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 – oral ribavirin

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INITIAL
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potential exposure
1st line – 

oral ribavirin

Post-exposure prophylaxis (PEP) should be considered for exposed close contacts of patients with Lassa fever, including laboratory and healthcare workers.

Recommendations for the use of oral ribavirin as PEP are restricted to high-risk exposures, which include: penetration of skin by a contaminated instrument (e.g., needlestick), contamination of mucous membranes or broken skin with blood or bodily secretions (e.g., blood splashing in the eyes or mouth), participation in emergency procedures (e.g., resuscitation after cardiac arrest, intubation, or suctioning) without use of appropriate PPE, and prolonged (i.e., for hours) and continuous contact in an enclosed space without use of appropriate PPE (e.g., a healthcare worker accompanying a patient during medical evacuation).[38][39]

Antiviral drugs (including ribavirin) are not recommended for non-exposed close contacts due to the absence of evidence of proven effectiveness as prophylaxis. UK Department of Health: management of Hazard Group 4 viral haemorrhagic fevers and similar human infectious diseases of high consequence Opens in new window

Primary options

ribavirin: children: consult specialist for guidance on dose; adults: 35 mg/kg (maximum 2500 mg/dose) orally as a loading dose, followed by 15 mg/kg (maximum 1000 mg/dose) every 8 hours for 10 days

ACUTE

suspected infection or symptomatic

1st line – isolation, infection control measures, and contact tracing

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ACUTE
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suspected infection or symptomatic
1st line – 

isolation, infection control measures, and contact tracing

Symptomatic patients or those with suspected infection should be isolated in a hospital setting, and all healthcare workers in contact with the patient should wear personal protective equipment (PPE).

The World Health Organization (WHO), Centers for Disease Control and Prevention (CDC), and UK Department of Health (DoH) have produced detailed guidance on PPE for viral haemorrhagic fevers, including Ebola, and this should be followed for Lassa fever:

WHO: steps to put on personal protective equipment Opens in new window

WHO: steps to remove personal protective equipment Opens in new window

CDC: guidance on personal protective equipment to be used by healthcare workers during management of patients with confirmed Ebola or persons under investigation for Ebola Opens in new window

UK Department of Health: management of Hazard Group 4 viral haemorrhagic fevers and similar human infectious diseases of high consequence Opens in new window

Blood sample collection, packaging, and transport should be carried out according to national protocols, whilst the patient remains isolated and PPE is used. Specimens should be sent to a laboratory that is suitably equipped to handle biosafety level 4 pathogens. Careful communication with laboratories, before samples are sent, is paramount to prevent transmission to laboratory staff.

Contact tracing should be done to identify those who have travelled with, lived with, or cared for a patient with Lassa fever within the last 21 days and who are asymptomatic. These individuals should be assessed and provided with post-exposure prophylaxis with oral ribavirin if they meet the required criteria (e.g., penetration of skin by a contaminated instrument, mucous membrane or broken skin exposure, participation in emergency procedures without use of appropriate PPE, or prolonged/continuous exposure in an enclosed space without use of appropriate PPE).[38] The WHO has produced guidance on contact tracing for Ebola, and this can be followed for Lassa fever: WHO: implementation and management of contact tracing for Ebola virus disease Opens in new window

Plus – intravenous ribavirin

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ACUTE
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suspected infection or symptomatic
Plus – 

intravenous ribavirin

Treatment recommended for ALL patients in selected patient group

Has been shown to reduce mortality from 55% to 5% in Lassa fever patients if administered within the first 6 days of illness; however, there has been only one published trial of ribavirin in treating Lassa fever in humans, which had limited testing of dose.[34]

Side effects of ribavirin include haemolytic anaemia and infusion-related reactions, such as rigors. Side effects, particularly at the dose required to achieve theoretical efficacy, may be severe and often leads to poor adherence with treatment.[38]

Primary options

ribavirin: children ≤9 years of age: consult specialist for guidance on dose; children >9 years of age and 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 – analgesia/antipyretic

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ACUTE
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suspected infection or symptomatic
Plus – 

analgesia/antipyretic

Treatment recommended for ALL patients in selected patient group

Pain and fever should be managed with an analgesic/antipyretic (e.g., paracetamol). Opioid analgesia (e.g., morphine) can be used if pain is severe. Non-steroidal anti-inflammatory drugs including aspirin should be avoided due to their associated increased risk of bleeding.

Primary options

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

Plus – fluid and electrolyte management

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ACUTE
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suspected infection or symptomatic
Plus – 

fluid and electrolyte management

Treatment recommended for ALL patients in selected patient group

Patients with significant diarrhoea should have regular assessment of their electrolytes, with replacement provided as necessary. Intravenous fluids should be initiated and titrated to maintain adequate volume status.

Plus – blood products

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ACUTE
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suspected infection or symptomatic
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with coagulation deficits
Plus – 

blood products

Treatment recommended for ALL patients in selected patient group

Coagulation deficits are uncommon, but should be corrected with blood products (e.g., fresh frozen plasma, cryoprecipitate) as necessary. Thrombocytopenia should be corrected with a platelet transfusion if there is bleeding. Blood transfusions are reserved for patients who are anaemic and who have ongoing bleeding.

Plus – anticonvulsant

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ACUTE
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suspected infection or symptomatic
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with encephalopathy
Plus – 

anticonvulsant

Treatment recommended for ALL patients in selected patient group

In symptomatic patients, encephalopathy is quite common among those who present after more than 6 days of symptoms. There is no specific treatment for encephalopathy associated with Lassa fever; however, patients may benefit from treatment with ribavirin. Specific symptoms (e.g., seizures) should be managed with standard care (e.g., an anticonvulsant) in accordance with local protocols and availability.

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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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