Why many Nigerian health workers are susceptible to Lassa fever

When Sale Abdullahi developed symptoms, including severe headache, nausea, fever and vomiting, on 25 February, he had a test for malaria and typhoid which came back positive.

Mr Abdullahi, a nurse anaesthetist at the General Hospital, Kafin Madaki, in Ganjuwa Local Government Area (LGA) of Bauchi State, north-east Nigeria, was immediately placed on medications by a doctor at a private hospital, Remee Clinic and Maternity, in the Bauchi metropolis.

After days of trying out different medications, including artemether, ceftriaxone and ciprofloxacin, Mr Abdullah’s condition deteriorated and the fever worsened while on admission at the private clinic.

Nobody suspected it was Lassa fever until a urine analysis showed that his urine was looking bloody after which he was referred to the Lassa fever isolation centre for further lab investigation. There, he was diagnosed with Lassa fever and spent two weeks on admission.

“I battled with Lassa fever for good 29 days in all,” he said, adding that he observed at the isolation centre that healthcare workers (HCWs) are especially susceptible due to the close contact they have with patients.

Studies have shown that barriers to the control of Lassa fever include low index of suspicion, poor infection prevention and control (IPC) practices, lack of training on preparedness, and absence of local laboratories.

According to experts, early and accurate laboratory diagnosis is crucial for prompt initiation of treatments and prevention of further spread of Lassa fever because its symptoms at the initial stage can be mistaken for malaria.

The Lassa fever burden and the health system

Mr Abdullahi is a survivor of this viral haemorrhagic fever that is primarily transmitted to humans via contact with food or household items contaminated with urine or faeces from Mastomys rats.

Lassa fever, which is endemic in Nigeria, peaks during the dry season from December to April and continues to endanger the lives of many healthcare workers.

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Recently, the Nigeria Centre for Disease Control and Prevention (NCDC) confirmed that Lassa Fever was responsible for the death of three healthcare workers at the 44 Nigerian Army Reference Hospital Kaduna (44 NARHK), Kaduna State, north-west Nigeria.

According to the disease control centre, as of 28 April, a total of 32 healthcare workers have been affected by the rampaging disease in the current year, out of a total of 5,963 suspected cases, 857 confirmed cases, and 156 deaths.

An analysis of NCDC data in the last five years shows that a total of 197 healthcare workers have been affected: 20 in 2019; 48 in 2020, 10 in 2021, 63 in 2022, and 56 in 2023.

The trio of Ondo, Edo, and Bauchi states accounted for 76 per cent of all the confirmed cases in 2023 and 63 per cent in 2024 as of 28 April.

Understanding Lassa fever

While the knowledge and attitude towards Lassa fever prevention and control among healthcare workers were good, the practice was poor, according to a 2023 study of the Journal of Interventional Epidemiology and Public Health (JIEPH), published by the African Field Epidemiology Network (AFENET).

The cross-sectional study aimed to determine knowledge, attitude and practice toward Lassa fever prevention and control at the Alex-Ekwueme Federal University Teaching Hospital Abakaliki (AEFUTHA) in Ebonyi State.

Among 386 healthcare workers selected using a stratified random sampling technique, the study found that respondents who had previous training in IPC were 1.9 times more knowledgeable than others.

Only 28.2 per cent (109/386) of the respondents had adequate preventive practices towards Lassa fever. HCWs with tertiary education were 2.5 times less likely to have a good practice and those with less than 10 years of working experience in the hospital were 1.6 times less likely to have good prevention practice.

The study established that gender, educational status, patient contact and health workers’ years working in the facility were the factors associated with practice among them.

It recommended the provision of protective devices, routine training and supportive supervision of healthcare workers with a special focus on those prone to poor practices.

Another research by the PLOS Neglected Tropical Diseases published in 2022 surveyed the level of knowledge of Lassa fever and its prevention and control measures among healthcare workers during a Lassa fever outbreak in Katsina State, in northern Nigeria.

