Feature

Cholera: A story of waterborne infectious illnesses

It’s a public health disease concern,worrisome, say Profs. Babalola, Onajole

Fatalities dwarfed COVID-19 related deaths in 2021, common in slums –Others

Cholera remains a disease of public health importance in Nigeria associated with high morbidity and mortality. Drinking water, living in overcrowded environments and poor hand hygiene are significantly associated with the outbreak. According to medical experts, Cholera remains a global threat to public health and a key indicator of lack of social development, reports Isioma Madike

“It was Tuesday, November 26, 2021, and I was coming back to Mile 12, having made a detour from Ojota, to get my glasses,” recalled Adedeji, a resident of the Agility area of Mile 12, an outskirt of Lagos. While sitting in the taxi, Adedeji began to feel unwell, and had to rush to the bathroom. “I hurried to stop the driver so that he would stop,” continued the father of five children, who felt weak and without strength. Finding, nevertheless, the courage to walk, Adedeji arrived home but his condition was deteriorating. After minutes of diarrhea and vomiting, he went to the nearest primary health centre.

Worried by his condition, the nurse on duty referred him immediately to Ikorodu General Hospital, which is a few minutes’ drive from Mile 12. “Once there, the care began immediately”, explained Adedeji, who didn’t really know what was happening to him. For a whole week, medical teams took turns at Adedeji’s bedside and other patients in care at the hospital.

When his condition finally began to improve, Adedeji was able to go home. Recounting the near death ordeal, he said: “I have not yet identified the true cause of my illness, but I understood that we must use safe drinking water and wash our hands regularly. Since his return home, Adedeji ensures cleanliness in the house, and in the handling of cans and containers. He also ensures that water is always available at the entrance of the house and toilets as he now realises that what almost took his life is cholera. The disease, according to medics, is an acute diarrhea infection caused by ingestion of contaminated food or water. But, Adedeji’s case was not an isolated one.

Amaka, like Adedeji, didn’t know about cholera and its symptoms. She didn’t know anything until she fainted suddenly in her house. “I had diarrhea and began to vomit and then I fainted. I woke up in a health centre. I was told that I fainted, and some women took me there. I was embarrassed when I found out,” recalled Amaka with embarrassment.

She was taken to the health centre where she was diagnosed and received appropriate first aid. After that, the nurse at the centre informed the matron, who swiftly referred her to a general hospital within the neighbourhood. Without delays, she was attended to, as the doctors made sure the situation did not degenerate further.

Amaka said that she heard about people who had the same symptoms but wasn’t aware about them or their implications. She only goes out to fetch water and then returns home. She did not know about cholera and how to protect herself. She did not know how and when she was infected with the disease.

She could not answer the paramedics’ questions at the health centre when asked what she ate or where she drank water from. However, she did not realise that the water she brought from the village where she had travelled to for the Christmas, was the reason behind her infection. Cholera, medical experts say, is an infectious disease that causes severe watery diarrhea, which can lead to dehydration and even death if untreated. People, they also said, can get sick when they swallow food or water contaminated with cholera bacteria. The infection is often mild or without symptoms, but can sometimes be severe and life-threatening.

A Public Health Physician and the immediate past president of the Guild of Medical Doctors (GMD), Prof Olufemi Babalola, calls it a public health disease concern, which, according to him, is worrisome. He added: “Cholera is a waterborne infectious disease which tends to occur in outbreaks.

It is a disease of public health concern, which is easily preventable through the provision of wholesome and clean water to communities, preferably through pipe borne systems. That we are still having cholera outbreaks in Nigeria is a thing of concern and indicative of poor governance.

“The symptoms are watery diarrhea, cramps, vomiting, and rapid dehydration. If not treated, it can lead to death. It’s an infection of the small intestine by some strains of the bacterium vibrio cholerae. “Treatment is rapid replacement of lost fluid and electrolytes through ORAL REHYDRATION THERAPY (ORT) or intravenous drip. Public health measures include provision of pipe borne water and sanitary disposal of wet waste. “Cholera is an extremely virulent disease that can cause severe acute watery diarrhea.

It takes between 12 hours and five days for a person to show symptoms after ingesting contaminated food or water. It affects both children and adults and can kill within hours if untreated. “However, most people infected with it do not develop any symptoms, although the bacteria are present in their faeces for 1-10 days after infection and are shed back into the environment, potentially infecting other people. “Among people who develop symptoms, the majority have mild or moderate symptoms, while a minority develops acute watery diarrhea with severe dehydration.” Bayo Onajole, another Professor of Public Health and Epidemiologist at the Lagos University Teaching Hospital (LUTH), Idi-Araba, agrees that cholera is a public health disease concern. Onajole however, said the disease has always been with us because “our hygiene has been poor in so many ways. Our food hygiene and personal hygiene are poor.

