EPIDEMIOLOGY AND CONTROL OF LASSA FEVER

BY

SAMUEL BEAUTY ABIGAIL

AST/2382160433

BEING A SEMINAR WORK PRESENTED IN THE DEPARTMENT OF

BIOLOGICAL SCIENCE LABORATORY TECHNOLOGY, SCHOOL OF
APPLIED SCIENCE AND TECHNOLOGY AUCHI POLYTECHNIC,
AUCHI

IN PARTIAL FULFILMENT FOR THE REQUIREMENT FOR THE

AWARD OF HIGHER NATIONAL DIPLOMA (HND) IN BIOLOGICAL
SCIENCE LABORATORY TECHNOLOGY
(MICROBIOLOGY OPTION)

FEBRUARY, 2023

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 OUTLINE
Introduction
 Overview of Lassa
 Brief History/Historical account of Lassa Fever
 Geographical Distribution or Spread of Lassa Fever/distribution, diagram,
tables

Epidemiology of Lassa fever

 Transmission Pattern (Table)
 Risk Factors in the Transmission of Lassa Fever

Clinical Manifestation or symptoms

Diagnostic Measures of Lassa Fever
Prevention and control
Treatment
Conclusion and Recommendation
References

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 INTRODUCTION
Lassa fever is endemic in west Africa, where it probably kills several thousand people
each year. With access to the region improving, the opportunity, and the need, to improve our
understanding of this disease are increasing.
Lassa fever is a viral haemorrhagic fever transmitted by rats. It has been known since the
1950s, but the virus was not identified until 1969, when two missionary nurses died from it in the
town of Lassa in Nigeria. Found predominantly in west Africa, 1 it has the potential to cause tens
of thousands of deaths. Even after recovery, the virus remains in body fluids, including semen.
Increasing international travel and the possibility of use of the Lassa virus as a biological weapon
escalate the potential for harm beyond the local level. Access to the country is improving, so
renewed efforts to understand it are feasible.
The pattern of Lassa fever outbreaks in Nigeria over the years is worrisome and
increasingly becoming more challenging with frequent and widening geographical spread. Lassa
fever is endemic and fast becoming hyper-endemic in Nigeria. It affects the largest number of
people, creating a geographical network of endemic foci encompassing a population of perhaps
180 million from Guinea to Nigeria. Lassa fever presents signs and symptoms indistinguishable
from those of febrile illnesses such as malaria and other viral haemorrhagic fevers such as Ebola.
Clinical diagnosis of Lassa fever is difficult however it should be suspected in patients
showing fever with temperature not responding adequately to antimalarial and antibiotic
treatments. Laboratory diagnosis by serological, cell culture and molecular techniques is reliable
although very expensive. For now, there is supportive treatment but no licensed vaccine yet;
therefore, public awareness and advocacy are vital in educating and sensitizing the citizenry on
the risk associated with overcrowding and unhygienic practices both in our communities and
health institutions in Nigeria and its environs.

Overview of Lassa Fever

Lassa fever is an acute viral illness that occurs in west Africa. The illness was discovered
in 1969 when two missionary nurses died in Nigeria. The virus is named after the town in
Nigeria where the first cases occurred. The virus, a member of the virus family Arenaviridae, is a
single-stranded RNA virus and is zoonotic, or animal-borne. Lassa fever is endemic in parts of

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west Africa including Sierra Leone, Liberia, Guinea and Nigeria; however, other neighboring
countries are also at risk, as the animal vector for Lassa virus, the "multimammate rat"
(Mastomys natalensis) is distributed throughout the region. In 2009, the first case from Mali was
reported in a traveler living in southern Mali; Ghana reported its first cases in late 2011. Isolated
cases have also been reported in Côte d’Ivoire and Burkina Faso and there is serologic evidence
of Lassa virus infection in Togo and Benin. The number of Lassa virus infections per year in
west Africa is estimated at 100,000 to 300,000, with approximately 5,000 deaths. Unfortunately,
such estimates are crude, because surveillance for cases of the disease is not uniformly
performed. In some areas of Sierra Leone and Liberia, it is known that 10%-16% of people
admitted to hospitals every year have Lassa fever, which indicates the serious impact of the
disease on the population of this region.

Brief History/Historical Account of Lassa Fever

Lassa fever is an animal-borne, or zoonotic, acute viral illness spread by the common
African rat. It is endemic in parts of West Africa including Sierra Leone, Liberia, Guinea and
Nigeria. Neighboring countries are also at risk because the animal vector lives throughout the
region. The first documented case occurred in 1969. Lassa fever is named after the town in
Nigeria where the first cases occurred.
About 100,000 to 300,000 infections of Lassa fever occur annually, with about 5,000
deaths. Surveillance for Lassa fever varies between locations so these estimates are crude. In
some areas of Sierra Leone and Liberia, about 10-16% of people admitted to hospitals annually
have Lassa fever. This shows the serious impact the disease has on the region.

