Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

all patients

1st line – isolation and infection prevention and control

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all patients
1st line – 

isolation and infection prevention and control

Infection prevention and control (IPC) is of immediate concern and local protocols should be followed. Patients who are identified as being at risk of infection as per case definitions should immediately be isolated, and personal protective equipment (PPE) should be used until the infection is either confirmed or excluded.​[92]

The CDC and WHO produce detailed guidance on IPC in healthcare settings:

WHO: infection prevention and control guideline for Ebola and Marburg disease Opens in new window

CDC: infection prevention and control recommendations for patients in US hospitals who are suspected or confirmed to have selected viral hemorrhagic fevers (VHF) Opens in new window​​

CDC: guidance for personal protective equipment (PPE) Opens in new window​​​

Specimens for laboratory investigations (e.g., Ebola RT-PCR, FBC, serum creatinine and urea, LFTs, ABG, coagulation studies, blood cultures, and investigations for other conditions such as malaria) should be collected and sent off according to local and national protocols. Judicious selection of investigations is important in order to reduce risk of transmission to laboratory workers and other healthcare personnel.

WHO: how to safely collect blood samples from persons suspected to be infected with highly infectious blood-borne pathogens Opens in new window​​​

CDC: collection, transport, and submission for Ebola virus testing in the US Opens in new window

Placement of a central line early in the patient stay (if possible) allows bloods to be taken and fluids to be given while minimising the risk of needlestick injuries.[142]

A staffing ratio of at least one clinician (defined as nurses, clinical officers, or physicians) to four patients is recommended to allow patient assessment three times daily.[145]

Healthcare workers should facilitate communication with family and friends (e.g., use of mobile phones or the internet) in order to reduce psychological distress without increasing the risk of infection.[145]

Ebola disease is a notifiable disease.

Plus – fluid and electrolyte management

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all patients
Plus – 

fluid and electrolyte management

Treatment recommended for ALL patients in selected patient group

Oral rehydration solutions can be used for patients who can tolerate oral administration and who are not severely dehydrated, but the majority of patients require intravenous fluid replacement with either normal saline or lactated Ringer's solution.[20][94]Options include the peripheral or central intravenous route, or the intraosseous route.[145]

The volume of intravenous fluids required should be assessed based on clinical examination (i.e., level of dehydration, signs of shock) and fluid losses (i.e., volume of diarrhoea and/or vomitus). Large volumes of fluid replacement (up to 10 L/day) may be required in febrile patients with diarrhoea.[45]

Close supervision and frequent monitoring are required as it is important to assess response and prevent fluid overload. Patients should be checked frequently for signs of shock, dehydration, or overhydration, and the fluid rate adjusted accordingly. Systematic monitoring of vital signs (e.g., heart rate, blood pressure, urine output, gastrointestinal fluid loss) and volume status at least three times daily is required to detect hypovolaemia.[145]

The availability of point-of-care tests within the isolation facility makes monitoring the patient's biochemical status more efficient and reduces the risks associated with specimen transport.[115] Electrolyte monitoring should be performed daily, and repletion given as necessary.[20] More frequent monitoring can be considered if large volumes of intravenous fluids are being administered or if there are severe biochemical abnormalities present.

Large amounts of potassium replacement (e.g., 5-10 mmol [5-10 mEq/L] potassium chloride per hour) may be required.[22][134][148]

High blood lactate levels can be a reliable measure of hypoperfusion and can help guide fluid resuscitation.[115]

WHO guidelines should be consulted for specific recommendations on fluid and electrolyte management as well as on maintaining adequate nutrition during acute illness and the convalescent phase.

WHO: optimized supportive care for Ebola virus disease Opens in new window

WHO: clinical management of patients with viral haemorrhagic fever: a pocket guide for the front-line health worker Opens in new window

WHO: manual for the care and management of patients in Ebola care units/community care centres - interim emergency guidance Opens in new window

Plus – analgesia/antipyretic

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all patients
Plus – 

analgesia/antipyretic

Treatment recommended for ALL patients in selected patient group

Should be treated with paracetamol first line (for pain and fever).[143][152]

Opioid analgesics (e.g., tramadol, morphine) are preferable for more severe pain.[143][152]

Non-steroidal anti-inflammatory drugs (including aspirin) should be avoided due to their associated increased risk of bleeding and potential for nephrotoxicity.[143][152]

Analgesia may help dysphagia, if present.

