Lassa fever in Guinea: I. Epidemiology of human disease and clinical observations.

The arenavirus Lassa is found in West Africa, where it sometimes causes a severe illness called Lassa fever. Lassa fever has been seldom investigated outside of a few hyperendemic regions, where the described epidemiology may differ from that in areas of low or moderate incidence of disease. Through a prospective cohort study, we investigated the epidemiology and clinical presentation of Lassa fever in Guinea, where the disease has been infrequently recognized. A surveillance system was established, and suspected cases were enrolled at five Guinean hospitals. Clinical observations were made, and blood was taken for enzyme-linked immunosorbent assay testing and isolation of Lassa virus. Lassa fever was confirmed in 22 (7%) of 311 suspected cases. Another 43 (14%) had Lassa IgG antibodies, indicating past exposure. Both sexes and a wide variety of age and ethnic groups were affected. The disease was more frequently found, and the IgG seroprevalence generally higher, in the southeastern forest region. In some areas, there were significant discrepancies between the incidence of Lassa fever and the prevalence of antibody. Clinical presentations between those with Lassa fever and other febrile illnesses were essentially indistinguishable. Clinical predictors of a poor outcome were noted, but again were not specific for Lassa fever. Case-fatality rates for those with Lassa fever and non-Lassa febrile illnesses were 18% and 15%, respectively. Seasonal fluctuation in the incidence of Lassa fever was noted, but occurred similarly with non-Lassa febrile illnesses. Our results, perhaps typical of the scenario throughout much of West Africa, indicate Lassa virus infection to be widespread in certain areas of Guinea, but difficult to distinguish clinically.

Lassa fever in Guinea: II. Distribution and prevalence of Lassa virus infection in small mammals.

Rodents of the genus Mastomys form the reservoir for Lassa virus (LV), an arenavirus that causes a potentially severe hemorrhagic illness, Lassa fever (LF). Although Mastomys rodents exist throughout sub-Saharan Africa, areas of human LF appear to be quite focal. The distribution of small mammals and LV-infected Mastomys has been assessed in only a few countries. We conducted a survey of small mammals in selected regions of Guinea to assess the degree to which LV poses a public health risk in that country. A total of 1,616 small mammals, including 956 (59%) Mastomys, were captured from 444 households and seven bush sites. Mastomys made up > 90% of the captured animals in the savannah, savannah-forest transition, and forest regions of Guinea, while Mus musculus dominated in coastal and urban sites. Animals were analyzed via enzyme-linked immunosorbent assay (ELISA) for LV-specific antigen (blood and spleen homogenate) and IgG antibody (blood only). Virus isolation from spleen homogenates was also performed on a subset of animals. Lassa antibody and antigen were found in 96 (11%) and 46 (5%), respectively, of 884 tested Mastomys. Antibody and antigen were essentially mutually exclusive and showed profiles consistent with vertical transmission of both LV and antibody. LV was isolated only from Mastomys. ELISA antigen constituted an acceptable surrogate for virus isolation, with a sensitivity and specificity when performed on blood of 78% (95% confidence interval: 68-83%) and 98% (95-99%), respectively. The proportion of LV-infected Mastomys per region ranged from 0 to 9% and was highest in the savannah and forest zones. The proportion of infected animals per village varied considerably, even between villages in close proximity. Infected animals tended to cluster in relatively few houses, suggesting the existence of focal "hot spots" of LV-infected Mastomys that may account for the observed heterogeneous distribution of LF.

Genetic diversity among Lassa virus strains.

