Evidence-based recommendations for supportive care, fluid management, vasopressors and monitoring in Ebola, Marburg and related infections.
What this guideline saysGMJ summary
These guidelines provide GRADE-rated recommendations for the clinical management of all filovirus infections (Ebola, Sudan, Bundibugyo, Marburg, Taï Forest viruses). They expand on previous Ebola-specific guidance by applying systematic evidence reviews to key clinical decisions: monitoring, fluid resuscitation, vasopressor use, treatment of co-infection and management of haemorrhagic complications.
Strong recommendations include: systematic clinical and laboratory monitoring; balanced crystalloids (e.g. Ringer’s lactate) rather than 0.9% sodium chloride; norepinephrine rather than dopamine for shock; ultrasound-guided central line placement; and structured follow-up for survivors. Conditional recommendations address early vasopressor initiation, use of lactate and capillary refill time for monitoring, and tranexamic acid (recommended for postpartum haemorrhage but against for general haemorrhage due to DIC concerns).
The guideline emphasizes that high-quality supportive care reduces mortality even in resource-limited settings. It is designed for use alongside existing WHO guidance on infection prevention and control, specific therapeutics (mAb114, REGN-EB3 for Ebola virus), and facility design.
Key pointsfor clinicians
- Systematic patient monitoring with structured clinical assessment at regular intervals adapted to patient condition (good practice statement).
- For patients with some dehydration and ongoing gastrointestinal losses: protocolized oral rehydration (e.g. WHO Plan B) with 75 mL/kg ORS over first 4 hours (strong recommendation).
- For acute intravenous fluid resuscitation: use balanced crystalloids (Ringer's lactate) rather than 0.9% sodium chloride (strong recommendation, moderate certainty).
- For shock unresponsive to fluids: initiate norepinephrine early rather than late, using lowest effective dose to target arterial pressure (conditional recommendation for early use; strong recommendation for norepinephrine over dopamine).
- Peripheral intravenous administration of vasopressors is preferred initially (conditional recommendation); transition to central venous catheter placed under ultrasound guidance when needed (strong recommendation).
- Use serial lactate and capillary refill time (CRT >3 seconds abnormal) as part of perfusion assessment to guide fluid management (conditional recommendations, low certainty).
- Presumptive broad-spectrum antibiotics in suspected sepsis or bacterial co-infection (conditional recommendation for, low certainty).
- Tranexamic acid is suggested <em>against</em> for general haemorrhage in filovirus disease but <em>for</em> postpartum haemorrhage (conditional recommendations, very low certainty for general use).
Composition of crystalloid fluids for resuscitationextracted from the guideline
| Component | Human plasma | 0.9% sodium chloride | Ringer's lactate | Plasma-Lyte 148 |
|---|---|---|---|---|
| Sodium (mmol/L) | 135–145 | 154 | 130 | 140 |
| Chloride (mmol/L) | 95–105 | 154 | 109 | 98 |
| Potassium (mmol/L) | 3.5–5.0 | 0 | 4 | 5 |
| Calcium (mmol/L) | 2.2–2.6 | 0 | 2.7 | 0 |
| Buffer (mmol/L) | Bicarbonate 23–27 | None | Lactate 28 | Acetate 27, Gluconate 23 |
| pH | 7.35–7.45 | 5.5 | 6.5 | 7.4 |
What changed in this edition
- First WHO guideline to cover all filoviruses (Ebola, Sudan, Bundibugyo, Marburg, Taï Forest) rather than Ebola virus disease alone.
- Systematic evidence reviews and GRADE methodology replace previous expert-defined best practice approach.
- New strong recommendation for balanced crystalloids over 0.9% sodium chloride based on moderate certainty evidence.
- Conditional recommendation against tranexamic acid for general haemorrhage in filovirus disease (reverses previous practice in some settings).
- Peripheral administration of vasopressors now recommended as initial route, with transition to ultrasound-guided central access.
- Laboratory monitoring now recommended based on clinical assessment rather than routine testing to optimize resource use.
ApplicabilityGeorgia and the region
Georgia has experience managing viral haemorrhagic fever through its National Centre for Disease Control and Public Health and designated referral hospitals. Implementation of these guidelines would require: training clinical staff in protocolized fluid resuscitation (modified WHO Plan C) and early vasopressor use; procurement of balanced crystalloids (Ringer’s lactate), norepinephrine, point-of-care lactate testing and portable ultrasound for central line placement; designation of isolation facilities with appropriate infection prevention infrastructure; and stockpiling of essential monitoring equipment. The Georgian EPI programme’s experience with outbreak response and the established critical care capacity in Tbilisi and regional centres provide a foundation, though surge capacity planning and pre-positioned supplies would be essential for a filovirus event. Regional coordination through the Caucasus and Central Asia network would support cross-border preparedness.
Questions this guideline answers
When should I start vasopressors in a filovirus patient with shock?
Initiate vasopressors early after initial fluid resuscitation (typically after 1000–2000 mL in adults, or 30 mL/kg in children) if shock persists, rather than waiting for large fluid volumes. Start with norepinephrine via peripheral IV at 0.05 µg/kg/min, titrate to MAP target, and plan transition to central access. Monitor closely for extravasation every 30 minutes.
Why should I avoid tranexamic acid for bleeding in filovirus disease?
Although tranexamic acid reduces bleeding in trauma and surgery, filovirus-related haemorrhage often involves disseminated intravascular coagulation (DIC). Tranexamic acid may stabilize disseminated clots and worsen DIC, similar to its harmful effects when given >3 hours post-trauma. Use it only for postpartum haemorrhage where evidence of benefit is strong.
Which patients with filovirus disease need antibiotics?
Give presumptive broad-spectrum antibiotics (e.g. third-generation cephalosporin) when there is clinical suspicion of sepsis or bacterial co-infection (e.g. shock, high fever with respiratory signs, focal infection). Do not give routine antibiotics to all patients. Use laboratory tools (blood culture, biomarkers) when available to guide therapy and de-escalate appropriately to minimize antimicrobial resistance.
Related on GMJinterconnected resources
Dictionary of Public Health
GMJ News coverage
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- WHO Declares Hantavirus Pandemic Over as Ebola Resurgence Threatens AfricaSep 2026
- WHO releases first comprehensive clinical guidelines for Ebola and Marburg virus managementJul 2026
- Uganda Confirms First Marburg Case Amid Ongoing Ebola OutbreakJul 2026
Other guidelines on this topic
- Issuer
- World Health Organization
- Type
- Guideline
- Edition
- 1st edition, 2026
- Status
- Current
- Published
- 2026-06-12
- Languages
- English (publication states other languages may follow per WHO standard practice)
- Scope
- Clinical management of suspected or confirmed filovirus disease (Ebola, Sudan, Bundibugyo, Marburg, Taï Forest viruses) in all age groups; covers monitoring, fluid therapy, vasopressors, co-infection treatment, haemorrhage management and post-discharge follow-up. Excludes specific antiviral therapeutics (covered separately), vaccination, IPC and outbreak investigation.
- Audience
- Clinicians (physicians, nurses, midwives) caring for filovirus patients in treatment centres, isolation units and referral hospitals; national policy-makers planning outbreak response; public health professionals designing clinical protocols.
- Pages
- 86
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- B09774
- Evidence
- GRADE-rated recommendations based on systematic reviews of RCTs and observational studies; good practice statements where formal evidence synthesis would be disproportionate; multidisciplinary Guideline Development Group with field experience from multiple filovirus outbreaks.
- Next review
- Not specified (living document approach implied by reference to ongoing OSoC manual update)
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