2016 Lassa Fever Epidemic

By Dr. Chinedu Ibeh, Dept of Community medicine, UPTHWednesday, 3rd February 2015

OutlineIntroductionEpidemiologyTransmissionSymptoms and signsLaboratory diagnosesTreatmentPrognosisPreventionFederal and state govt responseIdentified gapsrecommendations

INTRODUCTIONLassa fever is an acute viral hemorrhagic fever caused by a single stranded RNA virus known as Lassa virus- a member of the Arenaviridae family.

It was first described in the 1950s but the virus causing Lassa disease was identified in1969 in the town of Lassa, in Borno State, Nigeria.

Lassa virus

INTRODUCTION CONTDOutbreak is common in sub-Saharan Africa infecting about 300,000 to 500,000 cases annually and causing about 5,000 deaths each year giving an average case fatality rate of about 1%.

Cases of the disease have been observed in Nigeria, Liberia, Sierra Leone and Guinea.

EPIDEMIOLOGYLassa fever is a zoonotic disease transmissible to

humans from infected rodents under natural conditions.

The primary animal host of the Lassa virus is the multimammate mouse(Mastomys natalensis)

It is endemic in Nigeria and causes outbreaks almost every year in different parts of the country, with yearly peaks observed between December and February

Humans usually become infected with Lassa virus from exposure to urine or faeces of infected Mastomys rats

MULTIMMAMATE MICE

EPIDEMIOLOGY CONTINUEDThe dissemination of the infection can be assessed by prevalence of antibodies to the virus in country populations.

For instance we have for:Nigeria - 21%Sierra Leone - 8–52%Guinea - 4–55%

MODE OF TRANSMISSIONInfection in humans typically occurs by

exposure to rodents excrement through the respiratory or gastrointestinal tracts.

Inhalation of tiny particles of infectious material (aerosol) is believed to be the most significant means of exposure.

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

Sexual transmission of Lassa virus has been reported.

TRANSMISSION CONTDThere 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.

Lassa fever occurs in all age groups and both sexes.

RISK OF TRANSMISSIONPersons at greatest risk are those living in

rural areas, urban slums,

communities with poor sanitation

crowded living conditions and Health workers in the absence of proper barrier

nursing and infection control practices

SIGNS AND SYMPTOMSThe disease is asymptomatic in 80% of cases but takes a complicated course in the remaining 20%.

After a 6 to 21 days incubation period, an acute illness with multi-organ involvement develops.

Initial non specific symptoms of fever, facial swelling, and muscle fatigue, as well as conjunctivitis and mucosal bleeding develops.

OTHER SYMPTOMS AND SIGNSThe other symptoms arising from the

affected organs are:GIT: nausea, vomiting(bloody), diarrhea,

abdominal ache, constipation, dysphagia, abdominal pain

CVS: chest pains, hypertension, hypotension, palpitation

RS: cough, chest pain, dyspneaCNS: seizures, hearing deficit, tremor,

disorientation, and coma may be seen in the later stages

SYMPTOMS OF LASSA CONTDTransient hair loss and gait disturbance

may occur during recovery.

The disease is especially severe in late pregnancy, with maternal death and fetal loss occurring in greater than 80% of cases.

Death usually occurs within 14 days of onset in fatal cases.

LABORATORY DIAGNOSESLassa virus infections can only be diagnosed definitively using the following tests:

reverse transcriptase polymerase chain reaction (RT-PCR) assay

antibody enzyme-linked immunosorbent assay (ELISA)

antigen detection testsvirus isolation by cell culture.

LABORATORY DIAGNOSES CONTD

Other laboratory test & findings in Lassa

fever include FBC (lymphocytopenia &

thrombocytopenia), andLFT(elevated AST)

LABORATORY DIAGNOSISDiagnosis needs biosafety level 3/4 laboratoryWe have only 7 laboratories with the capacity to diagnose Lassa fever in Nigeria located in:, University of Maiduguri Teaching Hospital, Maiduguri, Aminu Kano Teaching Hospital, Kano, University College Hospital, IbadanIrrua Specialist Hospital Edo State, Lagos University Teaching Hospital, Lagos ,National Centre for Disease Control, Asokoro, Abuja. National Centre for Disease Control Regional laboratory, UPTH

TREATMENTAdmit persons suspected of Lassa fever

infection into isolation facilities.

