Knowledge Attitude and Practices Toward Lassa Fever Control and Prevention Among Residents of Ile-Ife,Southwest Nigeria

Abstract

Lassa fever had been reported as a cause of death especially in endemic parts of Nigeria. This study assessed the knowledge, attitude, and practices toward Lassa fever control and prevention among residents of Ile-Ife, southwest Nigeria. Descriptive cross-sectional study was conducted among consenting randomly selected adults using an interviewer administered questionnaire. Data were analyzed using descriptive and inferential statistics. A total of 400 questionnaires with completed data were analyzed (response rate 96%). Majority, 207 (51.8%), were males while 193 (48.2%) were females. Most, 234 (58.5%), had tertiary education while 148 (37%) had secondary education. Fifty-nine percent had heard of Lassa fever with radio as their major source of information. About 76% had inadequate knowledge, 54% had negative attitude while 51% had poor practice toward Lassa fever. Determinants of knowledge of Lassa fever include having higher education (Adjusted Odd Ratio (AOR) = 11.49, 95% CI [3.10, 42.69], p = .0001), being in civil service (AOR = 0.22, 95% CI [0.09, 0.51], p = .01), and earning higher income (AOR = 4.23, 95% CI [2.61, 6.84], p = .0001). In conclusion, the knowledge, attitude, as well as preventive practices to Lassa fever were poor. It is necessary to increase public education and improve hygienic practices.

Keywords

Lassa fever outbreaks environment personal hygiene

Introduction

Lassa fever is an acute zoonotic illness caused by Lassa virus, an arenavirus, known to be responsible for severe hemorrhagic fever. Lassa virus was isolated in 1969 in Lassa town, Borno State, North East Nigeria. Lassa fever is endemic in West African countries including Nigeria, Liberia, Sierra Leone, Guinea, and Mali.¹ It accounts for 10% to 15% of all hospital admissions with case fatality rate of 50%. About 300,000 to 500,000 are infected yearly with 5,000 dying yearly.^2,3 The natural host of Lassa fever is the multimammate rat, Mastomys natalensis, which is commonly found in human households and eaten as a delicacy in several African countries, including Nigeria. Other rodent hosts, such as M. erythroleucus and the Rattus and Mus genera, have been suggested.^1,3,4 Recent evidence exists that Lassa virus is hosted by other rodent species such as the African wood mouse Hylomyscus pamfi in Nigeria and the Guinea multimammate mouse M. erythroleucus in both Nigeria and Guinea.⁵

Lassa fever infection is acquired mostly through the excreta of the natural host in the food that is inappropriately stored or dried in the open. Also, infection has been reported from direct exposure of the infective agent to broken skin, mucous membrane while person-to-person transmission has occurred. Lo Iacono et al.,⁶ using an innovative modeling approach to analyze data from published outbreaks and the number of Lassa fever hospitalized patients at Kenema General Hospital in Sierra Leone to estimate the likely contribution of human-to-human transmission, showed that almost 20% of the cases at Kenema General Hospital were secondary cases arising from human-to-human transmission. Also, much of this human-to-human transmission is associated with a disproportionally large impact of a few individuals called super spreaders. This discrepancy between the size of reported Lassa fever outbreak and clinical perception that human-to-human transmission is low should be noted in future assessment of the risk of Lassa fever and infection control guidelines.⁶

Lassa fever affects all age-groups and gender with a seasonal clustering around the late rainy season and dry season.^4,7,8 It is endemic in Edo state, Nasarawa state, and Plateau state with sporadic cases reported in over 22 out of 36 states in Nigeria.⁹ Also, outbreak of Lassa fever occurs with recorded fatalities much more than other hemorrhagic fevers including Ebola, but it receives much less attention.¹⁰ Lassa infection is symptomatic in about 20% of cases when it causes an acute illness with fever and general weakness followed by nonspecific symptoms such as headache, chest pain, vomiting, diarrhea, cough, pleural effusion, bleeding from orifices, and in the late stages, sometimes disorientation and coma. The overall case fatality rate is usually 1%, increasing to 15% of hospitalized cases.⁴

Despite the transmissibility of Lassa fever from animal to human, human to human, and possibly human to animal, meticulous adherence to appropriate infection control practices to prevent unprotected exposure to blood and other body fluids is essential for the safe management of suspected patients with Lassa fever and the prevention of onward transmission particularly given the nonspecific presentation of Lassa fever.⁶ There is no vaccine to prevent Lassa fever while Ribavirin, the only known drug that cure cases, needs to be commenced early in the infection.^9,10 It is therefore important for community members to be aware of the disease to ensure prevention and early diagnosis and treatment of cases. This study assessed the knowledge, attitude, and practices toward Lassa fever control and prevention among residents of Ile-Ife, southwest Nigeria.

