak have been reported in the United States.
- • CDC travel notices: Level 4 (avoid all travel) for Ituri and Nord-Kivu; Level 3 (reconsider nonessential travel) for Haut-Uele and Tshopo; Level 2 (enhanced precautions) for the rest of the DRC and for Uganda
- • Entry screening: travelers from Uganda or South Sudan are routed through Washington-Dulles, Atlanta or JFK
- • Post-arrival monitoring: 21 days after departure from an affected country; travelers from the DRC take a temperature daily
What this means at your triage desk
A febrile patient within 21 days of travel to the DRC is a screen, isolate and notify event, not a diagnostic puzzle to work through at the bedside. Place the patient in a private room, apply the enhanced PPE described below, limit the number of staff entering, and contact your facility's infection prevention team and the Southern Nevada Health District or your local health authority before further workup. Phlebotomy and other specimen collection should wait for health-department direction. Calling ahead lets the receiving facility prepare; a walk-in that is recognized late is how the 2014 Dallas transmissions happened.
Sources: WHO, Disease Outbreak News, Ebola disease caused by Bundibugyo virus – Democratic Republic of the Congo (8 Oct 2026; data as of 6 Oct 2026) · CDC, Ebola Outbreak: Current Situation (totals as of 7 Oct 2026) · CDC, Information for Travelers Returning from Ebola-Affected Areas · WHO, PHEIC determination (17 May 2026) · WHO, Expert advice on candidate treatments and vaccines (28 May 2026) · WHO AFRO, Uganda ends Ebola outbreak (27 Aug 2026).
Scope note: Hantavirus is included here for clinical completeness due to recent news and public interest in 2026. Unlike the filoviruses above, it is rodent-borne, not transmitted person-to-person, and is not a CDC Category A bioterrorism agent.
Hantavirus: Pulmonary Syndrome & Hemorrhagic Fever
An overview of hantavirus disease — rodent-borne transmission, the two major clinical syndromes (Hantavirus Pulmonary Syndrome and Hemorrhagic Fever with Renal Syndrome), and why early recognition is critical.
Clinical Presentation & Phases
EARLY/PRODROMAL PHASE (Days 1-3)
Non-specific symptoms: High fever, severe headache, myalgia, fatigue, sore throat
Indistinguishable from influenza, malaria, or other febrile illnesses
GI PHASE (Days 3-5)
GI symptoms predominate: Severe nausea, vomiting, diarrhea, abdominal pain
Massive fluid losses lead to dehydration and electrolyte imbalances
HEMORRHAGIC PHASE (Days 5-7+)
Bleeding manifestations: Petechiae, ecchymoses, mucosal bleeding (gums, nose), GI bleeding, hematuria
Not all patients develop overt bleeding - absence doesn't rule out VHF
TERMINAL/RECOVERY PHASE (Days 7-12+)
Death: Multi-organ failure, shock, DIC, cardiac arrhythmias
Recovery: Prolonged convalescence, weakness, arthralgia; survivors may shed virus for weeks
Laboratory Findings
- • Thrombocytopenia (low platelets)
- • Leukopenia early, then leukocytosis
- • Elevated transaminases (AST, ALT)
- • Elevated BUN/creatinine
- • DIC parameters: prolonged PT/PTT, elevated D-dimer
- • Low albumin, metabolic acidosis
Transmission
CRITICAL: Ebola is NOT Airborne
Despite common misconceptions, Ebola and most VHFs are NOT transmitted through the air. They spread through direct contact with body fluids.
This is why contact precautions - not airborne precautions - are the primary protection. However, negative pressure rooms are recommended when available.
HOW VHFs ARE Transmitted
- •Direct contact with blood
- •Contact with body fluids (vomit, diarrhea, urine, sweat, semen)
- •Mucous membrane exposure (eyes, nose, mouth)
- •Needlestick injuries
- •Contact with contaminated surfaces
- •Handling deceased bodies
HOW VHFs are NOT Transmitted
- •Airborne droplet nuclei
- •Casual contact (unless body fluids involved)
- •Food or water (except in endemic areas)
- •Mosquito bites (Ebola/Marburg)
- •Asymptomatic individuals
Key Point: Patients are NOT infectious until symptomatic. Contact tracing focuses on the period after symptom onset.
Highest-Risk Period
Viral load increases as disease progresses. Patients are most infectious during the hemorrhagic phase when viral titers are highest and bodily fluid production (vomiting, diarrhea, bleeding) is greatest.
Enhanced PPE for VHFs
WARNING: Standard Contact Precautions are INSUFFICIENT
VHF patients have high viral loads in all body fluids. Standard hospital gowns and gloves do NOT provide adequate protection. Enhanced PPE is mandatory.
