Hantavirus Treatment — Supportive Critical Care

There is no specific licensed antiviral for HPS in Europe or North America. Treatment is supportive critical care — mechanical ventilation, fluid management, vasopressors, ECMO where indicated, and renal replacement therapy for HFRS. Early recognition and intensive care are the strongest survival predictors.

HPS supportive care

Patients meeting clinical criteria should be transferred to an ICU with ECMO capability where geographically feasible. Per CDC and Argentine Ministerio de Salud guidance:

• Oxygenation — early high-flow nasal cannula or intubation; lung-protective ventilation (low tidal volume, plateau pressure ≤30 cmH₂O).
• Fluid management — cautious; the cardiopulmonary phase has profound vascular leak with relative hypovolaemia, but over-resuscitation worsens pulmonary oedema. Crystalloids first; vasopressors early.
• ECMO — veno-arterial ECMO has improved outcomes in Andes-virus HPS in Chile and Argentina. CDC and PAHO both list ECMO availability as a survival determinant.
• Antibiotics — empirical broad-spectrum cover until diagnosis confirmed (atypical pneumonia, sepsis, leptospirosis must be excluded).

HFRS supportive care

• Fluid and electrolyte management calibrated to the five-stage clinical course — restrictive during the oliguric phase, then permissive during the diuretic phase.
• Renal replacement therapy (haemodialysis or CRRT) for acute kidney injury — required in 30 to 60 percent of severe HFRS cases.
• Blood-product transfusion for haemorrhagic complications.
• Avoid nephrotoxic drugs (NSAIDs, aminoglycosides) where possible.

Antiviral therapy

Ribavirin has demonstrated benefit in early HFRS (meta-analyses of Chinese HTNV cohorts show roughly halved mortality when started within 7 days of symptom onset). Evidence in HPS is weaker and most trials have shown no benefit; the US placebo-controlled trial in SNV-HPS was stopped early for futility. Ribavirin is not licensed for hantavirus in the EU or US but is used off-label in Latin America.

Monoclonal antibody and convalescent plasma approaches have been investigated in Argentine and Chilean ANDV cohorts with suggestive but inconclusive efficacy data. Several mAb candidates are in Phase I/II trials in 2026.

Long-term sequelae

Survivors of HFRS may have persistent renal impairment (around 5 to 10 percent), hypertension, and proteinuria. HPS survivors generally recover normal pulmonary function within 6 to 12 months but report prolonged fatigue. Both syndromes have documented neurocognitive sequelae in case series — assessment and rehabilitation are recommended.

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Hantavirus treatment overview — 2026 standard of care

There is no licensed antiviral or specific therapy for hantavirus disease. Treatment is intensive supportive care focused on the syndrome (HPS or HFRS) and the patient's individual deterioration trajectory. Outcomes are strongly dependent on early recognition and admission to a centre capable of advanced critical care.

Hantavirus Pulmonary Syndrome (HPS) — critical care pathway

HPS deteriorates fast. The window from prodrome to respiratory failure can be 12-48 hours once cough or breathlessness appears. Standard of care emphasises early ICU admission, judicious fluid management, and immediate access to ECMO where indicated.

• Early ICU admission. Any patient with confirmed or suspected HPS who is short of breath, tachypnoeic, or hypoxic should be transferred to an ICU capable of mechanical ventilation and, ideally, ECMO referral.
• Restrictive fluid management. HPS pulmonary oedema is non-cardiogenic and capillary-leak-driven. Aggressive crystalloid resuscitation worsens it. Vasopressors (noradrenaline first-line) are preferred for haemodynamic support over volume.
• Lung-protective mechanical ventilation. Standard ARDS strategy: 6 mL/kg tidal volume on predicted body weight, plateau pressure <30 cm H2O, permissive hypercapnia, prone positioning when refractory.
• Veno-venous ECMO. The single most important intervention with outcome-changing data. Cohort studies from Chile, Argentina, and the USA show ECMO halves HPS mortality in patients with refractory hypoxia. Patients should be transferred to an ECMO centre BEFORE refractory arrest. The 2026 update from the Argentine Society of Intensive Care Medicine (SATI) recommends ECMO referral at PaO2/FiO2 ratio <100 on optimal ventilator settings.
• Vasoactive support. Noradrenaline first; vasopressin and adrenaline as second-line. Inotropic support may be needed if cardiac function is depressed (rare in HPS — most deterioration is vasoplegic shock, not cardiogenic).
• Renal replacement therapy. CRRT (continuous renal-replacement therapy) is used when AKI develops, which is common in late HPS.
• Source control. No specific source control beyond contact precautions for ANDV.