Methods

This study was conducted in Ile-Ife, an urban town with an estimated population of 167,000. The people were mainly Yoruba living with other Nigerian tribes such as Hausa and Igbo. Ile-Ife is the cradle of the Yoruba people.

The study design was a descriptive cross-sectional community-based survey with residents of Ile-Ife as the study population. The sample size was determined using an appropriate statistical formula for estimating the minimum sample size in descriptive health studies (n = Z²pq/d²),¹¹ where n = sample size, Z = standard normal deviate corresponding to confidence level at 95% = 1.96, d = degree of accuracy desired = 0.05, p = 62% have good general knowledge of Lassa fever⁶ while q = 1−p = 1−0.62 = 0.38; n = 1.96²× 0.62 × 0.38/(0.05²) = 362. A sample size of 400 was used after nonresponders were taken into consideration.

A multistage sampling technique was employed in this study. Stage 1 involves selecting 5 wards out of 21 wards in Ile-Ife using simple random technique (balloting). Stage 2 involves selecting 8 streets out of an average of 24 streets per ward by simple random technique (balloting). A total of 40 streets were selected. Stage 3 involves listing the houses on each selected street and using systematic sampling technique to select every fourth house on each street. Stage 4 involves approaching all adults older than 18 years old to participate in the study till the sample size was reached.

Data were collected using a pretested interviewer administered questionnaire that captured information on sociodemographic variables, knowledge, attitudes, and practices regarding Lassa fever.

Data were analyzed using SPSS version 16. The data were summarized using mean and standard deviation for continuous variables, frequencies, and percentages for categorical variables. Knowledge, attitude, and practice scores were computed with “+1” assigned for correct response and “0” assigned for incorrect response. These scores were graded as appropriate or inappropriate knowledge, positive or negative attitude, and good or poor practice using their mean score as the cut-off point. Bivariate chi-square test and multivariate logistic analyses were performed on respondents’ characteristics and knowledge of Lassa fever. Variables in the bivariate test with p value of <.2 were included in the multivariate model. A p value < .05 was accepted as significant.

Ethical Consideration

The Ethics and Research Committee of the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria approved the study. Written consent was taken from each participant after ensuring their privacy and confidentiality. Data collected were kept in a passworded computer.

Results

A total of 400 out of 417 questionnaires had completed data and were included in analysis giving a response rate of 96%. The mean age (SD) was 31.6 (±12.2) years with a range of 18 to 76 years. There were 207 (52%) males and 193 (48%) females. Most respondents had tertiary education (58.5%), were single (56.8%), Christians (84.2), Yoruba (77.8%), and earned over 20,000 naira/month (5USD; 58.8%). About 39% were not employed, 24% were trading while 22% were civil servants (Table 1).

Table 1.

Sociodemographic Characteristics of Respondents.

Variables	Frequency (N = 400)	%
Age-group (years)
18–29	225	56.2
30–39	88	22.0
≥40	87	21.8
Sex
Male	207	51.8
Female	193	48.2
Level of education
None	5	1.2
Primary	13	3.2
Secondary	148	37.1
Tertiary	234	58.5
Marital status
Single	227	56.8
Married	159	39.7
Divorced	4	1.0
Widowed	10	2.5
Occupation
None	155	38.8
Trading	96	24.0
Civil servant	88	22.0
Artisan	61	15.2
Income (Naira) (n = 245)
≤20,000 naira (5USD)	101	41.2
>20,000 naira (5USD)	144	58.8
Religion
Christianity	337	84.2
Islam	56	14
Traditional	7	1.8
Ethnicity
Yoruba	311	77.8
Ibo	62	15.4
Others^a	27	6.8

Hausa, Edo, and Ishan.

Figure 1 shows the knowledge, attitude, and practice toward Lassa fever. About 76% had inadequate knowledge, 54% had negative attitude while 51% had poor practice toward Lassa fever.

Figure 1.

Knowledge, attitude, and practice toward Lassa fever.

