CBRNE - Viral Hemorrhagic Fevers Treatment & Management

  • Author: David C Pigott, MD; Chief Editor: Zygmunt F Dembek, PhD, MPH, MS, LHD  more...
Updated: Mar 30, 2015

Prehospital Care

Supportive care is based on the patient's physiologic condition. Because most patients requiring prehospital evaluation and transport are in the early stages of the disease, universal precautions should be adequate. In patients with respiratory symptoms (eg, cough, rhinitis), use face shields and high-efficiency particulate air (HEPA) filter masks.


Emergency Department Care

Fluid resuscitation and supportive care are the mainstays of emergency department therapy. Intravenous crystalloids, oxygen, and cardiac monitoring are the most appropriate initial steps in the treatment of patients in whom viral hemorrhagic fever (VHF) is suggested. Other measures include the following:

  • Administer blood and blood products as clinically indicated
  • Avoid intramuscular injections and the use of aspirin or other anticoagulants
  • Minimize invasive procedures because of the risk associated with viral transmission from sharp objects

Infection control measures include the following:

  • Place patients in a private room
  • A negative pressure room is not necessary during early stages of the disease but may be necessary if patients have prominent cough, vomiting, diarrhea, or hemorrhage
  • Prevent nonessential staff and visitors from entering the room
  • All staff entering the room should wear gloves and gowns
  • Persons coming within 3 feet of the patient should wear face shields or surgical masks with eye protection (including side shields); use HEPA filter masks if patients have prominent respiratory, GI, or hemorrhagic symptoms
  • If large amounts of blood or other body fluids are present in the environment, use leg and shoe coverings
  • Before exiting the room, discard all used protective barriers and clean shoes with a hospital disinfectant or solution of household bleach
  • If possible, use an anteroom for putting on and removing protective barriers and for storing supplies
Contributor Information and Disclosures

David C Pigott, MD RDMS, FACEP, Professor of Emergency Medicine, Co-Director of Emergency Ultrasound, Vice Chair for Academic Development, Department of Emergency Medicine, University of Alabama at Birmingham School of Medicine

David C Pigott, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents' Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Zygmunt F Dembek, PhD, MPH, MS, LHD Associate Professor, Department of Military and Emergency Medicine, Adjunct Assistant Professor, Department of Preventive Medicine and Biometrics, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine

Zygmunt F Dembek, PhD, MPH, MS, LHD is a member of the following medical societies: American Chemical Society, New York Academy of Sciences

Disclosure: Nothing to disclose.

Additional Contributors

Jerry L Mothershead, MD Medical Readiness Consultant, Medical Readiness and Response Group, Battelle Memorial Institute; Advisor, Technical Advisory Committee, Emergency Management Strategic Healthcare Group, Veteran's Health Administration; Adjunct Associate Professor, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences

Jerry L Mothershead, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians

Disclosure: Nothing to disclose.


The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous author, Thomas W McGovern, MD, to the development and writing of this article.

  1. Simpson SQ, Spikes L, Patel S, Faruqi I. Hantavirus pulmonary syndrome. Infect Dis Clin North Am. 2010 Mar. 24(1):159-73. [Medline].

  2. Normile D. Emerging infectious diseases. Scientists puzzle over Ebola-Reston virus in pigs. Science. 2009 Jan 23. 323(5913):451. [Medline].

  3. Towner JS, Sealy TK, Khristova ML, et al. Newly discovered ebola virus associated with hemorrhagic fever outbreak in Uganda. PLoS Pathog. 2008 Nov. 4(11):e1000212. [Medline].

  4. Hayman DT, Yu M, Crameri G, et al. Ebola virus antibodies in fruit bats, Ghana, West Africa. Emerg Infect Dis. 2012 Jul. 18(7):1207-9. [Medline]. [Full Text].

  5. Lupi O. Mosquito-borne hemorrhagic fevers. Dermatol Clin. 2011 Jan. 29(1):33-8. [Medline].

  6. Rivers MN, Alexander JL, Rohde RE, Pierce JR Jr. Hantavirus pulmonary syndrome in Texas: 1993-2006. South Med J. 2009 Jan. 102(1):36-41. [Medline].

  7. CDC. Locally acquired Dengue--Key West, Florida, 2009-2010. MMWR Morb Mortal Wkly Rep. 2010 May 21. 59(19):577-81. [Medline].

  8. Government of Rio de Janeiro. Rio Against Dengue: Rio de Janeiro Movement Against Dengue. Dengue Case Report, Week 21, 2013. Available at http://www.riocontradengue.com.br/Site/Conteudo/PlantaoDetalhe.aspx?C=698. Accessed: June 28, 2013.

  9. Johansen LM, Brannan JM, Delos SE, et al. FDA-Approved Selective Estrogen Receptor Modulators Inhibit Ebola Virus Infection. Sci Transl Med. 2013 Jun 19. 5(190):190ra79. [Medline].

  10. De Clercq E. A Cutting-Edge View on the Current State of Antiviral Drug Development. Med Res Rev. 2013 Mar 11. [Medline].

