Community Engagement in the Prevention and Control of Lassa Fever in Africa: A Systematic Review

Abstract

Aims: This study aimed to determine community-initiated Lassa fever prevention and control strategies in Africa.
Materials & Methods: Literature search was performed on four databases, including PubMed, Google Scholar, African Journal OnLine (AJOL), and BioMed Central, using different combinations of the following search terms. A three-stage methodology was employed to conduct the study. At first, related articles were identified using pre-defined key terms, such as Lassa fever, Lassa fever control, Lassa fever prevention, community engagement and Lassa fever, and community participation and Lassa fever. Thereafter, articles were screened to remove duplicates and articles not relevant to the study objectives.
Findings: Community mobilization and sensitization and risk communication were some of the community-directed activities towards Lassa fever prevention and control. Also, stakeholders’ advocacy and engagement, rodent control practices, environmental sanitation, and proper food processing and preservation were practiced to prevent Lassa fever. In addition, a referral mechanism from the community to the health facility was constituted through the engagement of community health workers.
Conclusion: Health program managers should strive to provoke coordinated and sustainable community-initiated efforts to improve rodent preventive and control measures. Strategies should be developed and implemented to promote environmental sanitation and restrict cultural practices facilitating contact with rodents or infected persons.

Full text

Community Engagement in the Prevention and Control
of Lassa Fever in Africa: A Systematic Review
ISSN: 2588-4115; Infection Epidemiology and Microbiology. 2021;7(2):187-196
A B S T R A C TA R T I C L E I N F O
Article Type
Review Article
Authors
Olayinka Ilesanmi, PhD1
Ekomobong Oton, BSc1
Aanuoluwapo Afolabi, B.Tech1*
How to cite this article
Ilesanmi O., Oton E., Afolabi A.
Community Engagement in the
Prevention and Control of Lassa
Fever in Africa: A Systematic Re-
view. Infection Epidemiology and
Microbiology. 2021;7(2): 187-196
1 Department of Community
Medicine, College of Medicine,
University of Ibadan, Oyo State,
Nigeria.
* Correspondence
Address: Department of Microbiol-
ogy, FacultyDepartment of Com-
munity Medicine, College of Med-
icine, University of Ibadan, Oyo
State, Nigeria.
afoannade@gmail.com
Article History
Received: February 05 2021
Accepted: March 03 ,2021
Published: May 20 ,2021
Backgrounds: This study aimed to determine community-initiated Lassa fever prevention
and control strategies in Africa.
Materials & Methods: Literature search was performed on four databases, including
PubMed, Google Scholar, African Journal OnLine (AJOL), and BioMed Central, using different
combinations of the following search terms. A three-stage methodology was employed to

as Lassa fever, Lassa fever control, Lassa fever prevention, community engagement and Lassa
fever, and community participation and Lassa fever. Thereafter, articles were screened to
remove duplicates and articles not relevant to the study objectives.
Findings: Community mobilization and sensitization and risk communication were some
of the community-directed activities towards Lassa fever prevention and control. Also,
stakeholders’ advocacy and engagement, rodent control practices, environmental sanitation,
and proper food processing and preservation were practiced to prevent Lassa fe v e r. In
addition, a referral mechanism from the community to the health facility was constituted
through the engagement of community health workers.
Conclusion: Health program managers should strive to provoke coordinated and sustainable
community-initiated efforts to improve rodent preventive and control measures. Strategies
should be developed and implemented to promote environmental sanitation and restrict
cultural practices facilitating contact with rodents or infected persons.
Copyright© 2021, TMU Press. This open-access article is published under the terms of the Creative Commons Attribution-NonCommercial 4.0
International License which permits Share (copy and redistribute the material in any medium or format) and Adapt (remix, transform, and build
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1029252/iem.7.2.187
Keywords:
Lassa, Lassa fever, Lassa virus, Community involvement, Community participation
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CITATION LINKS