THE VECTOR
The natural hosts for the virus are multimammate rats (Mastomys natalensis), which breed frequently and
are distributed widely throughout west, central, and east Africa. 3 They are probably the most common
rodent in tropical Africa and are found predominantly in rural areas, and in dwellings more often than in
surrounding countryside. Members of the genus are infected persistently and shed the virus in their
excreta. Humans are infected by contact with the rats or by eating them (they are considered a delicacy
and are eaten by up to 90% of people in some areas). Rats found in houses of infected people are
seropositive for the virus 10 times more often than those in control houses. Virus antibodies occur after a

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febrile illness in twice as many people who eat rats as in those who do not, and deafness (an effect of
Lassa fever) occurs four times more frequently

Geographical Distribution or Spread of Lassa Fever

In total, 374 distinct locations were identified as having animal infections or likely index cases of
human outbreaks of Lassa fever. Human index cases were reported in nine different countries,
mainly focused in Liberia, Nigeria and Sierra Leone, but with some cases reported also in Benin,
Burkina Faso, Côte d'Ivoire, Ghana, Guinea and Mali. Reports of infection in animals were
found in four of these countries (Guinea, Mali, Nigeria and Sierra Leone) as well as in
Cameroon, where no human index cases have been reported. The majority of human cases were
diagnosed used serological techniques, although PCR diagnosis was often used in Nigeria and
Sierra Leone.

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 EPIDEMIOLOGY
Epidemiology is the method used to find the causes of health outcomes and diseases in
populations. In epidemiology, the patient is the community and individuals are viewed
collectively. By definition, epidemiology is the study (scientific, systematic, and data-driven) of
the distribution (frequency, pattern) and determinants (causes, risk factors) of health-related
states and events (not just diseases) in specified populations (neighborhood, school, city, state,
country, global). It is also the application of this study to the control of health problems
The reservoir or host, of Lassa virus is a rodent known as the “Multimamate rat
(Mastomys natalensis). Once infected, this rodent is able to excrete virus in urine for an extended
time period, maybe for the rest of its life. Mastomys rodents breed frequently, produce large
numbers of offspring, and are numerous in the Savannas and forests of West, central, and east
Africa. In addition, Mastomys readily colonize human homes and areas where food is stored. All

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these factors contribute to the relatively efficient spread of Lassa virus from infected rodents to
humans.
Transmission of Lassa virus to humans occurs most commonly through ingestion or
inhalation. Mastomysrodent shed the virus in urine and dropping and direct contact with these
materials through touching soiled objects, eating contaminated food, or exposure to open cuts or
sores, can lead to infection.
Because Mastomys rodents often live in and around homes and scavage on leftover human food
items or poorly stored food, direct contact transmission is common. Mastomys rodents are
sometimes consumed as a food source and infection may occur when rodents are caught and
prepared. Contact with infected rodent excretions. This aerosol or airborne transmission may
occur during cleaning activities, such as sweeping.
Direct contact with infected rodents is not the only way in which people are infected; person-to-
person transmission may occur after exposure to virus in the blood, tissue, secretions, or
excretions of Lassa virus-infected individual. Casual contact (including skinto- skin contact
without exchange of body fluids) does not spread Lassa virus. Person-to-person transmission is
common in health care [5].
The most common complication of Lassa fever is deafness. Various degrees of deafness occur
approximately one-third of infections, and in many cases hearing loss is permanent. As far as is
known, severity of the disease does not affect this complication: deafness may develop in mild as
well as in severe cases.
Approximately 15%-20% of patients hospitalized for Lassa fever die from the illness. However,
only 1% of all Lassa virus infections result in death. The death rates for women in the third
trimester of pregnancy are particularly high. Spontaneous abortion is a serious complication of
infection with an estimated 95% mortality in fetuses of infected pregnant mothers. Because the
symptoms of Lassa fever are so varied and nonspecific, clinical diagnosis is often difficult. Lassa
fever is also associated with occasional epidemics, during which the case-fatality rate can reach
50% in hospitalized patients.
Symptoms generally appear within 1-3 weeks following infection. An estimated 80% of
infections produce symptoms so mild that they remain undiagnosed. These mild infections are
characterized by a general malaise, headache and a light fever.
For the 20% of cases where Lassa fever become serous, symptoms can include:

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A. Hemorrhaging- in the gums, nose, eyes or elsewhere.
B. Difficulty breathing, cough, swollen airways, stomachache, vomiting and diarrhea (both
bloody), difficulty swallowing, Hepatitis

