New Telegraph

‘Rat race’: A nation’s Lassa dilemma

It’s difficult to distinguish it from malaria, says Prof. Onajole

Govt should strengthen health systems at the local level – Enabulele

It resurfaced when the nation is still grappling with an equally dreaded COVID-19 virus that has created panic across the country. Lassa fever, caused by rodents, has been brutal in magnitude since its current outbreak. The high incidence may be why it is regarded as a major problem in Nigeria today. But, is the country’s health systems prepared to confront this rampaging monster? Isioma Madike reports

It sneaked in like a thief in the night, and has left in its trail deaths in some neighborhoods, and panic in others. It has thus far dispatched over 92 Nigerians including care-givers to their untimely grave. The young, not so young, and the aged have all been victims of this rampaging monster.

Though it kept coming back since its first appearance in a small village of Lassa, in Borno State, Nigeria, where it derives its name in 1969, yet, it threw both the health community and the general populace into quagmire. Like the equally dreaded Ebola that ravaged the country not long ago, Lassa fever or Lassa hemorrhagic fever (LHF), an acute viral hemorrhagic fever caused by the natal multimammate mouse or rodent, the primary animal host of the Lassa virus, has rattled the health structures that were supposed to be on red alert.

The Nigeria Centre for Disease Control (NCDC) had, last week, confirmed in its situation report on the outbreak of the disease that the death toll from January through December 2021 had indeed jumped to 92, with Bauchi and Ebonyi states recording new deaths. According to the NCDC, week 50, which covered December 13 to 19, recorded three more deaths. While Bauchi reported two new fatalities, Ebonyi had one. It stated: “Cumulatively from week 1 to week 50, 92 deaths have been reported with a Case Fatality Rate (CFR) of 20.3 per cent, which is lower than the CFR for the same period in 2020 (20.7 per cent).” Nigeria, other reports said, had a total of 190 suspected new cases in the beginning in 11 states and the Federal Capital Territory (FCT). However, only 10 cases were confirmed in four states at that early stage.

The states were Edo – two, Ondo – four, Bauchi – three, and Ebonyi – one. Two among these numbers were healthcare workers, the reports added. The health sector, at least in the estimation of ordinary citizens, was again caught off-guard, just like it happened during the Ebola incident. This perception may be why some people have been insinuating that the health authorities’ and government’s ineptitude and unseriousness are to blame for the current epidemic. But, to some medical experts, clinically, Lassa infections are sometimes difficult to distinguish from other viral hemorrhagic fevers. One of those with this opinion is a Professor of Public Health and Consultant Epidemiologist at the Lagos University Teaching Hospital (LUTH), Adebayo Onajole, who insisted that viruses of this nature usually surface once in a while.

He also claimed to be aware of the government surveillance system in place. “But, the problem is that it is extremely difficult to distinguish it from other viral hemorrhagic fevers such as Ebola, Marburg and from more common febrile illnesses such as malaria. Most times it comes like the normal fever and there is always a low index of suspicion and most people affected may not present clinical symptoms.

“Some may just have it and with related treatment, survive without presenting any serious suspicion. “With our experience of the Ebola incident, the health authorities are now more alert to high index of suspicions towards certain clinical presentations of infections like we have now.