The arenavirus Lassa virus causes Lassa fever, a viral hemorrhagic fever that is endemic in the countries of Nigeria, Sierra Leone, Liberia, and Guinea and perhaps elsewhere in West Africa. To determine the degree of genetic diversity among Lassa virus strains, partial nucleoprotein (NP) gene sequences were obtained from 54 strains and analyzed. Phylogenetic analyses showed that Lassa viruses comprise four lineages, three of which are found in Nigeria and the fourth in Guinea, Liberia, and Sierra Leone. Overall strain variation in the partial NP gene sequence was found to be as high as 27% at the nucleotide level and 15% at the amino acid level. Genetic distance among Lassa strains was found to correlate with geographic distance rather than time, and no evidence of a "molecular clock" was found. A method for amplifying and cloning full-length arenavirus S RNAs was developed and used to obtain the complete NP and glycoprotein gene (GP1 and GP2) sequences for two representative Nigerian strains of Lassa virus. Comparison of full-length gene sequences for four Lassa virus strains representing the four lineages showed that the NP gene (up to 23.8% nucleotide difference and 12.0% amino acid difference) is more variable than the glycoprotein genes. Although the evolutionary order of descent within Lassa virus strains was not completely resolved, the phylogenetic analyses of full-length NP, GP1, and GP2 gene sequences suggested that Nigerian strains of Lassa virus were ancestral to strains from Guinea, Liberia, and Sierra Leone. Compared to the New World arenaviruses, Lassa and the other Old World arenaviruses have either undergone a shorter period of diverisification or are evolving at a slower rate. This study represents the first large-scale examination of Lassa virus genetic variation.

Diagnosis and clinical virology of Lassa fever as evaluated by enzyme-linked immunosorbent assay, indirect fluorescent-antibody test, and virus isolation.

The Lassa virus (an arenavirus) is found in West Africa, where it sometimes causes a severe hemorrhagic illness called Lassa fever. Laboratory diagnosis has traditionally been by the indirect fluorescent-antibody (IFA) test. However, enzyme-linked immunosorbent assays (ELISAs) for Lassa virus antigen and immunoglobulin M (IgM) and G (IgG) antibodies have been developed that are thought to be more sensitive and specific. We compared ELISA and IFA testing on sera from 305 suspected cases of Lassa fever by using virus isolation with a positive reverse transcription-PCR (RT-PCR) test as the "gold standard." Virus isolation and RT-PCR were positive on 50 (16%) of the 305 suspected cases. Taken together, Lassa virus antigen and IgM ELISAs were 88% (95% confidence interval [CI], 77 to 95%) sensitive and 90% (95% CI, 88 to 91%) specific for acute infection. Due to the stringent gold standard used, these likely represent underestimates. Diagnosis could often be made on a single serum specimen. Antigen detection was particularly useful in providing early diagnosis as well as prognostic information. Level of antigenemia varied inversely with survival. Detection by ELISA of IgG antibody early in the course of illness helped rule out acute Lassa virus infection. The presence of IFA during both acute and convalescent stages of infection, as well as significant interobserver variation in reading the slides, made interpretation difficult. However, the assay provided useful prognostic information, the presence of IFA early in the course of illness correlating with death. The high sensitivity and specificity, capability for early diagnosis, and prognostic value of the ELISAs make them the diagnostic tests of choice for the detection of Lassa fever.

Early diagnosis of Lassa fever by reverse transcription-PCR.

We developed a method based on a coupled reverse transcription-PCR (RT-PCR) for the detection of Lassa virus using primers specific for regions of the S RNA segment which are well conserved between isolates from Sierra Leone, Liberia, and Nigeria. The specificity of the assay was confirmed by Southern blotting with a chemiluminescent probe. The assay was able to detect 1 to 10 copies of a plasmid or an RNA transcript containing the target sequence. There was complete concordance between RT-PCR and virus culture for the detection of Lassa virus in a set of 29 positive and 32 negative serum samples obtained on admission to the hospital from patients suspected of having Lassa fever in Sierra Leone. Specificity was confirmed by the failure of amplification of specific products from serum samples collected from 129 healthy blood donors in Sierra Leone or from tissue culture supernatants from cells infected with related arenaviruses (Mopeia, lymphocytic choriomeningitis, Tacaribe, and Pichinde viruses). Sequential serum samples from 29 hospitalized patients confirmed to have Lassa fever were tested by RT-PCR and for Lassa virus-specific antibodies by indirect immunofluorescence (IF). RT-PCR detected virus RNA in 79% of the patients at the time of admission, comparing favorably with IF, which detected antibodies in only 21% of the patients. Lassa virus RNA was detected by RT-PCR in all 29 patients by the third day of admission, whereas antibody was detectable by IF in only 52% of the patients. These results point to an important role for RT-PCR in the management of suspected cases of Lassa fever.