Viral Haemorrhagic Fevers: Recognition, Isolation and Emergency Management

1. Learning objectives

By the end of this lesson, the learner should be able to:

• Define VHF and distinguish a suspected VHF from a confirmed infection.
• Identify relevant exposure, incubation, prodromal and severe-disease features.
• Protect self, the patient, other patients and the community from avoidable transmission.
• Perform a structured ABCDE assessment without creating unnecessary exposure.
• Give safe pre-hospital and hospital supportive care while arranging testing and referral.
• Recognise shock, bleeding, encephalopathy, respiratory failure, renal injury and other complications early.
• Document, hand over, report and follow up occupational exposures correctly.

2. Definition and scope

Viral haemorrhagic fevers are severe illnesses caused by several virus families that injure the vascular system, immune system and multiple organs. The name does not mean that every patient bleeds. Many patients initially have fever, weakness, headache, myalgia, vomiting or diarrhoea; haemorrhage may be absent, late or microscopic. Severe disease may result from capillary leak, dehydration, shock, coagulopathy, encephalitis, acute kidney injury or secondary infection.

A suspected case is a person whose acute illness and epidemiological history meet the current national or outbreak case definition. A probable case meets the clinical and epidemiological definition but is awaiting or unable to have definitive testing. A confirmed case has a validated laboratory result or other accepted confirmation. EMTs should not attempt to diagnose or rule out VHF by appearance alone.

3. Important VHF pathogens and transmission patterns

4. Epidemiology, incubation and risk assessment

Symptoms may appear after an incubation period that varies by virus and exposure. CDC screening guidance commonly uses a 2–21 day window for several high-consequence VHFs, but the exact period depends on the suspected pathogen. Ask about the entire risk window specified by current national guidance.

4.1 Ask about exposure, not just travel

• Residence in, travel to or transit through an area with a current or recent VHF outbreak.
• Contact with a person who had an unexplained febrile illness, bleeding, vomiting or diarrhoea.
• Attendance at a funeral, burial or body-washing ceremony, or handling human remains.
• Unprotected healthcare, laboratory, ambulance, mortuary or cleaning work.
• Contact with bats, caves, mines, non-human primates, livestock, ticks, mosquitoes or rodents.
• Contact with blood, body fluids, needles, linen, clothing, equipment or surfaces contaminated by a patient.
• Recent injections, invasive procedures, sexual exposure or breastfeeding considerations where relevant to the suspected virus.

4.2 Questions that improve risk stratification

1. When did fever or the first symptom begin, and how has it progressed?
2. Where has the patient been during the possible incubation period?
3. Who has been ill at home, work, school, a health facility or a funeral?
4. Which body fluids were encountered, by whom, and was PPE used?
5. Were there animal, tick, mosquito, rodent, cave or occupational exposures?
6. Has the patient taken antimalarials, antibiotics, NSAIDs, anticoagulants or traditional medicines?
7. Is anyone else at home or in the facility ill, and where can contacts be reached?

5. Clinical course and warning features

6. Initial contact: protect, recognise, separate and notify

6.1 Before touching the patient

1. Pause at the doorway or scene perimeter. Ask the patient or caller about fever, gastrointestinal symptoms, bleeding and exposure before entering.
2. Put on the level of PPE required by the facility or outbreak protocol. Do not improvise by wearing only gloves when splash or aerosol-generating procedures are possible.
3. Limit the number of responders and move non-essential people away.
4. Prepare a designated isolation or treatment area and dedicated equipment before transfer.
5. Notify the senior clinician, infection-prevention lead and public-health focal person early.

6.2 First communication with the patient

• Use calm, respectful language: explain that temporary separation protects the patient, family and staff.
• Give the patient a mask if tolerated and safe, and provide a lined emesis bag or closed container for secretions.
• Ask the patient not to touch staff, surfaces or other patients unnecessarily.
• Do not shame the patient or disclose suspected VHF publicly; maintain confidentiality while making the required notification.

