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Cholera is a diarrheic condition that is caused by bacteria known as Vibrio cholerae. The bacterium is an enterotoxin that affects the ileum. Patients with this disease present with a sudden onset of rapid watery stool that is painless (Sekar, 2012). Early stages of cholera are manifested by rapid vomiting and nausea. When cholera is not treated, it can results into hypoglycemia in children, circulatory collapse, dehydration, renal failure and acidosis.
The infection is transmitted by asymptomatic carriers. Cholera is mostly asymptomatic or occasionally causes moderate diarrhea particularly with EI T micro-organisms or biotype. Death occurs within a few hours in severely dehydrated cases where by the rate of case-fatality may go beyond the 50% mark. However, timely and effective rehydration reduces the death rate to 1%.
A cholera outbreak was first detected in The Central African Republic (CAR) in the early months of 1997 and hit the country for the second time in 1999.
The affected regions within the country included the sub-prefecture of Ngaoundaye. This is located along river Oubangui which is located near the border with Chad(Dworkin, 2010). Sékia moté village had the very first few reported cases and within a short period, the outbreak had spread to the prefecture of Lobaye and its environs and to the city of Bangui. Ombella Mpoko district and seven other villages where the Oubangui River passed later became part of the tragedy.
The outbreak was primarily discovered after the chief’s son of Sékia mote village became sick and passed away after showing signs of profuse diarrhea, abdominal pains and fever. The chief of Sékia mote village reported the case to the district’s governor on the very same day it occurred, who then alerted the Ministry of Health immediately later that day.
Both private and public health facilities in the Central African Republic (CAR) recorded extraordinary cases of watery diarrhea from Sékia moté village and several other villages to the Ministry of Health (Kamradt, 2015).
On the 25th of September 2011, a stool sample was obtained from a patient that had been transferred and got admitted at the community clinic in Bangui by two of the laboratory technicians from the Central African Field Epidemiology and Laboratory training Program (CAFELTP)(Nair, 2014).
After three days of thorough testing, the National Laboratory in Bangui (NLB) isolated Vibrio cholera sero group 131 from the earlier submitted specimen of stool with the help of a laboratory expert, from the NCIRD/GID.
This fostered the drive of Global Immunization Division, Immunization Systems, and Centers for Disease Control and prevention (CDC) since they were certainly convinced that the disease was cholera. On September 30th, cholera outbreak was declared officially in CAR. Rapid response team was put in place by the Minister of Health (MOH). The team comprised of CAFELTP residents, WHO, MSF staff, UNICEF, MOH staff, and others. The team established a series of control and preventative guidelines that would curb the spread of the outbreak.
The first measure entailed enhancing treatment capacity and cholera surveillance at the already existing health facilities. Secondly, the city of Bangui and affected villages had to have cholera treatment facilities. Thirdly, endorsing practices such as improved sanitation, proper food preparation, proper funerals and burial. The fourth measure was on affected people were to be advised on usage of oral rehydration solution and encouraged to seek medical attention at the onset of watery diarrhea. Finally, there were to be provision of chlorine for treatment of drinking water.
The rapid response team had a report of the case as by October 23rd. The record indicated that there were a total of 172 individuals who were suffering from acute watery diarrhea and also recorded 16 cholera deaths. This study was carried out with the goal of identifying risk factors associated with cholera outbreak. Moreover it also focused on assessing how prepared the affected districts were in controlling the outbreak.
Many households were constructed along river Oubangui. The distance between the river and these households was approximately 20 meters. Generally, there was poor hygiene in the village characterized by mud and stagnant water (Kurjak, 2015). The children in the village were playing and walking bare feet in the mud and at times not fully dressed. Villagers were commonly using pit latrines whose maintenance was poor. Oubangui river was has many uses which include a source of drinking water, fishing, swimming and defecation.
The Ministry of Health requested CAFELTP resident advisors to assist in investigation and control of cholera outbreak in Central Africa Republic. The CAFELTP officials formed a rapid response team that worked in the affected areas. The team members were assigned different duties. For instance, one of the epidemiological officials was charged with the responsibility of reporting and collecting data on cholera outbreak where as two other lab technicians had the responsibility of collecting and analyzing samples.
