Regional cholera outbreak threat in west Africa as cases increase eight-fold in Lake Chad basin

A nurse administers sugar solution to a child suffering from cholera
There are an estimated 1.3 - 4 million cases of cholera worldwide each year  Credit: PHILIMON BULAWAYO/Reuters

A cholera outbreak is threatening to sweep further into west Africa's Lake Chad basin after the start of this year’s rainy season led to an unusually high spike in cases of the disease, UNICEF has warned.

Although the rainy season has just started, cases of the disease in Nigeria, Niger, Mali and Cameroon – known collectively as the Lake Chad basin – are already up eight-fold compared to the average caseload over the past four years, with more than 23,000 people affected and 388 deaths reported so far. More than 5 million people are living in outbreak areas.

Nigeria is currently the most impacted country with some 90 per cent of cases.

Under-reporting by governments could mean, however, that real figures are much higher – particularly in Nigeria where cases could be eight times more than official numbers suggest.

Julien Graveleau, a UNICEF cholera specialist for the region said that the wet weather was helping the outbreak to spread. “It’s creating an ideal environment for the propagation of cholera,” he said.  

A lack of access to clean drinking water and poor sanitation conditions mean that the region is prone to repeated cholera outbreaks with the most serious recent outbreaks occurring in 2010 when 62,000 people were affected and in 2014 when 41,000 people contracted the disease.

High rates of poverty - with some 60 per cent of people in the four affected countries living on less than $1.25 a day - means few people can afford basic hygiene measures. 

"The real problem is the poverty," said Foura Sassou Madi, medical coordinator for Medicins Sans Frontiers in Niger. "How can someone take care of their hygiene – for example by buying soap – if they live on less than a dollar a day?"

War and displacement in Nigeria in particular have also exacerbated the poor hygiene situation in the area and made conditions for the disease's spread ripe. The ongoing conflict with Boko Haram has led to the collapse of basic water and sanitation facilities and some 2.4 million people have fled their homes. Hundreds of thousands of people are living in overcrowded camps without access to sufficient water or clean toilets.

The current outbreak has already reached a number of major cities including Cameroon’s capital Yaounde, home to almost 2.5 million people, Daounde in the country’s south and Maradi, a transport hub of 270,000 people in Niger.

“The next few weeks will define if we have a major outbreak in southern Cameroon,” said Dr Graveleau.

“One of the concerns we have is we are on track to reach the numbers in the 2014 outbreak - and we could possibly could reach the numbers in the 2010 outbreak,” he added. “We have clear concerns about propagation in Yaounde and Daounde and possibly up to Mali and Burkino Faso.”

Dr Sassou Madi said that Maradi's road link to other parts of the country could lead the outbreak to spread further into Niger too if it was not quickly contained. 

"Maradi is the main road route in the country with a lot of buses travelling from Maradi to other regions which could spread the outbreak to other parts of the country," he said. 

Cholera is a serious bacterial infection that causes severe watery diarrhoea and stomach cramps which can lead to dehydration and even death.  Around 75 per cent of people who get the disease do not develop any symptoms making the infection easy to unwittingly pass on. Each year, up to 140,000 people worldwide die from the condition.

Cholera, which can kill within hours if left untreated can be prevented by a vaccine. The vaccine’s efficacy however, deteriorates over time and is usually only given during outbreaks  to stop the disease's spread, rather than as a longer-term preventative measure.

No large-scale vaccination campaigns have been carried out in the affected areas in Niger and Cameroon, although Dr Sassou Madi said he was hopeful vaccines could soon arrive in Niger.

He said that with stepped up actions to improve the sanitation situation more generally, the outbreak could be contained but that so far the response was lagging. 

From its origins in east India in the nineteenth century cholera has spread worldwide and cases of the disease have risen again since 2005.

Although war-torn Yemen is currently home to the world’s largest cholera outbreak with one million suspected cases, the Lake Chad Basin is one of several regions in Africa where the disease remains a particular concern year after year.

Dr Graveleau said that the only way to stop the disease from returning to the region was through more permanent improvements in water and sanitation such as consistent access to clean water and decent toilets.

“It’s the only way we can stop the cycle of cholera in Africa and especially in the Lake Chad Basin which is becoming an endemic area,” he said.

“Cholera is not a new disease. It was a very concerning disease a century ago in Europe and we know how to get rid of it. As a humanitarian community and governments we run from one outbreak to another. Each time there’s an outbreak we arrive with emergency packages – this is saving lives – but cholera is both an emergency and a development issue and on the development side not enough has been done," he said. 

"We know where the cholera hotspots are – by targeting four per cent of the population in Africa (35 million people) we could decrease cholera by 50 per cent.”

“This is the only way we can get out of the continuous cycle of cholera,” he added.

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