MORBIDITY AND MORTALITY

Presentation of cases used to be highest during the dry season (January to March) and
lowest during the wet season (May to November). However, recent data from Kenema (1999-
2002) show that admissions were highest during the change from the dry to the wet season. This
change might be related partly to population movements during the civil unrest in Sierra Leone
and overcrowding among refugees. Travel becomes increasingly difficult as the wet season
progresses and may help to account for the decrease in numbers of cases later in the season. All
the cases reported were diagnosed clinically. Until 1998 laboratory confirmation of diagnosis
was available retrospectively and 60-70% of cases were confirmed, but in 2000 over half of a
series of 22 cases were wrongly diagnosed. Thus, these recent apparent changes in infection
patterns must be interpreted with caution.
People of all ages are susceptible. The disease is mild or has no observable symptoms in
about 80% of people infected, but 20% have a severe multisystem disease. The incubation period
is 6-21 days. The virus is excreted in urine for three to nine weeks from infection and in semen
for three months.1 The extent of sexual transmission is unknown.
Sensorineural hearing deficit is a feature of the disease: it was found in 29% of confirmed cases
compared with none of febrile controls in hospital inpatients. In the general population, 81% of
those who experienced sudden deafness had antibodies to Lassa virus versus 19% of matched
controls. There is no apparent relation between the severity of viral illness, initial hearing loss, or
subsequent recovery.
Lassa fever was responsible for 10-16% of all adult medical admissions in 1987 in two
hospitals studied in Sierra Leone and for about 30% of adult deaths. The case fatality rate in
Kenema varied from 12% to 23% for the period 1997-2002. A recent case series showed low
admission rates and high case fatality rates for people aged less than 18 years (who make up 51%
of the total population (United Nations Development Programme)) compared with older people.
During pregnancy, high rates of maternal death (29%) and fetal and neonatal loss (87%) have

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been recorded (uterine evacuation improves outcome significantly), with 25% of all maternal
deaths in Sierra Leone being due to Lassa fever. An estimate of the case fatality rate in the
general population is 1-2%, much lower than in hospitalized cases, possibly as a consequence of
differences in severity.

TRANSMISION
The reservoir, or host, of Lassa virus is a rodent known as the "multimammate rat"
(Mastomys natalensis). Once infected, this rodent is able to excrete virus in urine for an extended
time period, maybe for the rest of its life. Mastomys rodents breed frequently, produce large
numbers of offspring, and are numerous in the savannas and forests of west, central, and east
Africa. In addition, Mastomys readily colonize human homes and areas where food is stored. All
of these factors contribute to the relatively efficient spread of Lassa virus from infected rodents
to humans. Transmission of Lassa virus to humans occurs most commonly through ingestion or
inhalation. Mastomys rodents shed the virus in urine and droppings and direct contact with these
materials, through touching soiled objects, eating contaminated food, or exposure to open cuts or
sores, can lead to infection. Because Mastomys rodents often live in and around homes and
scavenge on leftover human food items or poorly stored food, direct contact transmission is
common. Mastomys rodents are sometimes consumed as a food source and infection may occur
when rodents are caught and prepared. Contact with the virus may also occur when a person
inhales tiny particles in the air contaminated with infected rodent excretions. This aerosol or
airborne transmission may occur during cleaning activities, such as sweeping. Direct contact
with infected rodents is not the only way in which people are infected; person-to-person
transmission may occur after exposure to virus in the blood, tissue, secretions, or excretions of a
Lassa virus-infected individual. Casual contact (including skinto-skin contact without exchange
of body fluids) does not spread Lassa virus. Person-to-person transmission is common in health
care settings (called nosocomial transmission) where proper personal protective equipment (PPE)
is not available or not used. Lassa virus may be spread in contaminated medical equipment, such
as reused needles.

RISK FACTOR
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 Individuals at greatest risk of Lassa virus infection are those who live in or visit endemic
regions, including Sierra Leone, Liberia, Guinea, and Nigeria and have exposure to the
multimammate rat. Risk of exposure may also exist in other west African countries where
Mastomys rodents exist. Hospital staff are not at great risk for infection as long as protective
measures and proper sterilization methods are used.

