1. INTRODUCTION

Lassa Fever (LF) remains a health burden in several endemic areas of West Africa including Nigeria, and the toll in case fatality remains unabated over several decades. The disease results in 500,000 cases annually and approximately 5000 deaths in endemic West Africa. Although the overall case fatality rate is 1% [1], mortality can be as high as 15–20% in hospitalized LF patients and up to 50% during outbreaks [2–5]. LF was first described in 1969 in the town of Lassa, in present-day Borno State, Nigeria, and recurrent seasonal outbreaks occur in the Lassa belt of West Africa comprising Nigeria, Liberia, Sierra Leone, and Guinea. LF is also known to be endemic in Benin, Ghana, and Mali [1]. LF disease is an acute viral hemorrhagic disease caused by Lassa Virus (LASV), a bisegmented single-stranded RNA virus, which belongs to the family Arenaviridae [1,6]. The putative reservoir of LASV is the Mastomys natalensis, which is known to exhibit asymptomatic infection but results in copious shedding of the virus in the urine, feces, saliva, and blood of infected rats [1,7]. The presence of M. natalensis, a rodent indigenous to most of sub-Saharan Africa, within households is closely associated with LF outbreaks in rural settings and precipitated by accessibility to grains and sociocultural practices such as bush burning [8].

In 80% of human cases, the disease is asymptomatic, but in the remaining 20% a complicated course leading to death may result in nonspecific symptoms indistinguishable from other Viral Hemorrhagic Fevers (VHFs) such as Ebola and Marburg. Typically, human infection results from contact with secretions and excretions of infected rats and other infected persons through respiratory or gastrointestinal tracts. Inhalation of aerosolized infective viral LASV particles is the most significant means of exposure, although infection through mucous membranes and abraded skin has been reported [9,10]. The severity of LF correlates with the titers of LASV in blood and bodily secretions [11]. There is no evidence of LASV transmission during the incubation period or after recovery, apart from sexual transmission because of delayed clearance from the gonads of <3 months after acute infection. However, the frequency of transmission through sexual contact has not been established [12].

Currently, Ribavirin is the only effective drug of choice for LF treatment. Ribavirin (1-β-d-ribofuranosy-l-1,2,4-triazole-3-carboxamide), a guanosine analog, when administered intravenously within the first 6 days of illness reduces mortality from 55% to 5% [13,14]. Although the precise mechanism of action is in dispute, Ribavirin appears to interfere with viral replication in inhibiting RNA-dependent nucleic acid synthesis. The drug has been used in varying degrees in the treatment of other arenavirus infection (Junin and Machupo viruses), hemorrhagic fever with renal syndrome, Crimean–Congo hemorrhagic fever, hepatitis C, respiratory syncytial virus pneumonia, La Crosse encephalitis, influenza, and other adenovirus infections [14]. Research in recent years has focused on finding alternative therapeutics, and results in experimental animals using ST-193 developed by SIGA Technologies Inc., Corvallis, Oregon, 97333, United States, are promising [15].

Psychosocial manifestations of stigmatization and discrimination (perceived or real) in disease outbreaks have been described as a global phenomenon that is as old as the disease itself—a term that essentially induces a sense of stigma [16–18]. Stigma has been defined as a mark of shame or an attribute that is deeply ­discrediting within a particular social interaction. Stigma and discrimination against infected individuals pose significant barriers, negatively affecting access to care and treatment [15,19–21]. These can substantially increase the suffering of infected individuals and can be strong disincentives for individuals in seeking prompt medical care. Consequent to such delays in treatment is the propensity for affected individuals to remain undetected in the community. In addition, stigmatization against professionals and volunteers working in the field has been implicated as a leading cause of high rates of stress and burnout. As noted by Person et al. [22], this attitude toward infected persons stems from the evolving nature and inherent scientific uncertainties associated with infectious diseases.

