“Curtail and contain” is new rule as cholera outbreak worsens with rains

The rains are here, and so is cholera. In the last one week alone, 832 suspected cases of cholera have been reported from across 16 council areas in six states, according to weekly epidemiological reports from the Nigeria Centre for Disease Control. Eight cases proved positive for cholera, and eight people died. The figures in […]

The rains are here, and so is cholera.

In the last one week alone, 832 suspected cases of cholera have been reported from across 16 council areas in six states, according to weekly epidemiological reports from the Nigeria Centre for Disease Control.

Eight cases proved positive for cholera, and eight people died.

The figures in the preceding week were even bleaker: 190 cases in 11 council areas in seven states; 17 positive for cholera; 17 dead. This time last year, only three cases suspected to be cholera were reported, from Kaduna south.

At least 5,659 infections suspected to be cholera have been reported since January. In total, the reports have come from 61 local government areas across 19 states. 

Among them, 162 reports tested positive for cholera—and 84 of the patients died. This time last year, only four people died among 85 suspected cases of cholera across 11 states.

Latest outbreaks have been reported in Adamawa, Bauchi, Borno, FCT, Kaduna, Kano and Zamfara, with bases ranging from 100 in Adamawa to just the one in FCT and Zamfara.

The numbers are increasing, and the spread of the disease is widening—thanks to a lethal combination of uncontrolled sewage disposal, open defecation, and rainfall.

Both the NCDC and the World Health Organisation have issued warnings about cholera spreading more during rains. NCDC issued tips about how to prevent it; WHO warned the outbreaks could spread even more with rains, if they are not tackled quickly.

It is not a hidden fact. Epidemiological data over years shows through history that acute diarrhoeal cases rise when rains begin, says Ifeanyi Okodu, of health emergencies at WHO.

“Having this knowledge helps collaborations to put down preparedness plan and preposition supplies, train health care workers, set up efficient surveillance to pick this and respond,” he says.

The victims of Girl Government Secondary School cholera outbreak admitted at Kawo General Hospital Kaduna. pic by Shehu K. Goro

Years of insurgency attacks and military campaigns have crippled badly beaten health services across the northeast.

Humanitarian and development efforts have been on since the military managed to drive Boko Haram into a corner to try and revive health systems.

Last year, Borno faced an outbreak of cholera—but experts believe the epidemic has served as a lesson to contain the current one.

“We are at a stage where we are seeing more outbreak. It is rainy season, and this is what we often see because cholera is endemic,” says says Adeolu Alakija, convener of a dialogue early this week on humanitarian development and peace nexus on the northeast.

“Cholera is not just about medicine, it is about water and vaccination.”

Last year, combined efforts facilitated the vaccination of 915,000 people against cholera.

“This year, we are hoping we are able to curtail this before it gets to that stage,” says Alakija.

Response to the outbreak has been massive. The United Nations approved N720m through the Nigerian Humanitarian Fund to manage the outbreak in Yobe.

Groups like Medecins Sans Frontieres, which first reported pockets of outbreaks have helped set up treatment centres. After that, attention has widened to trace sources of infections and individuals that patients infected may have been in contact with. Another dimension is water source—and likely sources of infection.

The ease of spread of cholera is tied to the lifestyle of communities. Many people infected with cholera-causing bacteria Vibrio cholera do not develop any symptoms. But the bacteria is present in their faeces up to 10 days after they are infected and is shed during defecation back into the environment.

This is where the rains come in. Water mixes up the bacteria in sand, and rainfall moves things around. So the bacteria end up in areas far away and possible where open defecation isn’t a problem but water source is. Then a new outbreak begins.

Response has been so active, at least 25 different teams of 13 members each are working with Borno state government alone to ensure they “curtail and contain” the outbreak, according to Ngozi Azodoh, director of special projects at the federal health ministry.

“It is not something that the health sector alone can deal with. The health commissioner is working with other sectors, as water, to ensure we don’t keep going through this cycle.”

It is a lesson learnt from last year’s outbreak, says Rex Mpazanje, who represented WHO country director Wondi Alemu on a panel at the dialogue convened in Abuja on the north east.

“Cholera in Borno and Adamawa is being responded to,” he said. “Last year, it took longer. This time we have upfront deployed the capacities necessary to contain the cholera situation. We trace every contact, the source of infection and control sources, and manage every person afflicted in treatment centres. This is being done heavier up front that it was last time we had cholera in this area.”

Response to the outbreak, in addition to treating patients, has moved on active tracing of infection routes and chlorination of water sources. NCDC speaks of plans for a nationwide campaign with the federal ministry of water resources and partner agencies.

The disease kills an estimated 143,000 people around the world, according to some estimates.

Six in 10 of those deaths occur in sub-Saharan Africa. It comes with acute diarrhoea, which can kill within hours if left untreated.

The victims of Girl Government Secondary School cholera outbreak admitted at Kawo General Hospital Kaduna. pic by Shehu K. Goro

Cholera has a clear link to water, sanitation and hygiene. It can be treated, but it can also be prevented. A new study has been considering targeted vaccination guided by the risk factors for cholera.

It concludes that better targeting anti-cholera efforts at district and neighbourhood levels could much more effectively reduce the burden of the disease.

For the study, researchers collected datasets showing locations of outbreaks in 37 African countries from 2010 to 2016. The cholera cases averaged 141,988 cases, and researchers in a study published in the Lancet, mapped them down to “hotspots” of infection.

Each grid on the map was equivalent to some 20-square kilometers on land. By targeting the worst hotspots, vaccination would reach the most-at-risk areas.

And the researchers are also looking to develop a global map updated real time at each reported infection.

 “We really want to understand where we could go to have the greatest impact in vaccinating populations at risk,” says Duncan Steele, deputy director and strategic lead for enteric vaccines in the Enteric and Diarrhoeal Diseases team of the Bill & Melinda Gates Foundation.

Born in Zimbabwe, with time spent in Tanzania, Steele has seen outbreaks of cholera in both countries. In one outbreak in Tanzania, schools shut down, routine immunisation clinics for children and family planning clinics for women closed because the healthworkers were needed to help address incoming cases from the outbreak, Steele recalls.

Spending N720m on cholera control is a cost-effective intervention, he says. “It is not only preventing illness for people involved but it also has a broader impact on social populations around it.”

Think of the cost of illness and lost wages, economic disruptions and hospitalization expenses.

With rains again, 18 states are battling an outbreak of cholera. The difference is more people have died already than this time last year. Only quick “curtail and contain” move might mark real change.

Need to know: Symptoms of cholera

Cholera causes severe acute watery diarrhoea. It takes between 12 hours and 5 days for a person to show symptoms after ingesting contaminated food or water. It affects both children and adults, and can kill in hours if untreated.

Many infected do not show symptoms but excrete the bacteria in their faeces up to 10 days after infection.

Defecation shed the bacteria into the environment, potentially infecting other people.

Among people who develop symptoms, the majority have mild or moderate symptoms, while a minority develop acute watery diarrhoea with severe dehydration. This can lead to death if left untreated.