As Lassa fever ravages many parts of the country, killing patients and care givers, Moses Emorinken writes on why Nigeria has not been able to rid itself of the deadly virus

It is often assumed to have been put under control, but it keeps coming back, leaving devastating consequences in its wake.

Lassa fever, a disease that is endemic and indigenous to Nigeria, occurs yearly, particularly during the dry season. And whenever it does, it wrecks widespread havoc on a mass scale, leaving behind many victims hospitalised and hundreds dead.

Not surprisingly, there has been an upsurge of the disease across the country, with the usual yearly harvest of deaths. By January 28, this year, there have been 258 confirmed cases and 41 deaths in 19 states, with majority of the cases from Ebonyi, Edo and Ondo.

Other are Kano, Delta, Taraba, Plateau, Bauchi, Kaduna, Enugu, Ogun, Osun, Nasarawa, Kogi, Borno, Benue, Adamawa, Gombe and Rivers states.

Many experts lament that, with the predictable cycle of the destructive disease, Nigeria should  have learnt and developed a more lasting solution and approach by now that can save the people from the cruel grip of Lassa fever.

However, it seems the best the country can do year-in-year-out is to reel off casualty figures, throw in some money for treatment interventions and compare this year’s casualties with previous years’ and await what happens in the coming year.

The illness was first reported in Lassa community in Borno State in 1969, when two missionary nurses died from an unusual febrile illness.

Nigeria since then has not been the only country grappling with the scourge of Lassa fever. Countries like Benin, Ghana, Guinea, Liberia, and Mali, Sierra Leone are also caught in similar web.

In less than five weeks when Lassa resurfaced in Nigeria, death toll seems to be increasing by the day. Does Nigeria really have a lasting solution for Lassa fever? Why is it a recurring decimal in the country?

From findings, from 2017 till date, there have been 2,009 confirmed cases of infected people, with a total of 252 confirmed deaths.

Also, from 31st of December 2019, six healthcare workers were affected – five were confirmed and one probable; meaning experts were not able to isolate the virus. Two later died of Lassa fever.

According to the World Health Organisation (WHO), Lassa fever is a viral haemorrhagic fever that is transmitted to humans via contact with food or household items contaminated with rodent urine or faeces.

Secondary human-to-human spread within a community may occur through inhalation or ingestion. Nosocomial transmission (infections that develop as a result of a stay in hospital or are produced by microorganisms and viruses acquired during hospitalisation) is also not uncommon.

Caused by the Lassa fever virus, a single stranded RNA virus belonging to the arenaviridae family, it occurs very frequently in various parts of Nigeria and affects about  500,000 persons yearly in West Africa.

Interestingly, about 80 per cent of people who become infected with Lassa virus have no symptoms. Also, one in five infections results in severe disease, where the virus affects several organs such as the liver, spleen and kidneys.

The incubation period for Lassa fever varies from six to 21 days. It is symptomatic and usually characterised by fever, myalgia, nausea, vomiting, sore throat, abdominal and chest pains. Illness may progress to more serious symptoms, including haemorrhaging (bleeding), neurological problems, hearing loss, tremors and encephalitis (inflammation of the brain).

Death usually occurs within 14 days of onset in fatal cases. The disease is especially severe late in pregnancy, with maternal death and/or fetal loss occurring in more than 80 per cent of cases during the third trimester.

Although Lassa fever is known to be endemic in Nigeria with the peak season anticipated from December through June, experts say the increase in new confirmed cases and deaths should be monitored closely and addressed appropriately.

At the moment, there is no approved vaccine for Lassa fever. Early supportive care with rehydration and symptomatic treatment improves chances of survival.

The antiviral medication ribavirin has been recommended, but evidence to support its use is weak. More so, it is not cheap.

Poor hygiene, bad health-seeking behaviours

In Nigeria, medical doctors explain that the bulk of the cause for the prevalence and perpetuation of most diseases in Nigeria is primary the result of unhealthy lifestyle, poor personal hygiene and the low premium people place on their health.

This is the same with Lassa fever. Lassa virus commonly spreads to humans from other animals, specifically the natal multimammate mouse (rat).

Rats, common in most households, are also eaten as a delicacy in some areas. In fact, it seems like rats, apart from being everywhere, have acquired a new social status in Nigeria, as they have literally become ‘domestic animals,’ ‘socialising’ and dwelling with human beings, especially in big cities with heavy populations.

Because rats can quickly produce a large number of offsprings, they tend to ‘colonise’ human settlements, thus increasing the risk of rat-human contact.

Once the rat becomes a carrier, it will excrete the virus throughout the rest of its lifetime through faeces and urine, creating significant opportunity for exposure.

Speaking with The Nation, Nigerian Medical Association (NMA) President, Dr. Francis Faduyile, said all hands needed to be on deck before the country can record any meaningful success in curtailing Lassa fever.

“It is not only the job of government, but everyone also needs to be involved. Lassa fever has been with us for decades and has been largely contained.

