Cholera: A Ticking Time-bomb


Nigeria, a cholera endemic nation, has been facing a new wave of the deadly disease since January this year, though the outbreak spiked about a couple of months ago, thereby throwing the country into panic, DAVID MAXWELL writes.

Cholera outbreaks can raise a lot of concerns  in a country where sanitation and access to clean water can be challenging.  Like many countries facing similar challenges, Nigeria often struggles with infrastructure limitations, healthcare access disparities, and sanitation issues that exacerbate the impact of cholera outbreaks. 

For instance, lack of clean water, inadequate sanitation facilities, and limited healthcare resources can severely hinder efforts to prevent and manage cholera outbreaks effectively, thereby collectively collectively underscoring the urgent need for improved public health infrastructure and preparedness strategies to address such outbreaks more robustly.

On June 9, the Lagos State government declared a cholera outbreak. Three days later, it announced that 324 suspected cases had been reported in the state, including 15 people who died and 40 who were discharged after treatment. The Nigeria Centre for Disease Control and Prevention reported that as of June 13, 1,141 suspected cholera cases had been recorded across 30 states in Nigeria, which further increased to 1,300 cases by June 20.  There were 65 confirmed cases with 30 deaths reported from 96 local governments in 30 out of the 36 states, but these figures have spiked recently with the current outbreak taking a turn for the worse.

In 2021, Nigeria saw one of its worst cholera outbreaks in years, with more than 2,300 people dying from suspected cases as the country struggled to deal with multiple disease outbreaks. With a higher fatality rate than in the previous four years, the 2021 outbreak was worsened by what many considered to be a bigger priority for state governments: the COVID-19 pandemic. 

At least 69,925 suspected cholera cases were recorded as of September 5 in 25 of Nigeria’s 36 states and in the Federal Capital Territory,  Abuja, according to the Nigeria Center for Disease Control. Children between 5 and 14 were the most affected age group, and the overall fatality rate for cholera cases was 3.3%, more than double the 1.3% fatality rate among COVID-19 cases in the country

At least 2,323 people were believed to have died from cholera that year, but there are concerns that the number was an undercount given that many affected communities are in hard-to-reach areas.

States in Nigeria’s north, where flooding and poor sanitation increase the risk of transmission, were the hardest hit, with the 19 states in the north accounting for 98% of the suspected cases.

Cholera is endemic and seasonal in Nigeria, where only 14% of the population of more than 200 million have access to safely managed drinking water supply services, according to government data from 2020, which also shows that open defecation was still practiced by at least 30% of residents in 14 states.

Speaking to our reporter, Margaret Oluchukwu, a Community Health Worker said, “until today, open defecation is still a problem with several communities even in the FCT still battling to end it. The official records aside, there is yet to be a single state in Nigeria that has practically ended open defecation because the government at various levels are not doing enough in sensitisation, creation of laws and enforcement.

“Even programmes like Water And Sanitation Hygiene, WASH, noble as they are, do not permeate to the rural areas. This is because many rural areas especially those communities designated as ‘hard to reach,’ which need more of the intervention programmes like WASH, are still not covered.

“These are the factors that has made Nigeria endemic cholera and other diseases caused by poor hygiene. It is only when we face a new wave of the recurring outbreaks that the government, its partners and health workers will all begin to run from pillar to post to create the impression we are all working.

“The government from federal to state and at the local government level, the World Health Organisation, WHO, the United Nations Children’s Fund, UNICEF, and all the health workers who are always at the forefront in any health crisis must rise up to the occasion and commence an extensive sensitisation campaign while the government and the donor agencies must provide the needed support in terms of facilities, equipments and infrastructure. It is only then that we can effectively curb further outbreaks.”

According to Dr Stella Smith, a molecular epidemiologist, “Cholera has been endemic in Nigeria since it first appeared in 1972. The 1991 outbreak was the most severe on record, resulting in 59,478 cases and 7,654 deaths, a case fatality rate of 12.9%.

The World Health Organisation recommended benchmark case fatality rate is less than 1%. This rate is the number of deaths in the country as a percentage of the total confirmed cases (both alive and dead). Rates in Nigeria’s outbreaks have mostly fluctuated between 1% and about 4%.

The 1991 rate was high due to very poor sanitation and hygiene strategies. Little or no surveillance was in place and there was no community engagement or education on the dangers of the disease.

“Nigeria is prone to a variety of factors that lead to recurring cholera outbreaks. They include lack of access to potable (safe to drink) water. Safe water is needed to maintain good hygiene practices. Other factors are lack of continued surveillance even after the outbreak has ended; flooding; poverty (although currently cholera treatment is free in all government facilities); lack of health facilities; illiteracy; lack of infrastructure for water supply and waste disposal; and conflict, leading to overcrowded conditions for displaced people.”

Experts say the long-term solution for cholera control lies in economic development and universal access to safe drinking water and basic sanitation. Actions targeting environmental conditions include the implementation of adapted long-term sustainable WASH solutions to ensure use of safe water and basic sanitation and good hygiene practices. In addition to cholera, such interventions prevent a wide range of other water-borne illnesses, as well as contributing to achieving goals related to poverty, malnutrition and education. 

Cholera can be spread when people do not wash their hands with soap and water after defecating and then cook or serve food with unwashed hands. It also spreads when people eat food without washing their hands before and after eating. 

If cooked food is not covered, it may get contaminated from flies that carry the bacteria as it also spreads when raw fruits and vegetables are not thoroughly washed in clean running water before being eaten. Eating raw seafoods contaminated with cholera bacterium is another way people get infected.

Not filtering and boiling unsafe water before drinking, or drinking sachet water that is not treated, and when an infected person defecates outside and contaminated faeces are washed into the water system that people drink from.

“With the springing up of boreholes all around residential areas since the government’s municipal supply of pipe born water is almost completely fading away in Nigeria without recourse to the rule of a borehole to be sunk at least 30 meters or 98 feet away from a pit latrine or septic tank, we can see that as a people, we are only paying lip service to combating cholera and other deadly diseases caused by poor hygiene,” Soye S..Emine, a medical doctor said.

In all, the number of cholera cases reported to WHO has continued to be high over the last few years. During 2022, 472 697 cases and 2349 deaths were said to have been reported to WHO from 44 countries, with the WHO saying “the discrepancy between these figures and the estimated burden of the disease is due to many cases not being recorded due to limitations in surveillance systems and fear of impact on trade and tourism.”

“For Nigeria to be a cholera endemic country with sanitation, infrastructure, accessibility to health facilities and sensitisation still lagging behind conventional standards, for Nigeria, cholera is a ticking time bomb that only a quick fix can prevent from detonating and consuming the country,” Emine warned.


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