HAEMORRHAGIC

FEVER: LASSA

DR SALAHUDEEN ABDULRASHEED
Introduction.

Viral haemorrhagic fevers (VHF) are zoonotic infections

characterized by fever, headache, malaise, vomiting, mucosal
and gastrointestinal bleeding.
VHF are caused by RNA viruses in these four families:
Arenaviridae, Bunyaviridae, Flaviviridae and Filoviridae.
-Pigott DC, 2009
Arenaviridae.

Viruses in this family include

*Lassa fever
*Junin (Argentina HF)
*Machupo (Bolivian HF)
*Sabia (Brazilian HF)
*Guanarito (Venezuelan HF).
*Lujo
-all are transmitted by rodents.
Bunyaviridae.

Has these 3 classes

-Phlebovirus (Rift valley fever)---Mosquitoe vector
-Nairovirus (Crimean-Congo HF), Tick borne
-Hantavirus (Haemorrhagic fever with renal syndrome, hantavirus
pulmonary syndrome)--Rodent transmission.
 Filoviridae..

Marburg
Ebola.
Reservoir animal is unknown
Flaviviridae.

Yellow fever and Dengue fever

Both are mosquito borne.
Epidemiology
Epidemiology
HF Transmission.

From rodents to man.

Through the bite of mosquitoes and ticks.
From man to man.
In hospital settings.
Can affect all age groups and
assumed epidemic proportion in healthcare settings with poor
infection control protocol.
Mortality high in pregnant women.
 Background: Lassa Fever 10

Acute Hemorrhagic illness caused by

the arenavirus Lassa
Endemic in parts of West Africa
Caused by an RNA virus/ Arenaviridae
Zoonotic infection/Mastomys rodents
Rodent reservoir
Mastomys species complex (multimammate rat)
Occasional nosocomial outbreaks with 5000 deaths/year
 EPIDEMIOLOGY 12

Estimated 300,000 500,000 infections /yr with 5,000 deaths.

Antibody levels:
Nigeria 21%,
Sierra Leone 8-52%,
Guinea 4-55%
EPIDEMIOLOGY- CONT 13
 EPIDEMIOLOGY-CONT 14

The incubation period is 6-21 days.

The virus is excreted in urine for 3 to 9 weeks from
infection and in semen for three months.
The extent of sexual transmission is unknown.
Estimateof the case fatality rate in the general
population is 1-2%, much lower than in hospitalised
cases, possibly from differences in severity.
 EPIDEMIOLOGY-CONT 15

During pregnancy:
high rates of maternal death (29%) and fetal and
neonatal loss (87%) have been recorded (uterine
evacuation improves outcome
Lassa virus:
The mortality rate is 92% for fetuses in early pregnancy
75% for fetuses in the third trimester and
100% in the neonatal period for full-term babies.
 Rodent and Transmission 16

RESERVOIR Wild rodents; in West Africa, the multimammate rat, of the Mastomys
species
The rat speciesM. natalensis . The virus is shed freely in urine, droppings and
saliva. The rats may show no feature of the disease.
Mastomysoften live in homes, the virus is easily transmitted to humans.
Transmission occursvia
direct contact with rat urine, feces, and saliva;
via contact with excretion or secretion infected materials;
 Rodent and Transmission 17

via ingestion of excretion-contaminated food.

Victims can also become infected via skin breaks, and via mucous membranes from
aerosol transmission from dust-borne particles.
In areas where the rodents are used as a food source, this providing additional
exposure .
Laboratory workers become infected usually from contact with rodent saliva and
patients samples
Mastomys Natalensis-Lassa Rat 18

Multimammate rat
Peri-domestic
Inhabits fields and cleared forest
Prolific breeder (8-12 pups/litter)
Infected at birth and become
chronic asymptomatic carriers of
Lassa virus
Shed virus in the urine and feces
Numerous sub-species
 Modes of Transmission of Lassa Virus
19

