ARUKAINO UMUKORO writes that the outbreak of Lassa fever was a disaster waiting to happen
Some have described it as a dreaded viral assassin.
Within a space of about 10 weeks, it has spread from remote areas in a few states to more than half of Nigeria’s 36 states, as well as the Federal Capital Territory, Abuja, and left a trail of death and suspicion in its wake.
The cold, death tracks left by the Lassa fever virus late last year in remote villages in Niger, Bauchi and Kano states has since snowballed into a national emergency.
Lassa fever has reportedly killed about 63 people out of 212 suspected cases in 62 local government areas across 17 states in the country since its outbreak in August last year.
At an emergency National Council of Health meeting on the outbreak of the disease, which held last Tuesday in Abuja, the Minister of Health, Prof. Isaac Adewole, had listed the affected states as Niger, Bauchi, Kano, Taraba, Rivers, Ondo, Oyo, Edo, Lagos, Plateau, Gombe, Delta, Nasarawa, Ebonyi, Ekiti, Kogi and Zamfara, and the Federal Capital Territory.
Rats, garri spreading deadly virus
According to the World Health Organisation, Lassa fever is an acute viral haemorrhagic illness caused by Lassa virus, which is transmitted to humans from contact with food or household items contaminated with the excreta or urine of infected multimammate rats.
This specie of rats is a common sight in both rural and urban areas in Nigeria. In some parts of the country, it is a culinary delight.
According to the United States Centers for Disease Control and Prevention, Lassa fever was first discovered in 1969 in Lassa village in Borno State, Nigeria, where two missionary nurses had died. The number of Lassa virus infections per year in West Africa is estimated at 100,000 to 300,000, with approximately 5,000 deaths.
WHO noted that person-to-person infections and laboratory transmission can also occur, particularly in the hospital environment when there is absence of adequate infection control measures.
Because the disease is endemic in the rodent population, people living in rural areas, especially in communities with poor sanitation or crowded living conditions, are at greatest risk.
Like in Fuka, a remote village in Muyan Local Government Area of Niger State, where the recent cases of Lassa fever were first reported.
By the time it was discovered, 16 people had already died from the virus.
Locals in the village of about a few thousand people are mainly yam and rice farmers. It also boasts of thriving market days where market women especially, sell food items like garri, which is made from processed cassava tubers. In a bid to determine their quality, it is common for buyers to taste it first before buying.
As food, garri could be soaked in water and eaten with any protein combination, or cooked with hot water and eaten with soup.
In Fuka, as well as in other rural and urban areas in Nigeria, it is common for residents to leave food items in the open in the market place, exposing it to the urine and faeces of infected rats that might crawl over them
Experts say such practices expose food items, such as garri, a popular staple for millions of Nigerians to Lassa virus.
The President, Society for Public Health Professionals of Nigeria, who also chairs one of the committees set up by the Federal Ministry of Health to address the Lassa fever outbreak, Prof. Michael Asuzu, said the first case was recorded in August last year. He noted that most of the cases occurred around a market area.
While he noted that he could not establish that the outbreak could have started from the market, Asuzu said the mode of transmission could be linked to the exposure of food items such as garri in market places, because rats can contaminate other food items, aside from garri.
He said, “The first cases occurred in August last year in a rural community in Niger, where they were trying to develop a market and they said it was a mysterious disease to them. Nobody reported the deaths, until the son of the principal of a school there was infected and the principal reported the case in December.
“If not for that necessary action by the principal, more people would have died of Lassa,” a regular visitor to the village told SUNDAY PUNCH on the telephone.
In Lagos, a 25-year-old student of the Ahmadu Bello University, Zaria, Kaduna State, is currently undergoing treatment at Lagos University Teaching Hospital, Idi-Araba, for Lassa fever. The student was rushed to LUTH on January 14 from a private clinic in Ojokoro area of the state.
On a visit last week, our correspondent was not allowed access to the ward.
