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Cholera - what's working?

Cholera patients in Bauchi, September 2010 Aminu Abubakar/IRIN
After years of cyclical cholera outbreaks in West Africa, water and sanitation standards are still notoriously low in most of the affected countries, but in some areas the cholera response is working better now than in the past. IRIN spoke to governments and aid agencies about innovations and traditional wisdom for preventing cholera.

By the end of June 2012, cholera had killed nearly 200 people in West Africa and infected 10,330 according to the UN Children’s Fund (UNICEF). Numbers are continuing to rise, particularly in the Sahel zone, where a recent upsurge has killed 60 people and infected 2,800. On 2 July 34 cases and two deaths - both children - were reported in northern Mali near Gao, on the edge of the Niger River.

Elsewhere in West Africa case numbers are rising, but are lower than this time in 2011, when 82,070 people had contracted cholera, or in 2010 when 60,000 West Africans in the Lake Chad Basin, which includes parts of Chad, Niger, Nigeria and Cameroon, were infected.

But West Africa is just at the start of its rainy season – cholera usually peaks between August and December.

Cholera is characterized by diarrhoea and vomiting, and can cause death within hours if it is particularly virulent, or hits weak victims like children.

The victims: children

Francois Bellet, the West Africa water, sanitation and hygiene (WASH) programme specialist at UNICEF, worries that people who are hungry or malnourished as a result of the food crisis in the region are particularly vulnerable to infection. UNICEF is particularly concerned about the Sahel, where the spread of cholera is aggravated by a massive displacement of people fleeing the conflict in northern Mali.

In some areas - such as Niger’s regions along the Niger River - the Ministry of Health reports nearly three times as many cholera patients this year as in 2011.

An estimated 400,000 children in Niger are suffering from severe malnutrition this year. “A child below the age of five who has recovered from severe and acute malnutrition will be back for treatment in a matter of days or weeks if he or she is drinking contaminated water,” Guido Borghese, UNICEF’s advisor on Child Survival and Development, said in a communiqué.

The transmitters: fish

Cholera spreads along West Africa’s waterways - coastal regions, rivers and lakes - where busy fishing and trade routes run. The coast is “like a cholera highway”, said Bellet, as are major waterways such as the Niger River, which flows through Guinea, Mali, Niger, Benin and Nigeria.

An actor, personifying cholera, tries to creep up on his victims
Photo: Anna Jefferys/IRIN
Cholera prevention in Guinea is paying off
The bacteria build up under the scales of fish and are often still there if the fish on sale in the markets have not been properly cleaned.

Given the role of women role in cleaning, descaling, smoking and selling fish in most of West Africa, it is they and their children who are particularly vulnerable to infection. Children make up some 80 percent of the cases in Sierra Leone’s Port Loko district, according to UNICEF.

The Guinea-Sierra Leone outbreak started on the island of Yeliboya in Sierra Leone’s Kambia district before spreading to islands off the coast of Guinea and into Forecariah prefecture. Islands in Boffa prefecture are known for their poor sanitation services and high levels of trade - perfect conditions for cholera to spread, said Bellet.

Vaccine: a new approach

The cyclical nature of cholera and the fact that immunity builds after large-scale epidemics are some of the reasons for this year’s lower caseload, said practitioners.

In Chad - which so far has zero cases this year compared to 5,000 in 2011 - widescale prevention efforts have paid off. And in Guinea the response has been much quicker and more coordinated this year.

In addition, a new approach has been tested in Guinea - notably a cholera vaccine used by Médecins Sans Frontières-Switzerland (MSF) for the first time in Africa to stem an epidemic.

The vaccine has had good results so far. In the Boffa and Forecariah prefectures of Guinea, where 77 percent of the population were given the double dose, and 95 percent received a single dose, there have been no cases reported since, said Iza Ciglenecki, innovation coordinator for diarrhoeal diseases at MSF-Switzerland. It is too early to know the full results, she said, but when used in other regions the vaccine has been 65-75 percent effective in stemming the spread of the disease.

Moringa, alum stone
Chadians and Malians put the leaves of the moringa tree into well-water, which kills some pathogens, while Tuaregs and West African fishermen use alum stones to clarify murky water, a very effective process, though to be 100 percent safe it should still be treated or boiled, said UNICEF.
This is potentially a huge step forward, but at US$3.70 for two doses the vaccine is expensive. The World Health Organization (WHO) and NGOs are discussing guidelines for when to use it in response to future epidemics. “If we multiply these interventions in the future, we could even create regional stocks to make it cheaper, but it is too early to say - we need to learn more first,” said Francois Verhoustraeten, Guinea programme officer at MSF-Switzerland.