CLINICAL MANIFESTATION OR SYMPTOMS

Signs and symptoms of Lassa fever typically occur 1-3 weeks after the patient comes into
contact with the virus. For the majority of Lassa fever virus infections (approximately 80%),
symptoms are mild and are undiagnosed. Mild symptoms include slight fever, general malaise
and weakness, and headache. In 20% of infected individuals, however, disease may progress to
more serious symptoms including hemorrhaging (in gums, eyes, or nose, as examples),
respiratory distress, repeated vomiting, facial swelling, pain in the chest, back, and abdomen, and
shock. Neurological problems have also been described, including hearing loss, tremors, and
encephalitis. Death may occur within two weeks after symptom onset due to multi-organ failure.
The most common complication of Lassa fever is deafness. Various degrees of deafness occur in
approximately one-third of infections, and in many cases hearing loss is permanent. As far as is
known, severity of the disease does not affect this complication: deafness may develop in mild as

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well as in severe cases. Approximately 15%-20% of patients hospitalized for Lassa fever die
from the illness. However, only 1% of all Lassa virus infections result in death. The death rates
for women in the third trimester of pregnancy are particularly high. Spontaneous abortion is a
serious complication of infection with an estimated 95% mortality in fetuses of infected pregnant
mothers. Because the symptoms of Lassa fever are so varied and nonspecific, clinical diagnosis
is often difficult. Lassa fever is also associated with occasional epidemics, during which the
case-fatality rate can reach 50% in hospitalized patients.

DIAGNOSTIC MEASURES OF LASSA FEVER

At hospital admission, most patients have antibodies to the virus (53% with IgG and 67%
with IgM). Together, enzyme linked immunosorbent assays (ELISAs) for Lassa virus antigen and
for virus IgM are 88% sensitive and 90% specific for acute infection. Other effects of illness
include lymphocytopenia and a moderate thrombocytopenia, which are maximal 10-11 days after
the onset of symptoms. The thrombocytopenia is associated with a serum inhibitor and with the
occurrence of haemorrhage, depression of platelet aggregation, and the severity of Lassa
fever.21 With reverse transcription polymerase chain reaction, Lassa fever can be diagnosed in all
patients by the third day of illness, but immunofluorescence identifies only 52% of the patients .

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 PREVENTION AND CONTROL
Given that the host of the Lassa virus is rodents which are so abundant in endemic areas, one
plausible means of prevention is promoting good personal and community hygiene to discourage
rodents from entering homes. According to the Practical examples here would include storing
grain and other foodstuffs in rodent-proof containers, disposing of garbage far from the home,
maintaining clean households, keeping cats to hunt vermin, cooking all foods thoroughly and
constant hand washing. More so, family members and health care workers should always be
careful to avoid contact with blood and body fluids while caring for sick persons. Along this line,
for added safety, patients suspected to have Lassa fever should be cared for under specific
isolation precautions, which include the wearing of protective clothing such as masks, gloves,
gowns and face shield and the systematic sterilization of contaminated equipment.

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 TREATMENT
Ribavirin and general support are needed.24 Ribavirin is almost twice as effective when
given intravenously as when taken orally, and if given within six days of the start of
illness it may reduce deaths by 90%. Dehydration, oedema, hypotension, and poor renal
function are common; fluid replacement or the use of blood transfusion requires careful
monitoring.

CONCLUSION
This essay presents a succinct synopsis on the Lassa fever. The essay contends that the
disease is only endemic in the Western, Central and Eastern part of Africa. It goes without
saying that people in the western world are also susceptible since secondary transmission
can occur by coming in contact with infected person’s bodily fluid. As argued in the essay
however, the disease is endemic in the Western, Central and Eastern Africa because Lassa
virus – the causative agent of the disease – is hosted in multi-mammate rat which is a
common rodent in the region. Most important, these rodents live in most homes in the
region and are even considered a delicacy. The study also points to the asymptomatic
nature of the disease which in combination of the disease having some similar patterns

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with febrile illness and other RNA virus caused diseases makes diagnosis based on
symptoms relatively impossible. Hence, properly designed clinical diagnosis like ELISA
has been deemed a panacea. With respect to prevention, luck with clinical drugs or
methods are scarce besides maintaining good personal and community hygiene to prevent
the disease host reservoir Mastomys natalensis, from co-habiting with humans. In
addendum, people should avoid eating food that has been contaminated with the rodent’s
faeces and urine. For treatment, only Ribavirin combined with supported care has been
clinically approved. More so, the potency.

REFERENCE
1. Ross, D. I. (2009). The lassa ward: One Mans’s Fight Against One of the World Deadliest
Diseases. (pp. 24:45-55). Saint Martin’s Press.
2. Frame JD (2012) Surveillance of Lassa fever in missionaries stationed West Africa. Bull
WHO 52(4-6): 593-598.
3. Frame JD (2012) Surveillance of Lassa fever in missionaries stationed West Africa. Bull
WHO 52(4-6): 593-598.
4. Gary GW (1977) A neutralization test survey for Lassa fever activity in Lassa, Nigeria.
Transmission Routes Social Tropical Medical Hygiene 71(2): 152-154.
5. World Health Organization (2000). WHO Lassa fever fact sheet No 179. Geneva: WHO,

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