We are all vulnerable —Experts
How poor surveillance fuels fever
By Chioma Obinna
Nigeria may be battling the worst outbreak of Lassa fever in history. The fever which has afflicted over 284 has killed about 154 Nigerians from different parts of the country from August 2015 to date.
Fresh cases are recorded every day in some states like Ondo and Bauchi, where the outbreak had earlier stopped, signalling that the disease could spread further. What implications does this development portend for Nigeria a year after the latest outbreak began? What lessons do we learn? Could this outbreak become an epidemic? No one can provide definite answers to these questions presently.
The new Director-General of the Nigeria Centres for Disease Control, NCDC, Abuja, Dr. Chikwe Ikpeazu, had, recently, in an interview, maintained that Lassa fever outbreak is yet to become an epidemic but there are fears that the continued deaths of Nigerians as a result of the fever may be pointing in a different direction.
Health watchers believe that unlike the response to Ebola outbreak, government may have failed to do same to Lassa. Rather, the outbreak has been greeted with the attitude of complacency.
For instance, the Minister of Health, Prof Isaac Adewole, while speaking to State House Correspondents in Abuja said Nigeria cannot win the battle against Lassa the same way it won the battle against Ebola because Lassa is endemic in Nigeria.
The Minister also, at an Emergency National Council on Health meeting, said the country should not be talking about control, but rather should sign off the obituary of Lassa.
He said: “I call it an embarrassment because as a nation we cannot witness Lassa fever every year; it is rather abnormal for a nation that has resources like we should have to be witnessing such epidemic.”
He promised that with the strengthening of the nation’s epidemiology surveillance and response, Lassa would be put under locked and key.
Before now, millions of Nigerians did not imagine the seriousness of the threat of Lassa outbreak. Unfortunately, months after the inauguration of the committee on the fever, the current outbreak has taken a new dimension, as the country may have failed to interrupt the transmission. Currently, the likely risk for medical personnel is the newest security threat confronting Nigeria. With the deaths of many doctors in the country, the threat of possible epidemic of the disease cannot be ruled out coupled with the resurgence of wild polio virus at a time Nigeria is facing serious economic challenges.
Contrary to the assumption that Lassa is a seasonal disease, the Chairman, Lassa Fever Control Committee, Prof Oyewale Tomori, at a symposium in Lagos, disagreed that the outbreak was an emergency, adding that poor disease surveillance system has caused the escalation and persistent re-occurrence.
According to him, no fewer than three people are diagnosed of the disease daily in the latest out-break.
“We have little value for life, until more than 100 people die, it is not an emergency. For many years, Lassa has been with us but we don’t take it serious. In other parts of the world, when a single person dies of a disease, it is a national emergency. For how long are we going to continue to call tragedy an embarrassment?
He explained that the breakdown in disease surveillance did not make the country notice that Lassa has consistently brought sorrow, pains and agony to several homes.
“If you are not hearing of new cases, it is not that the disease is not occurring, but because our disease surveillance is not up to par. We deceive ourselves that it’s a seasonal disease, but the fact remains that it occurs throughout the year. At least, three people are diagnosed of Lassa daily somewhere in the country,” Tomori said.
“We abandon disease surveillance and control activities; there was a time people worked together, the laboratories at Ibadan, the Ministry of Health, NIMR, joined forces to protect the country. In the 60s to 80s at Ibadan, we produced every reagent we needed in the country. We did not depend on importation. But now we are lazy and everybody wants to make money from importation.”
Sadly, with the new trend of the infectious disease, only few Nigeria laboratories can give accurate results.
To Tomori, Six to seven laboratories in the country cannot give proper results due to lack of support. The only few that function in the country have the support of partner agencies and backing from abroad.
The professor of virology also, in a report, described Lassa as an annual recurrent budget of death for poor people of Nigeria, adding: “Because we have lived in a state of denial of the disease, we handle it with characteristic laxity, laissez-faire, negligence, sloppiness, slackness, disregard, triviality and freewheeling abandon.
“Lassa lacks the zeal and trepidation that Ebola outbreak inspired and Nigeria still wakes up every year an outbreak is reported, “running like a decapitated chicken in any which direction, and forgetting about the disease till another year another outbreak.”
To another stakeholder, a renown professor of pharmacognosy and President, Bioresources Development Group, Prof. Maurice Iwu, Lassa was more than an embarrassment because the country has the personnel required, knowledge of the fever and how to prevent it, but the disease still claims lives.
Iwu argued that unless the country adopts the approach used during the Ebola outbreak, many more people would fall victim. “As long as Lassa fever is anywhere in the country, as long as we have restaurants that don’t keep good hygiene, as long as we have houses that are co-infested with rat and horse, as long as we have dirty environment, we are all vulnerable,” he said.
“The only thing we can do is keep track of the virus, and from time to time do research. Our universities should make sure that 80 percent of their research is localized to treat our own diseases, issues and viruses we live with.”
Findings by Sunday Vanguard show that as far as the average Nigerian is concerned, a confirmation of pockets of the disease across the states is alarming, while an epidemic would be catastrophic. Such fears are well founded. The latest Lassa fever outbreak affected 24 states in Nigeria. Unlike outbreaks of the past, it is spreading in rural and urban areas. In the country today, millions of people are walking around with high fevers and other kinds of symptoms that could confuse diagnosis of Lassa fever. Worse still, Nigeria has been listed among countries that may be threatened by global spread of Zika virus, another terrible, viral disorder caused by mosquitoes. This time, even health workers are not spared.
