Ebola and Viral Haemorrhagic Fevers: What Indian Clinic Doctors Need to Know

What Are Viral Haemorrhagic Fevers?

Viral Haemorrhagic Fevers (VHFs) are a group of severe, life-threatening illnesses caused by several distinct families of viruses. They are characterised by fever, general illness, and in severe cases, multiple organ dysfunction and haemorrhage. The most prominent VHFs include:

• Ebola virus disease (EVD): Caused by Ebola virus (Filoviridae family). Case fatality rate 25–90% in untreated outbreaks. Transmitted through contact with blood, body fluids, or organs of infected individuals or animals (fruit bats as reservoir).
• Marburg virus disease: Same family as Ebola, similar presentation. Linked to cave bat exposure in Africa.
• Crimean-Congo Haemorrhagic Fever (CCHF): Tick-borne. Relevant for western India — Gujarat, Rajasthan. Occasional outbreaks documented in India.
• Nipah virus: India-endemic. Multiple outbreaks in Kerala since 2018. Transmitted through fruit bats, infected pigs, or human-to-human contact. Case fatality rate up to 75%.
• Kyasanur Forest Disease (KFD): India-specific tick-borne haemorrhagic fever in Karnataka, Maharashtra, and Goa. Known endemic area — alert for patients from these regions.

VHF Risk in India: What Clinic Doctors Should Know

Ebola and Marburg are not endemic in India, and no confirmed imported cases have been reported to date. The VHF threat relevant to Indian clinic doctors is primarily:

1. Imported cases: Returning travellers from Sub-Saharan Africa with unexplained haemorrhagic fever. The risk is low but real, and the consequences of missing the diagnosis are severe due to the highly contagious nature of these viruses.
2. Nipah virus: Kerala has had repeated outbreaks (2018, 2019, 2021, 2023). This is a real and active VHF risk for Indian doctors, particularly in Kerala and adjacent states. Human-to-human transmission makes healthcare workers at risk.
3. CCHF: Tick bites in animal-handling populations in Rajasthan and Gujarat. Documented nosocomial transmission to healthcare workers in India.
4. KFD: Monkey fever in the endemic belt — Karnataka's Shimoga, Uttara Kannada, Udupi districts, and spreading into Goa and Maharashtra.

Clinical Presentation: Red Flags to Watch For

VHFs present in two phases. The early phase resembles any severe viral fever — the haemorrhagic features that give these diseases their name appear later and only in a proportion of patients.

Early phase (Day 1–5):

• Sudden onset high fever (often 39–40°C)
• Severe headache, myalgia, malaise, weakness
• Nausea, vomiting, diarrhoea (often severe)
• Abdominal pain
• Conjunctival injection

Late/severe phase (Day 5–10 in Ebola/Marburg):

• Bleeding from multiple sites: gums, nose, IV sites, gastrointestinal
• Petechiae, ecchymoses, purpura
• Haematemesis, melaena
• Shock, multi-organ failure

Key clinical differentiator: Unexplained fever + haemorrhagic signs + travel history to endemic area (Africa/endemic Indian zones) = VHF must be excluded before any other diagnosis is confirmed or ruled out.

Screening Protocol for Your OPD

The most important screening tool is the travel and exposure history. Ask these questions of any patient presenting with unexplained high fever of 48 hours or more:

Immediate Isolation and Referral Steps

If you have a patient who meets VHF suspicion criteria (fever + travel/exposure history + any haemorrhagic sign), follow these steps in order:

Mandatory Reporting Requirements

VHFs are notifiable diseases under the Epidemic Diseases Act and the Integrated Disease Surveillance Programme (IDSP). As a clinic doctor, you are legally required to report any suspected case immediately — even before confirmation. Failure to report is a punishable offence.

Who to notify:

• District Health Officer (DHO) — primary contact for all notifiable disease reports
• State IDSP Surveillance Officer — handles outbreak investigation
• NCDC (National Centre for Disease Control) helpline: 011-23918004

What information to give when reporting: Patient name, age, sex, address and contact number, date of symptom onset, travel history details, clinical presentation summary, and your assessment of contact history. This information drives the contact tracing that prevents spread.

Document everything in the patient's record — time of presentation, your clinical assessment, when you called IDSP, what instructions you received, and all clinic staff who had contact with the patient. If an outbreak investigation follows, this documentation protects both the patient and your clinic.

Frequently Asked Questions

Is Nipah virus contagious like Ebola?

Yes — Nipah spreads through human-to-human contact with infected body fluids, including respiratory secretions. Healthcare workers without adequate PPE have been infected in previous Kerala outbreaks. If any patient presents from a Nipah-affected district with fever and neurological signs (encephalitis, altered sensorium), apply the same isolation and reporting protocol as for Ebola.

Is there a vaccine for Ebola I should recommend to patients travelling to Africa?

The rVSV-ZEBOV vaccine (Ervebo) is approved for Ebola Zaire strain. It is used in outbreak response and is available through WHO/public health channels in affected countries. Pre-travel Ebola vaccination for general travellers is not standard practice — advise travellers to Africa to check travel advisories, avoid contact with ill individuals and animals, and seek medical care immediately for any fever on return.

What if I suspect KFD in a patient from Karnataka?

Kyasanur Forest Disease presents with biphasic fever, haemorrhagic signs, and neurological complications in the second phase. Report to district health authorities immediately. Karnataka has a KFD vaccination programme for populations in endemic areas — if your patient is from the endemic zone and unvaccinated, report and seek ICMR guidance.