Haemorrhagic Fever with Renal Syndrome (HFRS) — phased treatment

HFRS has a longer, more predictable course than HPS, which allows phase-specific management. The five classical phases (febrile, hypotensive, oliguric, diuretic, convalescent) each demand a different focus.

• Febrile phase: paracetamol for fever, IV fluids if dehydration, monitor platelet count. Consider ribavirin (see below).
• Hypotensive phase: cautious crystalloid resuscitation, vasopressors as needed, ICU admission for severe cases. Avoid aggressive volume that will worsen the later oliguric phase.
• Oliguric phase: fluid restriction, electrolyte management, dialysis (haemodialysis or CRRT) commonly needed. Bleeding management with platelet transfusions if active haemorrhage and thrombocytopenia.
• Diuretic phase: anticipated polyuria can be 4-8 L/day. Match fluid replacement to output, monitor electrolytes (especially potassium and magnesium).
• Convalescent phase: gradual return to baseline. Some patients develop long-term hypertension (Puumala) or chronic kidney disease.

Ribavirin in hantavirus — evidence and indications

Ribavirin is a nucleoside analogue with in-vitro activity against multiple hantaviruses. Clinical evidence is mixed:

• HFRS (Hantaan virus): Chinese RCT data from the 1990s showed mortality reduction when ribavirin was given within the first 4 days of symptom onset. WHO and Korean clinical guidelines endorse early ribavirin for HFRS.
• HPS (Sin Nombre, Andes): a 2004 US RCT did not show benefit for HPS. Subsequent observational data have been inconclusive. Current US and Chilean clinical guidance does NOT routinely recommend ribavirin for HPS, but some centres still use it in early disease (within 72 hours of symptom onset) on a compassionate-use basis.
• Side effects: haemolytic anaemia is dose-limiting. Teratogenic — contraindicated in pregnancy and requires reliable contraception for 6 months after treatment in both sexes.

Investigational therapies in 2026

• Monoclonal antibodies (ANDV): several neutralising-antibody candidates are in Phase 1/2 trials. The Chilean group (Ferrés et al.) has reported on intravenous immunoglobulin from ANDV convalescent donors with possible benefit when administered early in contact-traced household cases.
• Favipiravir: in-vitro activity demonstrated. No randomised clinical data in hantavirus disease.
• Vandetanib: a tyrosine kinase inhibitor with reported in-vitro activity against ANDV; no human trial data.
• ECMO scale-up: the Chilean Ministry of Health announced a network expansion in May 2026 to ensure 24-hour ECMO transfer capability across Magallanes and Aysén in response to the MV Hondius cluster.

Hantavirus prognosis and survival

Rehabilitation after hantavirus

Discharge from acute care is the start of recovery, not the end. Hantavirus survivors face several rehabilitation challenges:

• Pulmonary rehabilitation (HPS): structured exercise-based programmes for 6-12 weeks improve exercise tolerance and quality of life. Patients should be screened with pulmonary function tests at 6 weeks and 3 months post-discharge.
• Renal follow-up (HFRS): serum creatinine and urinalysis at 1 month, 3 months, and 12 months. Persistent proteinuria warrants nephrology referral.
• Cardiac assessment (HPS): echocardiogram if post-discharge fatigue or exercise intolerance is disproportionate; some ICU survivors have transient stress cardiomyopathy.
• Psychological support: ICU PTSD rates after hantavirus are comparable to other severe-illness ICU stays (~20-30%). Routine screening at 6-8 weeks post-discharge is recommended.
• Return to work: most patients can return to office or light physical work at 6-8 weeks; heavy manual work usually requires 3-6 months.