Table 2 shows knowledge about Lassa fever among respondents. Fifty-nine percent have heard of Lassa fever with radio (60.1%) as major source of information. Among those aware, 27.3% knew it is caused by a virus, 35.7% knew it can be prevented, while 70.2% knew it is transmissible with rat identified as the vector (91%). About 40% knew early presentation increases survival of cases with Lassa fever, 45.4% have heard people die from infection.

Table 2.

Knowledge About Lassa Fever Among Respondents.

Variables	Frequency	%
Heard of Lassa fever
Yes	238	59.0
No	162	41.0
Lassa fever is caused by a virus (n = 238)
Yes	65	27.3
No	173	72.7
Lassa fever is preventable (n = 238)
Yes	85	35.7
No	153	64.3
Lassa fever is transmissible (n = 238)
Yes	167	70.2
No	71	29.8
Lassa fever is transmitted by (n = 167)^a
Rats	152	91.0
Human	20	12.0
Mosquito	9	5.4
Early presentation increases survival of Lassa fever cases (n = 238)
Yes	95	39.9
No	143	60.1
Aware of Lassa fever outbreak (n = 238)
Yes	108	45.4
No	130	54.6
Main source of information about Lassa fever (n = 238)
Radio	143	60.1
Health worker	35	14.7
Friend	35	14.7
Others^b	10	10.5
Know somebody infected (n = 238)
Yes	13	5.5
No	225	94.5

Multiple response.

Neighbor, teacher, textbook, and place of worship.

Table 3 shows attitude and practices of respondents to Lassa fever prevention. Over 94% believed that drying foodstuff on the floor do not predispose to Lassa fever while 13.5% would consume such contaminated foods. Only 29.5% kept food in enclosed containers while 56.5% ate rat meat.

Table 3.

Attitude and Practices of Respondents to Lassa Fever Control and Prevention.

Variables	Frequency (N = 400)	%
Attitude
Eating bush rat predispose to Lassa fever
Agree	112	28.0
Disagree	288	72.0
Drying foodstuff on the floor predispose to Lassa fever
Agree	23	5.8
Disagree	377	94.2
Caring for Lassa fever patient can lead to having Lassa fever
Agree	38	9.5
Disagree	362	90.5
Lassa fever can be treated at home
Agree	54	13.5
Disagree	346	86.5
Suspected case should be reported to nearby health center
Agree	110	27.5
Disagree	290	72.5
Practice
Eats rat meat
Yes	226	56.5
No	174	43.5
Consume foodstuff dried on bare floor
Yes	54	13.5
No	346	86.5
Wash hands with soap and water always
Yes	322	80.5
No	74	19.5
Clear bush surrounding the house
Yes	302	75.5
No	98	24.5
Keep food in enclosed containers
Yes	118	29.5
No	282	70.5

Table 4 shows the association between sociodemographic variables and awareness of Lassa fever. Significant sociodemographic variables include having secondary or tertiary education, being a civil servant, earning >20,000 naira (5USD) per month and being a Christian (p < .05).

Table 4.

Association Between Sociodemographic Variables and Knowledge of Lassa Fever.

Variables	Knowledge of Lassa fever		Test statistics χ²; p
Variables	Inadequate (%)	Adequate (%)	Test statistics χ²; p
Age-group (years)
18–29	163 (73.8)	58 (26.2)	1.475; .478
30–39	67 (76.1)	21 (23.9)
≥40	73 (80.2)	18 (19.8)
Sex
Male	154 (75.1)	51 (24.9)	0.090; .764
Female	149 (76.4)	46 (23.6)
Marital status
Married	131 (79.4)	34 (20.6)	2.030; .154
Not married	172 (73.2)	63 (26.8)
Level of education
None or primary	3 (23.1)	10 (76.9)	Fischer’s p = .0001
Secondary or tertiary	300 (77.5)	87 (22.5)
Occupation
Unemployed	115 (74.7)	39 (25.3)	17.464; .001
Civil servant	90 (90)	10 (10)
Trader	62 (68.9)	28 (31.1)
Artisan	36 (64.3)	20 (35.7)
Income/month
≤20,000 naira (5USD)	84 (58.3)	60 (41.7)	37.155; .0001
>20,000 naira (5USD)	219 (85.5)	37 (14.5)
Religion
Christianity	261 (76.8)	79 (23.2)	1.270; .260
Islam or traditional	42 (70.0)	18 (30.0)

Table 5 shows the logistic regression analysis of determinants of knowledge of Lassa fever. The significant determinants include having higher education (AOR = 11.49, 95% CI [3.10, 42.69], p = .0001), being in the civil service (AOR = 0.22, 95% CI [0.09, 0.51], p = .01), and earning higher income (AOR = 4.23, 95% CI [2.61, 6.84], p = .0001).