“I can tell you that the patient is currently receiving treatment and is getting better. The doctors and nurses attending to him also get their temperatures taken daily as a precaution,” the Public Relations Officer, LUTH, Mr. Kelechi Otuneme, told SUNDAY PUNCH.
Our correspondent gathered that the patient, on his return from school, took ill at his parent’s residence at Ifako, Agege; a bustling area in the state, which has many open markets where garri and other food items are sold in the open, sometimes around filthy environments.
Unlike Lagos, however, it has been tales of deaths in other states across the nation.
Following the death of a medical doctor at the Obafemi Awolowo University Teaching Hospital Complex, Ile Ife, who was suspected to have died of Lassa fever last Tuesday, about 55 persons had reportedly been placed under surveillance. In the Federal Capital Territory, Abuja, a young man was reported to have died of the disease. It was not clear how many of the victims first contracted the virus. However, an infectious disease specialist, Dr. Joseph Onigbinde, noted that the mode of transmission, through contaminated food items such as garri, was undisputable.
“This is because most Nigerians like to eat garri, especially when soaked in water; it is most likely that Lassa fever could be transmitted through this means, he said.
Onigbinde warned Nigerians to be wary of soaking garri during this period, especially for the masses who mostly survive on it.
More than half of Nigeria’s population live on less than two dollars a day.
He said, “Those who drink garri must be careful. If one must drink garri during this period, I would suggest that one should fry it again a little before soaking it in water, otherwise it might be dangerous. Lassa fever virus cannot survive beyond 56 degrees centigrade. Effective personal hygiene and environmental sanitation are important too. Nigerians must be careful when buying foodstuff in the market, especially our women; they should not taste garri carelessly before buying it, because one does not know how it was prepared and if rats have crawled over it.”
Poor man’s disease
Lassa fever was described as a ‘disease of the poor’ by the Director of the World Bank funded African Centre of Excellence for Genomics of Infectious Diseases, Redeemer’s University, Ogun State, Prof. Christian Happi.
A professor of Molecular Biology and Genomics, Happi, led the research team that traced the ancient origin of Lassa fever virus to Nigeria. The discovery, published in August last year, showed that Lassa fever virus emerged from present day Nigeria 1,060 years ago, and spread 400 years ago from Nigeria to other West African countries.
“Lassa fever is described as a disease of the poor because you find it mostly in rural communities, Happi said.
His view was buttressed by a consultant epidemiologist, Institute of Lassa Fever Research and Control, Irrua Specialist Teaching Hospital, Edo State, Dr. Danny Asogun, who said the spread of Lassa fever could be attributed to poverty and ignorance.
“There is a lack of awareness of the disease in the grassroots areas. People there may have heard about it, but poverty has prevented them from knowing how to react positively to it. I think it is a combination of ignorance, poverty and poor environment, these are critical issues,” Asogun said.
Rural communities, such as in Niger, Bauchi and other states, have recorded more deaths from Lassa fever. This trend is also common in other West African countries, where high rates of infection and deaths have mostly occurred in rural communities.
In November 2014, in a village near Tanguiétain, in Benin Republic, residents didn’t realise that the mysterious infectious disease responsible for the deaths of their loved ones over a two-week period was Lassa fever, until a team of health officials from WHO and the country’s Ministry of Health came to investigate.
No access to primary health care
Beyond poverty and ignorance, the Lassa fever outbreak has also exposed the soft underbelly of Nigeria’s primary healthcare system, Onigbinde noted.
He said, “Lassa has always been with us in Nigeria, it was detected since 1969. What is happening now only goes to show we are not prepared at all.”
In Fuka, the only Primary Health Centre in the village had long been abandoned. So, there was no immediate access to health care for the affected persons.
Asuzu, noted that the outbreak occurred in remote areas in other states with no access to primary health centres, so the cases were not reported to the authorities on time.
There are currently no definite statistics of the number of primary health centres in the country and the Federal Government is in the dark about the figure.
This was evident during the emergency National Council on Health meeting on Lassa fever outbreak last Tuesday in Abuja. The Minister of Health, Prof. Isaac Adewole, had set up a committee to map out all the Primary Healthcare Centres across the nation.