7. Structured emergency assessment: safe ABCDE

Use the same emergency priorities as for any critically ill patient, but modify the technique to minimise splashes, sharps and repeated contact. Record the time and trend of every observation.

A – Airway and cervical protection when indicated

• Assess whether the patient can speak, protect the airway and clear secretions.
• Look for blood, vomitus, facial swelling, seizures or reduced consciousness.
• Position safely, suction only with appropriate PPE and closed systems where available.
• Prepare for advanced airway support only with the most experienced team, a clear indication and a plan to reduce aerosolisation.

B – Breathing

• Count respiratory rate, inspect effort and listen for noisy breathing or focal signs.
• Measure SpO₂ with a clean or dedicated probe; correct the reading for poor perfusion and nail products.
• Give oxygen according to local emergency protocol and monitor response.
• Consider pneumonia, aspiration, pulmonary oedema, metabolic acidosis or severe anaemia in a patient with distress.

C – Circulation, perfusion and haemorrhage

• Check pulse rate, rhythm, blood pressure, capillary refill, skin temperature and mental status.
• Look for dehydration, ongoing diarrhoeal losses, bleeding, jaundice and signs of shock.
• Control visible external bleeding with direct pressure and absorbent material; do not explore wounds unnecessarily.
• Establish IV or intraosseous access only when essential, using the minimum number of attempts and sharps safety.
• Use isotonic crystalloid cautiously for suspected hypovolaemia and reassess after small boluses, especially if pulmonary oedema or cardiac disease is possible.

D – Disability

• Assess AVPU or GCS, pupils, seizures, agitation and focal neurological signs.
• Check capillary blood glucose promptly; treat hypoglycaemia according to protocol.
• Consider hypoxia, shock, fever, electrolyte disturbance, encephalitis, medication effects and hypoglycaemia.

E – Exposure and examination

• Expose only the area needed, preserve dignity and prevent chilling.
• Inspect skin, mucosa and conjunctiva for rash, petechiae, jaundice, dehydration and bleeding.
• Check for tick attachment, injection sites, pregnancy-related bleeding or injuries only when clinically necessary.
• Decontaminate equipment and surfaces immediately according to facility IPC policy.

8. Differential diagnosis and essential tests

Do not label every febrile patient as VHF, but never dismiss a credible exposure. Important alternatives include severe malaria, bacterial sepsis, meningitis, typhoid fever, dengue, yellow fever, rickettsial disease, leptospirosis, acute HIV infection, viral hepatitis, poisoning, obstetric haemorrhage and haematological disease.

9. Immediate and pre-hospital management

1. Scene safety and isolation: identify a clean zone, transition zone and contaminated zone where feasible; keep a written exposure log.
2. Call ahead: tell the receiving facility the clinical status, exposure concern, PPE requirements, number of staff exposed and equipment needed.
3. Position: place a shocked patient supine with appropriate leg elevation only if it improves perfusion and does not worsen breathing; use lateral recovery position for an unconscious breathing patient who is vomiting and has no contraindication.
4. Oxygen and ventilation: provide oxygen for hypoxaemia or respiratory distress; use bag-mask ventilation only when essential and with a high-efficiency filter and trained team.
5. Fluids: treat clinically significant dehydration or shock with carefully reassessed isotonic crystalloid. Avoid both under-resuscitation and indiscriminate large-volume boluses.
6. Glucose and temperature: correct hypoglycaemia, prevent hypothermia and use a safe antipyretic plan. Avoid aspirin and NSAIDs when bleeding, thrombocytopenia or renal injury is possible.
7. Bleeding: apply firm direct pressure, use absorbent dressings and avoid unnecessary intramuscular injections, rectal temperatures and traumatic procedures.
8. Transport: use the designated vehicle and route; restrict attendants, secure waste and linen, and perform supervised doffing and disinfection after handover.

