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"Ebola virus disease" AND treatment

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Ebola virus disease 2025 2026 outbreak update

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Ebola Virus Disease (EVD)

Virology & Classification

Ebola virus belongs to the family Filoviridae, genus Ebolavirus. It is an enveloped, non-segmented, single-stranded negative-sense RNA virus. There are six recognized species:
  • Zaire ebolavirus - most lethal and most commonly responsible for major outbreaks
  • Sudan ebolavirus
  • Bundibugyo ebolavirus - currently circulating in the 2026 DRC/Uganda outbreak
  • Tai Forest ebolavirus
  • Reston ebolavirus (non-pathogenic in humans)
  • Bombali ebolavirus

Epidemiology

First described in 1976 in Sudan and what was then Zaire (now the Democratic Republic of Congo). Major milestones:
OutbreakCasesDeathsCFR
2013-2016 West Africa (Zaire strain)28,65211,325~70%
2018-2020 DRC (Zaire strain)~3,500~2,290~66%
2026 DRC/Uganda (Bundibugyo strain)>1,000+>220+ongoing
The mortality rate ranges from 25% to 90% depending on strain, outbreak setting, and quality of care. In European and US treatment centers with ICU-level support, mortality fell to approximately 18.5% - much lower than in resource-limited settings. - Rosen's Emergency Medicine, p. 2632

2026 Active Outbreak (Breaking)

As of late May 2026, a Bundibugyo virus disease (BVD) outbreak is ongoing in the DRC (Ituri, North Kivu, South Kivu provinces) and Uganda. Key points from CDC and ECDC:
  • Declared a Public Health Emergency of International Concern (PHEIC) by WHO
  • Over 105 confirmed + 906 suspected cases in DRC as of late May
  • Two suspected cases reported in Italy (travelers from Uganda to Lombardy)
  • No approved vaccine exists for Bundibugyo strain (unlike Zaire strain)
  • Complicated by armed conflict, funding cuts, and regional instability
  • 10 African countries classified as at-risk by the Africa CDC

Transmission

  • Direct contact with blood, secretions, saliva, vomit, feces, or semen of an infected (symptomatic) person
  • Patients are not contagious during the incubation period - only once symptomatic
  • Incubation period: usually 5-7 days, range 2-21 days
  • Unsafe burials are a major amplification route
  • Natural reservoir: believed to be fruit bats (Pteropodidae family)

Clinical Features

Early phase (days 1-5):
  • High fever, severe headache, myalgias, malaise
  • Sore throat, profound vomiting and diarrhea
  • Symptoms mimic many other infections (making early diagnosis difficult)
Later phase (days 5-7+):
  • Hemorrhagic manifestations: spontaneous bleeding, ecchymosis, petechiae
  • Erythematous maculopapular rash that desquamates
  • Hypovolemia and severe metabolic derangements from GI fluid losses
  • Progression to shock and multiorgan failure
Note: Not all patients develop hemorrhagic complications. The "hemorrhagic fever" label is somewhat misleading since coagulopathy is a late and variable feature.

Laboratory Findings

  • Thrombocytopenia
  • Anemia
  • Coagulopathy (elevated PT/PTT)
  • Transaminitis (elevated AST, ALT)
  • Elevated creatinine
  • Hypocalcemia, hypokalemia
Diagnosis: RT-PCR on plasma specimen is the gold standard. Rapid antigen point-of-care tests (15-minute turnaround) now exist with good sensitivity/specificity vs. RT-PCR. Always test for malaria co-infection - 11% of Ebola patients in one Guinea study had concurrent malaria. - Rosen's Emergency Medicine, p. 2632

Differential Diagnosis

  • Malaria (far more common in endemic regions - must be excluded)
  • Typhoid fever
  • Other viral hemorrhagic fevers (Marburg, Lassa, Crimean-Congo)
  • Meningococcemia
  • Leptospirosis
  • Septicemia from bacterial causes

Management

Guiding principle: Identify - Isolate - Inform (CDC framework)
Supportive care (mainstay):
  • Aggressive IV fluid resuscitation and electrolyte correction
  • Empiric malaria treatment and broad-spectrum antibiotics
  • Antipyretics
  • Organ support: vasopressors, renal replacement therapy, mechanical ventilation as needed
  • Blood product transfusion for coagulopathy
Specific therapies:
  • mAb114 (Ansuvimab / Ebanga) - single monoclonal antibody; FDA-approved in Dec 2020 for Zaire ebolavirus
  • REGN-EB3 (Atoltivimab/Maftivimab/Odesivimab / Inmazeb) - triple monoclonal antibody cocktail; FDA-approved Oct 2020 for Zaire ebolavirus
  • Both are significantly more effective than older candidates (ZMapp, remdesivir)
  • Important: These are approved only for Zaire strain - no specific therapy for Bundibugyo strain as of 2026
Infection control:
  • Full PPE with extensive donning/doffing training is mandatory
  • Negative pressure isolation rooms
  • Tiered hospital system: frontline facilities → Ebola assessment hospitals → Ebola treatment centers

Vaccines

Ervebo (rVSV-ZEBOV-GP)
  • Live attenuated recombinant vesicular stomatitis virus (VSV) vector expressing Zaire Ebola glycoprotein
  • Single IM dose
  • Approved for adults ≥18 years; deployed with ring vaccination strategy
  • Indicated for outbreak responders and biosafety level 4 facility workers
  • Common adverse effects: local reactions, headache, fever, arthralgia (especially in women)
  • Post-vaccination precautions: avoid sharing utensils/razors for 2 weeks; barrier contraception for 2 months; avoid blood donation for 6 weeks
  • Does not protect against Bundibugyo strain (active 2026 outbreak)
Zabdeno + Mvabea (Ad26.ZEBOV + MVA-BN-Filo)
  • Two-dose regimen (prime-boost), EMA-approved, also for Zaire strain only
A 2026 systematic review and meta-analysis (PMID: 41176150) evaluated immunogenicity and safety of Ebola vaccines in children, reflecting growing attention to pediatric vaccination for future outbreaks.

Pathogenesis (Brief)

The Ebola glycoprotein (GP) mediates cellular entry via endosomes. The virus infects macrophages, dendritic cells, hepatocytes, adrenal cortex, and endothelial cells. Key mechanisms:
  • Macrophage/DC infection leads to massive cytokine release ("cytokine storm")
  • Dendritic cell dysfunction impairs adaptive immune activation
  • Direct viral injury to endothelium + coagulopathy causes vascular leak and hemorrhage
  • Liver destruction reduces clotting factor synthesis

Post-Ebola Syndrome

Survivors carry a substantial burden of sequelae. A 2024 systematic review and meta-analysis (PMID: 38840082) documented high prevalence of somatic symptoms in EVD survivors, including musculoskeletal pain, eye disease (uveitis), hearing loss, and neurological complications. Ebola virus can persist in immune-privileged sites such as the eye and semen for months after recovery.
Sources: Harrison's Principles of Internal Medicine 22E (2025), Rosen's Emergency Medicine 10e, Goldman-Cecil Medicine; CDC MMWR 2026; ECDC Threat Assessment Brief May 2026.
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