Primary options

paracetamol: children: 10-15 mg/kg orally/rectally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 500-1000 mg orally/rectally every 4-6 hours when required, maximum 4000 mg/day

Secondary options

tramadol: children: consult specialist for guidance on dose; adults: 50-100 mg orally (immediate-release) every 4-6 hours when required, maximum 400 mg/day

OR

morphine sulfate: children: 0.2 to 0.4 mg/kg orally every 4-6 hours when required, or 0.05 to 0.1 mg/kg intravenously every 4-6 hours when required; adults: 2.5 to 10 mg orally/intravenously every 4 hours when required

Plus – anti-emetic

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all patients
Plus – 

anti-emetic

Treatment recommended for ALL patients in selected patient group

Oral or intravenous anti-emetics (e.g., ondansetron, promethazine) are recommended.[143][152]

Primary options

ondansetron: children: consult specialist for guidance on dose; adults: 8 mg orally every 12 hours, or 4 mg intravenously every 8 hours when required

OR

promethazine: children: consult specialist for guidance on dose; adults: 12.5 to 25 mg orally every 4-6 hours when required

Consider – antiviral monoclonal antibody

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all patients
Consider – 

antiviral monoclonal antibody

Additional treatment recommended for SOME patients in selected patient group

The WHO strongly recommends either atoltivimab/maftivimab/odesivimab (also known as REGN-EB3) or ansuvimab (also known as mAb114) for patients with confirmed infection with Ebola virus (species Orthoebolavirus zairense), and neonates ≤7 days of age with unconfirmed infection who are born to mothers with confirmed infection with Ebola virus (species Orthoebolavirus zairense).[162] Efficacy has not been established for other species of orthoebolaviruses.

Atoltivimab/maftivimab/odesivimab and ansuvimab are approved by the Food and Drug Administration (FDA) for the treatment of infection with Ebola virus (species Orthoebolavirus zairense) in children and adults, and atoltivimab/maftivimab/odesivimab has received orphan drug designation from the European Medicines Agency.

Atoltivimab/maftivimab/odesivimab and ansuvimab probably reduce mortality compared with standard of care (moderate-certainty evidence), ZMapp, and remdesivir. However, they may have little or no effect on time to viral clearance. It is very uncertain whether they increase the risk of serious adverse events.[162][164]​ The PALM trial found that of the patients who received atoltivimab/maftivimab/odesivimab, 33.5% died at 28 days compared to 51.0% of patients in the control group (ZMapp). Of the patients who received ansuvimab, 35.1% died at 28 days compared to 49.7% of patients in the control group.[163]

Adverse effects include hypersensitivity and infusion-related reactions, fever/chills, tachycardia, tachypnoea, hypotension, and elevated hepatic enzymes.

Both treatments are administered as a single dose intravenous infusion, and should be given as soon as possible after diagnosis. They may be used in older people, pregnant and breastfeeding women, and children and newborns.

Access to these therapeutics is challenging in many parts of the world, and choice depends on availability. They may need to be used under a compassionate use framework during an outbreak.

Primary options

atoltivimab/maftivimab/odesivimab: children and adults: 50 mg/kg of each component as a single intravenous infusion

OR

ansuvimab: children and adults: 50 mg/kg as a single intravenous infusion

Consider – broad-spectrum antibiotics

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all patients
Consider – 

broad-spectrum antibiotics

Additional treatment recommended for SOME patients in selected patient group

In some settings, especially in endemic areas where there is poor access to diagnostic tests, patients are routinely given broad-spectrum antibiotics as part of the management protocol. If started, reassess after 48 hours.[143]

Consider – convalescent whole blood or plasma

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all patients
Consider – 

convalescent whole blood or plasma

Additional treatment recommended for SOME patients in selected patient group

There is limited evidence from past outbreaks that transfusion of blood from convalescent patients could be beneficial in the acute phase of infection, and may reduce mortality.[6][157] Use of convalescent plasma is likely to be more achievable and effective than use of whole blood.[158][159]

Trials carried out in Guinea failed to show a survival benefit in patients treated with convalescent plasma, although the treatment appeared to be safe with no severe complications documented.[160][161]

The WHO has issued interim guidelines on the use of convalescent blood/plasma.

