31 December 2012

West Africa: Cholera - Lessons Learned

Photo: Anna Jefferys/IRIN
A mother washes her child in Kroo Bay slum in Freetown, where access to basic sanitation is severely limited and cholera outbreaks are regular occurrences.

Dakar — The cholera epidemic that struck Guinea and Sierra Leone in 2012 is winding down. What to do now? Start preparing - for cholera.

That's part of the message from donors, aid workers and health officials after the most serious cholera outbreak in years that infected some 30,000 people and killed 400 others in the two countries - mostly in Sierra Leone. They say there should be better preparations for cholera, based on lessons learned and on a strategy in Guinea that was put to the test in 2012.

Since 2009 the UN Children's Fund (UNICEF), Action Against Hunger (ACF), the Guinean government, the European Union aid body ECHO, and the US Agency for International development (USAID) have taken steps to prepare for an outbreak - including setting up community detection sites, public information campaigns and drills.

"Cholera thrives on disorganization," said Christophe Valingot, water, sanitation, and hygiene (WASH) specialist with ECHO. "Cholera spreads very rapidly - it can go from 30 cases to several hundred cases per week in a very short period. When there is little to no preparation, we've lost the chance to avoid all those infections."

But preparation is hardly a motivator for governments and donors. "We had a very difficult time justifying funds for this preparation work in Guinea," Valingot said.

Strategies needed

Data from the past decade in West Africa show that a country can go several years with few to no cases of cholera then be hit with thousands of cases. "Donors, NGOs, and governments go all-out during a serious epidemic then it's as if that all disappears completely with a couple of calmer periods," Valingot said. "What this means in the end is meagre progress against cholera."

Health workers said UNICEF's strategy proved effective in Guinea this year and ECHO and UNICEF are looking to replicate it across the region.

So why did Guinea still see some 7,300 cases? For one, the strain found in the region is far more virulent than past strains, said François Bellet, WASH specialist with UNICEF's West and Central Africa regional office.

"Of course we can't possibly know what the situation would have been in Guinea in the absence of this strategy," he told IRIN. "But given the virulence of this strain we might well have avoided a Zimbabwe 2008-09." In that period cholera infected some 100,000 people in Zimbabwe and killed more than 4,000.

As of mid-December Sierra Leone had 22,345 cases and 286 deaths in a population of 5.6 million; Guinea, whose population is nearly double that, registered 7,321 cases and 121 deaths.


WASH and health experts say the use of GPS in Guinea's capital Conakry was critical. Plotting clusters of cholera cases on a map helps health workers better target WASH activities. GPS also facilitates follow-up visits to identify high-risk practices that accelerate the disease's spread. Mapping and GPS were not systematically used in Sierra Leone, say UNICEF and ACF.

Bellet said the sentinel sites in Guinea were vital because they facilitated rapid health, water, and sanitation responses. The first cases of cholera in Guinea, in February, were detected and signalled at these community sites by people trained as part of the preparedness strategy. One of these community members contacted health officials, saying: "That thing has come back."

"They knew it was cholera before any biological tests," Bellet said.

They also knew it was more aggressive than usual. One traditional leader in the Guinean seaside village of Kaback told UNICEF he had witnessed six major epidemics but had never seen such a virulent illness. For Bellet this underscores the importance of community engagement and local wisdom.

At an 11 December meeting of ECHO, UNICEF, and ACF to recap this year's outbreak and response, one recommendation was to create sentinel sites in Sierra Leone. Participants also noted the importance of maintaining the sites in Guinea, where state funding is lacking and trained workers often move on.

Safe water, proper sanitation

While preparation and hygiene education must be a year-round affair, above all what needs to be constant is the availability of safe water and proper sanitation. Only in Africa - and primarily West Africa - are cholera cases on the rise each year. This correlates to the poor progress on water and sanitation infrastructure, ECHO's Valingot said.

"Cholera is a disease signalling loud and clear that something's wrong," he said. "If there is a high rate of cholera, this likely means there are a lot of children dying of other diarrhoeal diseases. Vibrio cholerae is not constantly present - often it is brought in. And if there are no barriers - proper sanitation, safe water - it explodes."

Epidemiologist Stanislas Rebaudet, who analysed the cholera strain found in Guinea, says the fact that it was probably imported and not present in the environment sends an important message: the disease is not inevitable and it pays to put up those barriers.

[ This report does not necessarily reflect the views of the United Nations. ]

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