Three multi-country epidemics are ongoing - each with separate strains: the Lake Chad Basin, affecting Chad, Cameroon, Nigeria and Niger; the West Congo Basin, with impacts in the Democratic Republic of Congo (DRC) and the Central African Republic; and Lake Tanganyika - which encompasses DRC and Burundi. In Chad and Nigeria, the epidemic started in 2010.
Why so persistent?
“If something is not working, you have to question if the response is appropriate,” said David Delienne, water and sanitation adviser at UNICEF’s West Africa office. “To stamp out cholera you need good surveillance systems to identify the epicentres of the disease - these do exist but it in some places surveillance is not systematic enough.”
Surveillance systems along the (very long) Nigeria, Cameroon and Chad borders are generally quite patchy, said Grant Laeity, emergency head for UNICEF, as the areas are so remote, with few health facilities, and tend to be far from the nearest administrative capitals (Abuja, Yaoundé and N’djamena, respectively). Some remote areas, such as north and northwest Cameroon, have very high case fatality rates of up to 22 percent, according to the World Health Organization (WHO).
According to WHO, five countries - Ghana, DRC, Nigeria, Cameroon and Chad -account for around 90 percent of the total number of cases and deaths.
The epidemic is the worst in Chad’s history, with 16,000 cases and 433 deaths. The country’s vast territory, and large-scale population movements, makes it hard to respond to each and every case, said Michel-Olivier Lacharité, programme director for Chad at Médecins Sans Frontières (MSF) France.
In remote health districts where there are only two or three cases, MSF, which alongside the government has treated 11,000 people thus far, may have to forgo treating them, prioritizing higher-density caseloads.
But even a small number of cases can cause the disease to spread further. “If it were a camp for displaced people, where no one was going anywhere, it would be a lot easier to contain,” Lacharité pointed out.
Over half of Chad’s health districts have been affected thus far.
“This disease is a paradox,” said Lacharité, “as it is very easy to treat with generic antibiotics and rehydration fluids.” But equally, it is very easy to spread, particularly since carriers often do not know they are infected, he said.
In northeastern Nigeria containing the disease has been hampered by high population density, and by sporadic conflict which has left health clinics empty in some districts, according to Laeity.
All of the affected countries have poor water and sanitation facilities, and none are on track to meet the Millennium Development Goal for basic sanitation. While there is more awareness of the need for better water and sanitation in the region, it has not necessarily led to changes in funding and behaviour, said Delienne. “Ghana, Mali have made some efforts…but overall, it [progress] needs to accelerate.”
Preventing cholera from spreading does not have to be complicated: setting up systematic information-sharing systems across borders to identify cholera “hotspots” is effective; as are practical measures such as encouraging hand-washing at borders, or disinfecting boats crossing to and from DRC capital Kinshasa to Congo-Brazzaville capital Brazzaville.
The governments of Guinea and Guinea-Bissau eventually set up effective information-sharing at the border, and encouraged those crossing to wash their hands, acts which contributed to the eventual decline in caseload.
But setting up a sanitation-police system at the border does not really make sense, said MSF’s Lacharité, partly because it would be so hard to administer.
Questions authorities need to ask include: “Is there enough water treatment going on in cholera hotspots? Is there adequate separation of drinking water from sewage systems? What kind of border checks are set up?” said Laeity.
In late 2010 UNICEF undertook a study to identify the key cholera hotspots and how the infection was spreading across borders; it is now working on how to implement the findings.
Health experts in Cameroon, Nigeria and Chad met in late September to discuss how to work more closely together to try to stem the spread of the disease, said WHO spokesperson Tarek Jasarevic. WHO is supporting health ministries in all of the countries involved, to improve disease surveillance and identify new cases; as well as sending out rapid response teams.
Third year running?
It is still “too early” to say whether each outbreak has reached its peak, said Laeity. While fewer cases have been reported in Chad and Cameroon over the past month, in Kinshasa and in Brazzaville, heavy rains are just starting, so transmission could well rise.
Health authorities in the Central African Republic declared an outbreak just two weeks ago - tests are under way to determine if it is the same strain as in a previous epidemic.
In Chad, the disease could well continue until 2012, said Lacharité. “It should continue to diminish now the rainy season has ended, but could easily stick around and climb again in next year’s rains.”
This article was produced by IRIN News while it was part of the United Nations Office for the Coordination of Humanitarian Affairs. Please send queries on copyright or liability to the UN. For more information: https://shop.un.org/rights-permissions