With a growing Bundibugyo Ebola virus outbreak underway in the Democratic Republic of the Congo — and the usual diagnostic testing failing to detect this strain in early weeks — the question is no longer theoretical: what should clinicians actually know about Ebola?
We put that question to Dr. Rob Fowler, Professor of Critical Care Medicine at the University of Toronto, former CCCTG President, and co-author of the WHO’s newly published Ebola clinical management guidelines. He has worked inside Ebola treatment centres in West and Central Africa. He is not speaking from a distance.
The presentation clinicians will see
Ebola virus disease does not announce itself. It presents as a non-specific febrile illness — fever, myalgia, headache, nausea, vomiting, diarrhoea — indistinguishable on initial assessment from malaria, bacterial sepsis, or a dozen other endemic illnesses. The haemorrhage that defines the popular image of this disease? Dr. Fowler was direct: most patients do not bleed significantly. Most do not require transfusion. The primary pathology is systemic — coagulopathy, AKI, hepatitis, dehydration, neurological effects — not exsanguination. Diagnosis is PCR-based. An epidemiological link is what prompts testing, not a specific clinical picture.
What moves the outcome
The mortality numbers across Ebola’s history are striking precisely because they are not fixed. Historical case fatality rates for Zaire ebolavirus ran around 70% in contexts with limited care access. In the 2014–2016 West African outbreak, that figure fell to 39% over the course of the epidemic — driven by improved supportive care, not antivirals. With full ICU-level care in a high-resource setting, mortality drops to approximately 18%.
The PALM trial in DRC established the evidence base for targeted therapy: MAb114 and REGN-EB3 reduced absolute mortality by approximately 20% beyond supportive care alone. That is now the standard of care for Zaire ebolavirus. For the current Bundibugyo strain, no validated monoclonals or proven vaccines exist yet. Trials are being organised now, testing candidate antibodies in the same rigorous framework — and Dr. Fowler raises the open question of whether antiviral plus monoclonal combination therapy might offer additive benefit.
Infection control: what actually protects you
Ebola is a contact pathogen. Transmission requires infected bodily fluids to reach mucous membranes — eyes, nose, mouth — or a sharps injury. The operative framework is contact discipline, not airborne protocol. Dr. Fowler’s guidance on PPE: the specific certification matters less than mucosal coverage and a careful doffing sequence. In the field, the dominant practical challenge is heat, not fear. The highest-risk moment is doffing while fatigued — not the patient encounter itself.
The suspect patient in Canada
High-consequence pathogen units are being established across Canadian provinces. But Ebola does not present at designated centres — it presents wherever the patient goes first. Dr. Fowler’s message: every healthcare facility should be able to approach a potentially infected patient safely using standard, pathogen-agnostic contact precautions. And crucially: the patient presenting as a suspect case almost certainly has something else — malaria, sepsis, another viral illness. They need care regardless of the final diagnosis.
His closing line: “Almost never going to be Ebola — but they’ve got something, and they need care.”
The WHO guidelines Dr. Fowler co-authored address fluid resuscitation composition, vasopressor choice, MAP goals, AKI management, and family-centred care in treatment settings. We will link them in the show notes.
Listen to S5E19 of The Critical Care Commute wherever you get your podcasts.
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