Update on the World Health Organisation, WHO, website showed that between August 2015 and 17 May 2016, WHO has been notified of 273 cases of Lassa fever, including 149 deaths in Nigeria. Of these, 165 cases and 89 deaths have been confirmed through laboratory testing (CFR: 53.9 percent). The cases were reported from 23 states.
Since August 2015, 10 health care workers (HCW) have been infected with Lassa virus, of which two have died. Of these ten cases, four were nosocomial infections. Just two weeks ago, two medical doctors died from the disease in Anambra and Delta States.
As of 17 May 2016, eight states reported Lassa fever cases (suspected, probable, and confirmed), deaths and/or following of contacts for the maximum 21-day incubation period. Currently, 248 contacts are being followed up in the country. The other 15 previously affected states have completed the 42-day period following last known possible transmission.
Public health response
Currently, two national laboratories are supporting the laboratory confirmation of Lassa cases by polymerase chain reaction (PCR) tests. All the samples were also tested for Ebola, Dengue, Yellow fever and so far have tested negative. The two laboratories that are currently operational are Virology laboratory, Lagos University Teaching Hospital and Lassa fever research and control centre, Irrua specialist hospital. Along with other key partners, WHO is supporting the Federal Ministry of Health in surveillance and response of Lassa outbreaks including contacts tracing, follow up and community mobilisation. Of particular concern since the onset of Lassa fever outbreaks in Nigeria is the high proportion of deaths among the cases that is still under investigation.
What it is?
According to WHO, Lassa fever is an acute viral haemorrhagic illness caused by Lassa virus, a member of the arenavirus family of viruses. It is transmitted to humans from contacts with food or household items contaminated with rodent excreta. The disease is endemic in the rodent population in parts of West Africa like Nigeria.
Prevention and control
Humans usually become infected with Lassa virus from exposure to urine or faeces of infected Mastomys rats. 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 Lassa fever. There is no epidemiological 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 been reported. It also occurs in all age groups and both sexes. 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.
The incubation period of Lassa fever ranges from 2–21 days. The onset of the disease, when it is symptomatic, is usually gradual, starting with fever, general weakness, and malaise. After a few days, headache, sore throat, muscle pain, chest pain, nausea, vomiting, diarrhoea, cough, and abdominal pain may follow. In severe cases facial swelling, fluid in the lung cavity, bleeding from the mouth, nose, vagina or gastrointestinal tract and low blood pressure may develop.
Protein may be noted in the urine. Shock, seizures, tremor, disorientation, and coma may be seen in the later stages. Deafness occurs in 25 percent of patients who survive the disease. Death usually occurs within 14 days of onset in fatal cases and severe late in pregnancy, with maternal death and/or fetal loss occurring in more than 80 percent of cases during the third trimester.
Lassa fever is difficult to distinguish from other viral haemorrhagic fevers such as Ebola virus disease as well as other diseases that cause fever, including malaria, shigellosis, typhoid fever and yellow fever. Definitive diagnosis requires testing that is available only in reference laboratories. Laboratory specimens may be hazardous and must be handled with extreme care.
There is currently no vaccine that protects against Lassa fever. The antiviral drug ribavirin seems to be an effective treatment for Lassa fever if given early on in the course of clinical illness. There is no evidence to support the role of ribavirin as post-exposure prophylactic treatment.
Lassa timeline (pls box this)
Lassa fever is not new to Nigerians. The first ever documented case of Lassa fever was reported in Nigeria in 1969 when two missionary nurses died in a town called Lassa in the part of Nigeria now known as Borno State. They had complaints of weakness, headaches, fever and general malaise.
A study in the journal Cell by a team that included Christian Happi of Irrua Specialist Hospital—where experts confirm strains of Lassa fever in samples had traced “ancient roots” of Lassa nearly 1,000 years to a region that is now present-day Nigeria.
Up till 2008, specimens were flown abroad for confirmation. Since 2008, two centres have stepped in to fill the gap in laboratory diagnosis and research into the fever—Lassa Fever Research and Control Centre at Irrua Specialist Hospital, Edo, and Lahor Research.
Samples from the latest outbreaks have undergone confirmation at Irrua, which also provided confirmation for cases from 2012 onwards.
In 2012, the number of cases peaked in 2012, when 1,723 cases with 112 fatalities were recorded.
In 2012, half a million vials of Ribavirin, an antiviral drug considered effective were procured after the first case of Lassa was reported in Ebonyi. By then, one doctor and up to four nurses had died, some others were hospitalised at Federal Teaching Hospital, Abakiliki.
Lassa fever has the greatest impact among haemorrhagic fevers—rivalled only by dengue. Up to 300,000 are infected annually in West Africa alone, and an estimated 5,000 of them die.
During 2012 and 2013, more than 2900 cases were reported in widespread outbreaks that occurred across many states.
In 2013, three deaths—among them a health worker, it struck in Benue and Ondo States.
Since the last quarter of 2015, the country has been battling the epidemic disorder, which at the last count, has reached 24 states and killed 154 people. More than 684 suspected cases have so far been recorded in the Borno, Gombe, Yobe, Taraba, Plateau, Nasarawa, Ebonyi, Edo, Ondo, Rivers, Bauchi, Anambra, Lagos, Niger, Kano, Nassarawa, Plateau, Oyo, Gombe and Ondo, Kano states and the FCT amongst others and still counting.