The patient returned to the UK, from Nigeria, on the 6th January.
There is no doubt that this patient will receive the best treatment available at the Royal Free Hospital, and no doubt too that no effort will be spared in protecting the health of all those that have come in contact with this patient since his return, especially those that have handled his clinical care (Lassa is transmitted via direct contact with body fluids). The HPA in the UK has a large network of approximately 3000 staff based at three major centres (Colindale, Porton and Chilton) and regionally and locally throughout England to do just this. In the USA it would be the responsibility of the Centers for Disease Control (CDC), in Germany it would be the Robert Koch Institute, in France; the Institute de veille sanitare. In South Africa; National Institute for Communicable Disease. So...that is not the subject of this blog!
The truth is that if the HPA was to pursue this in Nigeria, they would have no clue on who to call! The closest they would get is to the Director of Public Health in the Federal Ministry of Health. To his credit the present Director has been advocating for such a centre for some time now. The need for similar institutes across the world has also been recognised with the formation of the International Association of National Public Health Institutes as a catalyst (funded largely by the Bill and Melinda Gates Foundation). In Nigeria, rather than admit we do not have a similar centre, we have registered the Nigerian Institute for Medical Research Yaba (sorry website is "down" (23/01/09) as our National Public Health Centre. Oh well....
It is not a secret that Lassa is endemic in Nigeria, with occasional reports of outbreaks. The cases we hear about probably represent the tip of the iceberg. Apart from individual research interests, what government body is responsible for the public health investigation of these incidents. I dare say non...
A bit of history....In 1969 a disease characterized by high fever, muscle aches, mouth ulcers, and bleeding in the skin emerged in a village in northern Nigeria. Several people died and there was panic in the land. The causative virus was found to be harboured by a rat, Mastomys natalensis. It is spread to humans via the rat's urine in airborne droplets or contaminated food; however, the most feared means of transmission was by medical personnel treating patients in hospitals. This was later named Lassa fever, after the village in Nigeria where it first emerged.
Since then the emergence of HIV, Legionnaire's disease, Ebola haemorrhagic and several others where all warning signs to the world on the continuing threat caused by emerging infections, however it was the emergence of diseases like SARS, Avian Influenza and to an extent Anthrax after 9/11 that reawakened the consciousness of the world to the dangers these pose. Since then, countries have reacted with various levels of intensity to protect their population.
Influenza pandemics have occurred regularly throughout the history of mankind. In the two pandemics in 1957 and 1968, the casualties were in excess of 6 million worldwide. The WHO and the wider scientific community believe that we are as close to the next pandemic as we have been anytime in the past 37 years. The rapid spread of SARS from Asia to Canada, has shown that the ease of international travel and our own tendency to travel to all the nooks and corners of this world, makes Nigeria potentially an extremely fertile ground for the explosion of an infectious disease such as SARS.
The key to not being overwhelmed in the first wave of a global infection is to plan very carefully and thoughtfully while there is still time. European countries have been busy preparing pandemic preparedness plans, partly in response to this threat, by setting up a European Centre for Disease Control in Sweden.. Several African countries including our neighbours Ghana have established Field Epidemiology training programmes. You can find the African Network of Field Epidemiology Training Programmes (AFENET) here.
Yet the silence in Nigeria has been deafening.
The question is: can we afford to ignore this threat. Since we are barely coming to terms with the financial and infrastructural requirements to deal with the HIV/AIDS epidemic, and only just being rescued from the quagmire into which we put the Global Polio Eradication Programme, should the threat of the emergence or re-emergence of an infectious disease be a priority for health care resource allocation?
I dare say that if we ignore the threat, we might yet pay a very high price.
With a population of more than 140 million, Nigeria is Africa's most populous country. With the state of our health care provision at all levels being poor, the consequences would be devastating should such a virus spread here. Our response to the rumoured case of SARS in Nigeria in 2003 is a case in point. Lacking any central mechanism to deal with threats of this nature, the then Minister of Health quickly set up an "Inter-Ministerial Committee on the Prevention of SARS". Rumours made their rounds on the massive procurement of special masks, gloves, protective gowns, infrared digital thermometers, spray machines etc. if these things were indeed procured, where are they now?
When the first cases of Avian Influenza in Africa were identified in Nigeria, the response was similar; the Avian and Pandemic Influenza Rapid Response Team, led by the present Director of Public Health, Dr Abdulsalami Nasidi.
Although actions like quarantine, isolation, port-of-entry screening (in Nigeria - bird incineration, or using mobile police men to shoot them!) are often the most visible tools used in controlling the spread of emerging infectious disease, the most important aspect of these is to plan ahead.
At present, this is saddled on the technocrats in the Ministry of Health. Within the ministry is a Public Health Department that manages a series of vertical disease specific programmes. The only ones that can justifiably claim to be engaged in any visible activities are primarily driven by donor funds. No active coordination between the federal level and the states exists. If tomorrow we had to vaccinate front-line personnel for an emerging epidemic, who would decide what front-line personnel to vaccinate first, and how many. Do we start with doctors, the police, or maybe the army? Who will manage and coordinate the process? A new "Inter-Ministerial Committee"?
In addition to the threat of emerging infectious diseases, outbreaks of cholera, cerebrospinal meningitis, measles, and yellow fever occur regularly in Nigeria. While we might have been socialized to believe that this is a normal part of life, this most definitely should not be the case.
In conclusion, while we invest considerable resources in the apparent modernisation of our teaching hospitals we need to remember the not so glamorous infectious diseases. Surveillance, outbreak investigation and control are public health functions representing the first link in a chain of activities aimed at countering infectious viral and bacterial agents. Prevention often involves simple means to interrupt the transmission process of an infectious agent. For these activities to be successful, we must think of them now, or our predisposition to panic reactions might make the aftermath of the Ikeja ammunition dump explosion seem like child's-play.