ABSTRACT
Introduction: Lassa fever (LF) is a zoonotic acute viral haemorrhagic fever caused by the Lassa virus (LASV). Nosocomial infection with high case fatality rate of the disease has been described primarily in the hospital settings in many West African countries including Cross River state. The nosocomial spread is due to the current state of the health system, leading to poor medical practice. Hospitalized patients with LF may pose a substantial risk to health care workers (HCWs) and to other patients (Lavergne et al., 2016). Late diagnosis and wrong treatment are factors that can increase the likelihood of nosocomial transmission. Therefore, it is important that health care providers working in endemic communities have adequate knowledge on the disease, its clinical features and diagnosis (Ea, Da, Ec, Og, & Ebhodaghe, 2013).
Objectives: The study assessed knowledge, attitudes and practices and determined factors influencing them among health care providers working in five health facilities of Ogoja LGA in Cross Rivers state (the general hospitals, two health centres in the urban area and another two health centres in the urban area).
Methods: A descriptive cross-sectional survey and quantitative approach was used to collect data. Pre-coded structured questionnaire were used to conduct interviews. All health professionals who were working in these selected health facilities were enrolled into the study, if found eligible. Statistical analysis was done in Stata (version 14.1) Software. Frequency distribution was done to compute proportions on good KAP, gender, religion, educational level, and occupation. Multiple logistic regression analysis was used to assess the strength of association between the knowledge and attitudes and each independent variable to assess the strength of association looking at the adjusted Odds Ratio (AOR) with 95% confidence interval (CI).
Results: Sixty-three out of the 195 respondents (32.3%) had no idea what Lassa fever was. Of the remaining one hundred and thirty-two, 67.7% (132/195) who had heard about Lassa fever, their knowledge was accessed with a sixteen item questionnaire on knowledge according to case definition. Nearly forty-nine percent (64/132) had good knowledge about Lassa fever (p = 0.485; 95% CI = 0.4 – 0.6). Ninety-five percent of health professionals (186/195) were found to have good attitude towards a suspected case of Lassa fever (p = 0.95; 95% CI = 0.91 – 0.97). With regards to practice, all health professionals had good practices in dealing with a suspicious case of Lassa fever.
Conclusion: The study revealed a general low level of knowledge of LF disease among the HCWs. Most of the HCWs had good attitudes and all of them had good practices towards LF. Age and number of years of work were found to influence knowledge but not attitudes and practices. There was not statistical significant difference in the KAP of HCWs working in the general hospital compare to those working in the health centres. HCWs in urban HC had better attitude compare to those in the rural ones. The Ministry of Health, Cross River state should plan more training on Lassa Fever with emphasis on other professionals as much as medical doctors.
CHAPTER ONE
INTRODUCTION
1.1 Background
1.1.1 Lassa Fever Burden
Lassa fever (LF) is a zoonotic acute viral haemorrhagic fever caused by the Lassa virus (LASV). It was first described in north eastern Nigeria (Lassa, in Borno state, in the Yedseran River valley at the South end of Lake Chad) in 1969 (Ajayi et al., 2014). It is endemic in Benin, Cross River state, Liberia, Mali, Sierra Leone, and Nigeria with peaks in incidence closely related to season. Same cases have also been reported into western countries where LF is not endemic but was imported by returning travellers in Germany, Netherlands, Sweden, US and UK (Ea et al., 2013). According to the World Health Organization LF affects between 100,000 to 300,000 persons in West Africa per year and approximately 5,000 deaths (WHO, 2007). Around 80% of infected individuals are asymptomatic or have mild symptoms while 20% progress to disease. Case fatality rate is estimated to be around 15% among those who develop severe disease. However, in 2016, the mortality rate was reported to be above 50%. Pregnant women with LF have a high mortality rate especially in the third trimester. Recovered LF patients may experience hearing loss as well as other neurologic side effects (WHO, 2017). Based on prospective studies performed in four of the most affected countries, Cross River state, Sierra- Leone, Liberia, and Nigeria, Richmond and Baglole in the year 2003, estimated that 59 million people are at risk of primary LASV infections with an annual incidence of disease as high as 3 million and as many as 67,000 deaths per year (Lukashevich, 2012). LF affects all age-groups and gender with a seasonal clustering around the late rainy season and dry season (Olowookere et al., 2017).