  11. Burgeson JR, Moore AL, Gharaibeh DN, et al. Discovery and optimization of potent broad-spectrum arenavirus inhibitors derived from benzimidazole and related heterocycles. Bioorg Med Chem Lett. 2013 Feb 1. 23(3):750-6. [Medline].

  12. Ranjit S, Kissoon N. Dengue hemorrhagic fever and shock syndromes. Pediatr Crit Care Med. 2011 Jan. 12(1):90-100. [Medline].

  13. Lee AM, Pasquato A, Kunz S. Novel approaches in anti-arenaviral drug development. Virology. 2011 Mar 15. 411(2):163-9. [Medline]. [Full Text].

  14. Jiang X, Dalebout TJ, Bredenbeek PJ, et al. Yellow fever 17D-vectored vaccines expressing Lassa virus GP1 and GP2 glycoproteins provide protection against fatal disease in guinea pigs. Vaccine. 2011 Feb 1. 29(6):1248-57. [Medline].

  15. Morrison D, Legg TJ, Billings CW, Forrat R, Yoksan S, Lang J. A novel tetravalent dengue vaccine is well tolerated and immunogenic against all 4 serotypes in flavivirus-naive adults. J Infect Dis. 2010 Feb 1. 201(3):370-7. [Medline].

  16. Feldmann H, Jones SM, Daddario-DiCaprio KM, et al. Effective post-exposure treatment of Ebola infection. PLoS Pathog. 2007 Jan. 3(1):e2. [Medline]. [Full Text].

  17. Sarwar UN, Sitar S, Ledgerwood JE. Filovirus emergence and vaccine development: A perspective for health care practitioners in travel medicine. Travel Med Infect Dis. 2010 Jun 26. [Medline].

  18. Tuffs A. Experimental vaccine may have saved Hamburg scientist from Ebola fever. BMJ. 2009 Mar 23. 338:b1223. [Medline].

  19. Blaney JE, Wirblich C, Papaneri AB, et al. Inactivated or live-attenuated bivalent vaccines that confer protection against rabies and Ebola viruses. J Virol. 2011 Oct. 85(20):10605-16. [Medline]. [Full Text].

  20. Bausch DG, Hadi CM, Khan SH, Lertora JJ. Review of the literature and proposed guidelines for the use of oral ribavirin as postexposure prophylaxis for Lassa fever. Clin Infect Dis. 2010 Dec 15. 51(12):1435-41. [Medline].

  21. Borchert M, Muyembe-Tamfum JJ, Colebunders R, et al. Short communication: a cluster of Marburg virus disease involving an infant. Trop Med Int Health. 2002 Oct. 7(10):902-6. [Medline].

  22. CDC. Imported Lassa fever--New Jersey, 2004. MMWR Morb Mortal Wkly Rep. 2004 Oct 1. 53(38):894-7. [Medline].

  23. CDC. Outbreak of Ebola hemorrhagic fever Uganda, August 2000-January 2001. MMWR Morb Mortal Wkly Rep. 2001 Feb 9. 50(5):73-7. [Medline].

  24. CDC. Update: management of patients with suspected viral hemorrhagic fever--United States. MMWR Morb Mortal Wkly Rep. 1995. 44(25):475-9. [Medline]. [Full Text].

  25. Colebunders R, Borchert M. Ebola haemorrhagic fever--a review. J Infect. 2000. 40(1):16-20. [Medline].

  26. Feldmann H, Geisbert TW. Ebola haemorrhagic fever. Lancet. 2011 Mar 5. 377(9768):849-62. [Medline].

  27. Fisher-Hoch SP, Hutwagner L, Brown B, McCormick JB. Effective vaccine for lassa fever. J Virol. 2000 Aug. 74(15):6777-83. [Medline]. [Full Text].

  28. Fisher-Hoch SP, McCormick JB. Lassa fever vaccine. Expert Rev Vaccines. 2004 Apr. 3(2):189-97. [Medline].

  29. Geisbert TW, Daddario-Dicaprio KM, Geisbert JB, et al. Vesicular stomatitis virus-based vaccines protect nonhuman primates against aerosol challenge with Ebola and Marburg viruses. Vaccine. 2008 Dec 9. 26(52):6894-900. [Medline].

  30. Geisbert TW, Hensley LE. Ebola virus: new insights into disease aetiopathology and possible therapeutic interventions. Expert Rev Mol Med. 2004 Sep 21. 6(20):1-24. [Medline].

  31. Geisbert TW, Jahrling PB. Towards a vaccine against Ebola virus. Expert Rev Vaccines. 2003 Dec. 2(6):777-89. [Medline].

  32. Hartman AL, Towner JS, Nichol ST. Ebola and marburg hemorrhagic fever. Clin Lab Med. 2010 Mar. 30(1):161-77. [Medline].

  33. Holmes GP, McCormick JB, Trock SC, et al. Lassa fever in the United States. Investigation of a case and new guidelines for management. N Engl J Med. 1990. 323(16):1120-3. [Medline].

  34. Jahrling PB. Viral hemorrhagic fevers. Textbook of Military Medicine: Medical Aspects of Chemical and Biological Warfare. 1997.

