Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

potential exposure

1st line – ribavirin

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INITIAL
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potential exposure
1st line – 

ribavirin

Oral ribavirin has been used for post-exposure prophylaxis in CCHF.[80][97] In one meta-analysis, post-exposure prophylaxis with ribavirin reduced the odds of infection and the odds of death when used <48 hours after symptom onset.[98] Ribavirin post-exposure prophylaxis is generally well tolerated, and should be considered for healthcare workers who have had high-risk exposures such as needlestick injuries.[61][99][100] The World Health Organization (WHO) supports this recommendation.[81]

Primary options

ribavirin: children: consult specialist for guidance on dose; adults: 35 mg/kg orally as a loading dose (maximum 2.5 g/dose), followed by 15 mg/kg (maximum 1 g/dose) every 8 hours for 10 days

ACUTE

suspected or confirmed infection

1st line – isolation and infection control

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ACUTE
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suspected or confirmed infection
1st line – 

isolation and infection control

Most human-to-human transmission of CCHF virus is via direct contact with infected blood and body fluids. Therefore, it is recommended that in caring for any patient with suspected or documented CCHF virus infection, specific barrier precautions (including use of gloves, gowns, face shields, and masks) should be implemented immediately. For procedures that may generate an aerosol, healthcare workers should consider wearing an N95 or FFP2 respirator (European Norm [EN] 61010-1).[40][61]

To minimise risk of needlestick injuries, sharps containers should be available at all times and the use of safety-engineered devices should also be considered.[40][61]

Plus – fluid and electrolyte management

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ACUTE
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suspected or confirmed infection
Plus – 

fluid and electrolyte management

Treatment recommended for ALL patients in selected patient group

Initial vital signs should guide initial treatment. Adult patients usually require ≥3-6 L/day of intravenous or oral fluids to maintain circulating blood volume in the setting of ongoing gastrointestinal loss.[81]

Monitoring and aggressive correction of potassium levels, acid-base disturbances, and other electrolyte abnormalities can help prevent life-threatening arrhythmias and metabolic complications.[81]

General principles of management for children with CCHF are the same as for adults, with a focus on supportive care and volume resuscitation. Intra-osseous and subcutaneous routes of fluid resuscitation may be necessary in children unable to tolerate oral or intravenous rehydration.[81]

Plus – analgesia/antipyretic

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ACUTE
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suspected or confirmed infection
Plus – 

analgesia/antipyretic

Treatment recommended for ALL patients in selected patient group

Should be treated with paracetamol first-line (for pain and fever).[81]

Opioid analgesics (e.g., morphine) are preferable for more severe pain.[81]

Non-steroidal anti-inflammatory drugs (including aspirin) should be avoided due to their associated increased risk of bleeding and potential for nephrotoxicity.

Primary options

paracetamol: children: 10-15 mg/kg orally/rectally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 500-1000 mg orally/rectally every 4-6 hours when required, maximum 4000 mg/day

Secondary options

morphine sulfate: children: 0.2 to 0.4 mg/kg orally every 4-6 hours when required, or 0.05 to 0.1 mg/kg intravenously every 4-6 hours when required; adults: 2.5 to 10 mg orally/intravenously every 4 hours when required

Consider – ribavirin

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ACUTE
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suspected or confirmed infection
Consider – 

ribavirin

Additional treatment recommended for SOME patients in selected patient group

Ribavirin has been shown to be effective against CCHF virus in vitro.[86][87][88]​ In clinical practice, observational studies have found ribavirin to be effective, especially if given during the early phase of the infection.[40][79][80]​[89][90][91]​​​[92]​ A Cochrane review of five studies with 748 patients (including one randomised controlled trial) was inconclusive, with the authors stating that they didn't know whether the use of ribavirin in patients with CCHF reduced mortality, length of hospital stay, or the risk of patients needing platelet transfusions.[96]

Despite the lack of evidence, ribavirin is on the World Health Organization (WHO) essential medicines list for the treatment of viral haemorrhagic fevers, and is recommended by the WHO for use in CCHF. Observational data from Lassa fever, for which there has been more experience, suggest that ribavirin is most effective if given in the first 6 days of illness.[81]​​

Primary options

ribavirin: children: consult specialist for guidance on dose; adults: 30 mg/kg (maximum 2000 mg/dose) intravenously as a loading dose, followed by 15 mg/kg (maximum 1000 mg/dose) every 6 hours for 4 days, then 7.5 mg/kg (maximum 500 mg/dose) every 8 hours for 6 days

Plus – platelet transfusion and fresh frozen plasma

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ACUTE
|
suspected or confirmed infection
|
with haemorrhage/disseminated intravascular coagulation
Plus – 

platelet transfusion and fresh frozen plasma

Treatment recommended for ALL patients in selected patient group

Major bleeding occurs infrequently, but is a manifestation of advanced infection that is usually fatal. When available, platelet and plasma transfusions should be given according to local protocols.[80]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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