Exploring One Health in Nigeria: Cross-Training, Arboviruses, and Lassa Fever with Top Scientists

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is contagious, scott. Welcome to the Infectious Science podcast man. Thank you, matt. So really appreciate you coming here today and we've just been really excited to have you come and talk to us a little bit about the type of work that you're doing. You're one of the top scientists here at UTMB, and so we really like to get together with top scientists and pick their brains about their work. Part of this episode is that we're going to be hearing from some of your collaborators in Nigeria. We know that these are some incredible scientists, some incredible clinicians. They're really been great collaborators. Can you tell us a little bit about what the relationship with these partners, these collaborators, has meant to you and what you hope the program brings for the partnership in these countries, because it sounds like these are very well set up. They have clinical facilities, they have labs. They're actually doing some really amazing work. What's the relationship been like for you and what do you hope is going to come out of it for them?

Well in Nigeria. For example, I'd never been to Nigeria until about a year ago. We set up the center application through Bobo Pestler's relationships there. One of the reasons I've been really excited about working in Nigeria is that I focus on the arboviruses for the center. Nigeria used to be a British colony. There was actually a lot of very important arbovirus research done there until the 1960s when Nigeria was emancipated. Ever since there's been very little arbovirus research done there. Like Senegal, the Institute Pasteur has had good support the whole way since they were a French colony and maintain a lot of research on arboviruses. The same is not true for Nigeria or Sierra Leone. One of my goals is just to help rebuild their expertise on arboviruses and a little bit their capabilities and facilities. That's one of the overall goals of the CREED network, but I think that we do that in a little bit more depth than a lot of the other centers where they mostly focus on getting them set up to do sequencing. We try to do a whole lot more than that. We had to really start from scratch with some of our field sites teach them how to collect mosquitoes, how to identify them, how to assay them to see if they're carrying viruses In Nigeria. It's been a lot of fun to work with them to try to bring that area of science back to Nigeria. I think it's going to turn out that there's a lot of important things going on there that have just been flying under the radar for many years because nobody's working much on arboviruses there. We also Nathan Shea, who you talked to. You've probably seen more LASA patients than all but a handful of physicians in Africa. Even though he's a pretty young guy, he sees a lot of cases and knows a lot about LASA. I don't know so much about LASA, so I'm learning a lot from them. The same is true for some of the livestock diseases where the National Veterinary Research Institution is very strong. There I think you've talked to Pam Luca. They have a lot of expertise that we don't have here at UTMB. It's a great partnership between human and veterinary medicine, different fields of virology that are strong one place and not in another. The other thing that we've really done successfully is we have, for example, senegalese entomologists working to help bring the expertise up in Sierra Leone and Nigeria with mosquito work. They're really some of the best in the world and they know the populations in Africa much better than I do or anyone else in the US. Really Having different African groups with different expertise to do some cross training has been pretty fulfilling too as part of the center.

That's amazing. I think there's always this model in global health that we're trying to get away from, which is jet setting from high income countries to come and do stuff in low, low middle income settings, And this idea of really setting up in country networks, sharing expertise, learning from one another, approaching that with humility. I really think that's such a great example of getting stuff done.

Welcome back to the Infectious Science Podcast. I am Dr Dennis Bentham. I am an associate professor in the microbiology and immunology department at the University of Texas Medical Branch and the Galveston National Lab. Today we are recording a special episode. We are on the road As part of the West African Center for Emerging Infection Diseases. We are in Nigeria And I'm here today with Dr Nathan Sheyew He's an attending physician at the Joe's Teaching Hospital And Dr Pam Luca he's a veterinarian and molecular biologist at the National Veterinary Research Institute And Loya Inka Asala. He's a veterinary research officer, also at the National Veterinary Research Institute And I'm very excited because we will be talking about Nigeria, lhasa fever, african swine fever and some other zoonotic diseases in Nigeria And hopefully we'll have time to dive into one health in Nigeria as well. So welcome to the podcast, and I want to start with Dr Nathan Sheyew And maybe you can introduce yourself. Tell us a little bit about your career. How did you end up becoming an attending physician at the Joe's Teaching Hospital?

