Thought Leadership

Lassa Fever: Why the Nigerian government should fund disease diagnostics for epidemic preparedness

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Editor’s Note: Chidindu Mmadu-Okoli is a 2019 #PreventEpidemicsNaija Fellow at Nigeria Health Watch. In this piece she writes about a doctor whose Lassa Fever diagnosis was mis-handled and why funding disease diagnostics is critical for Nigeria’s health security efforts.
Thinking about death might have felt uncomfortable and scary but after a few weeks of being sick, Obiora Emeka could only find relief in such thoughts. He would lie in bed and watch people who seemed strong being taken out of the hospital ward, lifeless. Thoughts of death came to his mind over and over.
“I was dying on the bed. I was not listening to what people around me were saying. It was miserable. I may have just made friends with somebody in the ward. By evening, the person was dead! It was a house of horror! It was the worst thing anyone could experience…” 
Obiora Emeka, whose name has been changed to protect his privacy, is a young medical doctor who was doing his housemanship at the Federal Teaching Hospital, Abakaliki, Ebonyi State (FETHA) in 2015. Seven months into his housemanship, in January 2015, he resumed at the paediatric unit, after completing his rotations in Obstetrics and Gynecology (O&G) and Internal Medicine Departments of FETHA.
That day, a newborn in the hospital was bleeding profusely and doctors did not seem to know why. Dr. Emeka was asked to take care of the baby and he continued to manage the case, alone. Forty-eight hours later, the baby died. Unknown to him and other members of his unit, the baby’s mother was bleeding as well and exhibited symptoms of a viral haemorrhagic fever. The cause of the bleeding was never documented in the baby’s folder, nor verbally communicated to the team at the paediatric unit.

A general view of the Viral Haemorrhagic Fever Laboratory which serves as the South-East regional disease laboratory, and equipped to cater to Lassa and yellow fever diagnosis. Photo credit: Nigeria Health Watch

Two days after the baby’s death, Emeka developed a fever, and soon after, nausea and vomiting. He got treated for malaria and typhoid, but he was not getting better. He sought help from a private hospital in Abakaliki, but nothing changed. He finally suspected that based on his symptoms, there was a possibility he was infected with Lassa Fever, after his exposure to the newborn baby.
Despite not feeling better, he went back to work and told his superiors his suspicions, but they doubted his story. They maintained that the reports they got showed that there was no suspected case of Lassa Fever virus in FETHA. Yet his story prompted his superiors to ban Emeka from attending to patients. No one took him seriously until he collapsed at work.
He was then admitted into the executive ward of FETHA. His samples were taken and sent to the laboratory, but the results did not come out for weeks. He later on found out why.
“The laboratory staff abandoned my sample because they saw that Lassa Fever was queried on the form. It was so bad that some of the nurses often resisted checking my vital signs,” he said. “When I felt that I was not getting the right treatment I discharged myself and ran for my life. However, with the help of my family members and the Association of Resident Doctors in FETHA, I went to Irrua Specialist Teaching Hospital (ISTH) in Edo State where I got the needed management and treatment.”

The Viral Haemorrhagic Fever (VHF) Centre or Ward established by the state government in collaboration with the Nigeria Centre for Disease Control, at the Federal Teaching Hospital Abakaliki (FETHA) to cater to Lassa Fever cases from the South-Eastern Region. Photo credit: Nigeria Health Watch

Dr. Emeka was cured of Lassa but says he is still grappling with its after-effects.
“It’s not even Lassa that kills most people, but the complications that result from the people who have Lassa. The Lassa virus will go to the pancreas; kidneys, eyes and brain. It will cause diabetes, psychosis, kidney failure. The disease will come and go, but the complications will remain,” he said.
The first case of Lassa Fever was discovered in 1969, in the town of Lassa, Borno State. Since then, the disease has been responsible for the death of thousands of Nigerians.
Today, Lassa Fever is still a scourge in Nigeria. Between 1 January and 14 July, 2019, 3043 suspected cases of the disease were recorded in 22 states in Nigeria. Out of this, 603 were confirmed positive cases and 17 were probable cases. A total of 140 people have died and 18 healthcare workers have been infected with the disease.

Emeka’s Story: Symptom of a deeper diagnostics challenge in Nigeria
The resurgence of the Lassa virus offers insights not only into Nigeria’s cultural and political health but the state of her health security — particularly as it concerns epidemic preparedness. With a low epidemic preparedness level of 39%, limited availability of evidence-based medical care, delayed diagnosis and outbreak response, the national laboratory systems in Nigeria only satisfy 40% of the requirements for epidemic prevention and control.
In South-East Nigeria, the major laboratories in universities that cater to its teeming population, an estimated 21.7 million people, share the same concerns about challenges in disease diagnosis for epidemic prevention. These concerns were raised by laboratory staff of FETHA, University of Nigeria Teaching Hospital (UNTH), Enugu, and Nnamdi Azikiwe University Teaching Hospital (NAUTH), Akwa, Anambra, in separate interviews, evidence that the region is underserved.