Some studies have focused on stigmatization associated with such infectious diseases as Severe Acute Respiratory Syndrome (SARS), AIDS, tuberculosis, avian influenza, Ebola, and neglected tropical diseases [16,21,23–25]. For example, Bennis et al. [26] observed that neglected tropical disease such as cutaneous leishmaniasis had a psychosocial impact in high school students in a province in Morocco, leading to self- and social-stigma even though the disease is not life-threatening [9]. Although most studies have focused on virological and clinical considerations, few studies have attempted to address the psychosocial component of LF disease in Nigeria. The focus has been more on the impact the disease on the mental health status of health professionals than the potential level of stigmatization experienced from the social cycle—institutional, community, state, regional, and national. In the study by Ji et al. [23], both healthcare workers who treated patients with hemorrhagic fever and their survivors were found to be prone and demonstrated psychological symptoms following outbreaks. Among healthcare workers, psychological effects included coping with the deaths of colleagues, anxiety, fear of contamination, threats to their lives, and working excessive number of hours—which reduce work efficiency and increase occupational risks. Sources of mental stress for Ebola viral disease survivors included sufferings and deaths of family members and friends; the collapse of national, social, and ­economic security; high mortality rate; and strict biosecurity restrictions [23].

Evaluation of perceived LF-associated stigmatization toward LF patients and survivors are an important first step in early disease reporting and protection of public health. This study aimed to assess the perceived stigmatization associated with LF outbreaks among staff and students of the University of Benin (UNIBEN), Benin City, Nigeria.

2. METHODS

3. RESULTS

A total of 600 consenting respondents (300 staff and 300 students) participated in the study Table 1. The mean ages of staff and students of the University were 38.09 ± 9.41 years and 20.84 ± 4.61 years, respectively. The duration of employment for staff displayed a median of 4 years (interquartile range = 2–7) with a higher proportion of nonacademics (n = 274, 72.9%).

In the event of LF disease, 13.78% of staff (n = 39) and 21.6% of students (n = 62) were either unsure or unwilling to accept an approved LF vaccine for themselves even when this becomes available Table 2. Neither will 12.7% (n = 36) staff nor 18.1% (n = 48) students willingly approve vaccination of their children against LF when available. Meanwhile, 14.2% (n = 41) staff and 22.9% (n = 65) students (n = 65, 22.9%) indicated that they would refrain from reporting the LF when it occurs in a family member.

Lassa fever-associated stigmatization was high among students (n = 162, 57.9%) than among staff members (n = 112, 39.9%). By contrast, more staff (n = 169, 58.9%) showed a low LF-associated stigmatization in comparison with students (n = 118, 41.1%) with a significant association of p < 0.0001 (not shown in Table 1). The perceived stigmatization among staff was not significantly associated with age, sex, level of education, knowledge, risk awareness, and risk perception Table 3. In contrast, LF-associated stigmatization among students was significantly associated with sex (p = 0.012) and knowledge (p = 0.013) of LF transmission and prevention Table 4. The result of knowledge of LF prevalence, transmission and predisposing factors as well as risk awareness and perception are presented in Table 5 and 6 respectively. In the study population, perceived LF-associated stigmatization was higher among female respondents than their male counterparts.

4. DISCUSSION

The study reveals that there remains a potential for stigmatization against individuals with LF in Nigeria even as the current (2018) outbreak portends more challenges in the following years. The Nigeria Centre for Disease Control (NCDC) reported that the total number of confirmed and suspected cases was 175 from 19 states as of February 7, 2016 [32]. In comparison, 731 suspected and 275 confirmed cases have been reported from January 2018 to February 2019 [33]. Prompt health-seeking “behaviors” for the LF containment is influenced by psychosocial factors such as fear of self- or social-stigma. In consequence, fear of stigma or outright stigmatization will influence health-seeking behaviors and promote engagement in self-medication or other unorthodox therapeutic alternatives—thus hampering efforts at effective LF surveillance system. The public health implication is that the chain of LF infection is likely to be sustained because of ignorance of risk factors, which in turn leads to risky behaviors. Improved preventive practices and reduced social stigmatization to LF hinge on continued dissemination of accurate information on LF disease.

