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Preparing to respond to a Cholera Outbreak
Nigeria usually experiences outbreaks of Cholera during the rainy season. These outbreaks usually span from May up until September or October yearly. During these months, the country records high rainfalls, sometimes leading to an overflow of sewage systems and subsequent breakdown in overall hygiene standards. Furthermore, poor access to potable water and crowded living conditions are highlighted as contributory factors to the start and spread of a cholera outbreak.
In the Epi-week ending 11th June 2017, the Nigeria Centre for Disease Control (NCDC), through its event-based surveillance system received rumours of 12 deaths of Cholera in Kwara State. Initial rumour verification was carried out and a team was dispatched immediately for a full investigation and containment of the outbreak. Preliminary findings revealed a total of 1,178 suspects with 9 deaths across 4 Local Government Areas (LGAs) in Kwara State, with a CFR of 0.76% as at 14th June, 2017. Seven cases have been laboratory confirmed by culture. Affected cases have commenced treatment. Trainings on case management and infection, prevention and control are being carried out for clinicians and health care workers. Community sensitization is ongoing across the state. The Kwara State Government through the Ministry of Health is in the forefront of coordinating the response to this outbreak, supported by the NCDC and other partnering agencies.
Preparedness for an outbreak should commence ahead of an outbreak season. Firstly, risk mapping should be carried out to provide insight on the vulnerability of the state/populace for an outbreak or a specific outbreak. Preparedness activities for cholera should cut across all thematic areas as this will give a holistic approach in identifying resources required for preparedness. This includes:
1. Coordination: Developing a preparedness plan to guide activities and understand expectations/roles of every tier of government; Involvement of all identified key stakeholders; Early sensitization and planning with a Rapid Response Team (RRT); Forecasting, planning and coordination with stakeholders on interim measures to be put in place in the eventuality of a large outbreak e.g. setting up of interim water supply, rapid requisition and distribution of commodities for unexpected upsurge of cases, maintaining good hygiene conditions(personal and environmental).
2. Surveillance: Increased alert for Cholera by sensitizing the surveillance teams at the Local and State Government levels. This can be done through Capacity building; Adequate supply and distribution of data collection tools to all health facilities; Improve effective communication channels for receiving reports/information and feedback; Development of a data management system for better and quicker data analysis; Improvement of bio-surveillance activities for rumour capturing and verifications; Consolidating measures for active case search.
3. Case Management: Review of existing guidelines and protocols; Identification/designation of Cholera treatment centres and a case management team at the local and state government levels; Capacity building on case management and Infection, Prevention and Control team.
4. Laboratory: Identification of secondary, tertiary and public health laboratories with testing capacities, (stool testing and water analysis); Request and distribution of test-kits to Cholera endemic/Cholera prone areas for immediate response; Request and distribution of transport medium for specimen; Capacity building of identified laboratory staff in sample collection and transportation.
5. Logistics: Early forecast of outbreak commodities required; Mapping and pre-positioning of commodities e.g. intravenous fluids, in states based on data review of previous outbreaks; Stockpiling and distribution of antibiotics based on review previous epidemiological reports for previous outbreaks.
6. Risk Communications: Development of a risk communication plan; Pre-outbreak sensitization and mobilization; Design of communication tools specific for target audience; Early engagement of the mass media for sensitization program and improved/extended use of communication tools It is important to note that preparedness for any disease outbreak or event of public health concern is an intensive process which requires a multi-sectorial approach, if desired health outcomes are to be achieved. The NCDC held a Cholera preparedness workshop covering the thematic areas listed above, with State Epidemiologists from the eight most affected States, academia and partners. The Cholera preparedness plan and guidelines is being finalised and will guide actions during this outbreak. A Cholera alert letter has also been sent to all State Commissioners of Health and Epidemiologists, alerting them of the season and actions to take. We will continue to provide support, collaborate and guidance to states in preparedness and response activities for an outbreak. States are expected to coordinate these activities to ensure meaningful and sustainable results are achieved.
In the reporting week:
o There were 256 new cases of Acute Flaccid Paralysis (AFP) reported. None was confirmed as Polio. The last reported case of Polio in Nigeria was in August 2016. Active case search for AFP is being intensified as Nigeria has assiduously reinvigorated its efforts at eradicating Polio.
o 77 suspected cases of Cholera were reported from four LGAs in two States and one death was recorded.
o There were 42 suspected cases of Cerebrospinal Meningitis (CSM) reported from 22 LGAs in ten States. Of these, one was laboratory confirmed and one deaths was recorded. Ongoing surveillance for CSM has been intensified in the States.
o There were 361 suspected cases of Measles reported from 33 States. None was laboratory confirmed and four deaths were recorded.
In the reporting week, Enugu and Jigawa States failed to report. Timeliness of reporting increased from 81% in the previous week to 82% while completeness increased from 99% in the previous week to 100%. It is very important for all States to ensure timely and complete reporting at all times, especially during an outbreak.