Moreover, the advisors of these officials arrived in Bangui after two weeks. Upon arrival, they were taken through the events in Bangui by the CAFELTP staff and the officials from the MOH on the matter at hand and evolution of cholera. A data collection instruments and a protocol were developed by the residents and RAs. The main risk factors were highlighted as follows, lack of infrastructure for sanitation, drinking untreated water, and attending a cholera case funeral. Cholera Treatment Facility in Mbobo and Bangui district held arena for questionnaires pre-testing. In-country procedures such as mission orders, submission of terms of reference were followed before going to the field.
Coincidentally, during the outbreak investigation several campaigns on cholera awareness were underway in different areas of the country. The awareness involved sessions of community education and use of mobile Information Education Communication (IEC) resources presented on posters, TV, radio, cars, and mobile phones prevention messages.
Confirmation of the outbreak
The term outbreak is simply defined as a sudden increase or start of disease of fighting. It can also be defined as a sudden increase in numbers of a harmful organisms particularly the insects within a specific area. A disease outbreak is the occurrence of diseases in excess beyond the normal expectations in a specific geographical area, season or community.
An outbreak may emerge in a restricted geographical area or even spread to several countries. Its duration may be a few days, weeks or several years(Sekar, 2012). Definition of an outbreak enables those responsible for managing an outbreak occurrence to report the condition in its early stages to the responsible authorities.
The director of disease control conducted training sessions on cholera management in the hospitals as well as the community. The training was done to the health personnel in the affected districts. Weekly review notification records under joint custodian of the (WHO) and MOH, found 172 individuals diagnosed with suspected cholera. In the CAR from September 20th to October 26th, national case fatality rate was 9.3%.
Data on the number of individuals infected with cholera was sourced from the WHO Bangui office, cholera treatment centers and health centers in the affected areas. Medecins Sans Frontiers (MSF) were responsible for collection of the data on infected individuals. These information was used by the investigators in performing a comprehensive analysis of cholera outbreak.
Assessment on the level of epidemic readiness and response was carried out in each district using a checklist. General hygiene in the affected areas termed environmental investigation was also assessed. Stool and water samples were taken to the lab to be examined for Vibrio cholerae.
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Epidemic preparedness and response (surveillance)
None of the visited districts had either an epidemic readiness plan or a committee in place prior to the outbreak. There was provision of IV fluids and protective materials after the event of the outbreak. Some of the health centers such as Kamba had a radio system that was functional for communication, the health centers in Ngazi and Mogo had no means of communication. Unfortunately they had to travel for about 35 Km by bicycle or foot to the health facility (Shah, 2016).
Epidemic management funds were not available in the country before the occurrence of the outbreak. However, there were disinfectants in the entire health district that was visited. Chlorine used for water treatment was distributed by ministry of health to the two villages. Centers for chlorine treatment were planted at Bangui hospital, Ngazi and Mbombo health facilities. At the time of visit, these centers were functional although each had at least one cholera patient.
One personnel in Ngazi and Mongo village managed the public health surveillance system. The system was exempted prior to the occurrence of the epidemic.
Case definition entails a standard criterion that categorizes an individual as a case. It includes criteria for person, time, clinical features and place. The criteria should be specific to the outbreak under investigation (Madoraba, 2010).
Most houses were constructed along the Oubangui River. The distance between the river and the houses was less than 20 meters. There was generally poor hygiene in the village (Dale 2013). Mud and stagnant water were everywhere. Children played and walked in the mud bare feet and at times not fully dressed. There was common use of pit latrines; however, the latrines were poorly maintained. The Oubangui River served as a source of drinking water and swimming, fishing and defecation.
Diarrhea: Diarrhea as a result of cholera usually has a milky, pale appearance that resembles water that has been used to rinse rice, hence the name rice-water stool.
Dehydration: dehydration develops within hours after the commencement of the symptoms of cholera. The ranges of dehydration vary from mild to severe depending on the amount of fluid lost. Severe dehydration is characterized by a loss of 10% or more of total body weight.
Nausea and vomiting: occurs during the early phase of cholera. Sometime vomiting may occur for hours.
Other signs and symptoms of cholera include lethargy, irritability, dry mouth, and sunken eyes, dry skin that bounces back slowly after it has been pinched into a fold, extreme thirst, little urine output, irregular heartbeat (arrhythmia) and low blood pressure
The people of Bangui expressed symptoms that are consistent with the case definition of cholera outbreak. The environment in Bangui also had conditions that are likely to predispose people to developing cholera
Cases are categorized into three types; confirmed, possible and probable cases. Confirmed cases are the laboratory confirmed cases such as the cholera victims who had their stool tested for Vibrio cholerae. However probable cases have characteristics clinical features of the disease but they lack laboratory confirmations (Ramamurthy, 2011). For example, there were residents of Mbaika district who had bloody diarrhea but without laboratory testing. Finally, possible cases are those with some clinical features such as abdominal cramps and diarrhea such as three stools in a 24-hour period.
