Fighting Lassa: Five lessons from three special hospitals managing most cases of Lassa fever in Nigeria
At the Irrua Specialist Teaching Hospital, Mrs. Martha Okonofua moves around the ward with a smile. The Lassa Fever isolation ward at the hospital is unusually full. Mrs. Martha and her team are working extra hours as they are responsible for managing the highest number of Lassa fever patients in any hospital in Nigeria. Laughter can be heard from some beds as she walks by. Despite a general feeling of anxiety in the atmosphere, her disposition and presence lights up the mood. “For Martha, this ward is like a personal project and she is instrumental to solving this crisis,” Professor Sylvanus Okogbenin, Chief Medical Director of the Hospital, says about his trusted matron.
Mrs. Martha Okonofua, Matron at the Lassa fever isolation ward of Irrua Specialist Teachingg Hospital, Edo State. Photo credit: Nigeria Health Watch
“I have worked with the Irrua Specialist Teaching Hospital for 20 years. In that time, I have worked in the Lassa Fever isolation ward for eight years and became the matron in 2013. I have seen hundreds of cases. During this outbreak, we have managed over 200 patients and many of them have been successfully treated,” says Mrs. Martha Okonofua
Nigeria is currently witnessing its largest Lassa Fever outbreak in history. Since the first case of the virus was identified in a missionary nurse working in the village of Lassa in Borno State in 1969, cases have continued to increase in Nigeria, mostly in the states of Edo, Ondo, and Ebonyi. The anxiety associated with cases has created panic in many parts of the country and affected hospital operations across the country.
In tackling this Lassa fever outbreak, three specialist hospitals have emerged and grown in capacity and expertise to manage Lassa fever. These hospitals serve as examples to other health facilities in the country as many hospitals in Nigeria still struggle with managing cases of Lassa fever, often leading to panic. While there are plans to add to the number of specialist hospitals with the capacity to effectively manage Lassa fever cases, these three hospitals have shown that it is possible to grow in expertise in the management of Lassa fever in Nigeria through the sheer determination of their leaders, innovation of their staff and involvement of the entire community.
Interactive chart showing the status of Lassa fever at the three health centers at the end of March, 2018.
Irrua Specialist Teaching Hospital (ISTH), in Edo State, Federal Medical Center Owo (FMC), in Ondo State and the Federal Teaching Hospital in Abakaliki (FETHA), have been remarkable for various reasons. Most importantly, they provide care for over 80% of all Lassa fever cases in Nigeria. These three centres tell an unlikely story of how three hospitals in fairly rural locations have grown to become the frontline of Nigeria’s efforts to curb Lassa Fever. They have risen to the challenge, shown innovation despite limited resources, sustained momentum, created and nurtured new partnerships and risen to be trail blazers.
The following are five lessons that can be learned and adapted from their efforts in controlling the current Lassa fever outbreak in the country and in leadership generally.
- Change requires the engagement of all stakeholders
The Irrua Specialist Teaching Hospital ISTH is located 110 km from the historical Benin City, a two-hour drive across the rainforest terrain. Over the past ten years, it has nurtured the development of the Institute of Lassa Fever Research and Control (ILFRC), which now oversees the management of Lassa fever cases. Before its establishment, the number of people that died from Lassa fever when sporadic outbreaks of Lassa fever occurred in the area was quite high, in some cases more than 70%. This was primarily due to late presentation, poor case identification and non-availability of the drug Ribavirin, which is effective in Lassa fever if administered early enough.
The centre started as a proactive response to address these issues and over time, the figures have continued to improve remarkably, a reduction of deaths and an accompanying increase in confidence. While ISTH certainly cannot claim to have found all solutions to all the challenges, they have developed unique strengths in the management of Lassa fever and currently set the trail for other health facilities in Nigeria. Irrua Specialist Teaching Hospital will definitely be at the heart of any research planned on Lassa fever and the community will benefit from the innovation and determination of this facility.
2. Purposeful leadership, systems and structures as drivers of sustainable change
Speaking recently at a panel discussion organised by the Nigeria Centre for Disease Control (NCDC) in Abuja, CMD of ISTH, Prof. Okogbenin, listed building sustainable systems, structures, and having the right people in place as some of the elements that facilitated the smooth transition of leadership from the time of his predecessors to the current administration that he leads. This has helped ensure that new administrations do not begin brand new projects to duplicate previous ones but focus on scaling up existing systems and interventions. This obvious example is a rare characteristic in our polity in Nigeria, as most new leaders want to gain recognition for new projects.