Yeah, thank you, dennis. My academic career started Everything about my education is in the northeastern part of Nigeria. I was actually born in the northeast. I did my preliminary education in the northeast, my undergraduate in the northeast, but when I decided to come for residency I came to North Central Nigeria. So growing up as a kid I had the desire to become a medical doctor. But when I went to college I started tossing around other courses that probably might be better. Growing up I started to do some hand skills of walking in electrical workshop, repairing electric fans, electric motors. Then I started to say probably I could develop something. Some manually driven system can be changed when I develop electric motors. So then, still in college, i thought of probably I will do chemical engineering. Then another thought I could do geology, but somehow the thought to read medicine and surgery prevailed. Then, of course, i read medicine and surgery And it was quite interesting. And when I was studying medicine we are not studying to pass, who are studying to gain knowledge. We don't see reading, studying as a burden, but we read with excitement, we read beyond the required syllables And what we used to do those days is after reading. We have lots of group discussions, so we'll be challenging one another with what we've read and all of that, and that's for us to keep reading and studying, and studying. After that, while then I started my housemanship at the University of Maiduguri Teaching Hospital. So right when I was doing the housemanship, which is internship, then I also enrolled for a graduate program, master's in health planning and management, and actually just internship is a very hectic process. So all of that actually created a milieu and opportunity for me to work in difficult circumstances, and I tell you that some of the demanding situation and circumstances that I faced were just opportunities that I had developed from those experiences. So outside that, I now decided to go for residency. Then I came to Josh University Teaching Hospital And it was quite challenging because one needed to get sponsorship and the sponsorship was not too forthcoming. So I came to do residency with a little bit challenging financial resources, but to myself and to the family. So it was really difficult. There are times that one would even attempt to track down to the hospital. So you could imagine that a medical doctor could attempt to track down, because it was quite challenging. And as I kept on pursuing the residency, then I started having some resources. Then, at a time many of my colleagues had enough money to be buying cars and I had some money So I had the option. Then I got an opportunity to apply for an international course in the US international course on applied epidemiology. So the money that I had saved to buy a better car than the one that I was using, which was really not too good I just used that to invest in my education. So that was when I attended the international course on applied epidemiology organized by CDC and Emory University. So that became a trigger and it created an interest in research, collaboration, network and all of that. So I came back and I completed my residency and was employed as a consultant physician with the Joss University, teaching also, which is equivalent to like an attending physician. So in a nutshell, that is it. But I kept on having a desire to do another studies on genomics and bioinformatics. I just went for it again and also gained knowledge. So, in a nutshell, that's my educational pathway.

Thank you very much for sharing. You mentioned your interest in electronics and moving parts and you mentioned the hand skills and stuff like that. So why didn't you end up becoming a surgeon?

Well why I didn't become a surgeon. I checked my strengths and I realized that clinicians are the real, physicians are the real, because it needs. When I was in my preclinicals I was very good in physiology Well, even in most of the disease. But I love critical thinking, analytical thinking and all of that And I just like internal medicine. And to my mind, when I was doing my national youth service because in Nigeria, after completing your undergraduate, you will go for a mandatory national youth service, so during that time there's opportunity that you practice general medicine And at that time I could do several surgeries I repair hernia repairs, i do caesarean section, i do lumpectomy, that is, removing of lumps. So I felt that there was no need to go beyond that. That knowledge it is required if one is in any other place where there is no specialist, so you could draw from that. So even to this day, if there is opportunity to do surgery in a rural place, of course I will do it.

So for the young audience, the medical students or people interested in medical school, would you have any advice for the career? What was it for you? Was it the mentors, or was it serendipity, or what shaped your career?

OK, first I realized that many people study a course that they are not interested in, and so it becomes a burden. On the other hand, there are several people that study a course that was actually bequeated to them, or they were made to study a course that they never liked it. So you will see that the level of commitment will never be the same. So what I tell people is that when one has reached the point of decision making regarding a course of study, it's a very, very important decision in life that must not be taken just at a go, and many things need to come. Many people will just do a short-term analysis, say probably the duration of study or how difficult it is or how easy it is, but it's important to know that once you choose a career, it is something that you live with for the rest of your life. So it's important to have the short, medium and long-term overview analysis and know your strengths, know your interests, know where you're going.

Then, before you now take a decision, Can you also tell our audience how you ended up becoming part of the West Africa Center for Emerging Infectious Diseases? OK, for me first.