Cholera is a point source epidemic. It arises due to common sources such as contaminated food or an infected food handler. The period for incubation ranges from a few hours to 5 days after infection. Suspected cholera case was defined as any individual of any age that presented with acute watery diarrhea. The most affected individuals were the women living in villages along Bangui River.
The cholera outbreak in Mbaika district, Central Africa Republic where 170 patients and 16 cholera deaths reported, were related with risk factors that were food borne. There is a substantive association between cholera and eating cold cassava leaves. Epidemiological studies from Zambia indicated that the major transmission vehicle of cholera outbreak is contaminated food.
Vibrio cholerae could be inoculated into cooked food during preparation by an asymptomatic but infected person (Howard, 2011). However, the cause of contamination of cassava leaves may vary and the study did not determine its course. This hypothesis is true because earlier studies indicate that soiled kitchen ware can contaminate food and the Vibrio cholerae live for up to 2 days.
Cholera outbreak caused many deaths in the region. The death rate rose up to 24.2% in Matuu which is higher than the countrywide rate of 9%. MOH in collaboration with various partners assisted in the management of cholera. The investigation produced important results. The outbreak of cholera in Kamba district, Central African Republic where by more than 170 cases and 16 deaths reported, was as a result of risk factors that were food borne.
The case control investigation associated cholera with consumption cold leaves of cassava. Epidemiological study from Zambia indicated that during an outbreak, the major transmission vehicle of cholera is contaminated food. When food is prepared, Vibrio cholerae could be inoculated by asymptomatic but affected person. The source of contamination varies in cassava leaves. The study did not determine its course. According to previous studies, soiled kitchen ware can contaminate food where the Vibrio cholerae persists for 1-2 days.
There was lack of association between the outbreak and water-related risk factors. Cholera transmission through direct waterborne ways was not very evident in these areas. Other previous investigations have reported that drinking water sold in the streets was responsible for the outbreak of cholera in Latin America.
The study ruled out the link between cholera and drinking contaminated water, poor sanitation and attending burials that are cholera related in the district. Households in the two villages are built along the river which makes the area vulnerable especially during floods. Consumption of untreated water from Oubangui River was not proven risky but it should be avoided.
Delay in the analysis of stool samples should be discouraged. It leads to delayed confirmation of an outbreak as well as delayed implementation measures. According to this case, the delay occurred because the outbreak emanated outside Bangui. On the other hand, Bangui National Laboratory (NLB) did not have a means of transport for collecting stool samples from outside Bangui. It is very vital to have all the appropriate resources during an outbreak. Availability of epidemic readiness plan and a committee present in a district results in effective and timely management of the outbreak. Public health surveillance system management by only one individual in the entire district may not be effective in handling all the threats in public health.
The outbreaks of cholera in Central Africa are still ongoing but in a slow rate compared to the past three week. Considerable association between cholera and eating cold cassava leaves was identified. First and seventh regions were the only ones affected by the outbreak (Lewenson, 2013). Women and children living along the Oubangui River were the most affected by the outbreak. Lack of transport of samples to the National Laboratory delayed outbreak confirmation. Effective measures in cholera treatment there were to be implemented include; establishment of cholera treatment center, treatment of drinking water, health education on good food and general hygiene.
- The study provided epidemiological information that leads to cholera. They include consuming untreated water, poor sanitation and attending cholera areas.
- The major transmission vehicle of cholera is contaminated food.
- Consumption of water sold in the street can also result into cholera outbreak.
- Lack of laboratory materials transport and communication causes delay in analysis of an outbreak
- There is need for a stand by epidemic readiness plan and committee in the district that ensures well-timed management of the outbreak.
- Health education and social sensitization on habits of eating, community hygiene and personal, sanitation and burial practice.
- System for public health surveillance should be strengthened by the administration.
- Encouragement of eating food when still hot.
- Each region should be supported in development of a functional epidemic readiness plan and response committee and a definite epidemic readiness control plan as soon as possible.
- Ministry of health in conjunction with that of water should ensure that the communities have access to clean water.
- Laboratories should have basic resources to avoid delaying in laboratory confirmations.
- The surveillance system should be able to identify outbreaks and report in time.
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