Category Archives: Infection Prevention

Poorly Managed Lassa Fever Outbreak in Nigeria

Dr. Obinna O E Oleribe, Chief Executive Officer, E&F Management Care Centre, Abuja Nigeria (Twitter: @OleribeO) shares with readers his view and experiences concerning the August 2015 – May 2016 Lassa Fever outbreak in Nigeria and sees its handling as a strong indicator of weak and failing National Health System.

111435-EPR-Nigeria-Lassa-Fever-Outbreak-20120322On February 6th, 2016, the Vanguard Newspaper reported the growing Lassa Fever outbreak that had killed over 101 persons out of 175 suspected and confirmed cases since August 2015 when the outbreak began in Nigeria. More recently, the World Health Organization (WHO) announced that it had been notified of 273 cases of Lassa fever, including 149 deaths in Nigeria between August 2015 and May 17, 2016. Of the 273, 165 cases and 89 deaths were confirmed through laboratory investigation from 23 states of Nigeria. These deaths include two health care workers out of 10 infected with Lassa fever virus. As at the time of the WHO report (May 17, 2016), eight states were still reporting Lassa fever cases (suspected, probable, and confirmed), deaths and following 248 contacts for the maximum 21-day incubation period.

First diagnosed in Nigeria in 1969, Lassa fever (LF) is an acute viral illness caused by Lassa virus, a zoonotic, rodent-borne (multimammate rat), single-stranded ribonucleic acid (RNA) virus from the Arenaviridae, virus family. Since it first isolation in 1969 from a missionary nurse working in Lassa town of Borno State in North-Eastern Nigeria, Lassa Fever has become almost endemic in not only Nigeria, but the West African sub-region as it has continued to be a major public health concern in Nigeria, Liberia, Sierra Leone and Guinea with over 70 million people at risk of the disease. Annually, there are over 3 million cases and about 67,000 deaths from Lassa Fever globally. High association with nosocomial outbreaks, healthcare workers are at increased risk of infection and death. Also, the disease is fast spreading beyond the shores of West Africa into Europe and America from viremic travelers.

A look at the WHO website revealed that Lassa Fever has gained the importance it demanded and was rightly cited on its first page as a disease of public health importance (disease outbreak news). Also, as it is further decreasing the already very limited human resources for health in Nigeria and the rest of West Africa, one would have thought that healthcare managers across the world would have given it the attention it needed.

Heres how Nigeria beat EbolaIn July 2014, Ebola was identified in Nigeria (Lagos State) after Patrick Sawyer imported the disease from Liberia (where there was already an ongoing epidemic). The Lagos State Government, the National Center for Disease Control (NCDC), the Nigerian Field Epidemiology and Laboratory Training Program (NFELTP) and Federal Ministry of Health (FMOH) with the support of well-meaning Nigerian volunteers and some international organizations rose to the occasion and within four months (July 20 – October 20, 2014) kicked Ebola out of Nigeria. They achieved this unbelievable feat through decisive actions, interdisciplinary collaboration, intensive case management, detailed contact tracing, and active port health services. Using isolation, quarantine and supportive management of the infected, case fatality rate was kept at 40% as eight out of the 20 infected individuals succumbed to the virus including several health workers. What was more interesting was the immediate response of government and all relevant stakeholders. The success recorded was to the amazement of the entire world, and completely against all epidemic projects and statistical reasoning.

However, few months later, there is another epidemic of another viral hemorrhagic fever. This time around, by a virus that is not as deadly or virulent as Ebola.  It has lasted for ten months, killed more people (over 1100% of those killed by Ebola), affected over 800% more cases and with higher case fatality rate of 54%. One, cannot but wonder why Nigeria is finding it difficult to mobilize the same strategies that ended Ebola in Nigeria in 2014 to end Lassa Fever? Or are the structures and personnel not available for this particular outbreak? Or is the will to stop the outbreak lacking among policy makers and healthcare managers?

I believe that there is a need to focus on developing sustainable public health systems that can be mobilized to manage outbreaks across nation; have ready and equipped field workers and foot soldiers who will track, isolate and manage suspected, probable and confirmed cased of any outbreak; and maintain strong surveillance systems able to identify and contain any new, emerging or re-emerging outbreaks.

Nigeria and her leaders should value the lives of the Nigerian people. The government should take health issues more seriously. The citizens of Nigeria need a government that cares. Healthcare workers have a right to live – and not die while working to save other people’s lives. Every hand should be on deck right now to end this outbreak – and as much as possible ensure a delay of its re-emergence.

The time to end Lassa Fever outbreak is NOW. Let us all work towards stopping it once and for all.

Malaria Care: Investing in Infection Prevention to Save Health Workers’ Lives

wmdlogoThe recent World Malaria Day observances called on all partners to “Invest in the Future, Defeat Malaria.” The word ‘investments’ brings to mind huge supplies of insecticide treated nets and malaria medicines. The recent and ongoing Ebola crisis has shown how vulnerable health workers are when trying to diagnose and manage malaria when investments have not been made in safety equipment and training.

The Ebola epidemic in West Africa as well as its predecessors in Central Africa has taken a disproportionate toll on health workers. In the early stages of the outbreak, health workers regular front line clinics became infected when patients with Ebola, a disease which none had seen before, were initially thought to have malaria or other endemic febrile illnesses.

Health worker demonstrating RDT, using glovesContact with the various bodily fluids of these febrile patients during physical examination, including parasitological testing of blood for malaria diagnosis, combined with a lack of personal protection/infection prevention supplies and materials, resulted in many unnecessary health worker deaths. Many clinics closed, while those that remained open saw a drop in clients due to fears from beliefs that the unknown disease was emanating from the clinic.

It is necessary to ensure that health workers do not face such a fate again, nor be exposed to other blood borne pathogens like HIV and Hepatitis B. In addition attention is needed to protect others on the front line such as patent medicine shop workers and community health volunteers. A two-pronged approach is needed that combines education/training with a strong procurement and supply system for infection prevention and personal protection materials.

RDT Job AidWe should take advantage of World Health Organization guidance for infection prevention related to hemorrhagic fevers and within that has stressed the importance of general protection. Performing Rapid Diagnostic Tests (RDTs) for malaria is the time when most front line health workers could come into contact with a patient’s blood. Training materials and job aids as pictured here, stress the importance of hand washing and use of gloves, but the availability of regular water supplies and disposable gloves in many front line clinics is low or non-existent. The US Centers for Disease Control and Prevention (CDC) also offers the following guidance for malaria diagnosis and case management in countries where both Ebola and malaria are endemic. In addition to front line health staff, we have learned that community volunteers can safely practice infection prevention while performing RDTs by wearing gloves and correctly disposing the used materials.

Efforts to enable medicine shop workers to use RDTs have begun. They do become more vulnerable during Ebola outbreaks as public clinics may close due to health worker deaths. In Liberia medicine sellers who were taught to use RDTs were asked to stop the practice until safety could be assured.

Continuous investment in RDTs themselves as well as the safety and protective supplies and treatment is needed. RDTs if performed properly can save lives of community members. Infection prevention steps and equipment can save the lives of the health workers who care for the community.

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A longer version of this posting will appear in the May 2015 issue of Africa Health.