WHO: use of convalescent whole blood or plasma collected from patients recovered from Ebola virus disease for transfusion, as an empirical treatment during outbreaks Opens in new window

WHO: ethics of using convalescent whole blood and convalescent plasma during the Ebola epidemic Opens in new window

Plus – antacid or proton-pump inhibitor

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all patients
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with heartburn/ dysphagia/ abdominal pain
Plus – 

antacid or proton-pump inhibitor

Treatment recommended for ALL patients in selected patient group

Patients may benefit from administration of a suitable antacid or a proton-pump inhibitor (e.g., omeprazole).[143][152] Analgesia may help with dysphagia.

Primary options

omeprazole: children ≥10 years of age and adults: 20 mg orally once daily

Plus – supportive therapies

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all patients
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with diarrhoea
Plus – 

supportive therapies

Treatment recommended for ALL patients in selected patient group

Zinc is recommended in children with diarrhoea.[152]

Patients should be evaluated for gastrointestinal infections and managed accordingly.[152]

Faecal management systems were used successfully in the 2014 outbreak in West Africa in patients with severe diarrhoea. They were well tolerated and provided infection prevention and control benefits for healthcare workers.[117]

Diarrhoea should be managed conservatively; the use of antimotility agents is not generally recommended.[143]

Primary options

zinc: children <6 months of age: 10 mg orally once daily for 10-14 days; children ≥6 months of age: 20 mg orally once daily for 10-14 days

Plus – benzodiazepine or anticonvulsant

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all patients
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with seizures
Plus – 

benzodiazepine or anticonvulsant

Treatment recommended for ALL patients in selected patient group

Although uncommon, seizures are a feature of advanced disease and pose a risk to healthcare workers because they increase the risk of contact with the patient's body fluids.

Recognition and correction of contributing factors (e.g., high temperature, hypoperfusion, electrolyte disturbances, hypoglycaemia) is essential.

A benzodiazepine (e.g., intravenous/intramuscular or rectal diazepam) can be used to abort the seizure while an anticonvulsant (e.g., phenobarbital) can be given for repeated seizures.[143][152]

Primary options

diazepam: children: consult specialist for guidance on dose; adults: 5-10 mg intravenously/intramuscularly initially, repeat every 10-15 minutes if required, maximum 30 mg/total dose

OR

diazepam rectal: children: consult specialist for guidance on dose; adults: 0.2 mg/kg rectally as a single dose, a second dose can be given in 4-12 hours if necessary

Secondary options

phenobarbital: children: consult specialist for guidance on dose; adults: 10 mg/kg intravenously initially, followed by 5 mg/kg every 30-60 minutes until seizures under control, maximum total loading dose 30 mg/kg

Plus – sedative

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all patients
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with agitation
Plus – 

sedative

Treatment recommended for ALL patients in selected patient group

Although uncommon, agitation may be associated with encephalopathy or possibly a direct effect of the virus on the brain, and can occur in advanced disease.

Judicious use of a sedative (e.g., haloperidol or a benzodiazepine) is imperative for keeping the patient calm and preventing needlestick injuries in healthcare workers.[143][152]

Repeat doses are based on clinical response.

Primary options

diazepam: children: consult specialist for guidance on dose; adults: 5 mg orally/intravenously as a single dose

OR

haloperidol: children: consult specialist for guidance on dose; adults: 5 mg intramuscularly as a single dose

Plus – oxygen

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all patients
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with respiratory distress
Plus – 

oxygen

Treatment recommended for ALL patients in selected patient group

Oxygen should be titrated to maintain SpO2 >94%. Patients should be evaluated for pneumonia, fluid overload, wheezing, and congestive heart failure and managed accordingly.[143][152]

Plus – sepsis management protocol

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all patients
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with sepsis/septic shock
Plus – 

sepsis management protocol

Treatment recommended for ALL patients in selected patient group

Identification of sepsis or septic shock should be done rapidly using established criteria. Management follows the same principles as for bacterial sepsis. Local guidance should be followed, but should include: broad-spectrum empirical antibiotic therapy, ideally given within one hour of recognition; rapid intravenous fluid resuscitation with assessment of response; and appropriate airway management and oxygen administration.[153]

Blood lactate levels are a useful tool to help assess perfusion and response to resuscitation.

