CHOLERA IN NIGERIA

By Olayinka Ariba

MB4002

Masters in Public Health

G20626133

OBJECTIVE

o To outline cholera in Nigeria

o To describe and interpret the needs of Nigerians using epidemiological, quantitative and/or qualitative data.

o To describe the strategy implemented in Nigeria

o To describe how intervention will reduce the burden of cholera disease, to provide evidence from the literature of the effectiveness of this intervention.

o To review published literature to provide evidence on the effectiveness of hand washing

o To outline what actions would need to be undertaken, and by whom, in order to implement the intervention.

CHOLERAis an acute diarrheal infection of the small intestine caused by the ingestion of food and water contaminated by bacterium vibrio cholera.

An estimated 3–5 million cholera cases resulting to about 120 000 deaths yearly.

Nigeria accounts for 38% of cases from Africa with 44,456 cases, with highest case fatality rate (CFR) of 5.1% in Sub-Sahara Africa (WHO, 2010)

In Nigeria, 18 States in 2010 reported the outbreak of cholera with about 41,787 cases and1,716 deaths (case-fatality rate [CFR]: 4.1%).

In 2010, men had a higher prevalence (5.1%) than in women (4.9%)

Highest cholera cases of 4,600 cases was reported in Bauchi and 5,704 in Katsina States.in the Northern Nigeria (Dalhat et al, 2014)

(WHO, 2010)

Epidemiologic week of first reported cases in the Local Government areas during the three waves (Wave 1 (A): week 1 – week 9; wave 2 (B): week 10 – week 24; wave 3 (C): week 25 – week 42) (Dalhat et al., 2014)

.

DISTRIBUTION OF CHOLERA INCIDENCE BY WEEKS IN NIGERIA

(Dalhat et al., 2014)

POPULATION AT RISK OF CHOLERA

Everyone is at risk

But the most vulnerable group are malnourished children, people living with HIV and elderly people due to low level of immunity.

40.9% of children below 5 years are mostly affected

Refugees

Internally displaced persons(IDPs)

(Sack et al, 2004)

AGE DISTRIBUTION OF CHOLERA AND AGE-SPECIFIC CASE FATALITY RATES OF CHOLERA CASES, NIGERIA 2010

.

(Dalhat et al., 2014)

Age group

DocumentedCases

Attack rate per 100,000

0-4 years

3940 3.9

5-17years

5015 5.1

18-44years

430 4.4

45-64 years

1282 9.5

65 and above

297 14.5

Table 1 Table2

TRENDS IN CHOLERA CASES AND DEATH IN NIGERIA

Outbreak of cholera was

worsened by destroyed

sanitation and water

infrastructure .

Lower coverage of

effective drainage systems

and latrines resulting to

overflowing of latrines and

contamination of wells and

surface water due to

flooding in the rainy

season.

Year Cases Deaths CFR(%)

2010 41,787 1,716 4.1

2011 23,377 742 3.17

2012 597 18 3.02

2013 6.600 229 3.47

DATA ON MAJOR CHOLERA OUTBREAKS IN NIGERIA, 1991-1999

Year States Source No. Of reported cases

Case Fatality Rates

Age grour

1991 Cross river

--------- 588 13% ----

1992 Katsina Well water

622 7.7% 11-30 years

1995/1996

Kano Water source

2,630 15% 0-5 years

1997 Jos flood 847 23% 20-29 years

1999 Kano --------- 2,347 2% 0-5 years

1996 Ibadan Satched water

1,384 5.3% children

(Adagbada et al,, 2012)

POPULATIONS NEEDSA study in Nigeria by Dalhat et al in identified the peples

need as: Need for effective surveillance and response. Sufficient access to services Qualified health workers.

Another study in Nigeria by Adagbada et al in 2012 identified the need of the people as:

o Need for adequate manpower, equipment and medications.o Improvement on surveillance system, for early alert of

cholera outbreak.o Mechanisms for quick intervention to prevent infection. o Intervention measures to address poor sanitation and

unsafe water supplies in order to prevent new cholera cases.

o Establishment of communication channel and reporting.

RISK FACTORS

Poverty Age Gender Poor infrastructures

(slum) High population

density low education, lack of previous

exposure

Low immunity Poor sanitary and

hygienic Exposure to

contaminated food and water

Periods of flood

(Ali et al, 2012; Adagbada et al, 202; WHO, 2014 )

HAND WASHING PROMOTION

Hand washing with soap is a “do-it-yourself vaccine” that prevents the spread of cholera infections.

It is cost-effective, easy and effective.

(WHO, 2014)

ACTION: HAND WASHING INTERVENTION

Advocacy: Promote campaign to create awareness

IEC Materials (posters and flyers) Health Education on hand-washing Qualified health workers

Technique: Wet hands with safe water Lather with soap thoroughly, if no soap,

scrub your hands with sand or ash Cover all surfaces, including under nails Rinse hands well with safe water Dry hands using clean towel or air dry

STEERING GROUPS

This is the involvement/engagement of key stakeholders which includes

Federal Ministry of Health NGOs (UNICEF, WHO) Donor agencies Public health practitioners Community health workers Community gatekeepers Private organisation; pharmaceutical companies Mass media

EVIDENCE OF THE EFFECTIVENESS OF HANDWASHING PROMOTION

A study by Shahid, N.S., Greenough, W.B 3rd,, Samadi, A.R., Hug, M.I, Rahman, N., (1996) indicates that hand washing with soap promotion can attain 26 to 62% decrease in the incidence of cholera.

