Nigeria has experienced several cholera outbreaks characterised by high Case Fatality Rates (CFRs). Yet evidence on the recurrent epidemic of cholera required for designing and implementation of appropriate interventions towards eliminating the scourge in the country seem lacking. CHIJIOKE IREMEKA reports that the resurgence of cholera with 72, 910 cases and 2, 404 deaths in 27 states of the federation and the Federal Capital Territory (FCT), is a worrisome public health crisis amid highly infectious Delta variant of COVID-19
…as 2021 outbreak surpasses 30 years record of 59, 478 cases
•Cholera is preventable, treatable but deadly, says NCDC
•Laying drinking water pipes in drainages, a risk factor
“Cholera is a deadly disease that kills without looking back. I lost a niece to Cholera. Its fatality rate is very high. By the time my sister could get help, the child was gone. It hurts me because I watched her die helplessly,” laments a mother, Mrs. Patience Chigozirim, who didn’t know what to do to stop her niece from dying.
According to Chigozirim, the most hurting part of the situation remained that she was helpless to the child, saying that she didn’t know the child was struggling with Cholera until she was confirmed dead by a doctor the next morning.
She thought it was a normal stomach upset and perhaps, food poisoning that would stop naturally or after administering raw pap to the child, which was the only medication she could think of that night as well as homemade oral drip. She narrated her experience: “I was hoping and believing that she will soon be well without thinking of death.
And because the sickness started at midnight, at about a few minutes past 1am, there was really nowhere to get help until she eventually died. “Initially, I was calming my sister down, reassuring her that her baby will soon be alright, else, we took her to the pharmacy in the morning, not knowing she was going to die. Death was the least on my mind,” she said. “My sister just gave birth at Enugu, in Enugu State and so, I went to help her as our mother wasn’t too strong for the stress.
While I was sleeping that fateful night, she woke me up while I was with her new born, and said her daughter was dying. “She was pooping and vomiting. I tried salt and sugar as an oral drip but it didn’t work as she kept throwing it up. I gave her raw pap to stop the purging but she wouldn’t drink it. We struggled like that waiting for the day to break but we didn’t know the morning would be too far,” she lamented.
“My younger sister, Veronica, became uncontrollable, crying when the situation was, indeed, frightening. We lost the three-yearold girl. It was horrible. It was a sad story. Cholera is bad. Doctor said that a severe one can even kill within three hours,” she added.
Thus, Nigeria, as a country, has witnessed and had been combating Cholera outbreaks with high CFRs since 1991 and there’s little or no progress in sight if the country will still experience cases above what was recorded 30 years ago despite touted interventions by the government and others.
Ideally, after three decades of the protracted war against Cholera, Nigeria shouldn’t be recording large-scale outbreaks and not even surpassing the figures recorded in the past when there was no access to education and other conditions necessary for the successful war against the disease as Cholera is 100 per cent preventable, experts have said.
They held that the country’s over 30 years’ experience in battling Cholera would have given her an ample opportunity to nip the disease in the bud by developing suitable strategies towards eliminating this menace, lamenting that successive and respective governments and their agencies were not alive to their responsibilities.
According to them, it’s more worrisome when the conditions that lead to the disease are all preventable, insisting that the government is currently doing little to end Cholera, which has inflicted a huge emotional and economic pain on the country.
This is, also, as medical experts and other stakeholders in the country charged the National Emergency Management Agency (NEMA), to proactively collaborate with the Federal and State Ministries of Health towards providing round-the-clock emergency medical assistance to communities affected by the epidemic as a way of curbing its further spread.
More so, with a total of 72,910 suspected cases and 2,404 deaths (CFR 3.3 per cent) in 27 states and Federal Capital Territory (FCT), the 2021 outbreak has surpassed the peak record of 1991, 30 years ago, where a total of 59,478 cases were recorded with 7,654 deaths as well as Case Fatality Rate (CFR) of 12.9 per cent.
Though the 1991 outbreak recorded more deaths (7,654) as against 2, 404 deaths recorded currently, medical experts and others are worried that the current outbreak may beat the record set by the 1991 outbreak earlier if the government continues with its laissez faire attitude.
They reasoned that with the coming on board of the Nigerian Centre for Disease Control (NCDC) and information at hand on infectious disease control, any serious government would not allow a repeat of such plague on her populace almost on yearly basis, which signposts the governments’ failure over the years.
