Wednesday, January 20, 2016

Lassa Fever Outbreak, Nigeria - A First Hand View



It was a Tuesday morning and I was covering the morning shift as usual. It was around 12pm and in came Patient 0. He was a 23 year old male who presented with symptoms of fever, cough, eye infection and skin rashes. That was his third visit to the hospital. A review of his previous visits showed he was being managed as a case of allergy, with little improvement. 

A quick examination showed a febrile state of 37.8 degrees, conjunctivitis, macula-papular rashes mostly on the face and upper trunk and a blood pressure of 160/100 mmHg, which was very high for a young man who had no previous history of hypertension. There was history of pain during urination. I requested for some investigations which showed evidence of infection along the urinary tract. At last I have a diagnosis: There was chest, urinary and eye infections, a clear case of sepsis. However, there were the rashes which were characterised as exanthems. Exanthems are eruptive skin rashes which are most commonly related to infections, and of these, viral infections are the most common. 

I explained to the patient that there was clearly an infective process going on, most likely a viral infection with super-imposed bacterial infection. The only way of knowing the infective organisms is through bacterial culture which is readily available here, and viral culture, in which the blood sample has to be taken to Lagos. I placed him on some drugs. 

During the night, the patient’s condition deteriorated. He had developed new symptoms; vomiting and abdominal pain and a drop of blood in his urine. That was the beginning of pandemonium. There was an outbreak of a viral hemorrhagic fever (Lassa fever) in Nigeria, Kano State inclusive, and Patient 0 was presenting with non-specific symptoms and blood in the urine! He was immediately referred to the Teaching Hospital. The State Emergency Response Team was quickly deployed to the hospital. Before the arrival of the team, we launched a discussion on why some doctors think it was a suspected case of Lassa fever and why others think it was not. 

During the past 8 weeks, Nigeria has been afflicted with an epidemic of Lassa fever. The outbreak was first reported in Bauchi in 2015, which was then followed by Kano State and subsequently other states (Nassarawa, Niger, Taraba, Rivers, Edo, Oyo, Gombe, Plateau, Ondo and Abuja). In his speech last week, the Minister of Health, Prof. Isaac Adewole, stated that “as at today, records of our surveillance show that the number of suspected cases is 93, number of 2 laboratory confirmed cases is 25 and the number of reported deaths is 43, with a case fatality of 44.0%.” 


A doctor testing village children for the virus during the 1993 outbreak - Mike Blyth, 1993 https://www.flickr.com/photos/blyth/2084030081/in/photolist-4ba6eg-4baJ9M-4be9QG-4b9YLc-4ba7aD-4becP9-4baar8-4b9Xbp-4b9Z7R-oiHjKy-4beK8f-4bacx8-4badcn-ay5rGp-ay89Ed-ay89VL-ay8atJ-ay89PN-ay8a2C-ay5rwB

Lassa fever is an acute viral hemorrhagic fever. It is a zoonotic infection, which means that humans become infected via contact with infected vectors. The animal host is a rodent called Mastomys natalensis or more commonly known as “multimammate rat” due to the female’s multiple and prominent mammary glands. Lassa virus may also be spread between humans though direct contact with blood, urine, faeces or other bodily secretions of an infected person. The disease was first discovered in 1969 when two missionary nurses died in Borno, Nigeria. The virus is named after the town in Nigeria where the first cases occurred. Most cases do not have symptoms. When symptomatic, the onset of illness is gradual and symptoms are not specific and difficult to distinguish from other viral hemorrhagic fevers and even common ailments such as malaria, typhoid and so on. Symptoms include fever, sore throat, chest pain, vomiting, diarrhoea, abdominal pain, headache, muscle pain, and others. As the disease progresses, the patient starts to bleed from the mouth, nose, vagina or rectum, skin or into the eyes. 

Back to patient 0. He presented with the above symptoms and a drop of blood in the urine! In my review of the his condition, I’ve confirmed an infection involving the urinary pathway, and it is not uncommon to find blood in the urine of such cases. All the same, there was an outbreak of a viral hemorrhagic fever and the wheels have been set in motion. The Emergency Response Team arrived to take data and do contact tracing for everyone that has come in contact with Patient 0. The hospital was in confusion and in a state of near-panic. There was no reason for panic. At least the panic is not going to reverse the infective process, if it is in fact Lassa fever. We can only pray. But the job has to be done. This is why we are health professionals. This is why we took an oath to preserve life, to serve humanity. This is the job. 