Community engagement in Lassa fever prevenon
Infecon Epidemiology and Microbiology Spring 2021, Volume 7, Issue 2
188
Introduction
Lassa fever (LF) infection is a zoonotic
disease endemic in West African countries
[1-2]. Discovered in 1969, LF was named
after the Lassa town in Borno State in

among missionary nurses [3]. LF is a disease
manifested as an acute hemorrhagic
condition characterized by nausea, febrile
illnesses, sore throat, chest and abdominal
pain, diarrhea, and coughing [2]. Though
80% of LF cases are asymptomatic, in severe
cases, the disease may be accompanied by
bleeding tendencies, shock, hearing loss,
neck and facial swelling [4]. LF infection is
estimated to be associated with a global
burden of 100,000 to 300,000 infected cases
and 5000 deaths annually. The overall case
fatality rate is 1-15% among hospitalized
patients with severe conditions [2, 4].
LF is caused by Lassa virus belonging to
the arenaviradae family, it is present in the
urine and feces of infected multimammate
rats (Mastomys natalensis) [5]. The primary
transmission route to human is through
direct contact with the mastomys rats
or through food and household items
contaminated with the urine and feces of
infected rats [6-7]. The secondary (human-to-
human) transmission route is through direct
contact with the blood-secreting organs
      
Nosocomial outbreaks of LF infection are
evidence of secondary transmission of LF
infection [8-9].
The public health consequences of
LF endemicity in West Africa regions
necessitate the demand for political will
and national policy towards its elimination
[1]. For example, in Nigeria, LF is viewed as
an epidemic-prone disease that is evolved
by an alert threshold of a single suspected
case and an epidemic threshold of a single
 [10]. This fact has reinforced
the commitment of health systems towards
its prevention and control through
effective measures, including laboratory
investigations, clinical care, early detection,
surveillance, and proper response to LF
outbreaks.
The World Health Organization highlights
preventive measures in communities as
one of the key considerations for LF control
[4]. Studies have shown that community
      
enablers in the control of communicable
diseases in low and middle-income countries
(LMIC). They could also bridge inequalities
in under-resourced health systems while
promoting behavioral changes and the
delivery of health outcomes to marginalized
populations [11-16]. Amodu and Fapohunda
(2019) described community engagement
as an attractive strategy for preventing LF [17].
Although these interventions are best known
as community engagement, the terms such
as “community participation”, “community
mobilization”, “community empowerment”,
and “community sensitization” have also
been shown to have similar meaning [15].
    
by community engagement in health
interventions, limited evidence exists on
the role of community engagement in the
prevention and control of LF. The possibility
of sustained community participation in
addressing the menace of LF in Africa has
    
Objectives: This study therefore aimed
to determine community-initiated LF
prevention and control strategies in Africa.
Materials and Methods
In this systematic review, an online
search was conducted on peer-reviewed
studies on the concept of Lassa fever and
community engagement. The search was
carried out on PubMed, Google Scholar,
African Journal OnLine (AJOL), and BioMed
Central databases. The following search

Ilesanmi O. et al.
Infecon Epidemiology and Microbiology Spring 2021, Volume 7, Issue 2
189
terms were used: “Lassa fever prevention
and community engagement”, “Lassa fever
control andcommunity engagement”,
“Lassa fever prevention and community
participation”, “Lassa fever control and
community participation”, “Lassa fever
prevention” and “community engagement”,
“Lassa fever prevention” and “community
participation”, “Lassa fever control” and
“community engagement” as well as “Lassa
fever control” and “community participation”
with the aid of Boolean operators “AND”,
“OR”, “NOT”, and parentheses. Some records
were also retrieved using cross-references
in published papers. The word “community”
was used to describe a group of people living
in a particular location and sharing similar
characteristics.
Due to the similarities in the contexts,
the terms “community empowerment”,
“community mobilization”, “community
intervention”, and “community sensitization”
included in the articles were considered
as “community engagement”. All articles
     
concepts were considered as eligible for this
review. However, only articles published
in English language were included for
ease of understanding by reviewers. All
three authors actively participated in the
literature search. The systematic review was
     
objectives. Figure 1 represents the PRISMA
  
this systematic review (Figure 1).
      
through the databases search, among which
112 duplicate articles were removed. In
      
commentaries, one debate, and four letters-
to-the-editor were further excluded. Also, 27
off-topic articles, two articles of non-African
settings, and 28 articles on other infectious
diseases were removed from the retrieved
articles. Overall, eight articles were selected
for further evaluation.
Findings
The selected articles were conducted
with various study designs; there were an
experimental study, two case reports, and

provided details of coordinated response
to LF outbreaks in Sub-Saharan African
countries; three studies were focused on
preventive practices executed by community
individuals, heads of households, and food
sellers in Nigerian communities. One study
was an experimental study reporting rodent-
control strategy executed by community
members as a preventive measure against
LF infection (Table 1).
Ajayi et al. (2013) conducted a cross-
sectional study providing details of outbreak
and response strategies contributing to
the control of the LF outbreak in Ebonyi
State, Nigeria from January to May 2012. A
predominant factor to the success of response
strategies was community engagement
involving advocacy, communication,
mobilization, and shared leadership. Also, a
referral mechanism from the community to
the health facility was constituted through
the engagement of community health
workers [8].
      
