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World Report

Lassa fever in Nigeria: the great unknown

An increased number of cases of Lassa fever in Nigeria, causing 57 deaths so far this year, points
to gaps in public health knowledge and interventions. Talha Burki reports.

As The Lancet went to press, the “We believe that most transmission sending out personal protective
Nigeria Centre for Disease Control occurs from the rodent reservoir to equipment and other materials to the
had reported 615 suspected cases humans, although there are important areas in need, but these things should
of Lassa fever and 57 deaths since exceptions; for example, within families be in place prior to any outbreak”,
the beginning of the year. By the and from patients to health-care said Ukwaja. In the initial stages of
AMI Images/Science Photo Library

same stage of 2017, the country workers”, explains Garry. This would the current outbreak, there were
had reported fewer than 200 cases. explain why Lassa fever has largely shortages of equipment. 11 health-
“It is a very unusual situation”, said remained a rural phenomenon. care workers are suspected to have
Wondimagegnehu Alemu, WHO repre­ contracted Lassa fever, four of whom
sentative in Nigeria. “Things are not out “‘Things are not out of hand, but have died. The shortages appear to
of hand, but there are certainly many there are certainly many more have eased, with donations from WHO,
more cases than we would expect.” cases than we would expect.’” Tulane University, and other partners.
Lassa fever is named after the “WHO is scaling up its support”, said
town in northeastern Nigeria in The causes for the increased number Alemu. “Six international staff have
which it was discovered in 1969. It is of cases this year are unknown. There been deployed to Nigeria to join
endemic to west Africa, spread by the might be more rodents this year than in 14 national staff who have been
multimammate rat that abounds in previous years, or the virus might have working with the authorities in three
the region and is sometimes eaten as become more infectious or more likely of the most affected states supporting
bushmeat. It is a viral haemorrhagic to cause severe symptoms. There might surveillance, logistics for laboratory
fever in the same family as Ebola. have been improvements in detection, samples, contact tracing, and infection
The disease burden is unknown—the although Garry has his doubts. “My prevention and control”.
commonly cited figure of 100 000 to sense is that the increase in cases is real”, Ebonyi State is home to around
300 000 cases per year amounts to he told The Lancet. 2·5 million people, 80% of whom are
little more than guesswork. There is Nigeria has only two laboratories subsistence farmers. It has been running
no vaccine and only one therapeutic, where Lassa fever can be definitively public awareness campaigns for several
ribavirin. “It is not a great drug, but diagnosed. “Inability to confirm years, warning the population of the
it is better than no treatment at all”, suspected cases due to financial and risk factors and symptoms of Lassa
points out Robert Garry, professor logistical issues is a major challenge”, fever. “It would be good if this was
of microbiology and immunology at notes Kingsley Ukwaja, resident scaled up nationally”, said Ukwaja. A
Tulane University School of Medicine, physician and epidemiologist at the promising inter­national development
New Orleans, LA, USA. Mortality among Federal Teaching Hospital in Abakaliki, is the commit­ment by the Coalition for
hospitalised patients is around 15%. Ebonyi State, Nigeria. Dozens of Epidemic Preparedness Innovations to
But there is uncertainty over what symptoms are associated with bring at least one vaccine candidate for
proportion of patients develop severe Lassa fever, ranging from malaise to Lassa fever to the end of phase 2 trials
disease and what proportion do not bleeding from the mouth. But in its by the end of 2021. But in the interim,
show symptoms; nor is it known how early presentation, it is very similar to west Africa will have to continue to
easily the asymptomatic patients pass influenza, malaria, shigellosis, typhoid contend with an unpredictable disease.
on the disease. fever, and yellow fever. “People in “We have to make sure Lassa fever stays
In Nigeria, Lassa fever typically takes endemic regions only think about Lassa on the agenda; what usually happens is
hold in the dry season around October fever after they have run through all the that policy makers show interest when
and continues until the rains arrive in other options, so patients come in late the outbreak is in force, but afterwards
April. During the dry season, farmers and more severely ill”, said Garry. This is Lassa fever gets overshadowed by other
burn their fields so that new planting particularly problematic since ribavirin priorities”, said Ukwaja. “This appears
can take place. The rodents that live is at its most effective soon after the to be a seasonal disease, and we should
in the fields flee the conflagration appearance of symptoms. It also means be making efforts to prepare for its
and seek alternative sources of food, delays in mobilising the response. arrival every year.”
which increases their contact with “Once an outbreak is confirmed,
human beings. the federal government will start Talha Burki

728 Vol 391 February 24, 2018