NCDC to Ensure Better Preparedness, Detection & Response to Lassa Fever

After what is now being called Nigeria’s worst Lassa fever outbreak was declared over, the Nigeria Centre for Disease Control (NCDC) hosted partners and stakeholders across Nigeria to the Lassa Fever after-action review meeting to assess their collective efforts in responding to this year’s outbreak, and plan for the future.

Lassa fever which is endemic in Nigeria is a viral hemorrhagic fever that is transmitted to humans via contact with food or household items contaminated with rodent urine or feces. Person-to-person infections and laboratory transmission can also occur when there is unprotected contact with blood or bodily fluids. Although the overall case fatality rate is 1% in all patients with Lassa fever (when asymptomatic and mildly symptomatic patients are included), mortality has been reported to be as high as 20% or higher among patients hospitalized with severe illness. Early supportive care with rehydration and ribavirin treatment improves survival.

In an interview with EpidAlert at the Lassa fever after-action review, the lead of the technical working group on Lassa Fever Elsie Ilori said that the NCDC wants to ensure better preparedness, detection & response, and reduce the risk of exposure of Nigerians to the deadly virus.

“We are here to identify best practices and challenges encountered during the response, validate existing mechanisms and identify areas for improvement” – Ilori said, identifying the need to strengthen intra-disciplinary collaboration and coordination, and preventing health workers getting infected or dying from Lassa fever as key in preparing for future outbreaks.

EpidAlert: How did the last Lassa fever response go?
Elsie Ilori: Well, we are still responding, we are not out of the season yet. The last Lassa fever outbreak has been very very educating, it has been a very good experience for us in that the coordination of the response was very good. We were able to coordinate our partners and were also able to support the states and carry them along. Lassa fever is actually a state response with the national supporting the state, but in most cases we found that the states were not ready to respond, so our teams responded, supported the state in their response and built up their capacity during their stay in the state. The response this year is an eye-opener, we were able to see a lot of gaps in preparedness at the state level, but we were able to meet up with some of those gaps and were able to train the state teams in their different areas; that is surveillance, case management, and health educators. We were also able to put them all together to make sure that they work together, as a team in the state.

Related: The Federal Government Declared the End of the Emergency Phase of Nigeria’s Lassa Fever Outbreak

Laboratory used to be a big issue in Lassa fever response, how did you overcome it this time?
Initially, there were two labs capable of testing for Lassa fever but this year we were able to scale up to four labs. We were also able to zone the labs according to their closeness to the state. There is a lab in Abuja ( the national reference lab) serving the north, there is one in iruwa Edo state serving the south-south and south-east, there is also a lab in LUTH serving the south-west. In Ebonyi state, we have a lab there testing for Lassa fever, but it is currently serving only Ebonyi state because we need to build them up. Those four labs are functioning presently, running samples, so we have scaled up our number of laboratories diagnosing for Lassa fever

A lot of work was carried out in community sensitization, and you also carried out a study in the south-east – Ebonyi specifically, to study the socio-cultural patterns, what are the key findings from that study?
From the study, we discovered that the cultural practices in the state were one of the factors that predispose them to get and transmitting Lassa fever, specifically the burial practices where they keep their corpse in the house and they go in and touch. We also found out that the communities, though aware of some info about Lassa fever, it’s like the messages we were sending across were not enough, after the analysis we had to come back and review the messages that we were passing across, because just telling them you need to wash your hands, isn’t enough, because of some of their cultural practices we had to change some of our messages and how the messages were delivered. This was very helpful in our response, the assessment was very key. We also discovered that the most affected people were the student, so we interacted with them to know which of their habits could predispose them to Lassa fever. For that, we are still carrying out some analysis to really get to the root of that matter and then be able to get the right messages across to each group.

NCDC transitioned to case-based reporting; how has that been working out?
Lassa fever has always been case-based, once there is a case of Lassa fever, you report using the case base reporting form, use the case investigation form which is more detailed. Here is where we have issues with the state, although the case investigation form isn’t new to them, they are not used to using it. Now we have reintroduced it to them and I think we have been able to get some positive response from the state

Are there still lingering challenges you think they should improve upon in that area?
Yes, of course. There will always be some challenges in terms of transmission of the form, filling of the form, sometimes there’s a confusion about who is expected to fill it, at what level do you start to fill the form. Those are areas that we are really working on with the states, it usually depends on the situation, for instance, if the case management physician gets to see a Lassa fever case and reports to the state epidemiologist, the epidemiologist is expected to go with the case investigation form to get more detailed information about the case. But when there is a lapse in reporting from the physician that’s when we have issues because by then they wouldn’t have been able to collect enough information from the patient, and by the time the state epidemiologists gets to the facility to do his/her investigation, it is a bit difficult to get the detailed information. Thus, we are working on this between the physicians and the epidemiologists

What is the objective of the Lassa fever after-action review?
This is for us to assess our response. In order to do this, we need to know- the situation on ground, how did we respond, and what we could have done better. The objective was to access our response for best practices that can be emulated in the future, and also to see the lapses, things we could have done better, and then try to proffer solutions to those lapses. We all come to share in our experiences, look at those gaps and then build up. The other part is for us to have interdisciplinary response, here we have people from different disciplines, we have the health educator, state ep, case management physician, lab scientist, surveillance officers, all coming together from the state to look at how they responded, what could have been better, share experiences and then profer solutions, and prepare for the next outbreak.
We need to look at our gaps, fill those gaps and prepare for the next outbreak.

In terms of implementation, you mentioned IHR/WHO can you explain that linkage to us?
The after action review meeting is one of the required action for IHR. The IHR countries are expected to report annually their capacities, their level of response, how they have fared in terms of their response to outbreaks and surveillance actions at their points of entry, apart from that we also have the joint external evaluation that we use to access also core capacities for ihr, the new part of this is the after action review which we use to access when there is an outbreak especially if it is one on a large scale like the case of lassa fever we just had, to access your response activities, build on good activities, work on your gaps and then prepare for the next one, so that we could try as much as possible to make sure that we prevent this kind of huge outbreak from occuring or prevent the outbreak itself, and when it eventually occurs we should be able to promptly respond.

What should we expect after the Lassa fever after-action review, and what is the cycle into the next response curve?
Like I mentioned earlier, we expect that we have our preparedness plan for the next outbreak and the states are also going to draw up their specific priority activities for the state. They are expected to go back to their state and do some advocacy with their honorable commissioner, get a source for funds to be able to carry implementation. Now at the national level, we have listed all the activities too, we have already started carrying out some activities in the states, we have started training states on Lassa fever diagnosis and management, preparing them and building their capacity to manage Lassa fever. At the state level, we also expect them to cascade the training, down to the local government level. The Health Educators aren’t supposed to work only during outbreaks, they are supposed to sensitise the people, before, during and after an outbreak, they are going to develop specific plans for their state, and bring in all the various activities, involve the state epidemiologist to carry out these activities, and start their community engagement. We are preparing, at the end of this review meeting, we have our preparedness plan and we start the activity that we have listed, and by the next outbreak we won’t have that kind of upsurge we would have been able to beat it in the board, we would have high index of suspicion, we will be able to treat any case that occurs, we would be able to manage it and then we would not have health workers getting infected or dying from lassa fever – which is one of the major things we are trying to achieve- since they would be fully prepared, to manage any lassa fever case.

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