According to the NCDC’s Cholera outbreak cumulative epidemiological summary as at September 12, 2021 (Week 36), of the suspected cases since the beginning of the year, age group 5 – 14 years, is the most affected age group for male and female. The report reads in part: “Of all suspected cases, 50 per cent are males and 50 are females. Twenty-seven states and FCT have reported suspected cholera cases in 2021.
“They are Abia, Adamawa, Bauchi, Bayelsa, Benue, Borno, Cross River, Delta, Ekiti, Enugu, FCT, Gombe, Jigawa, Kaduna, Kano, Katsina, Kebbi, Kogi, Kwara, Nasarawa, Niger, Ogun, Osun, Plateau, Sokoto, Taraba, Yobe, and Zamfara.
“In the reporting week, 13 states reported 1,182 suspected cases – Bauchi (472), Katsina (194), Borno (106), Jigawa (95), Yobe (80), Kaduna (68), Adamawa (63), Sokoto (38), Gombe (34), Abia (13), Taraba (10), Ogun (8) and Niger (1).
“There was a 58 per cent decrease in the number of new suspected cases in week 36 (1,182) compared with week 35 (1,677). Bauchi (472), Katsina (194) and Borno (106) accounted for 65.3 per cent of 1,182 suspected cases reported in week 36.
“During the reporting week, 48 Cholera Rapid Diagnostic Tests were conducted. RDT tests conducted were from Gombe (30), Adamawa (11), Katsina (3), Kaduna (2) and Abia (2). Of this, a total of 18 (38%) were positive by RDT. “A total of 10 Culture tests were conducted in Katsina (6), Adamawa (3) and Kaduna (1).
Of this, 2 (20%) were positive. Of the cases reported, there were 23 deaths from Kaduna (6), Adamawa (5), Katsina (4), Gombe (2), Jigawa (2), Bauchi (1), Borno (1), Ogun (1) and Taraba (1) states with a weekly case fatality ratio (CFR) of 1.9 per cent.
“Two new states (Abia and Ogun) reported cases in week 36. The national multi-sectoral EOC activated at level 02 continues to coordinate the national response.
“Three states of Bauchi (18,822 cases), Kano (10,187 cases) and Jigawa (9,300 cases) account for 53 per cent of all cumulative cases while 10 LGAs across 5 states (Bauchi (4), Jigawa (2), Zamfara (2), Kano (1) and Katsina (1)) have reported more than 1,000 cases each this year.”
Sunday Telegraph learnt that the outbreak is said to be exacerbated by poor access to clean water, open defecation and poor sanitation and hygiene.
According to the NCDC, Cholera is a waterborne disease with a high risk of transmission, and higher when there is poor sanitation and disruption of clean water supply, saying that practices such as improper disposal of refuse and open defecation endanger the safety of water used for drinking and personal use.
The agency noted that these practices increase the spread of water-borne diseases such as cholera, insisting that without proper Water, Sanitation and Hygiene (WaSH), Nigeria remains at risk of cholera cases and deaths.
In order to address the underlying issues in the long term, the agency said there is a need for access to safe drinking water and maintenance of proper sanitation and hygiene, while the NCDC continues to advocate for states’ prioritisation of actions that ensure access to and use of safe water, basic sanitation and good hygiene practices in communities.
In its report, the NCDC advised Nigerians to visit a health facility immediately if they experience a sudden onset of profuse watery diarrhoea, nausea, vomiting and weakness, saying that Cholera is preventable and treatable but can be deadly when the infected do not access immediate care.
NCDC activated the National Cholera Emergency Operations Centre (EOC) on June 27 and deployed rapid response teams to support the most affected states, but warned that those actions will not be enough as none of these medical interventions will solve the underlying issues leading to cholera outbreaks.
Recall that barely eight years after the 1991 cholera attack, the country witnessed yet another outbreak in March, 1999 in Kano State with cases spreading to Adamawa and Edo states and by May of that year; the outbreak resulted in 26,358 cases and 2,085 deaths. Sunday Telegraph learnt that from January to December 2010, Nigeria reported 41,787 cases and 1716 deaths (CFR 4.1%) across 18 states.
The last major cholera outbreak prior to 2018 was in 2014, during which the number of cases recorded surpassed over half of the number recorded between 2012 and 2013 as well as between 2015 and 2017. In line with global evidence, it was learnt that the Cholera’s burden in Nigeria is likely underestimated due to factors ranging from differences in case definitions and completeness to social, political, and economic disincentives for reporting Cholera.
Nonetheless, in response to the increasing global Cholera burden, the Global Task Force on Cholera Control (GTFCC), in 2017, launched the Global Roadmap Strategies which seek to reduce Cholera-related deaths by 90 per cent as well as eliminate Cholera infections in, at least, 20 out of the 47 endemic countries by 2030.