I said that I don't want to be just an ordinary clinician And I keep telling people that if you just be a clinician, they say that, ok, these are the symptoms of pneumonia Someone will be coughing, someone will have fever, someone will be weak. That is the lowest level of achievement, because anybody, just you, just know that, yes, fever, cough, body weakness is equals to pneumonia. And of course, there are other things that, yes, it will lead to investigation, but that is achieving, utilizing the potentials that we have. So it's important to go beyond that, to go beyond just ordinary thinking and asking relevant questions, making discoveries. And at some point I studied and looked at those who made discoveries Pluto, socrates, and someone that I respect so much was asking us and challenging us all those who made discoveries, do they have two brains? Do they have two heads? So if people passed all these great scientists, philosophers, they could sit down, they could think through. Why couldn't I? And so the first interest was in LASA, in infectious disease, because eventually I subspecialized in infectious disease And why I studied infectious disease? Because I realized that most the challenge that I have, most around me are infectious diseases, and then I realized that diseases that have epidemic potential, they are more challenging And I have several opportunities to see patients with LASA fever where you will see health workers. once they say this is suspected LASA fever, people will be running away. Then I will say that yes, this patient needs to be cared for, this patient needs to be attended to. So I now started developing interest in LASA fever And one thing that is general with health care or research or teamwork is lack of recognition of other low-corder staff or other people that are not in your discipline. Now it will surprise you that at a point someone who everybody will say this one is a junior faculty, a junior staff we are seeing because he works with the state minister of health. He said that we are seeing patients coming with LASA fever in this hospital, a vangial hospital, which is the place that the first case of LASA fever was ever managed in the world. And you are in the same city and you are in the teaching hospital. You are a specialist. Why is it that you have never reported to us that you had LASA fever? So if it was yes, i'm a senior faculty I could have said what are you saying? But low and pure, i said, ok, let me start looking. And immediately I start looking and of course we started seeing LASA fever. So then we started to see patients. We started to write publications, document our cases. Then I started to make some collaboration and I realized that there are several people who needed some expertise, those experts who are clinicians. And that's how Professor Slobodan Pesla, who is interested in LASA fever, who has done the convenience studies on LASA and has done some models of LASA fever hearing loss in mouse models So he wanted to replicate, to have a comprehensive study to see in humans. So that's how we wrote a grant NIH with him and we started to work on LASA fever.

Thank you, Dr Pam Luca. What about you? How did your career started out? Tell us a little bit about your story, Yeah.

I think my career started from the MVRI campus, because that's where I was born And my father worked there as an attendant. So when we were growing up we usually follow him to the vet clinic And I think one thing I learned from him is that he's a passionate person when it comes to taking care of animals, because then at the veterinary clinic animals could be admitted, kept their money each before. When they get better, then the owners come and take them, or if someone is traveling, he can just come to the clinic and keep his animal and give money for feeding, and then he does that with a lot of commitment and passion. So sometimes we follow him and we see And we also keep dogs sometimes too. In fact, here we don't really have special food for animals, but when you make food for my dad and he comes back and asks as his animal eating, you said no, he can take his food and give to the animal. So I think that's where I picked the passion. And then, even when I finished secondary school and was going for an undergraduate program, i think I told myself I was going to do veterinary medicine. I went to a preparatory class and then I was given something that would not give me a vet medicine course. I had to withdraw and then went back prepared myself again and went to the university And eventually I did veterinary medicine and came out. And as soon as I came out, i think I got a job as a sales rep for a veterinary company. So I was moving about selling drugs, selling animal feed and other things. So I think that too also helped me to build some capacity when it comes to human relationship, when it comes to personal drive, because as a rep, nobody tells you what to do. You're only given the target for the year. You break it down into months and maybe into weeks, and then you supervise yourself and you do your work. And it tells somewhere that you're doing your work. If the sales are going, then it shows you're working. If you're not making sales, it shows that you're not really working. So it's a system that helps you to be able to manage yourself and be productive and have some personal drive, because it's very necessary for whatever level of career you choose for yourself, because if you're always waiting for someone to give you a push, you do not always be there. But like Nathan said, if it's along the line of your interests, it's along the line of your strength. You can always jump out every day and find yourself doing that same thing that you love, but if someone is the one that is asking you to do this, do that. If the person is not there tomorrow, you will not be able to continue. So I think that I was able to get at the early stage of my career. So I did that work for a short while and when I was going in for that work I told myself I was going to do it for two years. Yes, i had the target. I said I was going to do this job for two years and after two years I'm off to do other things. Because then I was also interested in business, i was interested in financial issues, because then I also felt that if I did not study veterinary medicine, i would have studied economics, genomics, economics Oh, economics. Economics Because I was interested in business.

Right Yeah.