sectional study which shows how actions on
social determinant of health can contribute
to ending the LF pandemic in Tchaourou
community in Benin Republic. The study
pointed evidence to engaging community
members in risk communication and
stakeholders mobilization. Stakeholders
were saddled with the responsibility of
discouraging rats’ hunting and consumption,
bush burningh, and banning cultural norms
of cutting parts of a deceased body for
prayers [18].
Patassi et al. (2017) conducted a case report


Community engagement in Lassa fever prevenon
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190
of LF infection in Togo in 2016. Community
involvement in control measures included:
the use of the sensitization campaigns in
schools, mosques, churches, and across
borders as well as translation of health
information into the local language [19].
The prevention of LF infection by intensifying
rodent control practices in the Faranah
Region of Upper Guinea was performed in
an experimental study by Saez et al. (2018).
In this study, communal activities reported
for rodents control included the use of rat
poison, cats as predators, and dogs for rat
trapping or hunting [20].
In a case report, Woyessa et al., (2019) strived
to identify the causes of LF to promote LF
control and prevention in Margibi county
of Liberia during the 2018 LF outbreak. In
their study, the involvement of community
    
of community members’ contacts with LF
cases   
in the disease control [21].
Ossai et al. (2020) conducted a cross-
sectional study to determine the role of
knowledge and preventive measures in
combating LF among heads of households in
Abakaliki, Ebonyi State, Nigeria. The study
disclosed that activities such as regular
handwashing, good environmental hygiene,
proper food storage, and avoidance of
consumption of rats were effective measures
taken to control LF [22].
In a cross-sectional study detailing response
to LF outbreak in Ekiti State, Nigeria,
Adovi et al. (2017) highlighted community
mobilization and sensitization campaigns
as effective measures to control LF. Also,
community informants and volunteers were
mobilized to carry out contact tracing and
      [23].
      
preventive practices among food sellers
in major markets in Ibadan city of Oyo
State, Nigeria. These practices included the
proper covering of food in sacks or air-tight
containers and the use of rat repellants and
rat poison in food stalls [24].
Discussion
The endemic state of LF infection in Sub-
Saharan Africa has augmented the need for
community members’ involvement in the
prevention and control of LF. This systematic
review across LF-endemic countries
presented evidence about the importance of
community participation as a component of
the disease outbreak response. Community
participation is aimed not only at reducing
the magnitude of the outbreak, but also at
preventing future outbreaks [18].
      
be included in this review, community
members were found to play the greatest
role in community mobilization towards the
prevention and control of LF infection [8, 17-
19]        
study describing community mobilization
as the collaboration between community
stakeholders and members to raise
awareness on the health needs, resources,
and solutions to meet the challenges in the
community [25]. A randomized-controlled
study in South Africa demonstrated the
role of community mobilization in changing
gender norms and reducing HIV risk [26]. This
array of evidence therefore allows for local
ownership and sustainability of LF control
and prevention. However, in order to be
more effective, it is necessary to incorporate
community sensitization campaigns into
community mobilization strategy [12, 15].
According to the literature review, it was found
that the use of sensitization campaigns could
increase community members’ awareness
of LF [8, 18-19, 23]. In the reviewed articles,
community members were exposed to media
sensitization campaigns. The campaign
messages were targeted at reducing the risk of
exposure to LF infection. For example, Castro

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Infecon Epidemiology and Microbiology Spring 2021, Volume 7, Issue 2
191
Table 1) Findings obtained from the literature search in relation to the study objectives
Names
of
Author
Name of
Journal Title of Article Summarized
Objective
Study
Design
Study
Population Study Area Outcome
1Ajayi et
al., 20138
International
Journal of
Infectious
Diseases
Containing a LF
Epidemic in a
Resource-Limited
Setting: Outbreak
Description and
Lessons Learned
from Abakaliki,
Nigeria (January–
March 2012)
To describe
LF outbreak
and response
strategies
in Ebonyi
State, Nigeria
between
January-March
2012
Cross-
sectional

