For many years, cholera had not only been a recurring disease in Nigeria, even as it has also led to the deaths of thousands of people, especially children. The disease, according to experts, is mostly contracted through contaminated water and food. BENJAMIN SAMSON in this report seeks experts’ and stakeholders’ views on the current outbreak and how it can be curtailed.
According to the Nigeria Centre for Disease Control and Prevention (NCDC), no fewer than 1,141 suspected cholera cases had been recorded across 30 states with 30 deaths this year. The 10 states that have recorded 90 per cent of the cases include Bayelsa, Lagos, Abia, Cross River, Delta, Imo, Katsina, Nasarawa and Zamfara.
Admonitions
In an interview with this reporter, an epidemiologist, Chuks Igweh, said, “Cholera is a bacterial disease that causes severe diarrhoea, vomiting, and dehydration. It is spread mostly through contaminated food and water, which is why most outbreaks in Nigeria occur during the wet seasons. It requires the emergency attention of medical professionals and it is often fatal if not treated right away.
“There was a similar outbreak in 2017 which recorded 2,309 cases and 57 deaths in 111 LGAs of 26 states. Since 1991, there have been five outbreaks affecting 43,996 persons and claiming 836 lives. What this means is that cholera is a communicable disease that always lies in wait ready to pounce once the situations that lead to it apply.
“Other factors that are favourable for the disease are conflict situations where people are crowded in refugee camps, reduced or non-existent stomach acids, raw or uncooked seafood and vegetables, and type ‘O’ blood.
“In countries like Nigeria where open defaecation and the lack of potable, runny water are still rampant, cholera is very endemic. Governments at all levels have largely abdicated their responsibility to provide potable water. This has led many who can afford them to drill wells and boreholes.”
Sanitation
Igweh also attributed incessant outbreaks of cholera in the country to poor sanitation.
He said, “If you go back to this cholera case, it’s a problem of poor sanitation, good personal and environmental, it’s a problem of lack of access to water. The easiest way for good personal hygiene is hand-washing, especially after using the toilet, and before you cook your food.
“But in a situation where you tell people to do hand-washing and there’s no access to water, it’s a problem. So, I think everybody, including the federal government, the state governments, different agencies, local governments, and even the people themselves, the community, have to come together to fight the disease.”
Likewise, a public health physician, Margaret Abashi, in her view, blamed the root cause of the current outbreak of the disease on the lack of proper sanitation and inadequate healthcare infrastructure, saying “attributing the outbreak to rainfall is misleading and unscientific.”
She also blamed the government at all levels of paying lip service to water and sanitation, saying “it’s misleading to tie the intractable outbreak of cholera in Nigeria to rainfall and rain season.
According to the expert, it is also not empirical to do so. We have been shouting at rooftops on how to mitigate intractable disease outbreaks in Nigeria.
She said, “Unfortunately, it has continued to fall on deaf ears, but we have continued to field wrong persons in the front lead health agencies that should put in place infrastructure, equipment, systems, and processes, particularly, disease notification systems that will help us build a robust system capable of mitigating intractable disease outbreaks.”
She noted that the current outbreak is just one of the very many intractable disease outbreaks in the country that have become persistent and are about to become endemic.
“Sometime in November, December 2023, we had an intractable cholera disease outbreak in some parts of Cross River state. Was that during the rainy season? So, the argument about it is that the rains that are swelling the cholera outbreak are nothing and can be very unscientific.
“Agreed, disease outbreaks sometimes are seasonal. I also concede that cholera sometimes may be seasonal, but for it to become seasonal, it has to be that it had become endemic somewhat or had become intractable in the given environment or community or even a region,” she said further.
“The challenge is that the country has continued to pay lip- service to water, sanitation, and hygiene. I challenge you to go and dig it up. Of the 30 states already reported to have the outbreak, how many of them have a public potable water supply in place? I can categorically tell you that there is none. So, we do know that cholera is a disease that thrives where water, sanitation and hygiene are at its low rate.”
Open defaecation
A consultant paediatrician at the Federal Medical Centre, Jabi, Abuja, Ogbor Osaghe, told this reporter that there was a need for the county to begin to speak to issues about water, sanitation, and hygiene.
He emphasised the need for improved water, sanitation, and hygiene (WASH) practices, including addressing open defaecation and ensuring access to clean water which are essential for preventing future outbreaks.