Table 5.

Logistic Regression Analysis of Determinants of Adequate Knowledge of Lassa Fever.

Variables	OR	95% CI	p
Level of education
None or primary (ref)	1
Secondary or tertiary	11.49	[3.10, 42.69]	.0001
Occupation
Unemployed	0.68	[0.35, 1.33]	.255
Civil servant	0.22	[0.09, 0.51]	.01
Trader	0.90	[0.44, 1.84]	.76
Artisan (ref)	1
Income/month
≤20,000 naira (5USD; ref)	1
>20,000 naira (5USD)	4.23	[2.61, 6.84]	.0001

Discussion

This study reported inadequate knowledge, negative attitude, and poor preventive practices toward Lassa fever among residents of an urban community in southwest Nigeria. This finding requires urgent response so as to curtail the yearly occurrence of this deadly infection in Nigeria. The study population who were mostly young, males, educated, and employed will require continuous education on Lassa fever control and prevention so as to enable early referral of suspected cases and for notification purposes. Early referral of these cases will improve survival and reduce disease transmission. It will also ensure that the population will not become infected or serve as a source of infection to family and other community members.

Although most respondents have heard of Lassa fever with some knowing somebody infected previously, they displayed inappropriate knowledge. This finding had been reported in previous studies in Nigeria and elsewhere.^4,9,12 It is therefore essential that this population access accurate information on Lassa fever to reduce the occurrence of this disease and stamp out the nearly yearly outbreaks. Also, radio was identified as the major source of information about Lassa fever for most respondents. Previous studies have shown the importance of the media, especially the transistor radio, as source of necessary information for the general population, especially in resource-limited setting such as the study site.^13,14 This further shows that the media should have more programmes on Lassa fever that target the general population, especially in the local dialects.

The fact that the information available to this population about this life-threatening infection is inadequate needs further enquiry so as to improve the knowledge content of information placed on the media. This could be the main reason behind the nearly yearly outbreak of this deadly disease in Africa despite the fact that it is treatable and preventable. Emphasis should therefore be on more community-based education on Lassa fever control and prevention. Although some respondents knew that Lassa fever is transmissible with rat as the natural host, majority still engage in practices that encourage rat breeding through poor personal and environmental hygiene with exposure of rat excreta to foodstuff during drying on bare floor and storing in open containers. This important link is yet to be realized by the study population despite their high formal education status. Also, the latest finding on human-to-human transmission needs to be added in community-based education and mode of preventing such exposure such as reducing contact with suspected cases through use of personal protective equipment. The negative attitude and behavior of this population encourages Lassa fever outbreak, hence the need for strengthening of environmental sanitation laws and changes in government and nongovernmental organizations approach to control and prevention of the spread of Lassa fever.

High education, income, and working in civil service were factors determining Lassa fever knowledge. Several studies had reported similar finding as this group of people have better personal hygiene and environmental sanitation practices.^7,12–14 They also have access to information through various reliable sources. Therefore, it is necessary to focus on the less educated, those earning less income, such as traders and artisans, as they are likely to engage in behaviors that make them prone to Lassa fever infection. Motivating and training more environmental sanitation workers will help to prevent further spread of the deadly infection.

Furthermore, behavioral change in waste disposal, personal hygiene, and handwashing with universal precaution will curb the persistence of Lassa fever in the community.^10–14 Also, health-care workers will benefit from continuous training on recent and accurate information on Lassa fever diagnosis, treatment, control, and prevention. Isolated wards, personal protective equipment, and necessary drugs including Ribavirin in appropriate doses and route should be provided in such designated wards so that there will be no delay in attending to suspected cases.^15,16

We recognize that this study limitation includes its cross-sectional study design which relies on information from respondents, information bias such as recall bias may occur. Recall bias was reduced by asking questions to double-check the responses. Although the response rate was high compared with some community-based studies, a generalization of findings to other communities in this and other parts of the country will be limited. However, this study provides important information that will guide planning and implementing interventions targeted at controlling and preventing Lassa fever infection in the study area.

