Why cholera is spreading— Expert

In this interview with MOTUNRAYO JOEL, the National Chairman, Association of Public Health Physicians of Nigeria, Dr. Tanimola Akande, talks about cholera and the current outbreak affecting some parts of the country

What are the symptoms of cholera?

Cholera is a form of gastroenteritis caused by Vibrio Cholera bacteria. The patients with cholera present with profuse passing of watery faeces and vomiting which may be accompanied with fever. Such patients lose body fluids rapidly and become dehydrated and therefore have body weakness. The first case may not be recognised as cholera since some other gastroenteritis can present that way but as soon as many more cases are recorded within a short time, a high suspicion of cholera should be made.

What leads to cholera transmission?

Cholera is transmitted through the faeco-oral route. That means the bacteria are shed in the patient’s faeces and it gets into another person by mouth from water or food that is contaminated with the bacteria.

Is Nigeria susceptible to a cholera epidemic and why?

Nigeria is highly susceptible to cholera epidemics and there have been several ones in the past in the country. Currently there are epidemics of cholera in various parts of the country. This is because of poor basic hygiene and sanitation. Only about three-quarter of households living in urban areas have access to improved source of drinking water. The situation is worse in rural areas where less than half of the households have access to improved source of drinking water. In some of these communities people have their drinking water from polluted streams or rivers. In the same vein only about 40 per cent of the urban population have non-shared improved toilet or latrines and it is as low as about 30 per cent in rural areas. Surveys show that about three in 10 households in Nigeria use an improved toilet facility.

A situation where people still pass stool in the open makes the population vulnerable to epidemics of cholera. Such faeces are often washed by rain into streams and rivers that serve as drinking water for some people. In addition a high proportion visit toilets and will not wash their hands, this practice unfortunately is not uncommon among food handlers.

More states in Nigeria have recorded cholera outbreak, why is this happening?

The reason for the spread of cases of cholera in more states is not farfetched in view of the sanitary and water supply situation described earlier. Government and households are not doing enough to improve water supply and provide improved sanitary facilities. Whilst some people may have improved sanitary facilities in their homes, this may not be the case in their places of work particularly those in the informal sector. In most cities and towns public toilet facilities are not either not available or grossly inadequate. Some brands of packaged water (often called pure water) are also sources of cholera spread because of the poor sanitary condition of the factories where they were produced.

Why hasn’t Nigeria been able to curb cholera outbreak?

Nigeria has not been able to curb this epidemic because we have not been able provide all citizens with safe drinking water and improved sanitary facilities both in the homes and public places. People are probably also not well informed about cholera and the preventive measures they can put in place to curb it. Imagine that some people managed to build houses with about four – six rooms (the face-me-I-face-you type) but they find it difficult to go the extra mile to provide a toilet or latrine. It is a shame to find houses in cities and towns without toilets. You want to therefore ask what those in charge of approving plans or inspecting houses are doing if this simple measure cannot be enforced. It was not until recently when my area of residence got crowded with houses, that the dwellers stopped passing faeces all around the open spaces. Now we are luckier they have to move a little further. The houseflies that hover around such faeces are not discriminatory; they fly anywhere and land on anyone’s exposed food.

Does boiling of water prevent cholera?

The way cholera spreads is through contaminated food and water but particularly water. Boiling water, of course, is quite helpful in preventing cholera. Some other measures of disinfecting water through urban water supply chlorination and domestic water chlorination are also helpful.

What is the recommended treatment in patients who have developed cholera?

Patients who have developed cholera need to be quickly rehydrated since they would have lost some fluid. The rehydration (replacement of the lost fluid) could be though oral salt and sugar solution or the packaged oral rehydration salt (ORS). In severe cases the rehydration will be though intravenous fluid (drips). In addition the patients are given antibiotics to take care of the cholera bacteria.

Could a cholera outbreak occur in developed countries?

Cholera outbreak is not impossible in developed countries, but will be quite unlikely. Some people can have cholera and may not show symptoms. If such people travel to such developed countries and practised poor sanitary hygiene, they may infect a few people. This situation, even though it affects a few people, will still be considered an outbreak. It is unlikely to affect many people because of the good water supply, sanitary facilities and personal hygiene of citizens of developed countries.

What is your advice to the Federal Government on cholera prevention?

Government should put in place control measures to control cholera in the country. Government can promote the provision of adequate water supply in towns and cities. Health education programmes are quite helpful in controlling cholera. Government should ensure the provision of adequate sanitary (toilet) facilities such that there will be zero tolerance to open faecal waste disposal. While cholera vaccination is an additional measure for cholera control it is not as important as provision of potable water

What actions should various local governments take to support the Federal Government?

Local governments have a major role to play in the control of cholera from their roles in health care delivery. Inspection of houses and food premises is the responsibility of the local government. The local government has a big role to play in health promotion through health education so that people can have positive behavioural change.The Medical Officer of Health in local governments has the responsibility for the control of diseases. All LGAs in Nigeria should have MOH who with appropriate enabling environment can make the difference in the control of cholera.

How much is needed to curb cholera outbreak in the country?

The resources required to curb cholera such that we have the situation in developed countries is in billions of Naira. The money will be required to make all Nigerians have access to potable (safe drinking) water. Money is also required on the part of households to provide themselves with sanitary and safe toilet facilities. When the money requirement of households in Nigeria is put together it will also run into billions of naira. International agencies like UNICEF have also contributed immensely towards water and sanitation projects in various parts of the country.

What are your major concerns about moving forward?

The way forward in the control of cholera in Nigeria is to have measures in place to prevent epidemics of cholera. This requires a strong political will. An estimated 3-5 million cholera cases and 100 000-120 000 deaths due to cholera occur worldwide every year. Unfortunately the poor are much more affected. Health challenges that affect the downtrodden in the society hardly get the desirable attention. Even when it is quite clear that these measures cannot be totally provided immediately, steps must be seen to be taken towards having a country free of cholera outbreaks. The various indices of health that relate to provision of safe drinking water and sanitary waste disposal must be seen to be improving rapidly. Another concern is that there are too many other contending health issues that need to be addressed that will compete for attention and resources. However, improving water supply and sanitation will not only reduce cholera outbreak, several other health challenges can be reduced through these measures