Of the 400 healthcare workers who participated in the study, 51.8 per cent demonstrated inadequate Lassa Fever knowledge, with 62.9 per cent of those scoring low having a high self-perception of their Lassa fever knowledge on the global scale.

It found that the level of Lassa fever knowledge and its prevention measures among the study participants was low (64.4 per cent) and predicated on participants’ training status, place of work and their designations.

It emphasised the critical need for health authorities in Nigeria to prioritise continuous on-the-job training of HCWs on priority neglected tropical diseases such as Lassa fever.

More stories of infections, death

Similar to Mr Abdullahi, Jamila Suleiman of the Abubakar Tafawa Balewa University Teaching Hospital (ATBUTH), Bauchi, developed some symptoms that suggested she had malaria, but her fever only worsened after anti-malaria medications.

Mrs Suleiman who was then a house officer at the hospital also had surgery for a perceived evaporated bowel, after which she started bleeding from the surgical wound, and later from her nose and mouth.

She was admitted to the hospital’s intensive care unit after she lost consciousness and had a blood transfusion.

“I was still at the intensive care unit when the index of suspicion was raised that it was Lassa fever case, and the samples were confirmed positive at a specialist hospital,” Mrs Suleiman told PREMIUM TIMES.

Two days earlier, Mrs Suleiman had attended to a patient who presented symptoms “that would look like malaria with fever and loss of consciousness.”

“I was managing the patients as a case of cerebral malaria but the patient later died after about 48 hours, and we obtained a history that he lost his daughter two weeks before his presentation at our hospital with a similar illness,” she said.

“They were able to take the sample of the patient before he later passed on and it was also positive for Lassa fever. I give glory to God that I am here and alive to share my story.”

She admitted that poor prevention and control practices were the cause of her infection

Also in April 2022, Deborah Adekunle was diagnosed with Lassa fever at the Ondo State Infectious Disease Hospital (IDH), now Reference Hospital.

Mrs Adekunle initially started with anti-malaria, then proceeded with antibiotics when she wasn’t relieved of the fever and joint pains.

“When I didn’t get better, a colleague suggested they should take my sample for Lassa fever and by midnight, our hospital’s managing director called to confirm that the result was positive and that I should come back for admission the next day.

“Fortunately, I got relieved on the second and third day and I stayed in the hospital for 10 days to complete the ribavirin treatment.”

Ribavirin is an antiviral drug that has been used with success on Lassa fever patients and is administered for 10 days.

In a recent documentary by Breakthrough Action Nigeria, a USAID-funded project, Jacob Mtsenem, a male surgical unit nurse at Benue State University Teaching Hospital, narrated how he survived Lassa fever after a colleague died from it due to a late diagnosis.

From managing their fever with anti-malaria, Mr Mtsenem and his son were diagnosed with Lassa fever. His wife, a food seller who also presented similar symptoms, also faced stigmatisation.

“My son also presented similar symptoms, so they admitted us on the same day when my doctor said I was having signs of Lassa fever and he wouldn’t like to take chances,” he noted.

“My wife is a food vendor who also came down with it, she suffered stigmatisation and it discouraged people from patronising her.”

On 10 January 2022, a doctor with the World Health Organisation (WHO), Samuel Nyityo, lost his life in Benue State to Lassa fever.

Preparedness, low index of suspicion

In January, NCDC activated an Emergency Operations Centre for Lassa fever (LF-EOC) following a risk assessment that placed the country at “high risk” of increased Lassa fever transmission.

The centre explained that the country is at risk due to the increased number of states reporting cases, high case fatality in confirmed cases, the low index of suspicion among healthcare workers, infections and deaths of healthcare workers, and continued attrition of essential healthcare.

The disease control centre explained that the virus initially presents like other common illnesses accompanied by a fever, such as malaria.

Other symptoms include headache, general body weakness, cough, nausea, vomiting, diarrhoea, muscle pains, chest pain, sore throat, and, in severe cases, bleeding from ears, eyes, nose, mouth, and other body openings.