“Cholera is a bacterial disease that is caused by the vibrio cholerae. There are different types depending on the location. It is a faecal-oral transmission. This means that it is the contamination of faecal material from infected persons into the water or food that others consume and therefore they contact it.

“A major symptom of cholera is frequent watery stool and this tends to lead to severe dehydration over a very short time. Dehydration means the water in the body is low. When you have dehydration, it will lead to what we call electrolyte imbalance; potassium and others are excreted through the stooling and if it is not replaced, it tends to cause malfunction of various organs.

“The most important thing for prevention of cholera is to maintain good hygiene. Good hygiene includes a place of faeces disposal so that it does not contaminate the source of water. It is also important that we maintain personal hygiene. “Personal hygiene means that when we go to the toilet we wash our hands with soap and water. You can also maintain hygiene by washing your hands before you eat or put anything in your mouth. “For those who end up getting it, the most important thing that they need to do even before they go to see a doctor is to prepare the ORS; Oral Rehydration Solution. This replaces the electrolyte that is lost by the body.

“Even if the person is still vomiting and stooling, he has to take the solution. In the hospital they may need to be placed on antibiotics and depending on the severity of the water or food loss, the individual may be put on IVC. “If somebody who is infected prepares food, he/she may contaminate the food.

It is better to eat our food hot so that it does not allow the bacteria to multiply to that extent where it will cause infection. Basically that is what we need to do to reduce the spread of cholera, especially for children. “For children, about 70-80 per cent of their body mass is water and if a child loses so much water, the organs will shut down and the child will die. “However, the fatality depends at what point you pick it. If you make an early diagnosis and take the necessary measures, and also take antibiotics, more people will survive.

If you wait for too long, the fatality rate will depend on what point the treatment began at.” Onajole nonetheless said that Cholera should be prevented more by individuals and community rather than by government. This, according to him, is because if we do what we are expected to do, we will not come down with cholera. Early diagnosis and prompt treatment, he also said, should be in place. “Government can attend to it in three dimensions; increase the awareness and knowledge about cholera, transmission and preventive measures. It should also try to make provision for adequate potable water for drinking so that people have access to safe water.

“Three, the government should ensure that a lot of the primary healthcare centres have electrolyte and antibiotics in stock to manage the disease.” Also, Dr. Japhet Olugbogi, Public Health Physician, and chairman, committee on infectious diseases, Lagos NMA, has said that fatalities from cholera in 2021 dwarfed COVID-19 related deaths within the same period. Cholera, he insisted, is a very deadly disease, a bacterial disease, and an infectious disease in that it’s communicable from one person to another.

“So, unlike COVID-19 and other diseases, cholera has to deal with what you put into your mouth, when people consume bad water, water that is impure, use cutlery that is not washed or adequately washed, plates, utensils. “Even the tips of bottled water, tips of canned malts or plastic drinks, pure water that was soaked in bad water, all these are some things that can cause cholera because it is transmitted through the oral route unlike COVID-19.

“What I mean by faecal route is that when faecal matter stains all those items that I mentioned earlier, even the tips of our fingers, you put them in your mouth, and the person can have cholera. Now, people who have cholera, you can know them when they start defecating and vomiting and the faecal matter looks like rice water, and the individual defecates on so many occasions within a short interval.

“When they do that they are losing water from the body, losing electrolytes from the body, and before you know it the individual gets tired, weak and fatigued. If that defecation continues and the vomiting continues, the individual continues to lose all their strength and before you know it, the individual can pass away.

That is why it kills even much faster than COVID-19 or malaria. Cholera can kill somebody in one day and in hours. “And if you are catering for somebody who has cholera, the person needs to be very careful, when you leave in a house where somebody who has cholera stays or you are in a hospital or ward where somebody who has cholera, everybody around needs to be very careful because the vomitus and the faecal matter are very contagious.

“When somebody is passing stools that are watery you don’t know when such faeces stains the surfaces and when individuals who cater for them use their hands to touch the bed linings or the clothing around. “So, cholera can be transmitted when people who cater for those who have it, people who share an apartment or room or house with somebody who has cholera are.

People who had cared for them in the hospital can also develop cholera if care is not taken because it is very highly contagious. When one has cholera, doctors will need to give an IV fluid, which is called drip.” Olugbogi added: “There are special drips for it to replenish the water that the individual is losing because as the individual is losing water from the body, they are losing electrolytes and are losing a lot of minerals from the body that naturally give energy to the body. That is why you see them look as if they have been sick for several years after a few hours when they have cholera.