And then eventually, i think after I got employed with the National Veterinary Research Institute, where I started my career as a general person in the lab, doing diagnostics, managing some other scientists like technician, and then growing to the rank then to my master's in molecular biology and PhD, where I worked on ASF as the African Swine Fever, and I did the master's and the PhD in a resource limited environment. It's not like a high tech, but you were exposed to doing things, basic things, basic science, because you don't have the kit, the extraction kit, to do extraction although you are doing molecular biology. So you could do the conventional extraction of maybe chloroform isoamyl, you know all those things. And then, if it's a lysa, you could just get your antigen and you challenge some laboratory animals and generate polyclonal antibodies and you play around with it. So eventually, when you have the commercial one, it gives you an idea of what is making that to work. So I think that's actually what has been my journey into veterinary medicine. Like I said, it started with my father. It was what my dad was doing that I picked interest in And as I moved on, he finding things. But interestingly, i think, i went back to my yearbook, my secondary school yearbook and I realized that in that yearbook I said I wanted to be a virologist. So it's like a dream you had and it's coming to reality, although not as quick as you wanted it or not even as in the places you want, although I wasn't specific where I wanted to be. But I knew that this is what I want to be in life. And you know, like they say, be careful, what you wish for, you may get it. So that was what I wished for and maybe that has been the drive and it led me to where I am.

So there's no point in your early career or in your secondary school, where you thought about becoming a human doctor or physician, no, why not?

Because I think it's the environment, because I grew up in a veterinary research institute compound where I see a lot of veterinarians and some of them were like role model per se. I saw them and I said I want to be like them. So the environment had a role in what I became anyway, because I didn't grow up where there are a lot of medical doctors. Perhaps if I grew up where they are I would have become a medical doctor. But, like I said, I grew up in a place where veterinary medicine was practiced and my dad would also work there and his passion and his commitment. I said why not? But I knew that whatever I'd chosen to do, I would do better in it.

What's your favorite animal, favorite animal to work with?

Dog. I like dog because in my house right now I have a dog, I have a cat, my wife keeps poultry. I love animals.

Thank you for sharing. It's a very interesting story. Nathan, you mentioned that you specialized in infectious diseases and we touched briefly on LASA virus, so for our listeners, there might be some that know about LASA virus, but you also mentioned that LASA virus was discovered here in Nigeria. Can you tell the audience a bit about LASA virus? How do humans become infected And what does the disease look like in humans And what can be done to treat the disease?

Okay, before I dive into the issue of the LASA fever, because listening to Luka and Asala, they made reference to some historical perspectives. That has to do with either their parents or these things, and I realized that historical perspective it's very, very important in shaping one's career choice or many things in life. And my dad actually was a laboratory scientist and he is now over 87 years old. And do you know that he was the first person to have described how a mycobacterium tuberculosis baslite looks like? Yes, the pathogen, the jam that causes tuberculosis. So he would be describing to me and be telling me when I was young what they were doing, how they will use microscopes to make diagnosis of this disease, of syphilis, of gonorrhea, and he would even describe how they were doing autopsies, how they will cut skull and remove the brain and they will later stitch it back and nobody would know. And for me I just compared what they were doing that time with very short duration of training They were able to do so many things. So even that time, just listening to that, it kept on gradually increasing my desire to read medicine And he believed in me that this guy is very good and he will never fail anything. So to live to that expectation, i have to force myself to read extra hard so that failure will not be an option. So now talking about LASA fever. Lasa fever is an infectious disease, and an infectious disease that is caused by a virus. And why it is called LASA fever? Because the first disease that was eventually diagnosed in the United States first occurred in a white missionary who was working in a town in northeastern Nigeria called LASA So the actual name of the town is LASA And eventually the white missionary was lifted and brought to Plato State, nigeria, at the Evangel Hospital where she was initially managed, and after that several people came down with the disease. So if a patient has LASA fevers, there are some symptoms that the person will present. The first most common symptoms it will start with fever, then with sore throat and general body weakness, then, as time progress, then the patient will begin to bleed from the nose, at times from the gums, at times the person will be urinating blood, at times. Then the urine will begin to reduce until the kidney may shut down And the disease is transmitted through rodents. When someone either in the process of preparing because there are some areas that actually prepare rodents as delicacy So in the process of processing it to eat. Then there are some areas in Nigeria that spread dry foods outside and rodents could go and urinate or defecate on it. So if it is consumed it can also lead to LASA fever. But the most challenging thing about LASA fever is that it can be transmitted from human to human, and that's what pose a big challenge, both locally where it is and also the potential that it can be transported outside the country, because if someone is sick, or probably someone, may begin to have fever and eventually will travel to other parts of the country and eventually will now develop LASA fever and it will keep spreading. So essentially, this is the general picture of LASA fever.