Early and aggressive treatment using Ribavirin.

Supportive treatment using Fluid replacement and blood transfusion.

Induction of labour for infected pregnant women

in their 3rd trimester to improve the mother’s chances of survival.

TREATMENTThere is no evidence to support the role

of ribavirin as post-exposure prophylactic treatment for Lassa fever.

PROGNOSISAbout 15-20% of hospitalized Lassa fever

patients will die from the illness. The overall mortality rate is estimated to

be 1%, but during epidemics, mortality can climb as high as 50%.

The mortality rate is greater than 80% when it occurs in pregnant women during their third trimester; fetal death also occurs in nearly all those cases.

Termination of pregnancy decreases the risk of death to the mother.

PREVENTIONCommunity health education on Community/Personal Hygiene Preservation of food items in rats proof bags Blocking of rat holes/using traps /cats to hunt rats High index of suspicion among health workers and prompt

reporting and referral of suspected cases

Isolation of infected patients, good infection protection and control practices and rigorous contact tracing can stop outbreaks.

PPE like Gloves, masks, laboratory coats, and goggles are advised while in contact with an infected person.

There is currently no vaccine that protects against Lassa fever

PREVENTION IN THE COMMUNITYCommunity hygiene should be promoted to

discourage rodents from entering homes. Grains and other foodstuffs should be stored in

rodent-proof containers.Garbage should be disposed far from home Clean households should be maintained and

keeping of domestic cats as pets to prey on rats may be encouraged.

Family members should avoid contact with blood and body fluids while caring for sick persons.

Safe burial practices should be encouraged and enforced.

IN HEALTH CARE SETTINGSStaff should always apply standard

infection prevention and control precautions when caring for patients, regardless of their presumed diagnosis.

These include basic hand hygiene, respiratory hygiene, use of personal protective equipment (to

block splashes or other contact with infected materials),

safe injection practices.

FEDERAL GOVERNMENT RESPONSE TO THE CURRENT EPIDEMICFG Inaugurates 19 man Lassa Fever

Eradication Committee chaired by Prof. Oyewale Tomori, President Nigeria Academy of Science

Other members are :2. Prof. A. Nasidi, NCDC, Secretary/Member3. Prof. Sunday Omilabu, CMUL, Member

LASSA FEVER ERADICATION COMMITTEE4. Prof. George Akpede, Member

5. Prof. Clara Ejembi, ABUTH, Member6. Prof. Zubairu Ilyasu, Member7. Dr. Pelumi Adebiyi, UCH, Member8. Prof. Christopher Obionu, UNTH, Member9. Prof. Innocent Ujah, NIMR, Member10. Prof. Dennis Agboulahoe, Member11. Dr. (Mrs) Egejuru Eze, Federal Ministry of Agriculture, Member12. Representative, Federal Ministry of Environment, Federal Ministry of Environment, Member

LASSA FEVER ERADICATION COMMITTEE13. Dr. Daniel Iya, Commissioner for Health Nasarawa State, Member14. Mrs Gold Idehen R.I, Federal Ministry of Education, Member15.Emmanuel Agbegir, Federal Ministry of Information and Culture, Member16. Director, Public Health (Rep. by Dr. E. Ngige), Federal Ministry of Health, Member17. Abonyi Dominic, Environmental Health Officer, Registration Council, Member18. Dr. Sunny Asogun, Head Lassa Fever Research, Irua Specialist Hospital, Member19. Mr. Akin Fadeyi, Media Consultant, Member

LFEC TERMS OF REFERENCETo appraise the current epidemiological

situation of the past and current Lassa Fever Epidemics in Nigeria

To develop jointly with FMoH and NCDC an effective response plan for fighting and preventing the spread of Lassa Fever in Nigeria while availing professional advise to NCDC and FMoH  to arrest current and future Lassa Fever outbreak.

THE TERMS OF REFERENCE OF THE COMMITTEETo galvanize financial  support and good

will from other stakeholders and development partners.

To implement the Strategic Plan under the guidance of the Honorable Minister of Health

To advise the Hon Minister of Health on the Emergency operation and activities carried out in the affected states.

