Cholera outbreaks: Why they happen, hard to control

•Endless threats of epidemics, reflection of our poor priority as a nation –Prof Babalola
• ‘Govt should intensify community engagement, health enlightenment campaigns’
•Lack of clean water, proper waste disposal to blame, says Odubanjo

Cholera, according to medical experts, is a highly infectious disease that can cause severe, life-threatening diarrhoea. It is a public health concern, especially in communities with inadequate water treatment, poor sanitation and hygiene practices, reports ISIOMA MADIKE.

Overview

Nigerians now live in fear as people battle the siege of a cholera outbreak. Drinking water, overcrowded environments and poor hand hygiene are significantly associated with the disease that has disrupted everyday life and social relations.
The Nigeria Centre for Disease Control (NCDC), quoting the latest epidemiological report, has said that the cholera outbreak in Nigeria has seen a sharp increase in 2024, with suspected cases rising by an alarming 220 per cent. Lagos State, the agency said, had reported the highest number of suspected cases, contributing 43 per cent of the national total.
It also stated that by the end of epidemiological week 39, the country had recorded 10,837 suspected cases and 359 deaths. The figure, the agency said, represented a 239 per cent increase in fatalities compared to 2023. It said that the Case Fatality Rate (CFR) for the year stood at 3.3 per cent, slightly higher than the 3.1 per cent recorded in the previous year.
The NCDC has also said that in the past week alone, 198 new suspected cases were reported across five states, leading to 15 deaths and a weekly CFR of 7.6 per cent with the majority of cases occurring in children under the age of 5.
The current year, according to available statistics, indicates an increase in cases during peak seasons, emphasising the need for continuous monitoring and preventive measures. The urban slums and densely populated neighbourhoods with poor sanitation are not only high-risk areas but particularly vulnerable to cholera outbreaks.
For indirect transmission, poor sanitation practices, such as inadequate disposal of faeces and lack of hand washing, facilitate the spread of the bacteria.

Cases
“It was on Tuesday, as I was coming back home, having made a detour from Ojota, to get my glasses,” recalled Tobi, a resident of Agility in Kosofe Local Government Area of Lagos State. Agility is on the outskirt of Lagos. While sitting on the bus, Tobi began to feel unwell and had to rush home.
“I hurriedly stopped the driver,” continued the father of five children, who felt weak and without strength.
Finding, nevertheless, the courage to walk, Tobi arrived home and went straight to the rest room as his condition was deteriorating. After minutes of stooling and vomiting, his children took him 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 his house.
“Once there, the care began immediately”, explained Tobi, who didn’t really know what was happening to him. For a whole week, medical teams took turns at his bedside and other patients in care at the hospital.
When his condition finally began to improve, Tobi was able to go home. Recounting his 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, Tobi 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 diarrhoea infection caused by ingestion of contaminated food or water.
But, Tobi’s case was not an isolated one. Ngozi, like Tobi, didn’t know about cholera and its symptoms. She didn’t know anything until she fainted suddenly in her house.
“I had diarrhoea, 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 Ngozi
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 deteriorate further.
Ngozi 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 also 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.
She did not realise that the water she fetched from the compound “Konga” was the reason behind her infection.

