Lagos becoming Nigeria's cholera hotspot raises critical questions
In June, Caleb Ezechimere, a young medical laboratory scientist, died barely one month into his internship at the Military Hospital, Lagos.
"He had purchased some tiger nut drinks from a vendor, and everyone who bought from the same vendor ended up in the hospital, but he didn't make it," his sister-in-law, Jaachi Nwagbara, a medical doctor, recalled how Mr Ezechimere died from cholera.
"Till now, it's still a great loss. Everything reminds us of him. It was a preventable death, and that's the most painful kind of death. Preventable deaths from infectious diseases like cholera are unacceptable in the 21st century."
As of 29 September, Lagos, Nigeria's richest state, had recorded 134 deaths from 4,667 cholera cases. The state has the highest share of cases in Nigeria since the outbreak began in June. Being a water-borne disease, the recent outbreak has been linked to contaminated water sources, particularly unregistered tiger nut drinks, and inadequate water supply, especially in Lagos Island, the disease's epicentre.
Lagos becoming Nigeria's cholera hotspot raises a critical question: What drives the surge? This analysis examines cholera data over the years and the persistent issues of inadequate water supply and contamination.
Lagos: Topping Nigeria's cholera chart
States like Zamfara, Katsina, Bauchi, Cross River, and Bayelsa were the cholera hotspots in Nigeria. However, in the current outbreak, Lagos accounted for 43 per cent of the 10,837 suspected cases recorded in 35 states and the Federal Capital Territory (FCT) as of 29 September. Three local government areas (LGAs), Lagos Island, Eti Osa, and Lagos Mainland, recorded the most cases in the state.
PREMIUM TIMES' review of weekly epidemiological and situation reports of cholera from 2015 to 2024 by the Nigeria Centre for Disease Control and Prevention (NCDC) shows that Nigeria experienced the worst cholera epidemic in 2021, with 111,062 suspected cases and 3,604 reported in 33 states and FCT.
The case fatality rate (CFR), which means the proportion of people who died from the disease among all individuals diagnosed, was 3.2 per cent.
In that year, Lagos ranked 11th with 2,551 cases and 12 deaths, while northern states like Bauchi (19,558 cases, 320 deaths), Jigawa ( 15,141 cases, 517 deaths), Kano (12,116 cases, 368 deaths), Zamfara (11,931 cases, 244 deaths), and Katsina (9,20 9 cases and 238 deaths) topped the chart.
In 2018, when a total of 51,675 cases and 1,136 deaths were recorded nationwide, no cases were reported in Lagos State. States like Adamawa, Zamfara, Katsina, Bauchi, and Borno topped the chart. 4,221 suspected cases and 107 deaths were recorded in 20 states in 2017.
Out of the 23,763 cases and 592 deaths recorded in 2022 from 32 states and the FCT, Lagos State ranked 18th with 47 cases and one death.
However, NCDC data for 2023 does not have Lagos on the list of 31 states affected, as Nigeria recorded 3,683 suspected cases and 128 deaths.
From January to December 2016, Nigeria recorded 782 and 32 deaths in 14 states, compared with 5,330 cases and 186 deaths across 18 states and FCT during the same period in 2015. Bauchi, Kano, Jigawa, and Zamfara were states with the highest cases in both years.
Nigeria reported 4,108 cholera cases and 71 fatalities in 2019, followed by 1,858 cases and 75 deaths in 2020.
Inadequate water supply
With an estimated population of over 24 million, Lagos faces significant challenges in providing potable water for its residents. Despite the efforts of the Lagos Water Corporation and the allocation of N16 billion between 2019 and 2023, inadequate water supply remains a pressing concern.
While some residents have resorted to expensive alternatives, such as drilling boreholes without proper water treatment plans, others depend on vendors, known as "mairuwa," who sell water in jerrycans.
Apart from the financial burden, this exposes residents to the risk of cholera and other diseases, such as dysentery and typhoid.
In June, Nkoyo David, a 31-year-old who relocated from Gbagada to Bariga, suffered severe diarrhoea and vomiting after drinking borehole water because she was sceptical about consuming sachet water.
"I thought I was detoxifying. I didn't know there was a cholera outbreak," Ms David recalled. "It took me seven days to recover, and I was lucky. Some people weren't that fortunate."
Ms David's experience highlights the consequences of consuming water from unreliable sources. Residents of Adeniji Adele, Onola, and Tapa areas of Lagos Island who spoke with PREMIUM TIMES expressed frustration over the water supply.