1.1.2 Lassa Virus Infection
Lassa fever is an acute and occasionally severe rodent- borne viral haemorrhagic fever, with cases in humans geographically constrained to sub-Saharan West Africa (Gibb, Moses, Redding, & Jones, 2017). LASV is an arenavirus enveloped and contains two single-stranded RNA segments of ambience polarity encoding five proteins (N. E. Yun et al., 2012). The natural host of LASV is the multi-mammate rat, Mastomys natalensis which is commonly found in human households and eaten as a delicacy in several African countries and lives in close contact with humans (Olugasa et al., 2014). LF is symptomatic in about 20% of cases when it causes an acute illness with nonspecific symptoms such as fever and general weakness, headache, chest pain, vomiting, diarrhoea, cough, pleural effusion, bleeding from orifices, and in the late stages, sometimes disorientation and coma (Olowookere et al., 2017). Deaths from LF is due to the effective reduction of circulating volume of the blood which can cause shock, and multi-organ system failure (Shaffer et al., 2014). Presently, there is no licensed vaccine or immunotherapy available for prevention or treatment of this disease. The antiviral drug ribavirin has been demonstrated to reduce fatality from 55% to 5%, but only if it is administered within 6 days after the onset of symptoms (Branco et al., 2011). LF presents with nonspecific symptoms similar to many other endemic illnesses in West Africa, that making it difficult to diagnose clinically; therefore, laboratory testing is needed to confirm the diagnosis (Raabe & Koehler, 2017).
Humans contract LASV primarily through contact with excreta of its natural host. Although uncommon, secondary transmission of LASV between humans may occur through direct contact with infected blood or bodily secretions, such as saliva, vomit, stool, or urine (Bausch, Hadi, Khan, & Lertora, 2010). Human infections tend to be focal with periodic familial or village clusters with secondary cases due to person-to-person spread. Infections peak between January and May – during the dry season, but cases are seen year round (Gibb et al., 2017). In this second type of contamination nosocomial transmission plays an important role. According to Lavergne et al., nosocomial infection with high case fatality rate has been described primarily in the hospital settings in many West African countries including Cross River state. The nosocomial spread is due to the current state of the health system, leading to poor medical practices. Hospitalized patients with LF may pose a substantial risk to health care workers (HCWs) and to other patients (Lavergne et al., 2016). This nosocomial hazard can be minimized by proper and timely infection-control measures, careful management of infected patients, and, in some cases, administration of prophylactic therapy to HCWs after exposure. Late diagnosis and wrong treatment are factors that can increase the likelihood of nosocomial transmission (Ea et al., 2013). Since no human vaccine exists and therapeutic options are limited to the broad-spectrum antiviral ribavirin, rodent control and adjusting human behaviour are currently considered to be the only options for LASV prevention (Mariën, Kourouma, Magassouba, Leirs, & Fichet- Calvet, 2018). Late diagnosis and wrong treatment are factors that can increase the likelihood of nosocomial transmission and adverse outcomes.
HCWs are potentially exposed to blood-borne pathogens through contact with infected body parts, blood and other body fluids in the course of their work. It has been estimated that each year, as many as three million HCWs all over the world experience percutaneous exposure to blood-borne viruses Hepatitis C and B and HIV viruses. Apart from these pathogens, LASV is fast gaining prominence as an emerging nosocomial transmitted pathogen with significant public health impact in the West African sub region (Ekaete Alice, Akhere, Ikponwonsa, & Grace, 2013).
Therefore, important that health care providers working in endemic communities have adequate knowledge of the disease through its clinical presentation and its diagnosis. Because, when these HCWs are themselves ignorant of the disease, the tendency to misdiagnose and treat wrongly not only puts the health worker at risk, but also endangers the lives of the close family contacts and community at large. HCWs in the endemic area should have comprehensive information about the virus and the disease it causes.
1.2 Problem Statement
Viral haemorrhagic fevers like Lassa fever are among the most feared diseases due to their high case fatality rates, severe clinical presentations and ease of transmission. Unlike most viral haemorrhagic fevers, which are recognized only when outbreaks occur. LF is endemic in West Africa, with an estimated tens of thousands of cases annually (Shaffer et al., 2014). Since the identification of LASV, human- to-human transmission has been documented in several nosocomial outbreaks, leading to an initial perception that the virus was both highly contagious and virulent (Lo Iacono et al., 2015). The availability of laboratory testing has been limited by the designation of Lassa virus as a category (Raabe & Koehler, 2017). A pathogen by the National Institute of Allergy and Infectious Diseases (NIAID). Biosafety level 4 (BSL-4) precautions are recommended for handling potentially infectious specimens (Raabe & Koehler, 2017).