10. Hospital management: goals and sequence

10.1 Resuscitation and monitoring

• Place the patient in a designated isolation area and use a trained, minimum-size clinical team.
• Record temperature, pulse, respiratory rate, blood pressure, SpO₂, mental status, urine output, stool/vomit volume and fluid balance at a frequency matched to severity.
• Use a resuscitation chart with targets and reassessment after every intervention.
• Escalate for persistent hypotension, rising lactate, worsening confusion, oliguria, increasing oxygen need, recurrent vomiting or uncontrolled bleeding.

10.2 Fluids, electrolytes and nutrition

• Estimate ongoing losses from diarrhoea, vomiting, fever, bleeding and insensible loss.
• Use oral rehydration solution when the patient is alert, protecting the airway and able to drink; give small frequent amounts.
• Use IV isotonic crystalloid for shock, severe dehydration or inability to drink, with repeated clinical reassessment.
• Monitor sodium, potassium, bicarbonate, calcium, glucose, creatinine and acid–base status where available.
• Start enteral nutrition when safe; provide culturally acceptable energy and protein while preventing aspiration.

10.3 Medications and procedures

• Give paracetamol/acetaminophen for fever or pain within local dosing limits; review liver function and cumulative dose.
• Give an antiemetic and other symptom-directed medicines under protocol, using oral or IV routes rather than intramuscular injections where possible.
• Do not give antibiotics simply because VHF is suspected; start empiric antibiotics when bacterial sepsis, pneumonia, meningitis or another treatable co-infection is clinically plausible, and obtain cultures safely if this will not delay treatment.
• Specific therapeutics depend on the pathogen, country approval and treatment-centre protocol. WHO recommends monoclonal antibody treatment for eligible Ebola virus disease; this does not automatically apply to Sudan virus, Bundibugyo virus, Marburg or other VHFs.
• Specialist teams may consider disease-specific antivirals, investigational medicines or plasma protocols. EMTs should never self-prescribe these or delay referral while seeking them.
• Use renal-dose adjustments and avoid nephrotoxic or hepatotoxic medicines when organ injury is suspected.

11. Management of bleeding and coagulopathy

• Assess airway risk from oral or gastrointestinal bleeding and prepare suction safely.
• Apply local pressure to accessible external sites; use a pressure dressing and document saturation.
• Minimise venepunctures, arterial punctures, urinary catheterisation and other invasive procedures.
• Review antiplatelet, anticoagulant and herbal medicines with the senior clinician.
• Check haemoglobin, platelets, PT/INR, aPTT, fibrinogen and renal/liver function where available.
• Give blood components only on a documented clinical indication and with the required laboratory and transfusion safeguards.
• Do not assume that every visible bleed explains the shock; capillary leak, diarrhoeal losses, sepsis or occult bleeding may coexist.

12. Infection prevention and control

12.1 Standard and transmission-based precautions

• Perform hand hygiene before and after every patient contact and after removing gloves.
• Use gloves, fluid-resistant gown/coverall, eye protection, mask/respirator and boots or shoe covers as specified by the risk assessment and current protocol.
• For vomiting, diarrhoea, bleeding or aerosol-generating procedures, use the higher-level PPE pathway and trained observers where required.
• Use dedicated, disposable or easily disinfected equipment; keep a clean inventory outside the isolation area.
• Do not touch the face, phone, pens, door handles or clean notes with contaminated gloves.

12.2 Donning and doffing discipline

1. Remove jewellery and secure hair; cover skin breaks.
2. Inspect PPE with a trained observer and put it on in the prescribed order.
3. Work slowly; avoid splashes, sharp edges and leaning over the patient.
4. Disinfect gloved hands between high-risk tasks when compatible with the product and protocol.
5. Remove PPE in the designated doffing area, pausing at each step for inspection.
6. Perform hand hygiene after every removal stage and report any breach immediately.

12.3 Environment, waste, linen and bodies

• Clean and disinfect high-touch surfaces using an approved product, correct concentration and contact time.
• Place sharps directly into a rigid puncture-resistant container; never recap needles.
• Handle linen as infectious material; do not shake it or carry it against clothing.
• Contain vomit, stool and other fluids before cleaning; use trained personnel and appropriate PPE.
• Use safe, dignified and culturally sensitive burial procedures led by the authorised response team. Family viewing or touching is allowed only when the protocol makes it safe.