The recent outbreak, which occurs within the period in which we have outbreaks, the dry season – within November and March, is not new.

What is most important is for all health workers to be on guard and know that the part of the differential diagnostic is that Lassa fever is a possibility,” Faduyile said.

Also, a consultant family physician with Alliance Hospital Abuja, Dr. Adeoye Alabi, said what should tackled first is the poor personal hygiene awareness in the country, stressing that a lot can be achieved if people are made to understand that there is a dire need to take their health more seriously.

“First, personal hygiene is very crucial. Bushes around the house should be properly cleared so as not to harbour rodents.

We must also ensure that our uncooked food items are properly closed. Food stuffs should be in containers that are closed,” Alabi said.

To reduce the risk of Lassa fever, Dr. Chikwe Ihekweazu-led Nigeria Centre for Disease Control (NCDC), in a public health advisory, also cautioned the public along similar lines.

IT said: “People should ensure proper environmental sanitation, block all holes in your house to prevent rats from entry, cover dustbins and dispose refuse properly.

‘’Communities should setup dump sites very far from their homes to reduce the chances of having rodents within homes.

Store foodstuff like rice, garri, beans, corn/maize etc. in containers which are well covered with tight fitting lids, and avoid drying food stuff outside on the floor, roadside where it will be exposed to contamination.

“Avoid bush burning which can lead to displacement of rats from bushes to human dwellings and eliminate rats in homes and communities by setting rat traps and other means.

Practise good personal hygiene by frequently washing hands with soap under running water/or use of hand sanitizers when appropriate, and visit the nearest health facility if you notice any of the signs and symptoms of Lassa fever as mentioned earlier, avoid self-medication.”

Underperforming primary healthcare system

According to experts, the primary healthcare system plays a critical role in ensuring that those at the grassroots level, especially in the vast rural areas, have access to qualitative healthcare services.

It is the first level of contact for individuals, families and communities within the national healthcare delivery system.

However, rural areas are usually the worst hit by outbreak of diseases, in this case, Lassa fever; not only because of their ecological profile, but also because of the gross failure of the primary healthcare system to deliver on its mandate.

Once diseases hit such areas, the healthcare workers are usually not enough or well equipped to arrest the situation before making adequate referrals.

Conceptualised by the Alma Ata Declaration of 1978, the primary healthcare system is a grassroots approach towards universal and equitable healthcare for all. It is supposed to give to Nigerians upon demand, the provision of promotive, preventive, curative and rehabilitative services.

However, 42 years after, Nigeria still ranks among the worst in the world with respect to most health indicators. Yet, many primary healthcare centres lie waste in the country, even as efforts are afoot to build more across the country without adequate plans on how to sustain and equip them.

In Faduyile’s words: “The situation at the primary healthcare level is pathetic. We really do not have a primary healthcare system in Nigeria because it is largely collapsed.

We don’t have enough equipment to man the place or experienced and high level personnel being deployed at that level. So, they may not be able to do much.

“It is at the level of primary healthcare that we talk about education, mobiolisation and to be able to quickly diagnose some of these diseases within the community.

Even at that, they are not able to take charge of these outbreaks. We have to get the physical structures and equipment in place, and get doctors in place.

What is being advocated the world over is physician-led primary healthcare centres. But most states and local governments do not have physicians at the primary healthcare level, which is a major defect at that level.

“The government must up the ante to inform the public and get the necessary protective devices for health workers, and educate them on how they can identify, diagnose and quarantine infected people. Drugs must also be made available.”

Also, the Deputy Director, Prevention, Care and Treatment, Institute of Human Virology Nigeria (IHVN), Dr. Helen Omuh, told The Nation: “Lassa fever is more common in areas where we have high rodent population, and unfortunately, people especially in our rural areas expose their foods to rodents by spreading the foods outside and on the floor; in the process, rodents can run across.

“From our experience in working with primary healthcare centres, there are really not enough healthcare workers there. In some cases, you have only one staff manning a centre; some places you find two or three.

Because of the influx of patients needing attention, it might take them a while to treat and identify patients with the Lassa fever virus, except they are in the habit of doing triading (that is, looking at patients that need immediate attention and separating them from others).

“We need to ensure that our healthcare workers in the primary healthcare centres are well oriented as to the possible signs and symptoms of the Lassa fever so that they can easily suspect.

Part of being a good clinician is knowing when to refer; once you can easily suspect, you can readily refer. The government needs to increase the centres for managing Lassa fever and ensure that appropriate education is intensified.”

For Alabi, although there are primary healthcare centres splattered around states of the federation, are they really working?

He aded: “The primary healthcare system in Nigeria is not at the level it should be, and everything boils down to the political will on the part of the government.

Also, putting the right people in the right places is very crucial; when you put the wrong people in the right places, they politicise everything.

At the primary healthcare level, I don’t think we are doing enough. The primary healthcare centres are the closest to the people, and so should be prioritised and strengthened.”