Nigeria tackles cholera outbreak using housecalls, jingles, and health advisories

A young girl washes her hands as part of a demonstration of good hygiene practices to avoid cholera and other waterborne diseases. Photo by: Marianna Franco / EU / ECHO / CC BY-NC-ND

MUBI, Nigeria — Ashek Mohammed was about to go to bed when his son, Ahmed, began experiencing severe diarrhea and vomiting. It was almost midnight on June 28, and Mubi, a town in the northeastern Nigerian state of Adamawa, was quiet and empty.

But Mohammed knew leaving Ahmed untreated until morning would be a risk, so he carried his son on his back for 2 kilometers to get to the cholera treatment center in Mubi General Hospital.

“He is fine now and feeling strong,” Mohammed said, speaking at the hospital two days later, fixing his gaze on 14-year-old Ahmed, who lay motionless — intravenous fluids running into his body.

Cholera — a diarrheal disease that can kill within hours if it is not treated — is endemic in Nigeria, with outbreaks reported as far back as the 1970s. The ongoing outbreak, which began at the start of this year, has been confirmed in 12 states, including Adamawa, Borno, and Yobe in Nigeria’s northeast, where the a brutal nine-year insurgency by Islamic militant group, Boko Haram, has displaced more than 2 million people.

Between January and 22 June, a total of 13,009 suspected cases and 116 deaths, including 135  laboratory-confirmed cases, were reported by the Nigeria Centre for Disease Control. These figures represent a case fatality rate of 0.89 percent, well below the 1 percent rate that WHO adjudges as an emergency. But the outbreak comes at a time when the West African nation is batting outbreaks of Lassa fever, yellow fever, meningitis, and monkeypox cases as well.

This outbreak in the northeastern region has hit particularly hard amid the ongoing conflict. The densely populated camps are especially prone to bouts of disease. About 7.7 million people are in dire need of humanitarian assistance in 2018 in the worst-affected states of Borno, Adamawa, and Yobe. Across Nigeria, inadequate access to drinking water, poor sanitation conditions, as well as the arrival of rainy season — usually from May to September — continue to propel the recurrence of outbreaks.

In early May, WHO announced large-scale cholera vaccination campaigns targeting 2 million people in Zambia, Uganda, Malawi, South Sudan, and Nigeria.

Outbreaks in Nigeria cause extreme concern, because there is a tendency for the disease to spread to neighboring countries.

So far, the control response has been rapid, with a coordinated approach ensuring several actors have been working together to control the disease and reduce further spread.

The results are trickling in: Yobe, which received $2 million to tackle cholera in May, declared that the outbreak was over on June 12 after 14 days without a reported case.

Fighting back

When the outbreak was declared in Adamawa in May, WHO collaborated with the government to set up an emergency operation center with pillars including case management, surveillance and active case search, and social mobilization, coupled with water, sanitation, and hygiene services.

Mallam Kabiru Sadiq, the local incident manager in Mubi town, said a close investigation of the index case revealed that the source of the outbreak was water contaminated with coliform bacteria.

“We don’t have a standard water system that provides water, so people rely on either wells or water vendors who get water from shallow boreholes,” Sadiq told Devex.

Some 100 personnel were quickly deployed around the town to disinfect water points with chlorine. A 24-hour ambulance service, as well as a house-to-house search facilitated by WHO were activated to identify cases and refer them to the case management unit run by Médecins Sans Frontières.

WHO provided 25 new android smartphones to the active search team, which used an open data kit to track and map the cholera cases to facilitate faster response. More than 50 suspected cases were referred to the cholera treatment center through the data kit submissions.

WHO worked with state officials in Adamawa to train and deploy 100 women known as community health champions to teach households to use the purification tablets Aquatabs for household water treatment and storage, how to prepare and administer oral rehydration solution, and to provide information on how cholera spreads, its symptoms, how to report cases, or where to seek urgent treatment.

The group worked alongside the surveillance team to promote practices such as hand washing with soap, safe disposal of waste, and dissuading people from open defecation. Health personnel in the field also disinfect latrines and affected households.

Community leaders were sensitized to further increase the rate of awareness and promote reporting to health care facilities. Using Hausa language jingles, public health advisory posters on shops and buildings, and public service announcements, state health officials pushed for further awareness raising.

As more and more people in the communities became aware of the risk of cholera, so did the reporting of cases — leading to a decline in case fatality ratio.

“The case fatality ratio was 17 percent as of May 12, but dropped to 1.7 percent as of June 7, suggesting that cases are being detected and reported early by the surveillance team coordinated by WHO,” Sadiq said in early June.

Hadiza Umar’s husband called the hotline when she became unconscious — her body weak from dehydration, unable to move.

“I almost fainted when the ambulance came and brought me here,” Umar told Devex in the Mubi hospital cholera treatment center. She hauled herself out of bed and leaned forward to spit into a blue plastic bucket. This bucket sits beside the bed of every patient in the unit.

From chlorination, to random free residual chlorine tests in some households, to health promotion activities and case management, collaboration between government and partners including WHO, MSF, the Danish Refugee Council, International Rescue Committee, Solidarités International and more was a key component of the response strategy.

But the risk remains high.

At the entrance of the cholera treatment unit in Mubi General Hospital, a woman in a yellow hijab hunched over a trench drain, while a man with sunken eyes crouched beside her.

As he began to breathe faster and nearly collapsed, a health worker in white overalls and yellow rain boots rushed over, lifted him into his arms and rushed in for treatment.

For people like Ashek Mohammed and his son living in areas lacking clean drinking water, with poor sanitation facilities, and low hygiene practices, the possibility of a cholera recurrence still hovers nearby.

The views in this opinion piece do not necessarily reflect Devex's editorial views.

About the author

  • Linus Unah

    Linus Unah is a Nigerian journalist covering global health, conflict, agriculture, and development. His work has appeared in The Guardian, IRIN, NPR, NewsDeeply, The Christian Science Monitor, among others.

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