13. Nursing and EMT care plan

14. Exposure management for staff, family and contacts

1. Stop the task safely and move to the designated doffing area.
2. Wash or irrigate the exposed skin or mucous membrane immediately according to the exposure protocol; do not use caustic chemicals.
3. Report at once to the supervisor, infection-prevention lead and occupational-health/public-health team.
4. Document the patient, date/time, route of exposure, PPE used, breach, body fluid and witnesses.
5. Receive risk assessment, baseline testing where indicated, counselling and active monitoring for the pathogen-specific period.
6. Do not work while symptomatic; notify occupational health immediately if fever, fatigue, vomiting, diarrhoea, bleeding or other compatible symptoms develop.
7. Contacts require confidentiality, risk communication and follow-up by public-health teams—not informal community labelling.

15. Prevention and public-health control

• Early detection and immediate notification prevent delayed isolation and unsafe referral.
• Train all staff in triage, hand hygiene, PPE, injection safety, specimen transport, waste and doffing.
• Use safe water, sanitation, environmental cleaning and vector/rodent control.
• Promote early care seeking and discourage unsafe home treatment, injections, unprotected caregiving and body washing.
• Use vaccination when an approved vaccine is indicated for the specific disease and response strategy.
• Support survivors and families respectfully; apply pathogen-specific advice on sexual transmission, breastfeeding and follow-up.
• Maintain stock of PPE, chlorine/disinfectant, oral rehydration salts, IV fluids, sharps boxes, thermometers and communication forms.

16. Transfer and handover framework

Use an ATMIST/SAMPLE-style handover and state the VHF concern in the first sentence:

• A – Alert: “Suspected viral haemorrhagic fever; isolation precautions active.”
• T – Time: onset, arrival and key deterioration times.
• M – Mechanism/medical history: exposure, travel, contact, comorbidities and medicines.
• I – Injuries/illness findings: fever, vomiting, diarrhoea, rash, bleeding, jaundice and neurological status.
• S – Signs: serial vital signs, glucose, urine output and response to fluids/oxygen.
• T – Treatments: PPE, isolation, oxygen, fluids, medicines, bleeding control, specimens and exposure events.

17. Clinical scenarios

18. Common errors to avoid

• Waiting for haemorrhage before considering VHF.
• Taking a detailed history in a crowded waiting room.
• Using gloves without eye/body protection during splash-risk care.
• Repeatedly attempting IV access or performing unnecessary rectal, IM or invasive procedures.
• Giving NSAIDs or aspirin when thrombocytopenia, bleeding or renal injury is possible.
• Sending specimens without prior laboratory notification and approved packaging.
• Transporting the patient without calling the receiving facility.
• Removing PPE hurriedly or without a trained observer.
• Forgetting the staff exposure log, patient confidentiality or family communication.

19. Quick revision questions

1. Why can a patient have VHF without visible bleeding?
2. Name five exposure questions that change the triage pathway.
3. What are the first four actions before physically examining a suspected case?
4. How would you recognise shock in a patient with profuse diarrhoea?
5. Why are unnecessary IM injections, rectal temperatures and repeated venepunctures unsafe?
6. Which findings require urgent escalation during transport?
7. What information must be included in the VHF handover?
8. Describe the immediate response to a mucous-membrane splash.
9. Why must pathogen-specific treatment be directed by a designated treatment team?
10. List six community measures that reduce VHF transmission.

20. Key takeaways

References and further reading

• WHO: Ebola disease and therapeutics
• WHO: Marburg virus disease
• WHO: Clinical management of patients with viral haemorrhagic fever
• CDC: Screening and evaluating a person for VHF
• CDC: Infection prevention and control for VHFs
• CDC: Interim guidance for EMS systems
• WHO: Crimean-Congo haemorrhagic fever