A randomised control study done by...in Malawi, showed incidence rate of cholera reduced from 69% to31% in under five children.

Hand-washing with soap can reduces the risk of cholera infection by 42%-47% (Curtis and Cairncross, 2003).

Hand-washing reduces cholera incidence by 89% (Wilson, Chandler, Muslihatun & Jamiluddin, 1991).

WHO reports that hand-washing with soap is one of the surest ways to prevent cholera transmission.

ARTICLES ON THE EFFECTIVENESS OF HAND WASHING INTERVENTION

Study Participants

Study type

Results Strength Weakness

Hutin, Luby & Paquet, 2009

102 cholera cases77 controlled group

Case control study

Hand washing with soap before eating reduces outbreak of cholera from 26 to 62%

Groups matched by sex

Age stratificationUse of control groups

Lack of control: response initiative

Confounders:socio-economic status

Mahamud et al., 2012

93 cases and 93 controlled group

Case control study

Provision of soap and being educated on hygiene

Groups matched by age and area of residence

Recall bias of inquiry of exposureUnclear transmission route

ARTICLES OF THE RISK FACTORS OF CHOLERA DISEASE

Study Participants

Study Type

Findings Strength

Weakness

Dubois, Sinkala, Kalluri, Makasachikoya & Quick, 2006

71 cases and 71 controls

Case Control Study

Hand washing interrupts disease transmission in food borne outbreak

Groups matched by area

Controls not tested

Huang, D. and Zhou, J. (2007).

75 cases & 73 controls

Randomised control trial

Incidence of cholera in tervention group was lower than in control group

Process of randomisation

Similarity in groups

Blindings

Recall bias

Generalisability

Study Participants

Study Type

Findings Strengths & weakness

Danny V. Colombara mail, Karen D. Cowgill, Abu S. G. Faruque, 2013

Hospitalised under five children

Survey study

Increasing age, lower socioeconomic status, and lack of breastfeeding increased risk for cholera among under five

large sample sizewell-defined population,systematic sampling, expert laboratory diagnosis of V. CholeraeMisclassification bias

self-reported water and sanitation measures

Dalhat, M., Isa, A., Nguku, P., Nasir, S., Urban, K., & Abdulaziz, M. et al. (2014).

population of 44,121,223 in the 10 states

Descriptive study

Limited access to health care;Scarce health care system ; Poor sanitation ; poor surveillance system

Large number of cases

Absence of data

Recall bias

Confounders

Temporality issues

ARTICLES OF THE RISK FACTORS OF CHOLERA DISEASE

Study Participants

Study Type

Findings Strengths & weakness

Rosewell, A., Addy, B., Komnapi, L., Makanda, F., Ropa, B., & Posanai, E. et al. (2012).

54 suspected cholera cases and 122 controls.

Case control study

piped water distributionsystem and sanitation will likely reduce transmissionby enabling enhanced hygiene and limiting thecontamination of water sources.

Groups matched by age,sex, education and employment

Use of a control group

Small sample size

Acosta, C., Galindo, C., Kimario, J., Senkoro, K., Urassa, H., & Casals, C. et al. (2001).

180 cases and 360 matched controls

Case control study

bathing in the river, eating dried fish, and living>10 minutes walking distance from the closest water source.

Groups matched by age

Use of control group Small sample size

Temporality issues

ARTICLES OF THE RISK FACTORS OF CHOLERA DISEASE

EVIDENCE FOR LITERATURE SEARCHSOURCE SEARCH TERMS HITS LIMITERS REVI

EWED

Medline Cholera*, cholera in Nigeria,Vibro cholerea

5 Nigeria, Full text, Abstract, Peer reviewed, Public health,Academic Journal,

3

Cinhal cholera OR vibro cholerae AND risk factors in Nigeria OR V. cholerae AND Nigeria

29 English language, full text, scholarly journals date (2000-2014)

2

PubMed Cholera , cholera in Nigeria, Vibro cholerea

57 Nigeria, Full text, Abstract, Peer reviewed, Ten years, advanced search

3

Search resulted in 4 studies chosen to be included in this presentation after most suitable abstract where reviewed .

CONCLUSION

Nigeria accounts for 38% of cholera cases from Africa with 44,456 cases With highest case fatality rate (CFR) of 5.1% in Sub-Sahara Africa

Everyone is at risk, but the most vulnerable group are malnourished children, people living with HIV and elderly people due to low level of immunity.

Typical at-risk areas with cholera infection are communities with poor infrastructures, poor sanitation and hygiene and exposure to contaminated water and food.

Evidence shows that Handwashing with soap is an effective intervention that prevents the spread of cholera infections

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C. et al. (2001). Cholera Outbreak in Southern Tanzania: Risk Factors and Patterns of Transmission. Emerg. Infect. Dis., 7(7), 583-587. doi:10.3201/eid0707.017741  

Ali, M.; Emch, M.; Donnay, J.P; Yunus, M. & Sack R.B. (2002a). Identifying environmental risk factors of endemic cholera: a raster GIS approach. Health & Place 8 (3): 201-210

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