• September 2026

Ebola and the Anesthesia Professional: Practical Considerations During the Current Bundibugyo Virus Outbreak

by Brent Lee, MD, MPH, FASA

September 14, 2026

PDF  PDF

DOI: https://doi.org/10.66881/apsf.2026N022

TO THE EDITOR:

Since the COVID-19 pandemic, anesthesia professionals have understandably viewed emerging infectious diseases primarily through the lens of airborne transmission. COVID-19, Severe Acute Respiratory Syndrome (SARS), Middle East Respiratory Syndrome (MERS), and Andes hantavirus (ANDV) all require heightened concern for respiratory spread during airway management and other aerosol-generating procedures. Ebola disease caused by the Bundibugyo virus (EVD) is fundamentally different. Under routine clinical conditions, transmission occurs predominantly through direct contact with infectious body fluids and contaminated surfaces rather than by airborne spread (Table 1).1

Table 1. EVD vs Recent Respiratory Pandemics: Key Differences.1,6,7

Feature COVID-19/SARS/MERS/ANDV Ebola Virus Disease (EVD)
Primary route of transmission Airborne/droplet aerosols Direct contact with infectious body fluid; fomites
Airborne risk? Yes—primary route Ordinarily no: possible during AGPs (e.g., intubation, suctioning) if fluids are aerosolized
Who is infectious? Presymptomatic and symptomatic Symptomatic only (including deceased patients)
At-risk population General public; any exposure Close contacts and caregivers; predominately health care workers
Dominant PPE priority Respiratory protection (N95/PAPR, eye protection) Barrier/contact protection: impermeable full-body coverage, double gloves, face shield, respiratory augmented for AGPs
Fomite risk Moderate; largely superseded by aerosol risk High—virus persists days on contaminated surfaces
SARS: Severe Acute Respiratory Syndrome; MERS: Middle East Respiratory Syndrome; ANDV: Andes Hantavirus; PAPR: Powered Air Purifying Respirator; AGP: Aerosol-Generating Procedures.
Feature Primary route of transmission
COVID-19/SARS/ MERS/ANDV Airborne/droplet aerosols
Ebola Virus Disease (EVD) Direct contact with infectious body fluid; fomites
Feature Airborne risk?
COVID-19/SARS/ MERS/ANDV Yes—primary route
Ebola Virus Disease (EVD) Ordinarily no: possible during AGPs (e.g., intubation, suctioning) if fluids are aerosolized
Feature Who is infectious?
COVID-19/SARS/ MERS/ANDV Presymptomatic and symptomatic
Ebola Virus Disease (EVD) Symptomatic only (including deceased patients)
Feature At-risk population
COVID-19/SARS/ MERS/ANDV General public; any exposure
Ebola Virus Disease (EVD) Close contacts and caregivers; predominately health care workers
Feature Dominant PPE priority
COVID-19/SARS/ MERS/ANDV Respiratory protection (N95/PAPR, eye protection)
Ebola Virus Disease (EVD) Barrier/contact protection: impermeable full-body coverage, double gloves, face shield, respiratory augmented for AGPs
Feature Fomite risk
COVID-19/SARS/ MERS/ANDV Moderate; largely superseded by aerosol risk
Ebola Virus Disease (EVD) High—virus persists days on contaminated surfaces
SARS: Severe Acute Respiratory Syndrome; MERS: Middle East Respiratory Syndrome; ANDV: Andes Hantavirus; PAPR: Powered Air Purifying Respirator; AGP: Aerosol-Generating Procedures.

Clinically, EVD usually begins with nonspecific findings such as fever, fatigue, myalgias, headache, sore throat, vomiting, diarrhea, and abdominal pain, and may progress to shock, multiorgan failure, and, in some patients, overt hemorrhagic manifestations.2 The World Health Organization (WHO) has reported that prior Ebola outbreaks had case fatality rates of approximately 30% to 50%, underscoring the importance of early recognition, supportive care, and strict prevention of occupational exposure.2

Although the current Ebola outbreak remains centered in the Democratic Republic of the Congo and Uganda, recent imported cases in Europe remind us that patients with confirmed disease or significant exposure histories may occasionally present outside outbreak regions.3,4 Although such events remain rare, anesthesia professionals should understand the infection prevention principles unique to Ebola.