Despite deploying Oral Cholera Vaccines (OCVs) in Cholera hotspots, predominantly in the northern states – Borno, Bauchi, Yobe and Adamawa – as a fundamental step taken towards attaining these goals, certain professionals are of the opinion that the effort is still below the benchmark as evident in 2018 outbreak.
This has reaffirmed the serious public health threat of Cholera and, importantly, the need for the country to adopt holistic countermeasures to end the colossal loss of lives to these routine outbreaks. A medical doctor and a consultant surgeon, Dr. Ngozi Okafor, said after over three decades of battling Cholera and the lives lost to the disease, Nigeria shouldn’t be recording such large-scale outbreaks, insisting that Cholera is 100 per cent preventable.
She noted that the conditions that bring about the disease are all preventable, if the governments and its agencies have the genuine will towards ending this disease of the poor, lamenting that the country is not doing enough to eliminate high fatality rate.
She said: “The practice of open defecation, careless waste disposal or sewerage and drinking of water from contaminated sources should be discouraged through the provision of access to potable water and aiding regular hand washing and safe food practices.
“Again, laying drinking water pipes is a bad and dirty practice that should be discontinued.
The defenselessness to Cholera is allied with demographic and socioeconomic factors, including age and nutritional status. Malnutrition drives transmission and severity. Vitamin B12 deficiency and gastritis are risk factors for infection.”
Okafor noted that the bacteria that causes Cholera are expelled through the faeces for nearly two weeks after infection, saying that they can be shed into the environment to infect other people where no access to potable water, good personal and environmental hygiene are lacking.
Infection also occurs when people eat or drink something that’s already contaminated by the bacteria. Evidence from the 1995-1996 outbreaks in Kano revealed that poor hand hygiene before meals and vended water played a role including population congestion. Living in urban and semi-urban slums promotes Cholera too,” she added.
This, she noted, can happen through migration to commercial hubs such as Kano. It can also happen when humanitarian disasters force displaced people to live in camps.
There, they often have inadequate water supply and may be unable to observe good sanitary practices. According to the World Health Organisation (WHO), Cholera is an acute watery diarrhoeal disease caused by the ingestion of food or water contaminated with the toxigenic strains of Vibrio Cholerae Serogroups O1 or O139.
It’s often characterised by watery diarrhoea, with or without vomiting, and severe dehydration, which results in death if not treated immediately. The world body stated that CFR from untreated Cholera can be as high as 30 to 50 per cent, but prompt administration of rehydration therapy can reduce it to as low as one per cent. WHO reports that, “The global estimates for Cholera cases and deaths are about 2.9 million and 95,000 per year, respectively, disproportionately affecting sub-Saharan African countries, especially since the onset of the seventh pandemic in 1961.
A total of 17 African countries, for instance, recorded over 150,000 cases in 2017 from all Cholera outbreaks.
“In its most severe form, Cholera is one of the most fatal illnesses known because infected patients may die within a few hours if medical treatment is not provided. Every year, there are 1.3 million to 4.0 million estimated cases of Cholera and 21,000 to 143,000 deaths worldwide. Nigeria is among countries that are hard-hit annually.”
In Niger State, over 100 people have died of Cholera outbreak across the 25 local councils in the state, from April to date. The State Commissioner for Health and Hospital Services, Dr Mohammed Makun- Sidi, disclosed that the rate of open defecation and waste disposal attitude of citizens, especially the rural dwellers, is responsible for the annual menace of the disease. MakunSidi also cautioned the people of the state on the preventive measures to contain the disease.
The Commissioner advised those infected to seek for medical services from the public health services in their communities immediately symptoms occur.
As of August, Kogi State announced the death of eight people with 129 confirmed cases. This was disclosed in a statement by the State Ministry of Health, and Dr Austin Ojotu, the State Epidemiologist, in Lokoja, saying that cases were recorded in Kogi, Bassa, Lokoja, Ankpa, and Kabba -Bunu council areas. The State Epidemiologist said cases were recorded between February and August, adding that, “seven communities were affected in the aforementioned council areas with 129 cases.
“These are border communities with hard to reach terrains,” he said, adding that 66 of the Cholera cases were recorded in three communities in Kogi, Lokoja and Ankpa Local Government Areas, where all the eight deaths were also recorded.