According to the minister, the Federal Government, through the committee, will ascertain the number and locations of the centres in the country and whether they are functional or otherwise.
Adewole noted that the Federal Ministry of Health would rehabilitate about 10,000 Primary Healthcare Centres in the country within two years, where each ward is expected to have at least one functional centre.
In 1978, Nigeria was one of the 134 signatories of World Health Organisation member countries to have adopted the Alma Ata Declaration which established the primary health centres as the basic structural and functional unit of public health delivery system.
The goal of the declaration was to provide accessible and affordable health for all, especially at the grassroots.
According to the Primary Health Care in Nigeria: Strategies and constraints in implementation, published by the International Journal of Community Research, the Alma Ata declaration on Primary Health Care, “is meant to address the main health problems in communities by providing promotive, preventive, curative and rehabilitative services.”
A public health consultant at the University of Ilorin Teaching Hospital, Dr. Kayode Osagbemi, noted that very little seems to have been done since then to address the country’s primary health care needs. He said, “Nigeria is still at risk. More public health enlightenment should be encouraged. There is need for government and institutions to focus more on funding medical research in the country.
Happi added, “We need to target the primary health care centres if we want to put in place good surveillance system for the disease. Diagnosis has to be moved there; that is the reason why we are developing a rapid diagnosis test that will be deployed in these communities. It is obvious that we did not learn from Ebola outbreak. After the Ebola outbreak, we did not put in place adequate systems and measures to prevent such epidemics. I hope we would learn from this and put these things in place for proper diagnosis and containment.”
Asuzu said a functional primary health care was the bedrock of any country’s health care system. “Without a functional primary health care, the secondary and tertiary health care systems would not work properly because it would be an inverted pyramid that would collapse on it. Primary health care should be our priority,” he told SUNDAY PUNCH.
He further said, “If there were primary healthcare centres in all these places, it (Lassa fever) won’t have spread like it did. These centres should be run by competent people that can properly diagnose the disease.”
Many local government areas in the country have ill-quipped or no Primary Healthcare Centres. During a trip to Niger State, our correspondent visited some communities in Madaka, a small town in Rafi Local Government Area in Niger State. The region had only one poorly equipped primary health centre, which had only one resident doctor, and catered for the need of about 20,000 people in at least 10 communities.
It is the same scenario in many regions across the country, especially in remote towns and villages, where residents sometimes have to walk or commute for miles just get access to basic healthcare in the nearest state general hospital.
“We need to strengthen our national preparedness for epidemic diseases, increase surveillance at our airports, and community sensitisation,” the National President, Association of Medical Officers of Health in Nigeria, Dr. Yahya Disu, said.
Like Ebola, like Lassa
Like the deadly Ebola Virus Disease which killed over 11,000 people and infected more than 20,000 people in West Africa, Lassa virus can cause haemorrhagic fever with high case fatality rates.
The index case of EVD was recorded in Lagos State in August 2014, and then it spread to other states like Rivers. Eight out of a total of 20 people infected died of Ebola in Nigeria. In October, 2014, WHO declared Nigeria Ebola-free.
Lassa fever has so far caused the deaths of 63 persons, almost 800 per cent more than those that died of Ebola.
About 15 to 20 per cent of patients hospitalised for Lassa fever die from the illness, while only one per cent of all Lassa virus infections result in death.
Mild symptoms of Lassa fever include slight fever, general malaise and weakness, and headache; which begins to show typically between one to three weeks after the patient comes into contact with the virus, noted the US Centres for Disease Control and Prevention.
Lassa fever is not necessarily more deadly than Ebola, but it spreads faster, Onigbinde added.
He said, “We were just lucky during the outbreak of Ebola, otherwise we might still be battling it by now. That Nigeria was able to contain Ebola was not because we were prepared as a nation, it was just because our doctors were on strike and there was only one index case in a hospital that was relatively prepared for infectious diseases. We like the ‘fire-brigade’ approach. I kept saying that we may still have a repeat of Ebola or any other infectious disease, because we are not practicing the safety precautions of infectious disease control.