Existence of signs common to LF and other diseases such as malaria (fever, asthenia, vomiting) which is an endemic disease, leading cause of consultation in health facilities in Cross River state (30% of consultations). It is very difficult for HCWs to identify Lassa fever’s patient because of similarity of its signs and symptoms of another tropical diseases. Additionally in West African towns and villages where there are no facilities for laboratory diagnosis, most Lassa fever infections are treated as malaria (Ogbu, 2014). Therefore it is imperative that health care workers in endemic communities are adequately sensitized on the disease, it’s clinical features and diagnosis (Ea et al., 2013).
The difficulty of distinguishing between patients with LF and other patients suffering from most tropical diseases due to the similarity of symptoms and clinical signs and the absence of a diagnostic laboratory in this endemic area endanger health providers and increase the risk of developing nosocomial infections due to LASV. Hence the need to assess the knowledge, attitudes and practices of health providers in this community.
The reasons for choosing the city of Ogoja are based on the fact that previous studies have revealed an endemicity of LF in this city (Lukashevich et al. 2012; Klempa et al., 2013). Between 1990 and 1992 a large epidemiological investigation into the activity of LASV in the human populations of the Republic of Cross River state was conducted by Lukashevich et al. (2012). They sampled 25 villages, distributed in different prefectures to establish the LASV antibody prevalence using the ELISA assay. Their results allowed to calculate the average of seroprevalence by prefecture. Thus, the prevalence of LF in the city of Ogoja was 35% or 149/420 (Klempa et al., 2013) A second important aspect is the proven presence of native rodents belonging to the genus Mastomys which represents both the reservoir and the vector of LASV in some villages of Ogoja.
The Community Health Center of Ogoja which is the reference hospital of all this region and primary health centres which have been selected for this study are health facilities where a very large number of patients is coming for health care. Thus these health facilities could also receive any type of LF case because they are located in an endemic LASV area. Since the load of patients is heavier, HCWs are more likely to contract the disease and so their knowledge, attitudes and practices are critical.
1.3 Justification of Study
This study seeks to assess Knowledge, Attitudes and Practices among people attending primary health care LF in 5 health facilities of the prefecture of Ogoja in Cross River state.
The reasons for this study are first of all, no studies has yet been published on of health care personnel regarding infections (nosocomial) LF in this locality of the country. Secondly, the level of the KAP and the quality of the attitudes and practices of the caregivers make them most vulnerable to a disease as transmissible as LF and therefore deserves to be evaluated and known by the authorities in charge of health in the country. In addition to significantly enriching the medical literature, this study will provide novel empirical evidence to support efforts of previous basic research on LF in Cross River state. It will also be of great value to health care workers, medical researchers, the Governments of other countries in sub-Saharan Africa where this disease is endemic, as it provides general overview of the problem. Finally, this study will serve as a resource for other researchers who may want to undertake a similar study in other cities in the country or in other countries.
The difficulty of clinically distinguishing patients with FL and other patients suffering from most tropical diseases due to the similarity of symptoms and clinical signs and the absence of a diagnostic laboratory in this endemic area, thus putting at risk the HCWs who work there and increasing the risk of developing nosocomial infections due to LASV are among other reasons for choosing this topic. Hence the need to assess the knowledge, attitudes and practices of health providers in this community.
1.4 Research Questions
• What is the level of knowledge, attitudes, and practices of the health care workers on Lassa fever in hospitals in Ogoja?
• How does socio-demographic factors influence practices of healthcare professionals?
• Is there a (statistically significant) difference between the KAP of HCWs who are working at the Community Health Center and the KAP of those who are working in the health centres?
• Is there a (statistically significant) difference between the KAP of HCWs who are working in the urban health centres and those who are working in rural health centres?
1.5 Objectives General objective
To assess knowledge, attitudes and practices of HCWs on LF in 5 health facilities of Ogoja LGA in Cross Rivers state and determine whether KAPs differ by place of work (Rural vs Urban or Regional vs Health Centres)
The specific objectives of study are:
1. To determine the proportion of HCWs having good knowledge about LF.
2. To determine the proportion of HCWs having good attitudes and good practices in dealing with a suspected case of L.F.
3. To identify socio-demographic factors that could influence the KAP of HCWs working in these 5 health facilities on LF.
4. To assess whether KAP of HCWs vary by type of facility (General Hospital vs Health centres) and place of work ( Rural vs Urban)
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