  35. Leroy EM, Epelboin A, Mondonge V, et al. Human Ebola Outbreak Resulting from Direct Exposure to Fruit Bats in Luebo, Democratic Republic of Congo, 2007. Vector Borne Zoonotic Dis. 2009 Mar 26. [Medline].

  36. Leroy EM, Kumulungui B, Pourrut X, Rouquet P, Hassanin A, Yaba P. Fruit bats as reservoirs of Ebola virus. Nature. 2005 Dec 1. 438(7068):575-6. [Medline].

  37. Mahanty S, Bray M. Pathogenesis of filoviral haemorrhagic fevers. Lancet Infect Dis. 2004 Aug. 4(8):487-98. [Medline].

  38. McGovern TW, Christopher GW, Eitzen EM. Cutaneous manifestations of biological warfare and related threat agents. Arch Dermatol. 1999 Mar. 135(3):311-22. [Medline].

  39. Peters CJ, LeDuc JW. Ebola: the virus and the disease. J Infect Dis. 1999. 179 (Suppl 1):ix-xvi. [Medline]. [Full Text].

  40. Schmidt AC. Response to dengue fever--the good, the bad, and the ugly?. N Engl J Med. 2010 Jul 29. 363(5):484-7. [Medline].

  41. Stroher U, Feldmann H. Progress towards the treatment of Ebola haemorrhagic fever. Expert Opin Investig Drugs. 2006 Dec. 15(12):1523-35. [Medline].

  42. Towner JS, Rollin PE, Bausch DG, et al. Rapid diagnosis of Ebola hemorrhagic fever by reverse transcription-PCR in an outbreak setting and assessment of patient viral load as a predictor of outcome. J Virol. 2004 Apr. 78(8):4330-41. [Medline].

Ebola virus. Electron micrograph courtesy of the Centers for Disease Control and Prevention.
Marburg virus. Negative stain image courtesy of the Centers for Disease Control and Prevention.
Mastomys rodent, natural host of Lassa virus. Image courtesy of the Centers for Disease Control and Prevention.
Bunyavirus infection. Ecchymoses encompassing left upper extremity one week after onset of CCHF. Ecchymoses often are accompanied by hemorrhage in other locations: epistaxis, puncture sites, hematemesis, melena, and hematuria. Image provided by Robert Swaneopoel, PhD, DTVM, MRCVS, National Institute of Virology, Sandringham, South Africa.
Apodemus agrarius, the vector of Korean hemorrhagic fever caused by a hantavirus. Photo courtesy of David McClain, MD.
Bunyavirus infection - Hantaan virus. Patient with Korean hemorrhagic fever caused by Hantaan virus demonstrating typical 'sunburn flush' of cheeks, chin, and base of neck. Photo courtesy of John Huggins, PhD.
Bunyavirus infection. A patient with Korean hemorrhagic fever demonstrating conjunctival hemorrhages, facial petechiae, and "sunburn flush" of the cheeks. Photo courtesy of John Huggins, PhD.
Filovirus disease - Ebola fever. Patient with Ebola hemorrhagic fever during 1976 outbreak in Zaire demonstrating palatal petechiae and hemorrhage. Photo courtesy of Joel Breman.
Patient with morbilliform exanthem of dengue fever. Note islands of sparing characteristics for dengue. Photo courtesy Duane Gubler, PhD.
Patient with dengue hemorrhagic fever complicated by ecchymoses. Photo courtesy of Duane Gubler, PhD.
Dengue Virus Notice posted outside Maracanã Stadium, Rio de Janeiro, Brazil, 2012. Translation: This site is a strategic point for controlling Dengue.
Mastomys natalensis, natural host of Lassa virus. Photo courtesy of BioMed Central, originally published in Kelly JD, Barrie MB, Ross RA, Temple BA, Moses LM, Bausch DG. Housing equityfor health equity: a rights-based approach to the control of Lassa fever inpost-war Sierra Leone. BMC Int Health Hum Rights. 2013 Jan 2;13:2.
Table. Viral Families Causing Viral Hemorrhagic Fever
Virus FamilyDisease (Virus)Natural DistributionUsual Source of Human InfectionIncubation (Days)
ArenavirusLassa feverAfricaRodent5-16
 Argentine HF (Junin)South AmericaRodent7-14
 Bolivian HF (Machupo)South AmericaRodent9-15
 Brazilian HF (Sabia)South AmericaRodent7-14
 Venezuelan HF (Guanarito)South AmericaRodent7-14
PhlebovirusRift Valley feverAfricaMosquito2-5
NairovirusCrimean-Congo HFEurope, Asia, AfricaTick3-12
HantavirusHemorrhagic fever with renal syndrome, hantavirus pulmonary syndromeAsia, Europe, worldwideRodent9-35
FilovirusMarburg and EbolaAfricaFruit bat3-16
FlavivirusYellow feverTropical Africa, South AmericaMosquito3-6
 Dengue HFAsia, Americas, AfricaMosquitoUnknown for dengue HF, 3-5 for dengue
Medscape Consult
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.