Africa-Press – Liberia. In the shadow of a global pandemic that dominated health headlines for years, a persistent threat quietly continues to challenge West Africa. Lassa fever, a viral hemorrhagic illnessfirst identified more than five decades ago when an American missionary died after contracting it in Liberia, remains an enduring public health challenge across the region’s “Lassa Belt” stretching from Nigeria to Guinea.
In Liberia, several counties including Bong, Nimba, Lofa, and Grand Bassa, health officials and international partners are deploying lessons learned from previous outbreaks to strengthen surveillance, improve treatment protocols, and accelerate vaccine development. Their efforts represent a critical case study of how regions with limited resources can build resilience against persistent threats while preparing for emerging ones.
“Lassa fever has been endemic to Liberia for a long while now,” said Dr. Dougbeh Chris Nyan, Director General of the National Public Health Institute of Liberia (NPHIL) tasked to prevent and control public health threats and diseases. “Since the first outbreak in the 60s, we are still confronted with it.”
Dr. Nyan during a special interview at his NPHIL office in Congo Town-Monrovia. Credit: Joyclyn
Given Lassa fever’s pronounced seasonality—spillover from Mastomys rodents peaks in the dry season (roughly December through March) and falls to a trough in the wet season (May through November)—comparing case counts in March and September aligns with the end of the annual peak and the end of the off-peak period, respectively.
The disease—transmitted primarily via contact with food or household items contaminated by the urine or feces of infected multimammate rats (Mastomys natalensis)—thrives in rural settings where poor sanitation and substandard housing promote rodent–human contact.
As of July 14, the country’s infectious disease institute reported two cases compared to five cases and one death recorded in May. While on the surface this suggests a decline, systemic underreporting, driven by inadequate diagnostic access, reporting delays, and limited laboratory capacity in remote regions-likely conceals the true burden.
Front-line healthcare workers warn that many infections go undetected, underscoring the need for strengthened surveillance and diagnostics throughout both peak and off-peak seasons.
Epi-curve of Lassa fever Outbreak, Liberia, Sept 1, 2024 – March 30, 2025
“When it comes to Lassa fever, we need the awareness that it is here with us,” said Dr. Minnie Sangawulo Ricks, Medical Director and Chief Executive Officer (CEO) of Phebe Hospital and School of Nursing, one of the largest referral and teaching hospitals in central Liberia. “We get it from the rodents, the rats… and it’s not a witch like some people think. And it’s not a death sentence.”
This mix of misinformation, stigma, and limited surveillance capacity complicates Liberia’s response efforts, even as climate change and human activities like deforestation and bush burning increasingly disrupt rodent habitats, potentially expanding the geographic reach of the disease.
The rodent species that carries Lassa – commonly known in Liberia as “the rat with many breasts” or “platter” – thrives in areas increasingly experiencing environmental degradation. “I think the ecology plays quite a great role in disease prevention,” Dr. Nyan said. “Once we disturb the ecology, meaning the environment, certainly, we have a problem. It’s not only with Lassa; it’s also with other zoonotic diseases.”
This environmental dimension highlights how illegal mining and deforestation may contribute to disease spread, creating a complex interplay between economic activities, environmental health, and public health outcomes.
The Historical Context
Understanding Liberia’s current approach to Lassa fever requires acknowledging the disease’s deep roots in the country’s healthcare narrative. For decades, Lassa was known colloquially as “the nine days sickness” – a grim reference to its often-fatal progression. “Growing up as a child when you are told that someone has Lassa,” Dr. Ricks recalls, “we used to call it the nine days of sickness. You don’t expect the person to survive.”
The disease first gained international attention when an American missionary working at Phebe Hospital contracted the virus from a patient and subsequently died – the same hospital where Dr. Ricks now serves as medical director. This early identification established Liberia as a focal point for Lassa research, though for many years, actual response capacity remained limited.
The Ebola crisis of 2014-2016 marked a turning point. The devastating outbreak that claimed thousands of lives across West Africa exposed critical weaknesses in health systems but also catalyzed unprecedented investments in disease surveillance and response capabilities. Out of this crisis emerged new institutions, protocols, and partnerships that would ultimately strengthen Liberia’s hand against Lassa and other infectious threats.
In the aftermath of the Ebola outbreak, Liberia established the National Public Health Institute to coordinate disease surveillance and response efforts. This institutional innovation represents a significant step forward in the country’s public health architecture.