So please correct me if I'm wrong, When I've never seen a LASA patient. When I read textbooks about LASA fever, some people say because it's classified with other hemorrhagic fever such as Ebola virus or Crimean Congo or other hemorrhagic fever virus. Some people say the hemorrhagic presentation is not as prominent as is with, like maybe some of the other hemorrhagic fever viruses. Do you agree or do you disagree?

Well, from what we have seen, there are several unanswered questions, because there are times I have seen many patients coming down with severe hemorrhagic disease. They will come with LASA fever within three, four days. They are hemorrhaging, bleeding everywhere and they are gone. And then there are patients that will come with mild symptoms and of course you know that over 80% of LASA fever may be asymptomatic, but even the 20% symptomatic, the severity varies And even within the same family who are exposed to the same environmental condition, who had human-to-human contact with LASA fever, you will see the husband may have LASA fever with hemorrhage and probably the wife will just have LASA fever with mild symptoms, and some may be asymptomatic. And you could see that in one part of the country you may have severe symptoms and in some other part there may be mild symptoms. So if one will just give a blanket answer that it doesn't have comparative hemorrhagic symptoms like other, then it is not the entire story.

Okay, what can be done to save the patient?

Well, the challenge with saving patients with LASA fever has to do with early diagnosis, early presentation to the hospital and the requisite training to the personnel, first on infection prevention and control and also on the management And, aside from that, the issue of compassionate care. I tell you I have seen lots of patients with LASA fever who have died because they presented a late and you would see the anguish that the family and the fear because it comes with double stigma. You will see that family, they have lost a relation because of LASA fever and they are stigmatized. They are also afraid that they may eventually come down with LASA fever. So there's so much psychosocial challenges. So they need a compassionate care of a physician And on the other side you have several healthcare workers who are afraid to take care of patients who have LASA fever. So now here you are. You have a relation who is dying of LASA fever and you have healthcare workers who are times. For realistic purpose, they need to wear appropriate gear before they could see. So even if someone is wearing the appropriate gear, the first marks, n95 marks and the gown the relation would expect the healthcare worker should just rush without the appropriate gear in order to attend to the patient. Then, on the other hand, there are several others who wouldn't want to have anything to do with LASA fever. I just give you one case. We were trying to give a training on one of the hemorrhagic fevers, so someone was in the ER a health worker who was saying come for training. I said no, no, no, no. I don't want to have anything with LASA fever or anything, but the person is still in the hospital. So I realized that there is always a gap regarding compassionate care, regarding human capacity development and regarding interest.

Nathan, you mentioned that there are healthcare workers that don't want to go into those rooms, that don't want to work with these patients. What about you? Are you not afraid?

Yes, you see, i wrote a paper and I published it locally and I said that healthcare environment is a war zone And there are several people who enroll into army and they go to wars. And if anybody that elists as a military person, it means that, yes, he knows that he will prepare for war. So and you say you are a clinician. That's one thing. I'm a clinician Then. The second thing is that I have the compassionate care based on my faith and belief in God that, yes, i need to help those who are suffering, i need to care for those who are weak. So anytime someone has suspected or confirmed LASA fever, there's a trigger and for me it's so gratifying The number of patients that I've treated with LASA fever if they see me, the gratitude you can never, ever compare it. The sense of satisfaction, the gratitude when orders, even their family relations, are running away from them, but I come to help them, care for them You can never compare that.

What about your family? What about your wife and your children? What do they think about when you go into those wards?

Yes, unfortunately there was one incident that another hell worker, who is walking, even in my hospital, went and was telling my wife and my family you see a husband, he's going to be seen patient with LASA fever when others are running away. He's not wise. He's not wise, he's a fool. But the good thing is that I have a very strong family, very supportive wife. I remember if it is because, yes, she knows that, yes, i'm reading medicine And even in the early part of marriage, when I'm on call, we will drive to the hospital together. She will be in the car, i will go and see patients and go back And I carried her through all that. I'm doing And anytime, for instance, even before I subspecialize, if I go to help a patient, i will come and report and say see what I have done, see how I have saved this. So she's a partner. Actually She's a partner, and there are several times that I will be needed to go to attend to a patient. It may be even through the night. There was a time that patient was really ill And I saw that before the hospital ambulance would come and pick me and I because it will take time. So I just drove through the night And that wouldn't have been possible if my wife said no. If she said no, i wouldn't have gone because I have a justifiable reason. So it's a good support. And I tell you there is no career, there is nothing that one will be successful without a good, supportive family.

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