Management Of Lassa Fever in a Resource Limited Setting: Experience From Irrua Specialist Teaching Hospital Main author: Gloria Esoimeme Co-authors: Vivian Ogbonna, Juliet Idialu-Eigbobo, Danny Asogun

Introduction Lassa fever is a zoonotic viral hemorrhagic fever endemic in West Africa It is challenging to make a diagnosis of Lassa fever using only clinical features because of the similarity in symptoms between Lassa Fever and other common tropical illnesses  The diagnosis of Lassa fever is done routinely with indirect fluorescent-antibody test, enzyme-linked immunosorbent assays for Lassa virus antigen and immunoglobulin G and M antibodies The gold standard is the reverse transcription-polymerase chain reaction (RT-PCR) Most Lassa fever endemic areas are resource limited and the hospital laboratories are not equipped to carry out the tests for routine or confirmatory diagnosis of Lassa fever

Study Setting: Irrua Specialist Teaching Hospital, Irrua, Edo State, Nigeria Irrua Specialist Teaching Hospital (ISTH) is 371-bed hospital serving people in Central, Northern and Southern Senatorial Districts of Edo State, as well as neighboring states The hospital lacked the laboratory diagnostic tools for Lassa Fever until 2008 and all cases were identified and managed based on clinical suspicion and post- management confirmation by sending blood samples of patients to larger medical centers within and outside the country The hospital currently is the only designated Institute of Lassa Fever Research and Control Center in West Africa and receives referrals of suspected cases of Lassa Fever across the country

Objective Our main objective was to examine how cases of Lassa Fever were diagnosed and managed in Irrua Specialist Teaching Hospital (ISTH) prior to the use of RT-PCR for confirmatory diagnosis of the disease. Our findings will inform the management of Lassa Fever in resource limited health facilities lacking RT-PCR diagnostic test in Lassa Fever endemic areas across West Africa

Methods This is a retrospective cross-sectional study using the case notes of suspected Lassa fever patients at ISTH between 2001- 2006 We reviewed the case notes of all patients with clinical suspicion of Lassa fever: a total of 96 cases

Results Most cases of Lassa Fever presented with: Fever, vomiting, headache, cough, sore throat, diarrhea Majority of cases (70%) presented a week after onset of symptoms In 30% of cases, the index of suspicion of Lassa fever was high and patients received treatment with ribavirin on the same day of presentation Majority did not commence therapy until 14 days after onset of symptoms About 76% of suspected cases received ribavirin therapy About 24% of suspected cases did not receive therapy with ribavirin throughout their stay in the hospital probably from stock out of medication

Results…cont The effect of ribavirin was most noticeable on day 3 after commencement of ribavirin therapy About 48% of Lassa fever cases presenting at ISTH between 2001 and 2006 died, 45% recovered and 6 % of them were either referred or discharged against medical advice About 22% of patients who did not receive ribavirin recovered as opposed to 58% of patients who received ribavirin

Conclusions Majority of patients did not present in the hospital or commence treatment with ribavirin more than 14 days after onset of symptom probably from mis-diagnosis and medication stock out Symptoms are similar to other common tropical febrile illness like malaria However, in Lassa Fever endemic areas, the index of suspicion should be high in patients presenting with symptoms listed above We recommend that in resource limited areas, there should be increased campaign to increase awareness of the disease

Limitations This study was limited by several factors: We found it challenging to locate some of the files of some Lassa fever cases from misfiling Additionally, some of the case files had inadequate documentation, were illegible and had missing pages Lastly, there was no known laboratory confirmation of the Lassa fever cases beyond crude clotting time. It is possible that some cases described as Lassa fever may have been another disease