“Both private and public health institutions have let down their guards, even educational institutions too. As soon as Nigeria was declared Ebola free, nobody was cognisant of hygiene anymore. Now, Lassa fever outbreak has again exposed the failure of our health care system.”
Osagbemi noted that improving on public hygiene and effective public health control measures against disease outbreak were vital in preventing the spread of Lassa fever.
He said, “People should practise good personal hygiene and maintain good sanitary conditions in and around their homes, they should not leave their food unnecessarily exposed. The treatment of Lassa fever is through the use of antibiotics, anti-viral drugs and supportive treatment. It has been shown to be most effective when given early in the course of the illness. Patients are also given supportive treatment, which includes treating other complications.”
Asogun urged health workers to protect themselves while attending to patients. He also advised that persons with high fever, and who are not responding to medication, should report to the nearest health facility for proper diagnosis.
The US CDC report said the symptoms are mild and are undiagnosed for about 80 per cent of Lassa fever virus infections. In 20 per cent of infected individuals, however, the disease may progress to more serious symptoms including haemorrhaging (in gums, eyes, or nose, as examples), respiratory distress, repeated vomiting, facial swelling, pain in the chest, back, and abdomen, and shock. Neurological problems may also arise, including hearing loss, tremors, and encephalitis. Death may occur within two weeks after symptom onset due to multi-organ failure. The most common complication of Lassa fever is deafness, which may develop in mild, as well as in severe cases.
Onigbinde feared Lassa fever could cause more fatalities if it was not nipped in the bud early, through effective primary healthcare.
On a visit to Fuka village on January 13, the Minister of Health had noted that if the Primary Healthcare Centre had been functional, the Health Ministry would have been alerted about the outbreak and they would have been a prompt response to save lives.
When contacted, the Director of Public Health, Niger State, Dr. Mohammed Usman, told SUNDAY PUNCH that he would not make further comments on the issue since the minister had spoken about it.
One Lassa research centre for 170 million people
Beyond primary healthcare, SUNDAY PUNCH gathered that the Lassa Fever Research and Control Centre, at Irrua Specialist Teaching Hospital, Edo State, was the only centre for both the diagnosis and treatment of Lassa fever patients. The centre, which was established in 2007, has a dedicated ward that can admit up to 30 patients.
In a country of 170 million people, where the disease is endemic, there needs to be more specialist centres, noted Happi.
However, during the emergency meeting, Adewole was quoted as saying, “We currently have testing capability in 14 testing centres, some of which are in Maiduguri, Kano, Iddo, Irrua, Lagos, Port Harcourt and the FCT. We have treatment centres all over the country. We have enough personnel for managing Lassa fever. Unlike Ebola Virus Disease that is untreatable, Lassa fever is treatable. But we must start treatment on time to enable us to save the patients.”
Our correspondent also gathered that this month alone, the Irrua centre has admitted about 20 patients, a significant increase from the about 10 patients in total it had recorded over a three-month period before January.
“We need to upgrade the centre’s laboratory to include supportive diagnosis; apart from that for Lassa fever, there are other tests the patient would need, such as full blood count and urine tests. It would enhance clinical care, protect people and prevent staff from being infected,” Asogun said.
When SUNDAY PUNCH contacted the Director, National Centre for Disease Control, Abuja, Prof. Abdusalam Nasidi, he said he was at a meeting and would get back to our correspondent. At the time of this report, he had yet to do so.
In a recent interview with The PUNCH, the Minister of Health said Lassa fever would be eradicated by April.
It remains to be seen how that would be done, with primary health centres in the country crying for help, Onigbinde said.
“Our health institutions are not ready. We should sit down now and plan properly; strengthen them and take the common precautions to prevent infections in the future. Otherwise it could be another terrible epidemic; it could be dengue fever or yellow fever tomorrow. Right now, Lassa fever has shown that we are not prepared; we are only paying lip service to these issues. I think it is time we stood up and put our house in order.”