Conclusion

In conclusion, community members have inadequate knowledge, negative attitude, and poor preventive practice about Lassa fever. It is necessary to strengthen environmental sanitation laws, government, and nongovernmental organizations approach to control and prevention of the spread of Lassa fever. Also, community-based education will increase community knowledge, especially among the disadvantaged population.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

S. A. Olowookere lectures in the Department of Community Health, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria. He is a consultant family physician and honorary consultant, Family Medicine, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria. His research focuses on family medicine, communicable and non-communicable diseases.

C. A. Adegbenro lectures in the Department of Community Health, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria. He is a PhD degree holder. His research focuses on school health, health promotion and health education.

A. Idowu lectures in the Department of Community Medicine, Bowen University Teaching Hospital, Ogbomosho. He is a Community Health Physician. His research focuses on Community medicine and public health.

A. G. Omisore lectures in the Department of Community Medicine, Bowen University Teaching Hospital, Ogbomosho. He is a Community Health Physician. His research focuses on Community medicine and public health.

O. M. Shabi works as consultant family physician at the Department of Family Medicine, Federal Teaching Hospital, Ido-Ekiti, Ekiti State. His research focuses on family medicine, communicable and non-communicable diseases.

U. R. Ikem, a Medical Doctor, graduated with MBChB degree from Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria.

G. A. Ekwere, a Medical Doctor, graduated with MBChB degree from Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria.

I. F. Oderinde, a Medical Doctor, graduated with MBChB degree from Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria.

References

Lecompte

Fichet-Calvet

Daffis

. Mastomys natalensis and Lassa fever, West Africa. Emerg Infect Dis 2006; 12: 1971–1974.

Ogbu

Ajuluchukwu

Uneke

. Lassa fever in West Africa sub region: an overview. J Vector Borne Dis 2007; 44: 1–11.

Inegbenebor

Okosun

Inegbenebor

. Prevention of Lassa fever in Nigeria. Trans R Soc Trop Med Hyg 2010; 4: 51–54.

Ajayi

Nwigwe

Azuogu

. Containing a Lassa fever epidemic in a resource-limited setting: outbreak description and lessons learned from Abakaliki, Nigeria (January–March 2012). Int J Infect Dis 2013; 17: e1011–e1016.

Olayemi

Cadar

Magassouba

. New hosts of the Lassa virus. Sci Rep 2016; 6: 25280.

Lo Iacono

Cunningham

Fichet-Calvet

. Using modelling to disentangle the relative contributions of zoonotic and anthroponotic transmission: the case of Lassa fever. PLoS Negl Trop Dis 2015; 9: e3398.

Yun

Walker

. Pathogenesis of Lassa fever. Viruses 2012; 4: 2031–2048.

Ehichioya

Hass

Ölschläger

. Lassa fever, Nigeria, 2005–2008. Emerg Infect Dis 2010; 16: 1040–1041.

Olowookere

Fatiregun

Gbolahan

. Diagnostic proficiency and reporting of Lassa fever by physicians in Osun State of Nigeria. BMC Infect Dis 2014; 14: 344.

10.

Ftika

Maltezou

. Viral haemorrhagic fevers in health care settings. J Hosp Infect 2013; 83: 185–192.

11.

Reuben

Gyar

. Knowledge, attitudes and practices of Lassa fever in and around Lafia, Central Nigeria. IJPHER 2016; 2: 014–019.

12.

Ochei

Abejegah

Okoh

. Housing factors and transmission of Lassa fever in a rural area of south-south Nigeria. Gen Heal Med Sci 2014; 1: 15–20.

13.

Kish

. Survey sampling, New York, NY: John Wiley & Sons, 1965.

14.

Tobin

Asogun

Isah

. Assessment of knowledge and attitude towards Lassa fever among primary care providers in an endemic suburban community of Edo state: implications for control. J Med Medic Sci 2013; 4: 311–318.

15.

Adebimpe

. Community awareness and perception towards rodent control: implication for prevention and control of Lassa fever in urban slums of southwestern Nigeria. MJHS 2015; 2: 26–32.

16.

Aigbiremolen

Duru

Awunor

. Knowledge and application of infectious disease control measures among primary care workers in Nigeria: the Lassa fever example. IJBAIR 2012; 1: 122–129.