All responding agencies, including MSF, stressed that the vaccine is not a standalone solution and should be seen as a supplementary activity. “We put a lot of effort into all the strategies at once,” Ciglenecki told IRIN, referring to the need to raise awareness of public hygiene, targeting cholera hot spots, setting up early warning systems, and treating water. Agencies such as MSF, UNICEF and Action contre la faim (ACF) - Action against Hunger - an international NGO, have been implementing these measures for years in West Africa's cholera-prone areas.

Modern medical breakthroughs should not replace important basic hygiene practices: wash your hands after defecating, before cooking or eating, and try to disinfect water that may be dirty, say aid agency staff. Neither should they negate the usefulness of age-old techniques, said Bellet.


''If we could have what we had in Guinea across the region it would mean… when cholera broke out we could go and nip it in the bud''
Guinea’s response has been quick this year. People have learned lessons from the 2007 and 2008 outbreaks, the latter of which took one and a half years to clear up, said Grant Laeity head of emergencies for UNICEF in West Africa.

The Sector Chief of Khounyia in Kaback Island, Forecariah, told UNICEF that this year’s cholera strain was particularly virulent (he has witnessed six outbreaks on the island). But the local health clinic managed the cases within a couple of hours, and the next day sent samples for confirmation to Conakry, the capital, 35km away. A full water and sanitation package was sent to the island four days later.

In late June Guinea reported 997 cholera infections and 41 deaths, with about 50 cases in Conakry.

Monitoring has also improved. Six surveillance posts have been set up in high-risk zones across the country to detect potential cases and respond to them immediately, said Beatriz Navarro Rubio, head of ACF in Guinea.

“In Guinea we saw good surveillance plus an early declaration by the authorities, leading to prompt action by all, which was encouraging,” said Laeity “If we could have what we had in Guinea across the region it would mean… when cholera broke out we could go and nip it in the bud.”

Coordination between the responding actors has been “very good” said Rubio. Inter-agency disaster simulation exercises had taken place shortly before the outbreak, so everyone was ready to step into gear when cholera hit.

Guinea’s Ministry of Health has taken a strong lead in bringing the Ministries of Education, and Energy and Water Resources on board to agree on simple countrywide messaging that is spread in schools and on local radio said Guarav Garg, a communications specialist at UNICEF in Sierra Leone. The messages have reached an estimated one million of Guinea’s six million people. “Coordination ebbs and flows, but they [the Health Ministry] are in control,” said Garg.

Cholera new to Africa
Indian texts report cholera in India 2,500 years ago, but the disease is fairly new to Africa. The first reports of cases appeared 1970, and are thought to have been spread by pilgrims returning from Mecca. In 1971 it infected 14,000 Chadians.
“Most of the cases have been addressed, which shows that the individual and collective prevention measures that we have taken are starting to work,” said Dr Hawa Touré, national director of the Ministry of Health.

Sierra Leone: slow

In Sierra Leone the response has been less efficient. UNICEF said some 2,742 cases have been reported since February, starting in Kambia and Port Loko in the north, then moving to Pujehun in the south.

A spike in the number of cases in Kambia town in late May “set off alarm bells”, said Garg, as it is just a 2.5 hour drive from the capital, Freetown. “Rains have come early and a lot of people live close to rivers and openly defecate - this is a bad combination,” he noted.

SIERRA LEONE: Cholera in the capital
FREETOWN, 25 July 2012 (IRIN) - Freetown, the capital of Sierra Leone, is now the centre of a cholera epidemic after the first confirmed case surfaced in north of the country in February. Full report
So much untreated sewage has been pumped into Sierra Leone’s rivers and coastal waters that much of the water itself is contaminated with the cholera bacteria, UNICEF said.

The Ministry of Health has tested and chlorinated water points since December 2011, but most people use private wells, so it is not known whether they have been chlorinated or not, Garg told IRIN.

Innovations in cholera prevention here include UNICEF’s community-led approach to improved sanitation - which has vastly improved public hygiene in parts of the six districts where it has been implemented, but Kambia is not among them.

Sierra Leone has two things in its favour, said Garg: improving WASH services is a strong pillar in the government’s upcoming poverty reduction strategy, and elections will be held in December. “The last thing you want is a cholera outbreak before the elections - they’re [the government] realizing you can keep on responding, or you can start to prevent,” he commented.


As well as improving surveillance, better understanding the region’s cholera hot spots, and speedier government declarations of an outbreak, in a region with high volumes of cross-border trade and people-movement, coordinated prevention and response now needs to be a priority, say aid agencies.

In Côte d’Ivoire for instance, the current outbreak spread from Ghana; in 2011 cholera spread from Nigeria to Chad to Cameroon; cholera regularly passes between Guinea and Guinea-Bissau.

The governments of Sierra Leone and Guinea should quell further cross-border spread by quarantining the disease and creating a “protective shield” in the forested area between the countries, says UNICEF.

And all affected countries need to carry out cross-border simulation exercises – as recently took place in the Lake Chad Basin – so agencies understand their role as soon as an outbreak hits.


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:

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