“So, cholera is very dangerous and it’s usually commoner in slums, the outbreaks usually occurs in slums where they don’t have WASH services like water and sanitation and hygiene services, places where they don’t have toilets, places where they do what we call short put or open defecation, or people who have the habit of passing stool inside nylon or some containers and discard them in drainages or even throwing them into bushes. “These are the areas where cholera usually breaks out because when it rains, what happens is that the rain water, the flood wash this faecal matter into the homes, into the water sources and before you know it they start having cholera. There are some areas in Lagos where cholera broke out last year and we found that there are shallow drains there.

“Apart from that the pipes that carry water from some boreholes or from some tanks that are makeshift boreholes pass through drainages and you would see that some of them are already leaking and black rubbers were used to tire them.

“This is a recipe for disaster, such a habit is a recipe for cholera outbreak and it happens in so many places in Lagos. So, what we do is to advise those who have shallow wells in their areas where they use to cook or drink to insure that they boil these water, even tap waters, they should boil them and allow then to cool down and sift them before they consume them or before they use them to do anything or taking to the mouth. “Apart from that, landlords in many places need to plan to have proper drainages and sink proper boreholes and to have toilets when they build their houses. A lot of people build houses; they don’t make plans for these services.

“Cholera is real and we all need to create a better society for these vulnerable children and for all those other people that are vulnerable to ensure that they do not get killed by a disease that should not ordinarily kill them.” Executive secretary of the Nigerian Academy of Science (NAS), Dr. Doyin Odubanjo, also said that many diseases are killing more people than COVID-19, such as we see with the stats on cholera. Cholera, he also said, is very deadly and can kill, through severe dehydration/ shock, within a few hours if not managed quickly. The main symptom, he said, is severe diarrhea with what is characterized as ‘rice-water stool’.

“It’s prevented by ensuring proper hygiene (including hand washing) and potable water. It is transmitted by somehow ingesting the causative organism (in liquid or food),”he added. The onset of cholera, according to the experts, often starts with stomach cramps, vomiting and diarrhea, and if left untreated may progress to fluid losses of up to 1 litre per hour, resulting in severe dehydration and metabolic acidosis, and consequently kidney failure, shock, coma, and death. About 50 per cent of cholera cases, they said, are asymptomatic.

Asymptomatic cases, according to them, shed vibrios in their stools, and serve as a potential source of infection to others. Symptomatic patients, they also said, may shed vibrios before the onset of illness and will continue to shed the organisms for about 1 to 2 weeks.

Cholera is transmitted through the faecal-oral route via contaminated food, carriers and unsanitary environmental conditions. Its outbreaks tend to occur as a result of contamination of food or water with vibrio cholera organisms due to poor personal hygiene, unsafe environmental sanitation conditions, compounded by lack of potable water supply, especially in slums. Fatalities from the cholera outbreak in 2021, the experts further said, doubled the number of COVID-19 related deaths in the same period. According to the World Health Organisation (WHO), cholera is an acute diarrhea disease that can kill within hours if left untreated.

It is estimated that there are about four million cases of cholera every year — and up to 143,000 deaths worldwide. Since March 2021, cholera cases are said to have increased substantially in Nigeria, with cases recorded in 32 states, including the Federal Capital Territory (FCT). Speaking recently on Channels Television, Ifedayo Adetifa, director-general of the Nigeria Centre for Disease Control (NCDC), confirmed that cholera has taken more lives than COVID-19 in 2021. He said: “Sadly, cholera has actually killed more people than COVID-19 so far. We have had a little over 3,600 deaths from cholera from the beginning of the year to date.”

Data from the NCDC also showed that 1,289 people died of COVID-19 between February 2020, when the country recorded its index case, and December 2020. As of December 1, 2021, the number had climbed to 2,978, representing an increase of 1,689 or 131 per cent. On the other hand, the latest cholera outbreak had killed 3,566 Nigerians as of November 21, 2021, according to NCDC’s epidemiology report. Further analysis shows that casualties from cholera in 2021 alone surpassed recorded COVID-19 related deaths in almost two years. Adetifa said the NCDC is “working behind the scene to mitigate the spread of cholera, as the public attention is more on COVID-19 than other diseases. Nobody actually knows that we have teams out in five, six states now that have good cholera response. We’ve had rapid response teams in all of the states that have had cholera outbreaks,” he said.

 

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