EBOLA REQUIRES A DIFFERENT INFECTION PREVENTION STRATEGY

The greatest occupational hazards for anesthesia professionals are not routine inhalation of infectious aerosols but exposure to blood, secretions, contaminated equipment, sharps injuries, and self-contamination during personal protective equipment removal (Table 2).1,5 This distinction has practical implications because anesthesia professionals routinely perform high-risk procedures including tracheal intubation, vascular access, suctioning, resuscitation, and transport of critically ill patients. Successful management depends on preventing contact with infectious body fluids while maintaining safe patient care.

Table 2. Exposure Risk Stratification for Ebola Virus Disease.5,11

Category Description UKHSA Example Scenarios Anesthesia Examples
Category 5
Very High Risk		 Unprotected high-risk or prolonged contact with case or infectious material
  • Household or overnight contact while case was symptomatic
  • Needlestick injury
  • Confirmed splash on mucous membranes or broken skin
  • Unprotected direct laryngoscopy/intubation of EVD patient with copious oral secretions
  • Needlestick with EVD-contaminated needle
  • Blood or secretion splash to eyes, nose, or mouth during airway management
Category 4
High Risk		 Unprotected close (≤2 m) or direct contact with case or infectious material
  • Direct skin contact with case or body fluids without PPE (or PPE breach)
  • Unprotected sexual contact with recovered case within 3 months
  • Skin/mucous membrane exposure to contaminated environment without PPE
  • Unprotected handling of clinical or laboratory specimens
  • Passengers seated directly next to case on plane
  • Bag-mask ventilation of EVD patient without PPE
  • Inserting nasogastric or orogastric tube without PPE
  • Handling soiled breathing circuit or suction tubing without gloves
  • Transporting intubated EVD patient without appropriate PPE
Category 3
Medium Risk		 Unprotected close (≤2 m) contact but no direct contact with case or bodily fluids
  • Same room as symptomatic case without direct contact
  • Passengers one seat in front of or behind case on plane
  • Cabin crew serving in area where case was seated
  • Present in OR during EVD patient procedure without direct patient contact and without PPE
  • Preoperative assessment of symptomatic EVD patient conducted in same room without PPE
  • Assisting with transporting unprotected symptomatic patient without direct contact
Category 2
Low Risk		 Protected direct or close contact with correct PPE, no known breach
  • Direct contact with case or body fluids outside controlled environment, correct PPE worn with no breach
  • Exposure to contaminated environment while wearing correct PPE with no breach
  • Non-CL4 laboratory staff handling specimens with correct PPE and no breach
  • Intubation and airway management wearing full recommended PPE with no known breach
  • Post-case environmental cleaning in correct PPE
  • Handling breathing circuit or anesthetic equipment with appropriate PPE intact
  • Transporting EVD patient while wearing full PPE with no breach
Category 1
Very Low Risk		 Protected contact in controlled environment (HCID unit) OR unprotected contact before symptom onset
  • Household contact while case was asymptomatic (before symptom onset)
  • Clinical staff in Trexler/HCID unit with correct PPE and no breach
  • IKHSA CL4 laboratory staff with no PPE breach
  • Anesthesia professional working in designated HCID unit with full PPE no breach
  • Preoperative assessment of patient who was asymptomatic at time of contact but later confirmed EVD
  • Anesthetic review in controlled setting with Trexler isolator and correct PPE