In the absence of a response to initial management, inotropic support should be considered, preferably via a central venous catheter in an intensive care unit where invasive monitoring enables more aggressive fluid, electrolyte, and acid-base balance correction.[115][141]

Possibility of haemorrhage should be considered, particularly in patients with skin or mucosal bleeding.

WHO guidelines should be consulted for specific recommendations on the management of sepsis/septic shock.

WHO: optimized supportive care for Ebola virus disease Opens in new window

WHO: clinical management of patients with viral haemorrhagic fever: a pocket guide for the front-line health worker Opens in new window

WHO: manual for the care and management of patients in Ebola care units/community care centres - interim emergency guidance Opens in new window

Plus – supportive care

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all patients
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with organ dysfunction
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

Multi-organ dysfunction is a common feature of advanced infection and includes acute kidney injury, pancreatitis, adrenal failure, and liver damage.

Liver damage (e.g., hepatitis) is common; however, jaundice is not a common feature.[69]

Renal dysfunction is common in the advanced stages, but can be reversed with adequate fluid resuscitation in the initial stages.[69] In patients with anuria who do not respond to fluid resuscitation, renal replacement therapy has been used, although there are no trial data to support the efficacy of this intervention. Of the 5 critically ill patients in Europe and North America with multi-organ failure who were managed with both invasive mechanical ventilation and renal replacement therapy, 3 died.[45][107][134][136][156]

Plus – transfusion, vitamin K, tranexamic acid, or proton-pump inhibitor

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all patients
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with significant bleeding/haemorrhage
Plus – 

transfusion, vitamin K, tranexamic acid, or proton-pump inhibitor

Treatment recommended for ALL patients in selected patient group

Major bleeding occurs infrequently, but is a manifestation of advanced infection that is usually, but not always, fatal.

When available, fresh whole blood or platelet and plasma transfusions should be given according to local protocols and guided by clinical and laboratory (if available) indicators (e.g., haemoglobin, haematocrit, INR).[143][152][154]

Vitamin K, tranexamic acid, or a proton-pump inhibitor (for gastrointestinal bleeding) are reasonable treatment options in patients who are bleeding.[143][152]

Primary options

phytomenadione: consult specialist for guidance on dose

OR

tranexamic acid: consult specialist for guidance on dose

OR

omeprazole: children ≥10 years of age and adults: 20 mg orally once daily

Plus – antimalarial therapy

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all patients
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with malaria
Plus – 

antimalarial therapy

Treatment recommended for ALL patients in selected patient group

Malaria should be tested for and treated with appropriate antimalarial therapy if present while keeping in mind the patient's risk for Ebola disease and the possibility of a dual infection. In endemic settings, malaria treatment is usually given as part of the routine management protocol, with or without confirmation of the infection.

Give empirical antimalarial therapy until the malaria testing is negative or the treatment course is finished.[143]

Plus – monitoring and early treatment of complications

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all patients
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pregnant
Plus – 

monitoring and early treatment of complications

Treatment recommended for ALL patients in selected patient group

The WHO recommends the following key management principles in pregnant women: use both standard precautions and Ebola-specific infection prevention and control measures; include optimised supportive care in the clinical management of all pregnant women; atoltivimab/maftivimab/odesivimab and ansuvimab may be offered to pregnant women in the context of rigorous research, or in accordance with local protocols; do not induce labour or perform invasive procedures for fetal indications in pregnant women with acute infection; advise women with suspected or confirmed acute infection not to breastfeed until after two negative breast milk tests (by RT-PCR) separated by 24 hours (in the meantime, infants should be separated from the mother and given a suitable breast milk substitute).[84]​​

Intrapartum haemorrhage and spontaneous abortion appear to be common in infected women; therefore, obstetric management should focus on monitoring for, and early treatment of, haemorrhagic complications.[21][166][168][169][170]

The CDC has produced specific guidance for caring for pregnant women and neonates:

CDC: clinical guidance for Ebola in people who are pregnant Opens in new window​​

​CDC: clinical guidance for neonates born to patients with suspected or confirmed Ebola disease Opens in new window​​

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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