“It is important to mention at this point that most of the deaths have occurred before the reports got to the local government/state authorities. “Our findings also revealed that the majority of the deaths in all the outbreaks occurred at home,” the statement said. Speaking on the treatment of Cholera, a family physician, Dr. Bayo Ogunbumi, said it is dehydration that causes death from Cholera, saying that the mainly significant treatment to give is oral hydration solution (ORS), also known as oral rehydration therapy (ORT).
He noted that the treatment consists of giving large volumes of water mixed with sugar and salts as a home-based treatment, saying that pre-packaged mixtures are commercially available. “I expect every mother or every household to have this at home because some of the sicknesses that kill without mercy come at night when you can’t go anywhere.
But if you have the emergency drugs at home, when the sicknesses come, you will be well positioned to fight back. “By emergency drugs, I mean, depending on your body and the medical history of your household. Anti malarials, paracetamol, pain relievers, BP drugs, ORT or ensure you have sugar and salt to make your own, cough syrup for children, septrin for the heart and others.
“Severe cases of Cholera require intravenous fluid replacement. An adult weighing 70 kilogrammes will need at least 7 litres of trusted source of intravenous fluids. Antibiotics can shorten the duration of the illness but the WHO does not recommend the mass use of antibiotics for Cholera because of the growing risk of bacterial resistance.
“Anti-diarrheal medicines are not used because they prevent the bacteria from being flushed out of the body. With proper care and treatment, the fatality rate should be around 1 per cent.”
However, to reduce the risk of Cholera, former NCDC’s Director General, Dr. Chikwe Ihekweazu, advised the masses to ensure that water is boiled and stored in a clean and safe container before drinking. He advised: “Practise good personal hygiene by washing your hands frequently with soap under clean running water.
Use alcohol-based hand sanitiser if soap and clean water are not available. Ensure that food is well cooked before consumption. Avoid raw food such as fruits and vegetables, except you have washed them in safe water or peeled them yourself.
“Avoid open defecation, indiscriminate refuse dumping and ensure proper disposal of waste and frequent clearing of sewage.
“If you experience sudden watery diarrhoea, please do not self-medicate, visit a health care facility immediately and take all sick persons with the signs or symptoms above to a health care facility immediately “Healthcare workers are advised to practice standard precautions at all times – wearing of hand gloves while handling patients or providing care to an ill patient/relative.”
On the interventions aimed at eliminating the diseases, the NCDC had deployed National Rapid Response Teams (RRTs) to six states experiencing high levels of community spread: Benue, Kano, Kaduna, Zamfara, Bauchi, and Plateau as well as supports the ongoing nationwide surveillance through the routine Integrated Disease Surveillance and Response as well as Event Based Surveillance.
In other affected areas, international partners such as UNICEF and the International Organisation for Migration have supported the airing of public health messages about water sanitation, good hygiene, and Cholera in English and local languages to build social mobilization, distribute information, and initiate in-person awareness campaigns within smaller communities.
Led by the Federal Ministry of Water Resources, it was learnt that the government has provided 510,663 litres of water daily in 39 locations in Adamawa State, which accounted for 50 per cent of Cholera cases in 2019. It has also provided mobile solar-powered boreholes.
The International Organisation for Migration maintains 58 solar-powered boreholes in Borno State and drilled 11 new ones in 2019.
It also rehabilitated 10 and connected them to solar power. Also, in response to an outbreak at the displaced persons’ camps in Borno State in 2017, the National Primary Healthcare Development Agency and other partners conducted an oral Cholera vaccination campaign.
In 2017, reactive oral Cholera vaccine campaigns were implemented in Borno to stop an outbreak. Investments in water, sanitation and hygiene infrastructure are always necessary.
The oral Cholera vaccine is not a part of the routine vaccination in Nigeria. Sunday Telegraph found out that it is not 100 per cent effective against Cholera and does not protect against other foodborne or waterborne diseases. It is not a long time solution to Cholera and only bridges the gap between emergency response and long time Cholera control. UNICEF has promoted chlorination of water among communities in Cholera hotspots.
This has benefited an estimated 4.5 million people in Borno, Adamawa and Yobe states, including 680,000 displaced people in urban centres. Meanwhile, much remains to be done since Cholera has not been conquered completely. Cholera has been described as a “disease of poverty” because social risk factors play significant roles in its transmission. Regular health education during and after outbreaks is necessary. Community engagement would help to identify people who would be responsible for timely reporting of suspected cases of Cholera.
The teams that manage outbreaks at the local, state and federal levels should be well coordinated and respond swiftly when notified of a Cholera outbreak. These steps have been seen to work in South Sudan and Tanzania but require political will to get different sectors to collaborate.