That is the reason why public health officials have been able to curtail the spread of this; otherwise it could have been worse than we are seeing. “Having said that, the government needs to do more to strengthen the health sector, particularly at the local levels so as to be able to confront such malady effectively in future because clinthey would always resurface now and again. In any case, that does not mean we have to heap the blame on the government or the healthcare systems,” Onajole said. A Chief Consultant Family Physician and current President of Commonwealth Medical Association (CMA), Dr. Osahon Enabulele, also towed this line of argument. He told Saturday Telegraph that he is at loss as to where people are getting their views concerning the lacklustre attitude of the health officials and government on the issue at hand. The former President, Nigeria Medical Association (NMA), and President-elect of the World Medical Association (WMA), further said: “The thing I know is that Lassa is not a new thing and the health authorities are alive to the challenge. “What I think we should be talking about now is how to strengthen the health systems at the local level in terms of both primary and secondary structures. This is because an aggregate of that is what healthcare is supposed to be. “In any case, we need to continue to emphasise research into these areas; this should have been the thinking since the Ebola saga. Given the fatality rate of the current Lassa, the Federal Government should not trade blame like we are reading from the media. “Instead, it should step up effort like it’s already doing in terms of awareness, particularly at the grassroots and like I said earlier, move to fortify the local health system. “We should not forget that this type of health challenge will always come and there ought to be a system in place to tackle such anytime there is recurrence. We should not be reacting like we are doing now but be proactive. “When we do that, the rate of fatality would be minimal. Of course, from the current prevalence, nobody should be blamed for being panicky. That is my sincere contribution.” Yet, a gynaecologist and first vice president, Society of Gynaecology and Obstetrics of Nigeria (SOGON), Dr. Olurotimi Akinola, added another angle to the issue. He said: “Nigeria is endemic to Lassa; it’s homegrown unlike Ebola, which was imported and much more deadly. I don’t think there has been any year without an outbreak of Lassa in the country and so we have been having it.

“This particular one may not have been more fatal, though it’s frightening. And because of the rising level of awareness from the Ebola incident, health managers have been able to curtail it thus far. It is difficult to generally eradicate the occurrence except when there is a vaccine for it. You can’t exterminate all the rats; that is not possible.

“So, attention should be on getting the vaccine otherwise it will continue to recur. If you can recall, the fatal magnitude was more in 2013 plague. This is why it may be unfair to blame the current spread on the ineffectiveness of the public health officials or government.” Another Consultant Psychiatrist and former Chief Medical Director, Lagos State University Teaching Hospital (LASUTH), Ikeja, Dr. Olufemi Olugbile, seemed to agree with Akinola when he said that the disease is indigenous to Nigeria. To him, what is needed now is a high travel awareness from time to time.

“It’s basically a wake-up call for both public health practitioners and the general public, especially in the area of hygiene that we habitually neglect. I won’t admit that the current epidemic took us unawares, rather I’d commend the public health sector for the speedy way they have combated it. It could have been worse but for their alertness.

“However, I would recommend that the government should intensify the consciousness campaign against filth; it should increase things that promote cleanliness. Lassa is simply an environmental problem,” he said. In a conversation with a public health expert, Dr. Doyin Odubanjo, by reliefweb anchored by Adejuwon Soyinka, the past Chair, Association of Public Health Physicians of Nigeria (Lagos), said the Nigerian Academy of Science has called for the current outbreak of Lassa fever in Africa’s most populous nation to be declared a national health emergency because of its severity.

The Executive Secretary, Nigerian Academy of Science, in the interview, said it is serious enough given the worsening trend. “It has spread from just two states when it was first diagnosed in 1969 to 23 states in 2019. The situation has increasingly got worse over the years. “In 2018, the NCDC reported the largest ever number of cases in Nigeria, with over 600 confirmed cases and over 170 deaths. And the numbers have continued to rise. “An alarm was raised over the tripling of the number of suspected cases between 2017 and 2018 only for the reported number of suspected cases to rise in 2019.

Outbreaks have historically occurred during the dry season — November to April. But in recent years there have also been cases during the rainy season. “Fatality rates are also unacceptably high. Over the last few years they have remained between 20% and 25%. This is particularly bad given that there is an effective treatment for the disease if it’s detected early and patients are presented at the hospital,” he said. On why people get infected and why it has been persistent, Odubanjo reaffirmed that Lassa fever is a viral haemorrhagic disease caused by the Lassa virus, which naturally infects the widely distributed house rat. It’s transmitted through the urine and droppings of infected rats found in most tropical and subtropical countries in Africa.