According to a field epidemiologist and Consultant Public Health Physician at the African Field Epidemiology Network (AFENET), Adefisoye Adewole, health workers need to be proactive in managing Lassa fever.

Mr Adewole said Lassa fever is of public health importance because of its high morbidity and mortality, emphasising that “healthcare workers should have a high index of suspicion on diagnosis and management of the virus.”

Index of suspicion means the degree to which a healthcare provider suspects that a patient may be suffering from a particular illness or injury based on the patient’s clinical presentation of signs and symptoms, and the mechanism of injury, if applicable.

For instance in Bauchi, Mrs Suleiman and Mr Abdullahi observed that they had Lassa fever. However, the index of suspicion among healthcare workers was too low amidst late diagnosis due to the lack of a well-equipped laboratory at the hospitals.

Mrs Adekunle observed that there is a continuous outbreak of Lassa fever in Ondo State, emphasising the need for continuous sensitisation “as many people don’t believe the disease exists.”

To prevent the disease, Mr Adewole said Public health Emergency Operation Centres (EOC) operations across affected states should be optimal for effective prevention and control of Lassa fever.

The epidemiologist emphasised the need for continuous public sensitisation and enlightenment on Lassa fever, and the need for good personal and environmental hygiene.

“Safe waste disposal, encourage good hand washing practices, and discourage open drying of foodstuffs,” he said.

For an Obstetrician and Gynaecologist at Irrua Specialist Hospital, Qudus Lawal, who is a fellow of Lassa Fever Clinical Management, Lassa fever can be severe in pregnant women but can be managed if detected early.

Mr Lawal said practising basic preventive measures like a high index of suspicion and preventing contamination with rodents are things that can easily be instituted and “Lassa fever will be a thing of the past.”

Lassa fever vaccine, funding

According to Mr Lawal, a vaccine for Lassa fever is urgently needed for routine immunisation to break transmission and the continuous spread of the virus.

There is no licensed vaccine to protect against Lassa fever, although some vaccines are currently under development.

In April 2024, participants at HJF Medical Research International in Abuja, Nigeria, were vaccinated in the first Phase 2 clinical trial of a Lassa fever virus (LASV) vaccine candidate to date, according to IAVI, a non-profit scientific research organisation and the trial sponsor.

The study is funded by CEPI, an innovative global partnership working to accelerate the development of vaccines against epidemic and pandemic threats.

More than 600 participants in Ghana, Liberia, and Nigeria are expected to enrol in the IAVI-sponsored trial, funded by CEPI.

There is a need for increased funding for epidemic preparedness and response by the Nigerian government to tackle the recurrent burden or improve national health security. But Nigeria has not even met the 15 per cent recommended by the Abuja 2001 Declaration, allocating less than seven per cent per year.

According to the 2024 fiscal year budget, the federal government allocated N1.3 trillion to the health sector out of its total budget of N28 trillion.

READ ALSO: Lassa Fever: Nigeria records 857 cases, 156 deaths in four months

More on prevention, control

Infection Prevention and Control guideline, according to the NCDC in its national guidelines for Lassa fever case management, is an essential aspect of clinical management of Lassa fever which must always be implemented by health workers in managing the disease.

The guideline focused on the use of personal protective equipment (PPE) and hand hygiene in the care of Lassa fever patients.

It noted that all healthcare workers, including ward-aides and cleaners, must wear a full set of PPEs when providing direct care to patients managing medical or patient wastes, handling deceased bodies or cleaning.

Some of the IPC measures, according to WHO, are that healthcare workers caring for patients with suspected or confirmed Lassa fever infection should avoid contact with the patient’s blood and body fluids and contaminated surfaces or materials such as clothing and bedding.

“When in close contact (within one metre) of patients with Lassa fever, health workers should wear face protection (a face shield or a medical mask and goggles), a clean, non-sterile long-sleeved gown, and gloves (sterile gloves for some procedures),” WHO recommended.