"I have been working here for over 10 years, yet there is no public water supply. I buy water daily from vendors, which is not clean," said Abiola Lawal, a trader at Onola.
Rasheed Egbafolorun, a landlord in Onola, also said: "We don't have a public water supply; everyone has to drill their borehole. People patronising vendors are also at risk of cholera because most vendors don't wash their jerrycans."
Poor waste management and open defecation practices compound the situation. At the Adeniji Adele Canal, people could be seen urinating directly into the waterway, and business owners nearby confirmed that some individuals even dispose of their wastes in the canal during rainfall.
Contamination sources
The cholera outbreak in Lagos further raises concerns about the city's water quality and sanitation infrastructure. Experts point to various contamination sources that contribute to the spread of the disease.
The contamination sources include floodwater and poor drainage, septic tank leakage, poor waste management, overflow from canals, inadequate wastewater treatment, open defecation, and lack of sanitation facilities.
According to Mekwunye Kidochukwu, a WASH (Water, Sanitation, and Hygiene) expert, relying on individual boreholes exposes residents to contaminated groundwater, especially during floods.
Mr Kidochukwu, a hydrogeologist, environmental scientist and sustainable development consultant, said contamination spreads rapidly through soakaways, streams, gutters, and boreholes, creating a toxic mix.
"Major problems with the cholera outbreak and other water-borne diseases are linked to poor planning, waste management, and the inadequacy of the government in providing potable water to the people.
"Individual boreholes are not the ideal solution to water supply. It contributes so much to groundwater contamination. Flooding affects the boreholes, goes into the soakaway, mixes with the stream, gutter, and borehole, and everything goes together.
"Until the government addresses water supply and waste management, we are not going anywhere; we will have more cases of water-borne diseases, and the cases will increase," he said.
Lagos, Nigeria's economic hub and richest state, faces severe flooding, particularly during the rainy season (April-October). During this period, Nigeria experiences a surge in cholera outbreaks annually.
The Lagos State Chairman of the Nigerian Medical Association (NMA), Babajide Saheed, said the floods are exacerbated by poor drainage systems and landfilling of the lagoon, which affects boreholes and leads to contaminated water.
"More than 50 per cent of Lagosians depend on boreholes. In some areas, they open the septic tank and allow it to flow into the drainage system, which can go anywhere.
"What they call pure water is expensive in Lagos, so people just look for anything to drink. The food vendors also contribute to it with unhygienic practices," he said.
Population growth
Mr Kidochukwu said population growth has significantly contributed to cholera outbreaks in Lagos. The large population puts immense pressure on the state's small landmass, leading to inadequate settlement patterns and increased population density.
"Homes designed for one family now house three, tripling waste generation, and poor septic tanks can't handle the load. Some residents connect their soakaways to gutters, which discharge waste into nearby water bodies," he said.
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Lagos leads in cholera cases, while Kano, officially the most populous state, ranks 19th with 809 cases and 46 deaths (as of 29 September).
Recommendations
Mr Kidochukwu urged the government to prioritise water supply, improve waste management and implement effective water treatment systems.
The NMA chairman, Mr Saheed, said the government should be proactive with infection prevention and control measures.
"Lagos has to be proactive. The first is education and enlightenment as they used to do; the second is drainage system cleaning. The third one is that they should review buildings and how they impact the drainage system's free access," he said.
According to the Director General of the National Institute for Policy and Strategic Studies (NIPSS), Ayo Omotayo, in a presentation at the 2024 Lagos Physical Planning Summit, clean and safe water and comprehensive sanitation services should be part of strategies for modern infrastructure development in Lagos State.
The Lagos State Government acknowledges the problem and says it is working to resolve it. In June, the state government activated the Public Health Emergency Operations Centre (PHEOC) in response to the cholera outbreak.
The Commissioner for Health, Akin Abayomi, also announced the One Health Strategy, which he said recognises the interconnectedness of human, animal, and environmental health.
According to Mr Abayomi, PHEOC's activities would include implementing the One Health approach through relevant ministries, departments, and agencies of the government.
However, the cholera outbreak also highlights the need for improved epidemic preparedness and infection prevention and control (IPC) measures in the state.
NCDC recommends access to safe drinking water, proper sanitation, and hygiene practices to prevent cholera. Strengthening disease surveillance and enhancing IPC measures, as suggested by experts like Mr Saheed and Ms Nwagbara, is also crucial to preventing future outbreaks.