“We respond to these threats, we address how it’s spreading,” said Dr. Nyan. “We gather facts, we gather evidence, we transmit that evidence to various government agencies, including the Ministry of Health, to the President… and that evidence is used by the country, the region, and the world for policy formulation.”
This evidence-based approach represents a departure from earlier, more reactive strategies. Today, rapid response teams and county surveillance officers stand ready to investigate potential outbreaks, while cross-border epidemiological partnerships help monitor disease patterns across the porous boundaries that define the “Lassa Belt”.
These developments extend to laboratory capacity as well. Whereas Liberia once sent suspected Lassa fever samples to Sierra Leone for testing—a process that could take weeks—the country now maintains molecular testing capabilities at both the National Reference Laboratory and Phebe Hospital.
“Since the establishment of the molecular lab here in Liberia at Phebe Hospital, it has taken us four to six hours to get our results,” said Dr. Ricks, highlighting a critical improvement in response time that can mean the difference between life and death for patients.
The development of these diagnostic capabilities came through strategic partnerships. After the Ebola outbreak, the University of North Carolina established a molecular laboratory at Phebe Hospital specifically to address Lassa fever, recognizing the endemic threat it posed even as the world’s attention focused on Ebola.
These laboratory improvements are complemented by enhanced clinical protocols. “We have an infection prevention and control system in place,” said Dr. Ricks. “Every patient that comes to this hospital has to be triaged. And we also have the case definition of these hemorrhagic diseases.” This systematic approach helps identify potential cases early, allowing for prompt isolation and treatment.
Treatment typically begins immediately after blood samples are collected, without waiting for test results. “We initiate the treatment while awaiting the results,” said Dr. Ricks, describing the use of ribavirin, the primary medication for Lassa fever, which is provided free of charge through the government and international partners.
Dr. Ricks during a special interview in Monrovia. Credit: Joyclyn
However, significant challenges persist in the public health response. “Currently we are responding well in terms of our case definition and case detection. Dr. Nyan said, “But we need enough medications in the country.” Ensuring a consistent supply of effective treatments remains a priority, especially as cases continue to emerge across the endemic regions.
Healthcare Workers on the Frontlines
For healthcare workers in Lassa-endemic regions, the disease presents both a professional challenge and a personal risk. Unlike many countries where healthcare providers receive special protections and benefits given their exposure to infectious diseases, Liberian medical staff often work without adequate safety gear.
“Being a healthcare worker, you are at risk,” Dr. Ricks said. “And more so it’s frustrating in this country that when it comes to health insurance it’s not something genuine. We have had health workers that have died.”
This reality creates understandable hesitation among some staff. “Not many health workers want to go there because their life is not insured,” Dr. Ricks said, referring to isolation wards. “What happens if they contract the disease, even though we are careful how we’re dealing with patients?”
These concerns are not theoretical. Dr. Ricks recounts the case of a nurse who travelled outside Bong County, returned ill, and was treating herself at home. By the time she was brought to the hospital and diagnosed with Lassa fever, it was too late to save her life. Subsequently, both a student who had cared for her at home and that student’s girlfriend also contracted the disease, though fortunately, both survived.
Despite these risks, healthcare workers continue providing care, with particular attention to infection prevention protocols. “All of those that have worked in or that are working in isolation, there has not been anyone [who contracted Lassa],” said Dr. Ricks. “I also work in isolation because being a pediatrician, when I have children in isolation who are positive for Lassa, I go there.”
This testament to the effectiveness of proper protective measures offers some reassurance, but the underlying structural vulnerabilities remain a significant concern for the healthcare workforce.
Groundbreaking Vaccine Trials
Perhaps the most promising development in Liberia’s Lassa response comes in the form of vaccine trials now underway across the country. Building on methodologies developed during the Ebola crisis, researchers are evaluating multiple vaccine candidates that could finally offer protection against a disease that has defied control for decades.
“At present, there is no recognized treatment or vaccine for Lassa fever,” said Dr. Stephen Kennedy, a professor and principal investigator at the University of Liberia. “The Coalition for Epidemic Preparedness Innovation, a global partnership working to accelerate the development of vaccines, has been working in conjunction with other international partners like the International AIDS Vaccine Initiative… to be able to conduct a study to test the benefit of a Lassa fever vaccine.”