Rodent-human
Rodent excreta contaminating food
Direct contact (consumption or bite)
Aerosol(inhalation of excretions in air)
Human-human
Contact with blood or body fluids

Householdtransmission
Nosocomial
 SYMPTOMS 20

Major Criteria:
Abnormal bleeding (including from mouth, gums, nose, vagina and haemoptisis).
Swollen neck and/or face.
Red eyes or conjunctivitis.
Spontaneous abortion.
Deafness during illness (or attributed to Quinine).
Low blood pressure (systolic Bp <100mmHg) or shock.
21
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 SIGNS

Minor Criteria:
Major Signs

Petechial rash and hemorrhage Leucopenia (<400/mm)

New onset tinnitus or altered Nausea vomiting
hearing Abdominal pain
Persistent hypotension Plural effusion or ascites.
Elevated liver transaminases Swollen nymph nodes
AST>> ALT
Weakness.
Known exposure to a person
suspected to have LF
 Minor Signs 25

Headache
Sore throat
Vomiting
Diffuse abd pain/tenderness
Chest or retrosternal pain
Cough
Diarrhoea
Gen. myalgia or althralgia
Profuse weakness

 Clinical Presentation 26

Case fatality rate: 1-50%, 20-25% of hospitalized cases

Deafness common sequelae, up to 1/3 cases
Particularly severe in pregnant women and their fetuses (fetal death rate>95%)
Patients die from combination of increased capillary permeability, cardiac
suppression and coagulopathy leading to a low effective circulating volume
leading to shock, NOT loss of blood
Common laboratory findings:
Early leukopenia, late leukocytosis
Mild-to-moderate thrombocytopenia
 Clinical Presentation 2 27

Incubation period: 5-21 days

Mild onset over days:
Fever, malaise, headache, myalgia, arthralgia, prostration
Gastrointestinal symptoms common
Anorexia, nausea, vomiting, diarrhea, abdominal pain
Cough, dyspnea, chest pain may be seen
Pulmonary edema after IV fluids
Central nervous system may be involved in late stages
Agitation, confusion, tremor to coma and convulsions
Hemorrhagia :
Gastrointestinal, conjunctival injection/sub-conjunctival hemorrhage
Classic presentation: fever, neck/facial swelling, bleeding(petechial hemorrhage) and shock
 DIAGNOSIS OF LASSA FEVER 28

The signs and symptoms are none specific

Definitive diagnosis requires testing that is available only in highly specialised

laboratories.

Lassa fever,diagnostic, Research & Control Laboratory Irrua Specialist Hospital in

Edo State (can perform rapid diagnostic tests)

Virology Lab LUTH, College of Medicine Idi-Araba

 DEFINITIVE DIAGNOSIS 29

Antibody detection
IgM antibody to the virus by ELISA,
IgG seroconversion by ELISA of IFA.

2. antigen detection through ELISA or PCR,

3. Viral isolation from blood, urine or throat washings, (diagnostic standard)

 30
Differential Diagnosis
Malaria
Typhoid fever
Yellow fever
Influenza
Measles
Shigellosis
Leptospirosis
Meningococcemia
Rickettsial infections
Bacterial sepsis
Other viral hemorrhagic fevers(YF,WN,EB,MG)
 Case Management 31

Before lab result is available

Suspect case
1. Anti - malarial
2. Antibiotics
3. Monitor temperature
Probable case
1. Weigh patient
2. Set IV line
3. Grouping & cross-matching of blood
4. oxygen
5. IV ribavirin
6. If seizures Iv diazepam( with oxygen)
Confirmed case
Same as for probable case
 Case Management 32

Supportive treatment
Intensive care unit
Limit movement of patient
Fluid and electrolyte balance, supplemental O2, ventilation, pressors, dialysis
Consider capillary leak and risk of pulmonary edema when rehydrating
Steroids NOT indicated
Ribavirin
Convalescent plasma
May be effective if high titer of neutralizing antibody, but presence of ribavirin and risk of
transfusion-related infections make it obsolete
 Ribavirin 33

