NIGERIAN WATCH

6
NIGERIAN WATCH
12 - 25 Feb 2016
NEWSWatch
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Lassa FEvEr outbrEak IN NIgErIa cLaIms 101 LIvEs
A growing Lassa Fever (LF) outbreak in Nigeria has
killed 101 people, as West Africa battles to contain a
flare up of the virus, according to data from the nation’s
health authorities released February 6.
Nigeria Centre for Disease Control (NCDC) statistics
show that reported cases of the haemorrhagic
disease — both confirmed and suspected — stood
at 175 with a total of 101 deaths since August.
“As at today, 19 (including Abuja) states are
currently following up contacts, or have suspected
cases with laboratory results pending or laboratory
confirmed cases,” the NCDC said in a statement.
Deaths from the virus were recorded in the nation’s
political capital, Abuja, Lagos, and 14 other
states, the NCDC said.
While health authorities assure Africa’s most
populous country of more than 170 million they
have the virus under control, there are fears the
actual scale of the outbreak is under-reported.
The outbreak of Lassa fever was only announced
in January — months after the first case of the disease
happened in August — with subsequent
deaths reported in 10 states, including Abuja.
Last year, 12 people died in Nigeria out of 375
infected, while in 2012 there were 1,723 cases and
112 deaths, according to the NCDC.
In neighbouring Benin at least nine people have
died in a Lassa outbreak, with a total of 20 suspected
cases, health authorities revealed. Benin
was last hit by a Lassa fever outbreak in October
2014, when nine people suspected of having the
virus died.
The number of Lassa fever infections in West
Africa every year is between 100,000 to 300,000,
with about 5,000 deaths, according to the US Centers
for Disease Control and Prevention.
Here Chima Olugh, who is a pharmacist
with expertise in both public health and
primary care, details the nature of the
disease and lessons that need to be learnt
by Nigeria’s health authorities. Mr Olugh is
also Director of Consult Health Limited,
which provides expertise and advisory
services in primary care service design.
Lassa Fever (LF) is an acute
viral haemorrhagic fever
caused by the Lassa virus and
was first discovered in 1969
in the town of Lassa, in Borno
State, Nigeria. Similar to
Ebola, which is also
haemorrhagic, clinical cases
of LF had been known for
over a decade, but had not
been connected with a viral
pathogen.
The first reports of LF in
Nigeria emerged in
November but has now
spread to 14 other states,
amid a flurry of
contradictory information
released by State and Federal
Governments.
The primary animal host
of the Lassa virus is the
Mastomys rat. The virus is
transmitted by contact with
the faeces or urine of the rat
accessing grain stores.
Diagnosis and prompt
treatment is essential. Early
supportive care with
rehydration, coupled with
the treating of any symptoms
improves survival.
About 80% of people who
become infected with Lassa
virus have no symptoms.
However, one in five
infections result in severe
disease.
symptoms of LF
General symptoms include:
fever, general weakness,
malaise, headache, sore
throat, muscle pain, chest
pain, nausea, vomiting,
diarrhoea, cough and
abdominal pain.
In severe cases: facial
swelling, fluid in the lungs,
bleeding from the mouth,
nose, vagina or gastrointestinal
tract and low blood
pressure may develop. Shock,
seizures,
tremor,
disorientation and coma may
be seen in the later stages of
the disease.
In fatal cases death can
usually occur within 14 days of
onset. The disease is especially
severe late in pregnancy, with
maternal death and/or foetal
loss occurring in greater than
80% of cases during the third
trimester.
transmission
Humans usually become
infected from exposure to the
urine or faeces of infected
Mastomys rats. These rats
breed frequently and bear
many offspring, increasing
the potential for spread of the
virus from rats to humans.
Lassa virus may also be spread
between humans through
direct contact with the blood,
urine, faeces, or other bodily
secretions of a person infected
with LF. There is no evidence
supporting airborne spread
between humans.
Person-to-person
transmission occurs in both
community and health-care
settings, where the virus may
be spread by contaminated
medical equipment, such as
re-used needles. Sexual
transmission of Lassa virus
has also been reported.