The trials follow a similar framework to those that successfully delivered Ebola vaccines, with researchers adapting previous platforms by removing Ebola-specific components and inserting Lassa fever elements. “It’s almost the same base, the same foundation, the same framework of the vaccine that was used, and just a piece of it for Ebola was removed, and a piece for Lassa fever was inserted into that base of the vaccine,” said Dr. Kennedy. This approach accelerates development while leveraging established safety profiles.
The research goes beyond simple vaccine trials. Studies like “ENABLE 1.5” at Phebe Hospital are investigating the prevalence of Lassa fever with co-infection of malaria, addressing the diagnostic challenge that arises because “once someone gets a fever, everybody thinks, it’s malaria,” as Dr. Ricks said. This research may improve case identification and help target interventions more effectively.
However, challenges remain. The trials require sophisticated infrastructure, trained personnel, and community trust—and resources needed are in limited supply. To address these gaps, the University of Liberia has implemented both short-term solutions (like crash courses in clinical research) and long-term investments (identifying Liberians to pursue advanced degrees in relevant fields).
Community engagement presents a particular challenge. “Before we conducted the Ebola vaccine clinical trial, we had to do what you call social mobilization,” recalls Dr. Kennedy. “We go into the community. We speak to the community leaders to make sure that we seek their support. We seek their buy-in.” During the Ebola trials, Dr. Kennedy himself was among the first to receive the experimental vaccine, demonstrating his confidence in the research protocol.
To coordinate these complex efforts, the Lassa Vaccine Taskforce, a coalition chaired by the Minister of Health, brings together representatives from communities, international organizations, universities, research institutions, and healthcare facilities like Phebe Hospital. This multisectoral approach helps ensure coherent messaging and unified strategy.
“The intent is that at the end of the Lassa fever clinical trial, the University of Liberia should have the expertise to be able to conduct clinical trials for any vaccine in the future,” said Dr. Kennedy, emphasizing the capacity-building dimension of current efforts. This focus on sustainable skills development represents a critical shift from earlier models that prioritized external expertise over local capacity.
Balancing Research with Immediate Needs
A persistent tension exists between rigorous research protocols and urgent community health needs. Dr. Kennedy acknowledges this challenge directly: “How do you maintain that guideline at the same time address the issues of, say, loss of health in a hospital or, address the public health challenges lots of people face?”
His team addresses this through multiple strategies. First, anyone enrolled in clinical trials receives free healthcare for any illness during the trial period. Second, indirect funding supports broader hospital operations, enabling treatment for non-trial patients with suspected Lassa fever. Finally, training programs build institutional capacity that benefits all patients, regardless of trial participation.
This balanced approach helps maintain research integrity while addressing immediate community needs—a model with potential applications well beyond Lassa fever research.
The Road Ahead
Despite these advances, significant challenges persist. Healthcare workers remain vulnerable, with limited personal protective equipment and virtually no health insurance to protect them should they contract the disease while treating patients. Laboratory testing capacity, while improved, still falls short of ideal standards.
Most critically, sustainable funding remains elusive. As international attention shifts to other crises, maintaining momentum against Lassa fever will require consistent investment—not just in vaccine development, but in strengthening healthcare systems, improving surveillance networks, and addressing environmental factors that drive transmission.
“The government itself should be proactive in supporting the Public Health Institute and the Ministry of Health,” said Dr. Nyan. “That means the government should apportion a good amount of the GDP or the budget to be allocated to healthcare.”
Recent shifts in international aid priorities add urgency to this call for domestic investment. When asked about the potential impacts of foreign aid cuts, particularly from the United States, Dr. Nyan expressed confidence in the resilience of Liberia’s public health infrastructure. He recounted how NPHIL was able to respond effectively to a recent potential Mpox case at a prison facility using domestic resources rather than partner funding—a significant step toward self-sufficiency.
For individuals, addressing Lassa fever begins with simple preventative measures. “Keep our community clean so these rodents or rats can go far away from us,” advises Dr. Ricks. “Let’s keep our homes clean and learn to cook our food and cover our food.” These basic precautions, combined with prompt medical attention at the first sign of illness, remain essential components of the response.
As global health security increasingly depends on the strength of its weakest links, Liberia’s experience with Lassa fever offers important lessons. By building on past crises, investing in local capacity, and pursuing innovative partnerships, countries facing endemic diseases can transform persistent challenges into opportunities for sustainable improvement—protecting not just their citizens, but communities around the world.
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