Osaghe said, “If you also take a second look or a critical look at the practice of open defecation, it is crescendo in all the states so far. Of course, it is endemic and is unhealthy. I think Nigeria is among the leading nations across the globe in open defecation. So, why wouldn’t cholera find its place here? So, that’s to speak to your very first question that it is not correct scientifically, or empirically to tie the current outbreak to issues about the rainy season.
“In fact, in most parts of the state affected, particularly in the North, if you check, this is June running out, and the volume of rainfall has been lowest in the last decade around this time in those states. So, it is not rainfall. It is largely issues deriving from worse challenges we have in Nigeria and challenges about open defecation.”
He also stressed the need to strengthen healthcare infrastructure by investing in laboratories at all levels, from primary to tertiary healthcare, adding that “it is crucial for early diagnosis and treatment of cholera and other diseases.”
The consultant paediatrician said further that there was a need for a robust disease notification system which would be all-encompassing, adding that, timely and accurate data collection is necessary to track outbreaks and take necessary actions.”
He said the way out of intractable disease outbreaks such as cholera is to develop, expand, and strengthen medical laboratory services up to the primary health care point.
“We have to build capacities of laboratories in secondary and tertiary health institutions to be able to diagnose cholera routinely. Once there’s an outbreak; that is when the Nigeria Centre for Disease Control will mobilise. That is the only time we think we can call people. Investigation for such patients should include a routine screening.
“As I speak to you, I doubt if we have any of our tertiary health institutions in Nigeria. This is the reason for teaching hospitals, federal medical centres, specialist hospitals and general hospitals that have in-house capacity for all time to have resources in terms of human capacity, resources for material and infrastructure to diagnose the type of cholera we have now. If we are unable to do all these, then we are just joking. If that remains the condition, I tell you cholera will not go away. We need to do all this for cholera to go away.”
Further outbreaks
Meanwhile, as schools resume from the mid-term break and the Sallah holidays, there are fears the pupils may be at risk of contracting the disease.
Consequently, Osaghe said the infection could spread in schools if measures were not taken to prevent it.
“There will be gatherings of people in schools, and the moment they (schoolchildren) are sharing items, it can spread. If any of them is infected, it can spread to others, rather than if they are in their homes.
“Generally, the spread in schools is not a major concern, except maybe in boarding houses. In boarding houses, one person infected may infect others through contamination of the water and their food.
“So, for now, the students should go with their water bottles, rather than sharing water. Then, there should be hand-washing facilities in the schools, and even in their toilets.
“When they get home, they should wash their hands and take their baths before eating; and within schools, there should be no sharing of things for now, since there is an outbreak.”
Way out
Speaking on the way out, Igweh said, “Fortunately, with effective coordination, the disease can be contained quickly. But the real challenge is to work towards its total eradication from Nigeria as it has been done in many other countries.
“According to the World Health Organisation (WHO), no human should die from preventable diseases like cholera. To address this challenge, there is an urgent need for public enlightenment on healthy living.
“Experts have advised that people should ensure their food (cooked or uncooked) is properly covered while regular hand-washing should be adhered to always. More surveillance, more resourcing and better coordination will be necessary to reduce deaths from cholera and other preventable diseases.”
He said further, “Since cholera is more prevalent in rural areas, the problem becomes more compounded when and where there are no modern medical facilities to assist in the treatment of the disease. The spread of cholera becomes worse when the environment is not clean; when the water system is not treated and when sanitation is not taken seriously. The sad part is that in many of our states, the villagers and rural dwellers are left to rely on streams as the only source of drinking water, and there are no provisions for disposing waste. In most cases also, the people rely on stagnant water for washing their clothes and other items.
“Beyond what the government should do, Nigerians should not neglect the issue of personal hygiene. That cholera kills when a person loses too much body fluid means such deaths are preventable if victims are quickly rehydrated. Since no vaccine has been developed against cholera, what is commonly used is oral rehydration salts (ORS) as part of measures to mitigate the problem. But prevention is still very much better than cure. To that extent, our rural dwellers and the urban poor should be taught the rules of basic hygiene.
“That we are still witnessing serial outbreaks of cholera in Nigeria is a serious indictment on our health care delivery. The world has moved ahead of the era where cholera kills citizens. Healthcare officials and other critical stakeholders must therefore do more in providing adequate clean water for the citizens, especially for those that are in the rural areas. We must work towards banishing cholera from our country.