Meanwhile in the Teaching Hospital, Patient 0 was taken to the Accident and Emergency ward, where he was seen by the casualty officer who also made an assessment of a viral infection of unknown type. Upon further review, patient was diagnosed as a case of sepsis and adult measles. My first thought was “ Measles in an adult”? It’s not impossible but it is very rare. Patient 0 confirmed that he has been in close contact with 2 cases of measles in children. Measles is a highly contagious virus and is normally passed through direct contact and through air. It is one of the leading causes of death especially among children under the age of 5 years. 

Symptoms of measles include fever, conjunctivitis, rhinorrhoea, sorethroat and cough. At the initial phase, koplik spots may appear which are small, gray-white papules on the inside of the cheeks. This is mostly followed by the typical exanthem which erupts behind the ears and in the hairline, and then later spreads all over the skin. The exanthem resolves in the order of appearance. Most cases of measles occur with complications such as pneumonia, bronchitis, conjunctivitis, diarrhoea, encephalitis and so one. Complications are more common in children under the age of 5 years and in adults over 20 years. 

Patient 0 had presented with all of the symptoms of measles plus the history of exposure to 2 measles patients. He is 23 years old. Why would he have measles? People who are at risk of developing measles include unvaccinated children, unvaccinated pregnant women, severely malnourished, immune-compromised and any non-immune person who has not been vaccinated or was vaccinated but did not develop immunity. Patient 0 has fallen into the latter group. He was vaccinated but apparently he did not develop the immunity. 

This is in contrast to Lassa fever which does not have a vaccine. The people at the highest risk of Lassa fever are those living in areas of poor sanitation, family members that come in contact with body fluids of infected persons and health workers if caring for patients in the absence of proper barrier nursing and infection control practices. 

The working diagnosis for Patient 0 is Adult Measles. Confirmatory tests can only be done in Lagos which is about a thousand kilometres away. Thank God for clinical medicine as we can make a diagnosis of measles using symptoms, signs and some basic investigations. It does not require any special tests. In the case of Lassa fever, definitive diagnosis can only be done in specialised centres, currently available only in Lagos. 


A house being investigated for the virus in 1993 - Mike Blyth, 1993 - https://www.flickr.com/photos/blyth/2084023005/in/photolist-4ba6eg-4baJ9M-4be9QG-4b9YLc-4ba7aD-4becP9-4baar8-4b9Xbp-4b9Z7R-oiHjKy-4beK8f-4bacx8-4badcn-ay5rGp-ay89Ed-ay89VL-ay8atJ-ay89PN-ay8a2C-ay5rwB

It is however, good to know that Lassa fever can be prevented and controlled. But it will require a collaborated effort with the government, community and individuals. An important aspect of prevention and control is community hygiene. Since it is not entirely possible to eliminate all rodents, from the community, measures should be taken to discourage rodents from going into homes. Food should be stored in rodent-proof containers, garbage should be disposed of far away from residential areas, maintaining clean homes and keeping cats. Thus Lassa fever is one more reason to keep a pet. Family members caring for sick persons should be careful and avoid contact with body fluids of their sick relations. Health care workers should apply standard measure of infection prevention and control, and should apply universal precaution while caring for patients, irrespective of presumed diagnosis. Basic hand hygiene is very important and the use of personal protective equipments such as hand gloves, face masks, overalls and goggles. The government should try to get the diagnostic centres more evenly spread across the nation. Due to the previous Ebola scare, the government is better prepared now. Measures have been put in place to contain the epidemic. 

Patient 0’s condition is greatly improving. No more spikes of temperature, chest infection has improved remarkably and the exanthems have cleared. We wish him a very speedy recovery. We are most thankful to God that it was not in fact a case of Lassa fever. We are also praying for an end to this epidemic before it claims more lives.



*Dr Maryam Nasir Aliyu is currently volunteering with Ripples Foundation and using her medical experience to help us deliver Medical MOT events to communities in Kano State. She will be regularly posting on this blog to inform us of her experiences working as a doctor and living in Kano. Dr Maryam hopes that this post will inform people of the symptoms of the lassa virus and encourage those who are showing them to seek medical advice.


*If you would like to donate towards Ripples Medical MOT Programme which provides medical care to rural African villages, please visit http://www.totalgiving.co.uk/appeal/medicalmot
Dr Maryam Nasir Aliyu Web Developer

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