Lassa Outreach in Sierra Leone - An Interview with Richard Fonnie
The battle against Lassa fever in Sierra Leone is being waged on many fronts. While the efforts of the scientists in the Viral Hemorrhagic Fever Consortium focus on understanding the mechanisms related to the human immune response to Lassa infection, the Lassa Fever Outreach team addresses the realities on the ground. During my visit to Kenema Government Hospital earlier this year, I sat down with Richard Fonnie, the Lassa Fever Outreach supervisor to discuss the work he and his team undertake.
Anna Andersen (AA): Can you start by describing the team? How many people work on Lassa Fever outreach?
Richard Fonnie (RF): For now we are just two, myself and Lansana Kanneh. Formerly we were three, but one man was deployed with the ecology team. But when we talk about the outreach team, the ecology people are also included. So it’s a five-man team. They have their own work and we have ours, but we work together.
AA: How does the work of the outreach team differ from that of the ecology team?
RF: The ecology team traps the rodents in infected communities, whilst we go along with them to undertake case investigation. When a case is referred to the Lassa ward, from any community in the country, we are supposed to visit that community within 24 hours. We investigate the source of infection and identify any close contact to that particular index case. We make sure the name and age of anyone who might have been exposed are recorded. We also make sure these individuals are monitored for 21 days - that is within the incubation period from the last day of exposure to the index case.
Our task is to determine whether the patient contracted the disease from a primary or secondary source of infection.* How can we know that? We ask a series of questions, do an environmental assessment, as well as a household and personal hygiene assessment. From these we reach a conclusion. Out of the contacts that were close to the index case, maybe within that 21 day period one or two develop signs or symptoms of disease. This would indicate that they contracted the disease from the index case. But if there is no evidence of contact with the index case, then a person displaying symptoms must have ingested food or drink contaminated by an infected rat.
The other thing we do is we try to sensitize people about Lassa. The lack of knowledge about the disease is creating more problems for both us and the communities. When people don’t know about the disease, there’s a tendency for more cross infection to occur, either from the primary source or human to human. In order to cut down on transmission we need to educate everybody about the disease. We need to tell them about the dynamics of the disease, modes of transmission, signs and symptoms, and community preventive measures, which include sanitation, household and personal hygiene, and the proper covering of food and drinking water. In terms of the secondary source of infection we advise people to avoid direct contact with the bodily fluids of any infected person. They must know how to protect themselves before coming into direct contact with the bodily fluids of such cases that could lead to transmission.
We also have a scientific documentary on Lassa fever prevention and control that we screen as part of our sensitization campaigns. The best way to mobilize a community is if you have music to play or a film to show. These draw people’s attention and attract high numbers of community members. We then pause the music or film, talk about the disease and later continue the music or film for them to see and answer questions. These are the types of activities we do in the field.
AA: In the time that you’ve been involved in the Lassa Program since 1996, has the number of Lassa Fever cases increased?
RF: We’ve had two serious outbreaks in this country that have been recorded. One was in 2004 when we lost our dynamic doctor Dr. Aniru S. Conteh who was the Chief Physician for Lassa Fever, widely known worldwide. He died after contracting Lassa from a needle stick injury when he was trying to save the life of a nurse who had been infected from a child from the pediatric ward. Since then we have been working hard to make sure that we control the mortality rate of the disease. In 2006, if I remember correctly, we had another outbreak, which we were able to contain, and since then we have been able to keep transmission under control.
But if you compare Lassa in those days to now, formerly the peak season was in the dry season. We used to see the highest amount of cases between October and April. But from a few years back until now, that has changed entirely. We sometimes get the highest peak during the rains, and at times during the dry season, so it fluctuates. In 2010 we actually had the highest month for admissions in June. 42 people were admitted in June and amongst them 36 were positive for Lassa. And the mortality rate was under control. That’s good. We want to compare that to this year based on the activities we undertook in the field.
AA: How does the public react to Lassa?
RF: Actually their perceptions are changing gradually. Many are used to eating rat and rats are the reservoir host of the disease. If you tell people who have been eating rat for decades that the rat is known for the transmission of Lassa, it is difficult for them to understand. But with perseverance and encouragement people are gradually deviating from this habit. The taming of cats in households is also aiding to minimize the rat infestation in communities. Although young men in some villages do eat cats, we encourage them to stop. Cats are predators and they prey on infected rats in homes.
AA: Lastly, in your view, why should the people outside of Sierra Leone learn about Lassa?
RF: Many people are interested in Lassa, but they don’t have the chance to come here to see what exactly is going on. I would encourage people to visit the website to read, absorb and understand what Lassa is all about. This way you can at least prevent yourself from contracting the disease.
(*The primary source of Lassa virus infection is Mastomys natalensis, the rodent reservoir of the virus. Secondary infection occurs between humans.)