HCID: High Consequence Infectious Disease; EVD: Ebola virus disease; PPE: Personal protective equipment; OR: Operating room; Trexler unit: Trexler Patient Isolator; UKHSA: UK Health Security Agency; CL4: Containment Level 4.
Category Category 5
Very High Risk
Description Unprotected high-risk or prolonged contact with case or infectious material
UKHSA Example Scenarios
  • Household or overnight contact while case was symptomatic
  • Needlestick injury
  • Confirmed splash on mucous membranes or broken skin
Anesthesia Examples
  • Unprotected direct laryngoscopy/intubation of EVD patient with copious oral secretions
  • Needlestick with EVD-contaminated needle
  • Blood or secretion splash to eyes, nose, or mouth during airway management
Category Category 4
High Risk
Description Unprotected close (≤2 m) or direct contact with case or infectious material
UKHSA Example Scenarios
  • Direct skin contact with case or body fluids without PPE (or PPE breach)
  • Unprotected sexual contact with recovered case within 3 months
  • Skin/mucous membrane exposure to contaminated environment without PPE
  • Unprotected handling of clinical or laboratory specimens
  • Passengers seated directly next to case on plane
Anesthesia Examples
  • Bag-mask ventilation of EVD patient without PPE
  • Inserting nasogastric or orogastric tube without PPE
  • Handling soiled breathing circuit or suction tubing without gloves
  • Transporting intubated EVD patient without appropriate PPE
Category Category 3
Medium Risk
Description Unprotected close (≤2 m) contact but no direct contact with case or bodily fluids
UKHSA Example Scenarios
  • Same room as symptomatic case without direct contact
  • Passengers one seat in front of or behind case on plane
  • Cabin crew serving in area where case was seated
Anesthesia Examples
  • Present in OR during EVD patient procedure without direct patient contact and without PPE
  • Preoperative assessment of symptomatic EVD patient conducted in same room without PPE
  • Assisting with transporting unprotected symptomatic patient without direct contact
Category Category 2
Low Risk
Description Protected direct or close contact with correct PPE, no known breach
UKHSA Example Scenarios
  • Direct contact with case or body fluids outside controlled environment, correct PPE worn with no breach
  • Exposure to contaminated environment while wearing correct PPE with no breach
  • Non-CL4 laboratory staff handling specimens with correct PPE and no breach
Anesthesia Examples
  • Intubation and airway management wearing full recommended PPE with no known breach
  • Post-case environmental cleaning in correct PPE
  • Handling breathing circuit or anesthetic equipment with appropriate PPE intact
  • Transporting EVD patient while wearing full PPE with no breach
Category Category 1
Very Low Risk
Description Protected contact in controlled environment (HCID unit) OR unprotected contact before symptom onset
UKHSA Example Scenarios
  • Household contact while case was asymptomatic (before symptom onset)
  • Clinical staff in Trexler/HCID unit with correct PPE and no breach
  • IKHSA CL4 laboratory staff with no PPE breach
Anesthesia Examples
  • Anesthesia professional working in designated HCID unit with full PPE no breach
  • Preoperative assessment of patient who was asymptomatic at time of contact but later confirmed EVD
  • Anesthetic review in controlled setting with Trexler isolator and correct PPE
HCID: High Consequence Infectious Disease; EVD: Ebola virus disease; PPE: Personal protective equipment; OR: Operating room; Trexler unit: Trexler Patient Isolator; UKHSA: UK Health Security Agency; CL4: Containment Level 4.