FEDERAL GOVERNMENT RESPONSE TO THE CURRENT EPIDEMICDesignation of six additional diagnostic

centers for Lassa Fever by the health minister which brings to 12 the total number diagnostic Centres in the Country.

The six new diagnostic centres are to be situated at the highly  infected states of Bauchi, Niger, Taraba, Plateau, Nasarawa and Ondo.

FEDERAL GOVERNMENT RESPONSE TO THE CURRENT EPIDEMICDesignation of hotlines to either access

Nigeria Centre for Disease Control or Federal Ministry of Health when a case of Lassa fever is suspected: 08093810105, 08163215251, 08031571667 and 08135050005

Immediate supply of adequate quantities of Ribavarin to all the affected states

RIVERS STATE EXPERIENCEConfirmed cases in Rivers State is 3, and

number of deaths is also 3.2 LGAs (OBALGA and PHALGA) are affected.As at 1st February 2016, about 100 persons

were under watch and will be discharged after completing the 21 days(4/02/16) of observation without symptom (ie 21 days after the death of thelast case).

The contact tracing teams (13 teams) are still on, meeting and monitoring contacts with infected case every day.

RIVERS STATE EXPERIENCE 2 Three holding centers had been set-up in the state to care for

patients of the Lassa disease.

They are Potts Johnson, VIP ward of BMSH and ‘a space’ in UPTH..

Efforts to renovate the treatment centre at Oduoha in Emohua Local government that was used in 2014 during the Ebola outbreak is underway

Adequate stock of Ribavirin is available Lassa fever Local Government sensitization programme in the

State is ongoing from LGA to LGA

The Rivers state Government has launched ‘Operation kill all Rats’.

RIVERS RESPONSE TEAMThe Response team has 3 unitsCase Management/Decontamination unit:

They are responsible for managing patients in the isolation centers.They are also in charge of decontaminating contaminated areas.

Epidemiology/Surveillance unit:The do the active case search and contact tracing.Contact tracing is done twice daily via face to face visits or by phone calls.

RIVERS RESPONSE TEAMSocial Mobilization, Communications

And Training Unit.The are responsible for the massive sensitization campaigns, advocacies, public health enlightenment through the media and training of other categories of health care workers

IDENTIFIED GAPSPoor Synergy:Promotion of inter-sectoral, inter-professional and

multi-disciplinary collaboration should be encouraged.

The scourge should not be seen as Health Ministry or Federal or Doctors affair only.

Knee Jerk Response The seeming lack of epidemic preparedness for LF

affected the early containment of the outbreak.Therefore, a need for an established response

strategy in event of any hemorrhagic fever outbreak cannot be over emphasized.

IDENTIFIED GAPSInsufficient Laboratory Capacity There is need to scale up the provision of

diagnostic centres with capacity to diagnose emerging and reemerging diseases.

We should build at least one public health laboratory in each of the states of the federation, so that people can easily be referred to those centers for proper diagnosis.

IDENTIFIED GAPSPoor Information ManagementGovernment should on daily basis update

us with the efforts being made to contain the spread; the number of reported and confirmed cases; symptoms; Isolation and treatment centers; and preventive actions that should be taken by individuals.

Relevant jingles and posters should be all over.

IDENTIFIED GAPSPoorly Trained, Poorly Remunerated And Poorly Insured Health Workers

Empowerment of health workers on knowledge and preventative measures of LF

Addressing the legal issues, especially in relation to health workers and others involved in outbreak control, in terms of insurance and compensation of health workers who contract the disease

Ensuring that active surveillance, a high index of suspicion, and infection control measures are emphasized on hospital wards and in surgical theatres

RecapLassa fever is an acute viral haemorrhagic illness of 1-4

weeks duration that occurs in West Africa. The Lassa virus is transmitted to humans via contact with

food or household items contaminated with rodent urine or faeces.

Person-to-person infections and laboratory transmission can also occur, particularly in hospitals lacking adequate infection prevention and control measures.

Lassa fever is known to be endemic in west Africa and is currently a National epidemic in Nigeria.

The overall case-fatality rate is 1% but in epidemic, CFR may rise to 50%, CFR in 2016 epidemic in Nigeria is 34.31%

Early supportive care with rehydration and symptomatic treatment with IV Ribavirin improves survival.

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