Intravenous administration for 10 days

Efficacy demonstrated if given during the first 6 days of illness

Major side-effect is reversible, most-often mild anemia

Technically contra-indicated in pregnant women

may still merit consideration given high maternal and fetal death rates associated with LF
Efficacy of oral ribavirin as treatment unknown
 Specimen Transport: Planning
34

Sender
Arrangement with receiver and carrier
Notify receiver
Carrier
Prepare documentation
Notify the sender about packaging, transportation

route, delays
Receiver
Obtain import papers
Acknowledge receipt to sender
 VHF and the hospital.
The virus enters the health facility in the body fluids of a VHF patient.

All health care staff, laboratory staff, cleaning staff, other patients and visitors to the
health facilities are at risk for exposure to VHF.

The virus is transmitted during direct, unprotected contact with a VHF patient OR with a
deceased VHF patient.

The virus is also transmitted during unprotected contact with VHF infectious body fluids

OR contaminated medical equipment and supplies

OR as a result of an accidental needle stick or accidental exposure to infectious body
fluids.

The exposed person carries the virus back to the Community.
Control and Prevention

The prevention of HF in Africa presents many challenges.

Because the identity and location of the natural reservoir of
some are unknown e.g. Ebola virus there are few established
primary prevention measures.
The use of infection-control measures
Capability to perform diagnostic tests and be
Readiness to employ practical viral hemorrhagic fever isolation
precautions, or barrier nursing techniques
Direct contact with the body of the deceased patient be
prevented
 Haemorrhagic Fever 37

CONTROL/CONTAINING THE INFECTION

Education: health workers

general population
Adequate provision/supply of Ribavirin

Prompt treatment of suspected cases

Effective contact tracing and Rx of high risk contacts

Further Research and development of appropriate vaccine

Infection control

High index of suspicion.

Designated hospital personnel trained in VHF infection control
precaution.
Health Education to staff and community.
Standard and Isolation precautions to limit the spread of the
virus.
Standard Precaution.

This involves all practices and procedures for limiting or

preventing disease transmission in the health care setting.
Standard precautions are designed to prevent unprotected
contact between the health care workers and mucus membranes,
blood and all body fluids whether or not they contain blood.
Hand washing as a component of Standard Precautions
Standard Precaution
Use of personal protective equipment
- gloves
- gown
- face mask and eye shields
- apron
- boots/ shoe covers e.t.c.
 Develop Personal Safe Work Habits

Wash hands before and after

touching each patient
Wearfresh pair of gloves with
each patient
Wear protective coat and/or apron
Useprotective goggles and or
face masks.
Remember 5 Moments for Hand Hygiene

Sax H, Allegranzi B, Ukay I, Larson E, Boyce J, Pittet D. J Hosp Infect 2007;67:9-21

Isolation Precaution

Isolating the VHF patient will:

Restrict patient access to health facility staff trained to use VHF
Isolation Precautions.
Establish a barrier between the VHF patient and uninfected
patients, other health facility staff, and visitors.
The isolation room is a restricted area.
Isolation Precaution
Patient has dedicated staff and
hospital equipment and facilities.
Visitors are restricted and patients
investigations are reduced to the
barest minimum.
Waste management.
Trained hospital staff only.
Use of PPE is a must.
Waste should not be discarded with
regular hospital waste.
Linen maybe laundered but only in
dedicated section of the hospital
laundry otherwise incineration should
be done .
Disposal of dead bodies.
Bodies to be wrapped in plastic
body bags. Disinfect the outer
bag.
No traditional rites.
No lying in state.
Hospital personnel should
accompany body to the burial
site.
Grave should be about 2 meters
deep.
50
Summary of prevention and treament
Summary of isolation precaution
Thank you for you attention oooooo