PRACTICAL CONSIDERATIONS FOR ANESTHESIA TEAMS

Early recognition, supportive care, and meticulous infection prevention remain the cornerstones of management because no pathogen-specific therapy or licensed vaccine currently exists for Bundibugyo virus disease.1,8 Every anesthesia department should ensure familiarity with current recommendations from the Centers for Disease Control (CDC) for personal protective equipment (PPE), including supervised donning and doffing, as self-contamination during PPE removal remains a preventable source of occupational exposure.5,9 For confirmed patients and clinically unstable suspected patients, the CDC recommends full barrier protection including double gloves, an impermeable gown or coverall, boot or shoe covers, respiratory protection with an N95 respirator or, preferably for higher-risk airway procedures, a powered air-purifying respirator, and full face and head protection.5,9

When invasive procedures are unavoidable, careful planning is essential. Limit personnel, assign roles before patient arrival, prepare all equipment in advance, and emphasize first-pass success during airway management. When clinically appropriate, regional anesthesia may reduce airway manipulation but does not eliminate the need for meticulous barrier precautions or sharps safety.1 Disposable equipment should be used whenever feasible, and reusable equipment requires rigorous decontamination.

In the operating room, environmental cleaning after care of a patient with suspected or confirmed EVD should include immediate removal and disinfection of any visible blood or body fluid contamination, routine cleaning and disinfection of high-touch and other hard nonporous anesthesia and monitoring surfaces with a U.S. Environmental Protection Agency (EPA) registered hospital disinfectant effective against Ebola (CDC List Q or List L), and disposal of contaminated single-use materials, linens, and cleaning byproducts as Category A infectious waste according to institutional protocol.10 Porous items that cannot be effectively disinfected should be removed from the care area or discarded if contaminated, and the PPE doffing area should be cleaned regularly—at least daily and after gross contamination—by personnel trained in Ebola PPE and environmental infection control.10

PREPAREDNESS BEGINS BEFORE THE PATIENT ARRIVES

Fortunately, most anesthesia professionals will never care for a patient with EVD. Nevertheless, the current Ebola outbreak reminds us that preparedness must be tailored to the pathogen. COVID-19 emphasized airborne precautions; Ebola underscores the importance of barrier protection, contact precautions, and disciplined PPE practices. Simulation, team training, and familiarity with institutional protocols before the first patient arrives remain the most effective ways to protect patients, colleagues, and ourselves.

 

Brent Lee is the director of clinical excellence and performance improvement at North American Partners in Anesthesia and is an affiliated scholar at Georgetown University/MedStar National Center for Health Security and Resilience.

Brent Lee serves on the American Society of Anesthesiologists Committee on Trauma and Emergency Preparedness and has previously served as an Epidemic Intelligence Service Officer at the Centers for Disease Control and Prevention.

REFERENCES

  1. Missair A, Marino MJ, Vu CN, et al. Anaesthetic implications of Ebola patient Management: A Review of the Literature and Policies. Anesth Analg. 2015;121:810–821. PMID: 25551317.
  2. World Health Organization. Ebola disease caused by Bundibugyo virus, Democratic Republic of the Congo and Uganda. Disease Outbreak News. Published May 15, 2026. https://www.who.int/emergencies/disease-outbreak-news/item/2026-DON602. Accessed July 21, 2026.
  3. World Health Organization. Ebola disease caused by Bundibugyo virus, Democratic Republic of the Congo and Uganda. Disease Outbreak News. Published June 12, 2026. https://www.who.int/emergencies/disease-outbreak-news/item/2026-DON607. Accessed June 30, 2026.
  4. Associated Press. French health ministry confirms Ebola virus in doctor who worked in Congo. Published June 24, 2026. https://apnews.com/article/france-ebola-virus-case-congo-b6a854bf4ee2a0137c4fbd052f335bf9. Accessed June 30, 2026.
  5. Centers for Disease Control and Prevention. PPE: Confirmed Patients and Clinically Unstable Patients Suspected to Have VHF. Updated October 17, 2024. https://www.cdc.gov/viral-hemorrhagic-fevers/hcp/guidance/ppe-clinically-unstable.html. Accessed June 30, 2026.
  6. Centers for Disease Control and Prevention. Types of human coronaviruses. Reviewed January 10, 2025. https://www.cdc.gov/human-coronaviruses/php/types/index.html. Accessed June 30, 2026.
  7. Centers for Disease Control and Prevention. Clinical overview of hantavirus. Updated May 16, 2024. https://www.cdc.gov/hantavirus/hcp/clinical-overview/index.html. Accessed June 30, 2026.
  8. Centers for Disease Control and Prevention Ebola situation summary. Ebola outbreak: Current situation. Updated June 25, 2026. https://www.cdc.gov/ebola/situation-summary/index.html. Accessed June 30, 2026.
  9. Centers for Disease Control and Prevention. Guidance for Personal Protective Equipment (PPE) for Viral Hemorrhagic Fevers. https://www.cdc.gov/viral-hemorrhagic-fevers/hcp/guidance/index.html. Accessed June 30, 2026.
  10. Centers for Disease Control and Prevention. Interim guidance for environmental infection control in hospitals for viral hemorrhagic fevers. Updated May 2, 2024. https://www.cdc.gov/viral-hemorrhagic-fevers/hcp/infection-control/environmental-infection-control-hospitals.html. Accessed July 21, 2026.
  11. UK Health Security Agency contact classification guidance. Public health recommendations for asymptomatic contacts of Marburg virus disease and Ebola disease cases: Contact classification. Published October 2025. https://assets.publishing.service.gov.uk/media/68c7bfe07009f464cdc0cc48/Marburg_virus_disease_and_Ebola_disease_contact_classification_UK_settings.pdf. Accessed June 30, 2026.