In Irrua, various administrations have built on the Lassa fever control systems in place. What began as a Lassa Fever committee years ago has now grown to become the leading institute for Lassa fever management, detection and research in Nigeria and globally.
Collaboration, collaboration, collaboration.
The impact of both local and international partnerships developed over time is evident at both Irrua Specialist Teaching Hospital, Federal Medical Centre Owo and the Virology Centre of the Federal Teaching Hospital Abakiliki, with partners contributing significantly in their areas of strength to help curb the outbreak.
ISTH has a long-standing partnership with the Bernhard-Nocht Institute of Tropical Medicine, Hamburg, Germany. This has not only led to contribution of resources for Lassa fever diagnosis and treatment, but also capacity building of local staff who are continuously trained on global best practices. A remarkable feat from this strong collaboration is the ongoing establishment of a state-of-the-art molecular research and diagnostic laboratory within the Lassa fever Institute.
In December 2016, FMC Owo had a critical challenge with space to manage Lassa fever cases due to the high burden of the disease in Ondo State. One year after and in an exemplary partnership between NCDC, the hospital, State Government and the Alliance for International Medical Action (ALIMA), the hospital recently built and equipped a 38-bed capacity isolation centre and included isolation tests for patients.
In these three hospitals where Emergency Operations Centres (EOCs) have been set up, a coalition between Federal and State Government, Ministries and agencies within the environment and education sectors, security agencies and international partners have proven to be beneficial in ensuring a well-coordinated response.
Strategic partnerships such as the ones developed in these institutions are key in ensuring that when outbreaks of Lassa fever do happen, there is a coordinated response. This is because the right systems and competencies are in place, and technical support is available on request.
- Leaving no one behind
While there is still much that can be done at the Federal Teaching Hospital, Abakaliki, a resident doctor and epidemiologist working in the hospital said the hospital has taken proactive steps following the loss of some colleagues to Lassa in January 2018. These include mandatory health education of all employees on Lassa Fever, revamping of the virology centre, strengthening the activities of the Lassa Fever committee, developing and conspicuously displaying case management protocols, effective collaborations with other treatment centres, State Ministry of Health and other state agencies.
Dr. Ahmed Adeagbo Liasu, Chief Medical Director of FMC Owo, praised the commitment of his staff working on the Lassa Fever response. “These colleagues are not just government workers, because this is not their usual routine. They volunteered to be part of the Emergency Operations Centre, and they work even in the face of panic and limited resources.”
From the porters working at the isolation unit of ISTH, who move patient samples from the isolation ward to the diagnostic laboratories, to the security personnel at the gates of FMC Owo who check temperatures and provide hand sanitizers on entry, every staff of the hospital has shown a high level of responsibility, commitment and dedication to saving lives.
- Taking advantage of the opportunity in crisis situations
In 2017, Nigeria had only three diagnostic centres with the capacity to test for Lassa fever- Lagos University Teaching Hospital (LUTH), ISTH and the NCDC’s National Reference Laboratory, Gaduwa. In Abakaliki, a virology centre had been built but was yet to be operationalised.
By the end of January 2018, FETHA had faced a difficult situation as it had not only lost members of its host community to Lassa fever, but health workers had also been infected. The hospital had depended on ISTH, a three-hour drive from Ebonyi for diagnosis which affected early initiation of treatment. Within this context, the State and Federal Governments quickly mobilised resources. By the end of February 2018, FETHA Virology centre joined the list of facilities with capacity to diagnose Lassa fever, bringing the numbers from three to four.
In a bid to better understand the drivers of the current outbreak which has been described as unprecedented, staff at ISTH and its partners deployed the Lassa virus sequencing technology. This was not possible in the past using existing diagnostic methods. With this, the country has a better understanding of emergence or non-emergence of new strains of the virus and provides evidence for further studies on better treatment regimens, vaccine development and strengthened response activities.
In retrospect, 2018 has seen one of the biggest outbreaks in the history of Lassa fever epidemics in Nigeria and globally (NCDC’s weekly reports can be found here).
At the end of March 2017, 400 cases have been confirmed in Nigeria with Edo State accounting for the highest at 167 confirmed cases. Ebonyi State has the highest number of healthcare workers affected at 15, while Ondo State has the second highest number of confirmed cases at 97. But the national case fatality rate has remained relatively low at 24.3%, which means of the 400 confirmed cases, 303 have survived the disease.
These figures show that beyond the outbreak, institutions and states, such as ISTH, FMC Owo, and FETHA have taken ownership of their response. They have used the opportunities available to build and strengthen partnerships, apply best practices, and build better response systems that we are confident will gradually turn the tide in the fight against Lassa fever in Nigeria.