Medics speak
A former president of the Guild of Medical Doctors (GMD), Professor Olufemi Babalola, calls cholera a public health disease concern, which, according to him, is worrisome. It is a waterborne infectious disease, which tends to occur in outbreaks, he further said.
He added: “Cholera is an acute diarrhoea infection caused by ingestion of food or water contaminated with the bacterium vibrio cholera. It remains a global threat to public health and an indicator of inequity and lack of social development.
“It is a shame that Nigeria is still listed among nations that undergo cholera epidemics from time to time, putting us in the same group with Southeast Asian countries like Bangladesh and India, and other African countries like the Central African Republic, and the Congos. The fact that we have these epidemics is a reflection of our poor priority as a nation.
“Our cities do not have pipe borne water and everyone digs a well in his yard, if they can afford it. Otherwise, people drink brackish water, rain water, and gutter water. People cannot afford ‘pure water’ anymore.
“It is ironic that we cannot build latrines for our people, and we have to rely on the Carter Foundation to help us build Ventilated Improved Pit latrines. Otherwise, it is open defecation, popularly called ‘bush attack’.
In his contribution, the Executive secretary of the Nigerian Academy of Science, Dr Doyin Odubanjo, also said that many diseases are killing more people than COVID-19, such as is now obvious with the stats on cholera. Cholera, he said, is very deadly and can kill, through severe dehydration/shock, within a few hours if not managed quickly.
The main symptom, he added, is severe diarrhoea with what is characterised as “rice-water stool”.
Odubanjo said: “Simply, cholera is a creation of two major things – the lack of clean water and proper waste (mainly faeces) disposal. Hence the solution lies in the causes – provide potable water, public toilets and ensure the enforcement of proper sanitation. And housing/offices/shops should have proper functioning toilets with running water.”
Bayo Onajole, a Professor of Public Health and Epidemiologist at the Lagos University Teaching Hospital (LUTH), Idi-Araba, agrees that cholera is a public health disease concern. He, 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.”
Professor of Clinical Virology at Michael Okpara University of Agriculture, Umudike, Maduike Ezeibe, said that cholera is caused by a bacterium called vibrio cholera.
“First time the disease was diagnosed in Nigeria was in the early 1970s. The infection is spread through contamination of foods and water with faeces of infected persons. So, it is not surprising that fish is a major source of the bacterium because people defecate into streams and rivers.
“Some people also use human wastes and animal wastes to fertilise fish ponds. If such wastes are contaminated with the pathogen fish, other aquatic animals could be infected and/contaminated to become sources of infection for humans.
“Since cholera is a waterborne disease, the resurgence is understandable, considering the current lifestyle of Nigerians, with almost everybody drinking sachet water or bottled water. The old practice of families boiling their drinking water is no longer popular.
“So, once a factory of sachet or bottled water is careless and their product gets contaminated, all those who depend on it are at risk. With one outbreak, infected people who move from one location to another can contaminate water-sources or cooked foods.
“Being a bacterial disease, cholera is treatable with antibiotics. The only problem is that since its sources are direct contamination from infected humans or indirectly through aquatic foods, most of the infections are likely to have experienced sub-therapeutic doses of common antibiotics and so may have become antimicrobial resistant infections.
“There is, therefore, a need for Nigeria to pay attention to research on solutions for anti-microbial resistant infections so that cholera and other infections can be effectively treated. However, it is a vaccine preventable disease,” Ezeibe said.
He added: “Lagos Island is flood prone, flood water can contaminate boreholes (private and those of water packaging factories) and once individuals, especially those working in restaurants and food processing establishments get infected, they can spread it to people who patronise them.”
Stella Smith, a Professor of Microbiology and Director (Research), Department of Molecular Biology and Biotechnology at the Nigerian Institute of Medical Research (NIMR), Yaba, Lagos, also said: “I wouldn’t really say there is resurgence per se. Cholera, a disease of poverty, is endemic in our environment. However, the rains have helped in triggering off increased cases of cholera. It is only for the country to be prepared for these episodes.
“For fruits and vegetables, are they properly washed in running water? I see people who buy apples and just start eating or just take the ‘pure water’ that was given by the vendor to wash briefly before eating.
“In terms of environmental hygiene, this is very important, as the environment could have blocked drainages, indiscriminate refuse dump, improper disposal of faeces, and improper waste disposal.
“In an environment where there are streams, rivers or lake and where people defecate, wash their clothes, bathe and also fetch water for drinking, with the rains, the faeces are mixed with the water and if the faeces are already infected with vibrio cholerae, there is a possibility of getting cholera when one drinks the water.
“Wash your hands with soap and water always after using the toilet and you can always carry hand sanitiser as you go. Although COVID-19 is supposedly over, those non-pharmaceutical interventions are still relevant here. Ensure you also wash your hands before and after eating because hands are used for various activities that are not hygienic.”
Smith added: “There should be community engagement and health enlightenment campaigns, health education inclusive of distribution of flyers on the ways to prevent getting infected, both in schools and communities. The government is also conducting surveillance, doing a door- to- door search for case finding and contact tracing.
“Take ORS or homemade ORS such as 1L of clean safe water, with 6 teaspoons of sugar and half teaspoon of salt. If symptoms persist within the day, report to designated hospitals as treatment of cholera is free. Early reporting of cholera cases will prevent its spread, while late reporting could lead to death where there is severe dehydration and shock.”
For Dr Japhet Olugbogi, Public Health Physician, and chairman, committee on infectious diseases, Lagos NMA, Cholera 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,” he said.