and
suspected
cases of LF
in Federal
Teaching
Hospital
Abakaliki,
Ebonyi State,
Nigeria
1. Public advocacy
was conducted at
the state and district
levels.
2. Communication
channels of print
and electronic
media were utilized
in disseminating
information on LF
prevention.
3. Community and
religious leaders
were mobilized to
raise community
members’
awareness on
LF preventive
measures.
4. Community
health workers were
trained on case

referral system.
2

et al.,
2019 18
Open
Journal of
Epidemiology
From Social
Determinants of
Health Actions
to Fight against
the Lassa Virus
Hemorrhagic
Fever Epidemic
in Tchaourou
Commune in
Benin, 2018
To show
how an
action on the
health social
determinants
could end LF in
Tchaourou
Cross-
sectional
1. All
cases of LF
occurred in
Tchaourou
community.
2. All public
health
workers in
Tchaourou
and agents
of zonal

3. The
general
population
of villages
from which
LF cases
emerged
in the
Tchaourou
community
Tchaourou
Community,
Benin
Republic,
West Africa

mobilization and
risk communication
activities in affected
communities.
2. Traditional
healers and
community leaders
were sensitized on
LF prevention and
control measures.
These included
termination of
hunting animals
and burning bush,
and cultural norms
of cutting parts of a
deceased body for
prayers.
3
Patassi
et al.,
201719
Case Reports
in Infectious
Diseases
Emergence of
LF Disease in
Northern Togo:
Report of Two
Cases in Oti
District in 2016
This study
reported on the

of LF infection
in Togo, and
the response to
these cases.
Case
report
LF cases and
healthcare
workers in
Oti district
Oti district,
Togo
1. Public
sensitization and
social mobilization
were conducted in
public places.
2. Health programs
were produced
in the media and
translated into the
local language.
3. Also, sensitization
sessions were
organized in schools,
mosques, churches,
and across borders.

Community engagement in Lassa fever prevenon
Infecon Epidemiology and Microbiology Spring 2021, Volume 7, Issue 2
192
Table 1) Continuation
Names
of
Author
Name of
Journal
Title of
Article
Summarized
Objective Study Design Study
Population
Study
Area Outcome
4
Saez
et al.,
201820
PLoS Neglected
Topical
Diseases
Rodent Control
to Fight LF:
Evaluation
and Lesson
Learned from a
4-year Study in
Upper Guinea
This study
aimed to
assess the
feasibility and
acceptability
of community
rodent control
activities
Experimental
Male and
female
community
members
Faranah
region
of upper
Guinea
1. The use of
food containing
acute poison or
indomethacin, as bait
for killing rats.
2. The use of cats as
predators for rats in
many houses.
3. Children
engagement in
rat trapping or rat
hunting with dogs.
5
Woyessa
et al.,
201921
BMC Infectious
Diseases
Lessons
Learned
from the
Investigation
and Response
of LF Outbreak,
Margibi
County,
Liberia, 2018
This study

cause of LF to
promote LF
control and
prevention
Case report LF cases
Margibi
County,
Liberia
1. Community
informants were
engaged in active case

healthcare workers.
2. Community
members were
trained and deployed
as contact tracers to
identify and follow-up
contacts for symptoms
for 21 days after
contact with a LF case.
6
Ossai
et al.,
202022
Proceedings
of Singapore
Healthcare
Knowledge
and Preventive
Practices against
LF among Heads
of Households
in Abakaliki
Metropolis,
Southeast
Nigeria: A Cross-
Sectional Study
This study
determined the
knowledge and
prevention of
LF in Abakaliki
Cross-
sectional
Heads of
households
Abakiliki,
Ebonyi
State,
Nigeria
1. Ensured proper
storage of food.
2. Ensured good
environmental
hygiene around their
residence
3. Avoided the
consumption of
rats and foods
contaminated by rats.
4. Practiced regular
handwashing
7
Adovi
et al.,
201723
Central African
Journal of
Public Health
LF Outbreak in
Southwestern
Nigeria: The
Ekiti State
Response
amidst
Economic
Recession
This study
described the
LF outbreak
response in
Nigeria
Cross-
sectional
Suspected
cases of LF
and their
contacts
Ekiti
State,
Nigeria
A notable control
measure was
community
mobilization and
sensitization
campaign.
Concurrently,
trained volunteers
and community
informants were
mobilized to perform
contact tracing and
active case search at
the community level.
8
Adegoke
et al.,
201723
African
Journal for the
Psychological
Study of Social
Issues
Knowledge,
Attitude and
Practices of
Foodstuff
Sellers on LF in
Major Markets
in Ibadan
This study
assessed the
knowledge,
attitudes,
and practices
of food stuff
sellers on LF
in two major
markets
Cross-
sectional
Market
sellers (both
men and
women)
who sell
raw food
products.
Ibadan,
Oyo
State,
Nigeria
Food sellers practiced
individualistic
approaches to prevent
rat from infesting
their food stalls, using
rat repellents as food
preservatives or rat
poisons to reduce
the rat population.
Also, the food sellers
practiced the acts of
proper storage of food
in sacks or containers
with tight covering.