However, as postulated by Person et al. [22], a behavioral strategy that addresses the needs of a segment of the population at risk of becoming stigmatized and discriminated against is the best way of containing fear. However, this should be complemented by specific campaigns targeted at the other factions of the population with a high tendency to stigmatize. We also propose that education and communication campaigns be tailored to fill specific knowledge gaps on available therapeutics and strategy for support and reintegration of survivors into the social cycle.

Ribavirin has remained the drug of choice for decades, although uniform guidelines for use, dose, or duration of therapy remain a challenge [7,14,18,24]. This study shows LF-associated perception to acceptance of vaccination in the event of LF diseases as 13.8% of staff and 21.6% of students either will not or are unsure of accepting any vaccination against LF even when it becomes available. Staff (12.7%) and students (18.1%) were unlikely to allow their children to get immunized and accept such a vaccine in the event that they are affected by the disease. This may be attributable to the various side effects associated with the current Ribavirin therapy [14] or other factors. Ribavirin has been associated with many adverse effects such as hemolytic anemia, nausea, and vomiting, myalgia, fatigue, diarrhea, abdominal pain, headache, jaundice, skin rash, tachycardia, and thrombocytopenia—all of which are known to be reversible. Although the questionnaire did not ask specifically for perceived unacceptance, this may be linked with LF misinformation and associated social stigmatization.

Results of this study showed that female students were potentially more likely to stigmatize against LF patients than their male counterparts in the event of an LF infection. Conversely, a study on the psychosocial impact of scars due to cutaneous leishmaniasis by Bennis et al. [26] reported that more females than males were more vulnerable to self-stigma and often expanded the effects of social-stigma associated with the disease. They, however, did not find a significant association between self-stigma and sex or personal experiences. The findings of our study and those of Bennis et al. [26] may indicate that females are not only vulnerable to self-stigma but are also more likely to stigmatize against others in the event of an epidemic with the high social impact such as LF. This may be related to the level of self-consciousness in sub-Saharan Africa and accentuated by the cultural roles of females in domesticity and the high value placed on social acceptance. Hence, comprehensive campaigns should focus on dissemination of accurate information of LF transmission and prevention particularly among females may be a first step toward tackling perceived LF stigmatization.

Additionally, adequate and accurate information about knowledge, attitude, and practices associated with LF disease remains poor as indicated by several studies conducted in Nigeria [29–31,34–37], which is consistent with the finding of this study. In this study, a higher proportion of LF-associated stigmatization was observed among students (57.9%), which generally demonstrated poor knowledge (82.7%) of LF transmission and prevention. By comparison, knowledge of LF disease was good among staff (81.3%), and they also demonstrated a perceived lower level of social stigmatization (39.9%) to LF disease. Poor knowledge was found to be significantly associated with the level of perceived social stigmatization to LF disease (p = 0.013). This demonstrates a strong association between knowledge of LF disease transmission and prevention, and LF-associated social stigmatization. This finding is consistent with that reported by Des Jarlais et al. [21], who found a significant association between lower level of education and endorsement of a variety of stigmatization methods for the control of SARS and AIDS. However, the low level of education may simply reflect a generally poor knowledge about disease transmission and prevention.

5. CONCLUSION

The perceived stigmatization against LF in Nigeria is a grim reminder that the disease remains a public health threat. This study shows an association between perceived high level of LF stigmatization and poor knowledge of LF transmission. A comprehensive emergency response plan should incorporate accurate knowledge dissemination about the disease, its transmission, as well as available therapeutics as a first step toward tackling perceived LF stigmatization.

CONFLICTS OF INTEREST

The authors declare no conflicts of interest.