Required PPE Components
Tyvek suit or fluid-resistant isolation gown
PAPR preferred; N95 must be fit-tested
Outer gloves extended over gown cuffs, taped
Or dedicated boots that stay in isolation area
If significant fluid exposure anticipated
If not using PAPR with integrated hood
Isolation Room Requirements
- • Private room with adjoining anteroom for donning/doffing
- • Negative pressure with 6-12 air changes/hour (ideal)
- • Dedicated equipment - stethoscope, BP cuff stay in room
- • Waste management - autoclave or chemical treatment before disposal
- • Environmental decontamination - 0.5% hypochlorite (bleach) solution
Donning & Doffing Protocols
THE TRAINED OBSERVER IS MANDATORY
A trained observer MUST supervise every donning and especially every doffing procedure. Most healthcare worker infections occur during improper PPE removal.
The Dallas Lesson (2014): Two nurses were infected while caring for an Ebola patient. Both infections likely occurred during doffing. After the CDC mandated trained observers, no healthcare workers in designated treatment centers were subsequently infected.
DONNING SEQUENCE
Putting on PPE - performed in anteroom with observer
- 1Perform hand hygiene
- 2Put on inner gloves
- 3Put on coverall/gown (tie/zip securely)
- 4Put on boot covers
- 5Put on N95/PAPR
- 6Put on hood (if not using PAPR)
- 7Put on face shield/goggles
- 8Put on apron (if needed)
- 9Put on outer gloves (tape to sleeves)
- 10Observer verifies all components
DOFFING SEQUENCE
HIGHEST RISK! Removing contaminated PPE with observer
- 1Disinfect outer gloves
- 2Remove apron (if worn)
- 3Disinfect outer gloves again
- 4Remove outer gloves (inside-out)
- 5Disinfect inner gloves
- 6Remove face shield (by strap only!)
- 7Remove hood/PAPR
- 8Remove coverall (inside-out, rolling down)
- 9Remove boot covers with coverall
- 10Remove N95 (by straps only!)
- 11Remove inner gloves (inside-out)
- 12FINAL hand hygiene
Trained Observer Responsibilities
- • Read each step aloud from written checklist
- • Watch for ANY contact with contaminated surfaces
- • STOP the process immediately if error occurs
- • Guide remediation if contamination occurs
- • Document completion of each step
- • NEVER allow rushing - fatigue causes errors
Nursing Care for VHF Patients
Fluid Management
- • Aggressive fluid resuscitation - patients lose massive volumes through GI tract
- • Monitor urine output (goal >0.5 mL/kg/hr)
- • Replace electrolytes (especially K+, Mg++)
- • May need 5-10 L/day in severe cases
- • Colloids if severe hypoalbuminemia
Hemorrhage Management
- • Monitor for signs of bleeding
- • Blood products: PRBCs, platelets, FFP as needed
- • Avoid IM injections (causes hematoma)
- • Minimize venipuncture - use saline locks
- • Apply pressure to all puncture sites
Hemodynamic Support
- • Continuous cardiac monitoring
- • Vasopressors for refractory shock
- • Watch for arrhythmias (electrolyte imbalances)
- • Central line if needed (but infection risk)
Supportive Measures
- • Antiemetics for nausea/vomiting
- • Antidiarrheals with caution
- • Pain management - avoid NSAIDs (bleeding risk)
- • Nutritional support (enteral if tolerated)
Psychological Support
VHF patients are terrified and isolated. They cannot have normal human contact. Provide emotional support through communication, explain procedures, and arrange video calls with family if possible. Staff psychological support is equally important - caring for VHF patients is traumatic.
Treatment Options
| Virus | Specific Treatment | Status |
|---|---|---|
| Ebola (Zaire) | Inmazeb (atoltivimab/maftivimab/odesivimab) Ebanga (ansuvimab) |
FDA Approved |
| Ebola (Zaire) | Ervebo vaccine (rVSV-ZEBOV) | FDA Approved (prevention) |
| Lassa Fever | Ribavirin - most effective if given early | Off-label / IND |
| CCHF | Ribavirin - may reduce mortality | Off-label / IND |
| Marburg | Supportive care only; monoclonal antibodies investigational | No specific treatment |
| Hantavirus | Supportive care; ribavirin investigational | No specific treatment |
The 2018-2020 DRC Outbreak Breakthrough
During the DRC Ebola outbreak, clinical trials showed that monoclonal antibody treatments (Inmazeb and Ebanga) significantly improved survival - reducing mortality from ~70% to ~34% when given early. These became the first FDA-approved treatments for Ebola in 2020.
Key Takeaways
VHFs are caused by 4 viral families: Filoviridae, Arenaviridae, Bunyaviridae, Flaviviridae
Ebola is transmitted by DIRECT CONTACT with body fluids - NOT airborne
Patients are NOT infectious until symptomatic
Standard contact precautions are INSUFFICIENT - enhanced PPE required
A TRAINED OBSERVER is MANDATORY for all donning and doffing
Most HCW infections occur during DOFFING - never rush
Ribavirin is effective for Lassa fever if given early
FDA-approved Ebola treatments (Inmazeb, Ebanga) significantly improve survival