Ilesanmi O. et al.
Infecon Epidemiology and Microbiology Spring 2021, Volume 7, Issue 2
193
et al. (2009) conducted a malaria control
 
sensitization as a vital tool for controlling
infectious diseases in Africa [27]. Patassi et al.
(2017) in their study noted that sensitization
messages were translated and broadcasted
in the local language to enhance community
engagement [19]. In this review, it was found
that sensitization activities were conducted
among traditional and religious leaders when
there was a need to abrogate communal
practices, facilitating the occurrence and
spread of LF infection, for example, cessation
of bush burning prior to new farming
seasons. Woyessa et al. (2019) and Adovi
et al. (2017) both stated that local leaders
were engaged in the shared responsibility
of mobilizing community volunteers for
     [21, 23]. This
supports the fact that community volunteers
help improve the access of LF-infected
individuals to good health [28]. Such activities
therefore complement the services provided
by community health workers and reduce the
incidence of LF infection [28].

involvement of community members in
reducing contact with rats; however, among
the reviewed studies, limited studies
emphasized the role of community members.
For example, Tobin et al. (2015) demonstrated
poor acceptance of rodent control strategy
in many communities [29]   
be due to the relationship between humans
and rats, where rats are believed to pose
no threat to human well-being. Also, the
cultural practice of rat consumption in most
LF-endemic communities may ignore the
message of rodent elimination as a way of
controlling LF [29].
According to the reviewed that studies,
community participation in environmental
sanitation practices was found to be effective
in reducing rat infestation in the community.
Community members exhibit creative
personal approaches to environmental
hygiene. Such hygienic acts were reported
to contribute to a drastic reduction in the
prevalence of LF in Kaduna state, Nigeria
[30]. Also, Ossai et al. (2020) and Adegoke
et al. (2017) revealed the effectiveness
of individualistic strategies targeted at
reducing rodent-to-human contact and
human-to-human infection transmission.


Community engagement in Lassa fever prevenon
Infecon Epidemiology and Microbiology Spring 2021, Volume 7, Issue 2
194
Therefore, LF-preventive measures such
as regular handwashing as well as proper
processing and storage of food should be
promoted [22, 24].
Strengths and Limitations
The use of few databases to retrieve
published literature on LF could have limited
the results reported in this systematic review.
Despite this fall, the study contributes
to the existing knowledge regarding the
importance of community engagement
in disease prevention and control. The
endemic nature of LF in Africa, especially
West African countries further makes this
study very important in the study area.
Conclusion
   
to be involved in the implementation
of activities aimed at controlling and
preventing LF. Examples of these activities
include community mobilization and
sensitization, shared responsibility of
stakeholders, health systems’ support of
volunteers, rodent control mechanisms, and
environmental sanitation. However, there is
no evidence about the community-initiated
LF preventive and control measures. This
may be due to non-inclusion of municipal
members in program conceptualization and
planning. To empower and enable members
to initiate and develop LF prevention and
control strategies, it is important to include
and activate local engagement protocol as
a requirement of program design planning
phase. These interventions should be
designed to address the predisposing
factors of LF infection so that they could be
  
based organizations should be engaged
to implement interventions to promote
communal responsibility, such as coordinated
civic labor to promote environmental
sanitation and rodent control in public places.
Also, there is a need to culturally intensify
risk communication to promote behavioral
changes among community members and
families.
Acknowledgements: None declared by the
authors.
Ethical Permission: This study was a review
article; hence, no ethical approval was
required.
   The authors completed
    
icmje.org/coi_disclosure.pdf (available upon
request from the corresponding author), and
    
Authors’ contribution: The study was
conceptualized by OSI. Also, OSI, EAO, and AAA
participated equally in the review process,
manuscript drafting, and reviewing for critical
intellectual content. All authors granted

Fundings: None declared by the authors.
Consent to participate: Not applicable.
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