Attitudes, Perceptions, and Preparedness for Viral Hemorrhagic Fever Outbreaks Among Medical Students in Uganda.

Introduction

Filoviruses, including Marburg virus and Ebola virus, cause epidemics of viral haemorrhagic fever (VHF) with case fatality rates (CFRs) ranging from 25%–90% for Ebola virus and 24%–88% for Marburg virus. The outbreaks are the result of zoonotic spillover events from animal reservoirs and subsequent spread from person to person through bodily fluids.^1,2 Sub-Saharan Africa has experienced repeated filovirus outbreaks, with Marburg virus implicated in 18 documented events, including recent outbreaks in Tanzania (2023 and 2025), Rwanda (2024), and Equatorial Guinea (2023). Ebola virus has caused approximately 43 outbreaks in the region, including eight in Uganda, most notably the 2014–2016 West African epidemic that severely affected Liberia, Sierra Leone, and Guinea, where many frontline health care workers (HCWs) were affected due to a lack of preparedness, poor and weak health care systems. In Uganda, the most recent outbreak, reported in 2025, was caused by Orthoebolavirus sudanense and had a case fatality rate of 30%.^3–5 These outbreaks challenge public health systems by overwhelming healthcare facilities, complicating diagnostic processes, and requiring extensive resources for containment and treatment, especially in resource-limited settings.⁶

HCWs are at elevated risk of infection during VHF outbreaks due to their close contact with patients and frequent exposure to infectious materials.^7,8 Medical students, as integral members of the healthcare team, also face substantial occupational risk, particularly during clinical rotations in outbreak settings⁹ yet little is known about their attitudes and preparedness for VHF outbreaks. While studies from Guinea have reported good knowledge and favourable attitudes among HCWs, they have also revealed deficiencies in practical preparedness, such as inadequate suspect case identification and limited access to personal protective equipment (PPE).¹⁰ In Nigeria, healthcare workers demonstrated inadequate preparedness for the control of VHF, with notable gaps in knowledge and practice related to VHF identification, reporting, and management. The key barriers to effective VHF control included limited training, insufficient supplies for standard precautions, the absence of standard operating procedures (SOPs), and inadequate institutional support.⁵

In Uganda, a national survey of 691 emergency HCWs across 14 secondary and tertiary hospitals revealed a median Ebola knowledge score of 77.4%, with significantly higher scores among physicians, more experienced staff, and those with prior VHF training or access to information through social media.¹¹ However, assessments of private health facilities in Kampala highlighted limited preparedness, with most lacking written protocols, training opportunities, or involvement in national response efforts. Only 66% of HCWs expressed willingness to be vaccinated.¹² In rural districts like Kasese and Rubirizi, 54% of HCWs were unaware of the Ebola incubation period. Many facilities lacked case definition books, isolation units, SOPs, PPE stock, or simulation drills, reflecting significant systemic gaps in VHF outbreak preparedness.¹³

Despite medical students being exposed to similar clinical risks as HCWs, most existing literature on VHF preparedness has focused on frontline staff, with limited attention to this important group. Given their critical role in healthcare delivery and their vulnerability during outbreaks, assessing the attitudes and preparedness of medical students in Uganda is essential to inform institutional policy, optimize training curricula, and strengthen national outbreak preparedness. Moreover, understanding the attitudes and preparedness of healthcare personnel for viral hemorrhagic fever (VHF) is foundational to effective infection prevention and control (IPC) strategies, particularly in regions prone to VHF outbreaks.¹⁴ This study aimed to assess the attitudes and preparedness of medical students in Uganda towards VHF outbreaks, with a focus on Ebola and Marburg viruses.

Methods

Results

Discussion

This study assessed medical students’ attitudes, perceptions, and preparedness regarding Ebola and Marburg virus disease outbreaks in Uganda. Overall, the findings reveal generally positive attitudes toward Ebola and Marburg, but substantial gaps in preparedness, particularly in vaccination, confidence in clinical management, and CME exposure. These findings are consistent with evidence from other African settings showing that knowledge and attitudes among healthcare personnel often surpass practical preparedness for viral haemorrhagic fevers (VHFs).¹⁵ Most students showed positive attitudes toward Ebola and Marburg survivorship and vaccination; however, stigma around the reintegration of survivors into the community and concerns about vaccine safety persisted. This aligned with studies from Guinea, where healthcare workers (HCWs) had favorable views of VHF patients but still expressed concerns about reintegration and stigma. A good number of the population also had Ebola vaccine hesitancy.^10,16

Despite most medical students perceiving Uganda at risk of another Ebola or Marburg outbreak, the perception of personal risk was low. Fewer than half felt personally at risk of Ebola or Marburg infection, a pattern mirroring findings among HCWs in Uganda, where perceived personal vulnerability was low even during active outbreaks.¹¹ A lower perception of infection risk among future clinicians may undermine responsiveness during outbreaks and result in reduced uptake of protective interventions, such as vaccination.

PPE is an important part of worker protection during filovirus outbreaks. Many medical students reported using PPE to protect themselves from EVD and MVD. However, this equipment alone is insufficient and must be accompanied by other interventions, such as handwashing, among other interventions reported by medical students.¹⁷ Notably, only a small proportion of medical students reported practicing safe sex as a preventive measure against Ebola and Marburg virus diseases. This finding suggests potential gaps in knowledge regarding transmission and prevention of these infections among medical students, calling for the need to improve knowledge of the disease and close the gap between knowledge and practice.¹⁸

Self-reported vaccine uptake for both the Ebola and Marburg virus vaccines was low, a finding that was expected, as there is no approved vaccine against the Marburg virus, and the mass rollout of the Ebola vaccine in Uganda is still in trial phases.^19,20 The low reported vaccine uptake may be attributable to social desirability bias in participants’ responses. Participation in CMEs on EVD and MVD among medical students was also notably low, even though most had no clinical experience and low confidence in managing both diseases. These findings closely align with an assessment in the Mubende and Kassanda districts, where HCWs demonstrated low competence in cornerstone skills for VHF case management and a lack of training opportunities and written protocols for VHF outbreak response, especially in the private health sector.^12,13

Medical students constitute a critical component of the future healthcare workforce and can get involved in frontline clinical care during outbreaks. The observed gaps, limited participation in VHF outbreak-focused continuing medical education, and low confidence in clinical management stress the need to strengthen outbreak preparedness within undergraduate medical training, possibly through extracurricular learning modules. The generally positive attitudes and perceptions toward Ebola and Marburg virus disease observed among medical students may reduce VHF outbreak stigma, promote community trust, and facilitate adherence to public health measures during outbreaks among future HCWs.

Conclusion

In conclusion, medical students in Uganda demonstrated generally positive attitudes toward Ebola and Marburg virus disease; however, substantial gaps in outbreak preparedness were identified, particularly in continuous training in clinical management. There is a need for continuous medical education to strengthen VHF preparedness, correct misconceptions, and improve practical competencies. Investing in the preparedness of medical students is essential for safeguarding the future healthcare workforce and enhancing national readiness for viral haemorrhagic fever outbreaks.

Author’s contribution

MJ, MCS, RK, and IAB conceived the idea and wrote the paper in conjunction with WB, NN. M CS conducted the data analysis; RK and IAB guided the approach, data collection, and analysis tools design. All the authors reviewed the manuscript for intellectual content and approval of the final manuscript.

Ethical consideration

The Makerere University School of Biomedical Sciences Research Ethics Committee (SBSREC) approved the study protocol. Approval number SBS-2022-289. Written Informed Consent was obtained from participants. We maintained the confidentiality of the participants’ data by the use of participants’ identification numbers and not their names.