Image credit: Nigeria Health Watch

This is despite the support of the Nigeria Centre for Disease Control (NCDC) in setting up a Viral Haemorrhagic Fever (Lassa) centre in Ebonyi state in 2018, and providing a protocol for the management and treatment of Lassa fever. 
“Before 2018, when we have a suspected case, we take samples to Irrua, and it takes days to get results. Now with the help of NCDC, we take care of people within the south-east, including states like Cross-River. We have greatly improved in our turnaround time and rural health campaigns,” a FETHA staff said.
This support, which came along with a well-equipped virology laboratory that caters to all Lassa fever cases in and out of the South Eastern region, is still not without its challenges. 
“We really need more laboratory space for this work. The lab is small. We also need manpower development, training and retraining of staff, getting enough hands for the work and sustenance of the funding for this work. Training is really important because we need all our staff to be knowledgeable about IPC (Infection Prevention and Control), this way, they will not be scared of taking care of patients with the disease,” the FETHA staff continued.
Asides staffing, training and working conditions, which is a general issue in the region, there are other challenges peculiar to most laboratory networks. Dr. Chukwubuike of the UNTH laboratory, which caters to over 50 cases of infectious diseases monthly, said issues such as difficulty in reaching out to those in rural communities, delay in sample transportation to the regional lab, delay in supply and restocking of laboratory consumables, ageing of equipment, as well as epileptic power and water supplies are prominent.

Image credit: Nigeria Health Watch

The National Action Plan for Health Security (NAPHS) launched in 2018 further highlights core areas of weaknesses identified in Nigeria’s laboratory system. These include inadequate laboratory participation in the referral system, irregular supply of laboratory reagents and consumables, often leading to stock-outs. Other diagnostic problems that question Nigeria’s surveillance capacity for infectious diseases are limited availability of personal protective equipment, storage problems for reagents and consumables and expensive accreditation requirements for these resource-limited laboratories.
With the increasing interrelatedness of health and economic development, Nigeria cannot afford to relegate diagnostics in epidemic and pandemic preparedness. Government, policymakers, and the public frequently fail to understand that fully-functional diagnostic centres are not just essential for maintaining a disease-free nation but are also cost-effective for the Nigerian economy. Experts say a good place to start is by strengthening public health laboratories through strong collaborations, to provide the best services that are universally acceptable and serve as a critical component of disease prevention and management.
According to Dr. Chikwe Ihekweazu, the Director General of the NCDC, “We need the expertise and collaborations,” he says, “but we want a real partnership, not a master–servant relationship”.

Front view of the changing room which also serves as the conference room. Photo credit: Nigeria Health Watch

Richard Garfield, an epidemiologist at the US Centres for Disease Control and Prevention, said that to address multiple underlying causes of illnesses, nations need a ‘horizontal’ system of labs, clinics and staff that stretch across a country. “Vertical programmes are simple”. “This is much broader,” he explained. It now falls to leaders such as Ihekweazu to turn donor dollars into institutions that last.
This may not come easy. The NCDC has revealed that NAPHS in Nigeria would need roughly N122.38 (0.40USD) per person per year to establish a preparedness infrastructure that protects Nigerians from infectious diseases. With an estimated population of about 196 million people, Nigeria would require at least N220,264,800,000 (78,400,000USD) per year to cater for her citizens.
“It is a no-brainer for government to embark on poverty alleviation without factoring the health of the people through an efficient and elaborate diagnostics and laboratory system,” Dr. Iko Ibanga, the Executive Director of Pro-Health, a non-governmental organization charged with rendering with quality healthcare in rural north eastern Nigerian communities, said. In May 2019, the World Health Organisation (WHO) published the updated, second edition of the List of Essential In Vitro Diagnostics (EDL). The expanded EDL now includes non-communicable diseases and communicable diseases, like cholera. It seeks to provide guidance and recommendations to countries, the diagnostic tests that should be funded within their health system, as is the case with the Model List of Essential Medicines (EML).
As it stands, Nigeria’s epidemic preparedness is as strong as its weakest link — it’s time to ensure that diagnosis for disease outbreaks is not one of those weak links.
Author Bio: Chidindu Mmadu-Okoli is a 2019 #PreventEpidemicsNaija Fellow at Nigeria Health Watch. She is a Medical Laboratory Scientist, Digital Health Writer and Content Strategist and Author, Be Utterly Shameless.

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