“They are able to contaminate anything they come in contact with. The Lassa virus spreads through human to human contact with tissue, blood, body fluids, secretions or excretions. This includes coughing, sneezing, kissing, sexual intercourse and breastfeeding. In hospitals the disease is spread through contaminated equipment. People become ill six to 21 days after they are infected. “A fever is usually the first symptom followed by headaches and coughing, nausea and vomiting, diarrhoea, mouth ulcers and swollen lymph glands. Some patients also complain of muscle, abdomen and chest pains. “And later, patients’ necks and faces swell and they bleed from their orifices and into their internal organs. Lassa fever can be fatal, but it can be treated if diagnosed early,” he said.

He however added that a drug does exist for the treatment of the disease. But its efficacy, according to him, is affected by the fact that Nigeria has inefficient laboratory diagnosis and patients are admitted late to hospital. Odubanjo said: “The spread of the disease throughout the country may also have resulted from increased contact between humans and rodents.

This has happened as populations of rodents have grown, encouraged by a pervasively poor environmental sanitation. “Another factor is that inadequate attention has not been paid to the disease. This has led to poor funding for research into drugs, including vaccination, and compounded by weak disease surveillance and response systems and a relatively weak health system.” To successfully turn the tide, governments at state and federal levels, the public health expert recommended, need to mount an extensive and sustained public Lassa fever prevention and control awareness programme. “States of the federation also need to establish functional isolation wards for the treatment of Lassa fever patients. “It is also important to set up a mechanism for improving environmental sanitation in a sustained way throughout the country to reduce rodent population as well as rodent — human contact. Funds should also be provided for research into finding new drugs for Lassa fever treatment and the development of a Lassa fever vaccine,” he added.

In line with the new thinking, the National Association of Resident Doctors (NARD) has called on the government to improve existing response mechanisms to ensure rapid response in cases of disease outbreaks in the country. Former President of the association, Dr. Muhammad Askira, decried the emergency response arrangement set up by the government to tackle outbreak of any epidemic of this nature. Askira said that such outbreaks do not require ad hoc arrangements or committees; rather, there should be an existing strategy to cushion the effect in any emergency or epidemic situation. According to him, it will, in no small way, reduce the death toll arising from such cases.

He also recommended well-structured strategies from the local, state and Federal Governments to ensure that prompt attention was given to such situations. He said: “There should be on ground, at any given point, a well-structured strategic system, from the local to the Federal Governments, from the primary healthcare level to tertiary healthcare, whereby the team is already on alert for prompt and effective response to this type of epidemic. We should not wait until there is an outbreak before we start rushing to address the epidemic. “This involves a lot of logistics, which comes from the society, healthcare providers and the government itself. It can be in the form of financing, appropriate equipment and facilities, well and adequately trained manpower to handle suspected and confirmed cases. So, whenever these are not adequate or properly applied, we have pockets and periods of epidemic of this nature.’’ First identified in 1969, the hemorrhagic fever caused by the Lassa virus can be transmitted via contact with urine, faeces and blood of a rodent, commonly known as the multimammate rat. Human to human transmission has also been found to be possible. The virus is widespread in West Africa, particularly in Benin, Guinea, Liberia, Sierra Leone and Nigeria. Lassa fever can be deadly if not cured during its early stage. Typical symptoms of this disease include high fever, general weakness, sore throat, cough, nausea, vomiting, and diarrhea. Later symptoms include bleeding, rashes and swelling of the eyes and genitals. The incubation period lasts from six to 21 days, according to the World Health Organisation (WHO). Contamination can be prevented by, among other things, storing food in containers not accessible to rodents, disposing of garbage far from home and avoiding contact with bodily fluids of sick people. While most humans are infected either from contact with an infected rat or inhalation of air contaminated with rat excretions, like other hemorrhagic fevers, Lassa fever can be transmitted directly from one human to another. It can also be contracted through direct contact with infected human blood excretions and secretions, including through sexual contact. No evidence of airborne transmission person-to-person is seen. But, transmission through breast milk has also been observed. However, public health experts have advised that it is very important to practice preventive measures to avoid infection of Lassa fever by ensuring frequent hand washing with soap and running water, proper environmental sanitation, and proper covering of foodstuff to avoid contact with rats.

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