Persons at greatest risk are
those living in rural areas
where Mastomys are usually
found, especially in
communities with poor
sanitation or crowded living
conditions. Health workers
are at risk if caring for LF
patients in the absence of
proper barrier nursing and
infection control practices.
Diagnosis
Because the symptoms of LF
are so varied and nonspecific,
clinical diagnosis is
often difficult, especially early
in the course of the disease. LF
is difficult to distinguish from
other viral haemorrhagic
fevers such as Ebola virus and
many other diseases that
cause fever, including malaria,
shigellosis, typhoid fever and
yellow fever. There is
currently no vaccine that
protects against LF.
Prevention and control
Prevention of LF relies on
promoting good “community
hygiene”, to discourage
rodents from entering homes.
Effective measures include
storing grain and other
foodstuffs in rodent-proof
containers, disposing of
garbage far from the home,
maintaining clean households
and keeping cats.
Because Mastomys are so
abundant in endemic areas, it
is not possible to completely
eliminate them from the
environment. Family
members should always be
careful to avoid contact with
blood and body fluids while
caring for sick persons.
In health-care settings,
staff should always apply
standard infection prevention
and control precautions when
caring for patients, regardless
of their presumed diagnosis.
Laboratory workers are
also at risk, so samples taken
from humans and animals for
investigation should be
handled by trained staff and
processed in suitably
equipped laboratories.
On rare occasions,
travellers from areas where LF
is endemic export the disease
to other countries. Although
malaria, typhoid fever, and
many other tropical infections
are much more common, the
diagnosis of LF should be
considered in febrile patients
returning from West Africa,
especially if they have had
exposures in rural areas or
hospitals in countries where
LF is known to be endemic.
The case of Nigeria
It’s no secret the Nigerian
healthcare system struggles to
cope when faced with a
pandemic or epidemic of any
kind. One would have
thought that many lessons
were learnt from the Ebola
episode. But seemingly not.
The current outbreak first
emerged in 2015 – sometime
between August and
November – when some
strange deaths occurred in a
community in Niger State,
which left the community
confused.
This was followed by a
period of uncertainty and
anxiety, and they reached out
to the only rational
explanation they could
imagine – the supernatural.
By the time the public
health authorities were
informed and a diagnosis of LF
was made, the outbreak had
spread to many states.
Control efforts included a
mixture of persuasion to
report suspicious cases to
health
authorities,
establishment of task teams,
and even an emergency
meeting of the National
Council of Health.
One patient, however, is
reported to have “escaped”
the hospital where he was
being treated. The community
was scared; they did not know
who to trust.
The single most important
factor in the control of
outbreaks is trust in the health
care system by the citizens of
a country. A great “Centre for
Disease Control” is worth very
little in the context of a public
health care system that is
largely dysfunctional, which
its citizens do not trust.
The most likely
transmission mechanism for
the current LF outbreak is
person-to-person. While rats
are the likely source of initial
infection, it is extremely
unlikely, given the
geographical distribution of
cases, that there is any ongoing
zoonotic source of
infection.
Therefore, to break the
chains of transmission of the
LF virus, people must trust the
health authorities enough to
inform them of any signs of
illness and not seek alternative
sources of relief.
Those infected and affected
must trust that the healthcare
workers’ that they report to
will treat them and care for
them humanely in the
presence of overwhelming
historical evidence to the
contrary.
The Federal and State
governments are now
responding to the outbreak by
enhancing the disease
surveillance for early
detection, reinforcing
treatment of patients, and
conducting awareness
campaigns among the affected
population.
Major challenges are the
ongoing security risks in the
country limiting access to
some areas as well as the
limited availability of
resources to respond to the
escalating outbreak.
The World Health
Organisation (WHO) does not
advise or recommend any
restrictions on travel or trade
with Nigeria, although
travellers returning from
affected areas who develop
symptoms of fever (see above)
should seek medical advice.
One thing we can all be
sure of is that when this
outbreak is over, Nigeria will
be in a celebratory mode,
similar to that witnessed
during the Ebola period.
My advice would be for the
medical authorities to spend a
lot of time in reflecting on
what went wrong, learning
some lessons, and preparing
for the next epidemic.