Evidence-based recommendations for clinicians treating Ebola, Marburg, Sudan, Bundibugyo and Taï Forest virus infections worldwide.
What this guideline saysGMJ summary
These WHO guidelines provide comprehensive, evidence-based recommendations for the clinical management of all filovirus diseases (Ebola, Marburg, Sudan, Bundibugyo and Taï Forest viruses). Developed using the GRADE framework, they replace previous expert-consensus guidance and expand scope beyond Ebola virus disease alone. The guidelines emphasize that high-quality supportive care can reduce mortality, with recommendations covering systematic monitoring, fluid resuscitation, vasopressor therapy, laboratory monitoring, antimicrobial use and post-discharge follow-up.
Key messages include: use of protocolized oral rehydration (WHO Plan B) for patients with some dehydration; balanced crystalloids (Ringer’s lactate) rather than 0.9% sodium chloride for intravenous resuscitation; norepinephrine as first-choice vasopressor; presumptive broad-spectrum antibiotics for suspected sepsis; and structured post-discharge follow-up for all survivors. The guidelines acknowledge the challenges of implementing interventions in resource-limited outbreak settings with stringent infection prevention and control requirements.
The document provides 16 graded recommendations (8 strong, 8 conditional) plus one good practice statement, all with detailed implementation remarks. Each recommendation addresses feasibility, equity, acceptability and resource considerations relevant to outbreak contexts in low- and middle-income countries.
Key pointsfor clinicians
- Systematic patient monitoring should use structured clinical assessment at intervals adapted to patient condition (good practice statement)
- For some dehydration with ongoing gastrointestinal losses: use protocolized oral rehydration (WHO Plan B) with systematic monitoring
- For severe dehydration: use protocolized intravenous fluid regimen (modified Plan C) with frequent haemodynamic monitoring
- Use balanced crystalloids (Ringer's lactate) rather than 0.9% sodium chloride for acute intravenous fluid resuscitation
- For shock/circulatory impairment: use serial lactate measurement and capillary refill time (≥2 seconds abnormal) to guide fluid management
- For vasopressor therapy: use norepinephrine rather than dopamine or epinephrine; initiate early via peripheral intravenous catheter initially
- Use presumptive broad-spectrum antibiotics in confirmed filovirus disease with suspected sepsis or bacterial co-infection
- Suggest against tranexamic acid for general haemorrhage, but suggest for use in postpartum haemorrhage (within 3 hours of birth)
Clinical signs of dehydration severityextracted from the guideline
| Population | Some dehydration | Severe dehydration |
|---|---|---|
| Children | Two or more of: restlessness, irritability, sunken eyes, thirsty and drinks eagerly, skin pinch goes back slowly | Two or more of: lethargy or unconsciousness, sunken eyes, unable to drink or drinks poorly, skin pinch goes back very slowly (≥2 seconds) |
| Adults | Feeling thirsty, concentrated urine, infrequent urination, feeling dizzy or lightheaded, tiredness, dry mouth/lips/tongue, sunken eyes | Systolic BP <100 mmHg, heart rate >90 bpm, capillary refill time >2 seconds, cold peripheries, respiratory rate >20 breaths/min |
What changed in this edition
- Expanded scope from Ebola virus disease only to all filoviruses (Bundibugyo, Ebola, Marburg, Sudan, Taï Forest)
- Recommendations now based on systematic evidence searches and GRADE framework rather than expert consensus alone
- New evidence-based recommendations on vasopressor choice, fluid type, lactate and capillary refill monitoring
- Structured post-discharge follow-up now recommended with moderate certainty evidence
ApplicabilityGeorgia and the region
Georgia has limited endemic filovirus risk but may receive imported cases given its role as a regional referral centre and transport hub connecting Europe, Asia and the Middle East. National preparedness should ensure: availability of isolation facilities with appropriate infection prevention and control capacity; training of clinicians in protocolized fluid resuscitation (WHO Plans B and C); stockpiling of balanced crystalloids (Ringer’s lactate) and norepinephrine; establishment of biosafety level 3 laboratory capacity for filovirus diagnosis and monitoring; and protocols for post-discharge survivor follow-up including mental health, ophthalmology and reproductive health services. The recommendations on ultrasound-guided central venous access, lactate measurement and systematic monitoring align well with existing critical care capacity in Georgian tertiary hospitals, though outbreak response in remote areas of the Caucasus would require mobile laboratory and critical care capability.
Questions this guideline answers
What is the preferred intravenous fluid for resuscitation in filovirus disease?
Balanced crystalloids such as Ringer's lactate are strongly recommended rather than 0.9% sodium chloride, based on moderate certainty evidence of mortality reduction. The exception is patients with traumatic brain injury where normal saline may be preferred.
Which vasopressor should be used first-line in filovirus disease with shock?
Norepinephrine is strongly recommended over dopamine (moderate certainty evidence) and conditionally recommended over epinephrine (very low certainty). It can be initiated via peripheral intravenous catheter to avoid delay, with transition to central access anticipated.
Should all patients with filovirus disease receive antibiotics?
No. Presumptive broad-spectrum antibiotics are conditionally recommended only for confirmed filovirus disease with suspected sepsis or bacterial co-infection. Patients with low likelihood of bacterial infection should not routinely receive antibiotics but should be monitored and reassessed.
What laboratory tests are essential for filovirus treatment centres?
Core tests include: sodium, potassium, lactate, creatinine, glucose, complete blood count, malaria rapid test, HIV testing per national protocol, pregnancy test, blood group/matching, and urinalysis. Comprehensive centres should add urea, chloride, bicarbonate, calcium, phosphate, magnesium, creatinine kinase, liver enzymes, fibrinogen and blood culture capacity.
Should tranexamic acid be used for bleeding in filovirus disease?
Generally no – it is conditionally recommended against for general haemorrhage (from IV sites, gastrointestinal tract, oral mucosa) due to concerns about disseminated intravascular coagulation. However, it is conditionally recommended for postpartum haemorrhage, given within 3 hours of birth alongside standard uterotonic therapy.
Related on GMJinterconnected resources
Dictionary of Public Health
GMJ News coverage
- Issuer
- World Health Organization
- Type
- Guideline
- Edition
- 2026
- Replaces
- Previous WHO guidance focused on Ebola virus disease only (expert consensus-based)
- Status
- Current
- Published
- 2026-06-16
- Languages
- English
- Scope
- Clinical management of filovirus disease (Bundibugyo, Ebola, Marburg, Sudan, Taï Forest viruses) in adults, children and pregnant women
- Audience
- Clinicians, public health professionals, outbreak response teams managing filovirus disease worldwide
- Pages
- 19
- Licence
- CC BY-NC-SA 3.0 IGO
- Evidence
- GRADE-rated recommendations based on systematic reviews; 8 strong recommendations, 8 conditional recommendations, 1 good practice statement
GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
Was this article helpful?