Dear Editor,
Cholera is a well-known disease, caused by the toxin of the bacterium Vibrio cholerae, and has resulted in severe problems to the health systems of African countries, over the years, even after more than 50 years after its resurgence, in 1970. Among the nearly 1.4 to 4.0 million cases, and 21,000 to 143,000 deaths per year worldwide, most of the burden occurs in African countries, especially in Sub-Saharan Africa.(11. World Health Organization (WHO). Cholera. Geneva: WHO; 2021 [ updated 2021 Feb 5; cited 2021 Aug 8]. Available from: https://www.who.int/news-room/fact-sheets/detail/cholera
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The cholera in Africa occurs in two settings, as an endemic situation that happens every 2 to 3 years, in certain seasons, and as an epidemic situation that starts acutely and threatens thousands of lives, while burdening the healthcare systems.(22. Mengel MA, Delrieu I, Heyerdahl L, Gessner BD. Cholera outbreaks in Africa. Curr Top Microbiol Immunol. 2014;379:117-44.)Between 2015 and 2019, ten cholera outbreaks affected Sub-Saharan African countries: Democratic Republic of Congo (DRC) in 2019; Ethiopia in 2019 and 2017; Kenya from April to June 2015; Mozambique in April 2019; South Sudan in 2017; Tanzania in August 2015; Zambia in October 2017; Zanzibar in 2016; and Zimbabwe in 2018. Some of these outbreaks reached between 4,000 and 7,000 cases of cholera.(33. Centers for Disease Control and Prevention (CDC). Cholera - vibrio cholerae infection. Africa by Country. Atlanta (GA): CDC; 2021 [cited 2021 Apr 28]. Available from: https://www.cdc.gov/cholera/africa/locations.html
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In Africa, the recurrent and continuous cholera outbreaks have been associated mainly with overcrowding, water supply and sanitation problems, and poverty.(44. World Health Organization (WHO). Regional office for Africa. Cholera. Geneva: WHO Africa; 2021[cited 2021 Apr 28]. Available from: https://www.afro.who.int/health-topics/cholera.
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) Climate change and environmental reservoirs also take a toll on the cholera and ease the transmission of disease. Transmission also becomes easier especially in crowded life settings, such as during wars, in prison and refugees camps.(55. Tarh JE. An overview of cholera epidemiology: a focus on Africa; with a keen ınterest on Nigeria. Int J Trop Dis Heal. 2019;40(3):1-17.) Therefore, some African issues, such as cross-border migration, socioeconomic factors, and political instability, aggravate the situation.(66. Ajayi A, Smith SI. Recurrent cholera epidemics in Africa: which way forward? A literature review. Infection. 2019;47(3):341-9. Erratum in: Infection. 2019 Mar 11. Review.)
The preventive actions against cholera are based on improving sanitary conditions and hygiene. The World Health Organization (WHO) further advocates for the use of oral cholera vaccines (OCV) as a transient protection, since vaccines have been proven to be effective to combat cholera especially during an epidemic situation.(77. Hsueh BY, Waters CM. Combating cholera. F1000Res. 2019;8:F1000 Faculty Rev-589. Review.) Despite the efforts put into by the local governments, and the WHO initiatives to eliminate the disease, by launching the Global Task Force on Cholera Control, there are many obstacles hindering massive and proactive OCV use in Africa, and vaccination is still not at the expected levels. The success of the OCV program depends on huge financial investment, which is essential to build an immunization infrastructure, including vaccine logistics and transportation. Modeling data were also not able to bring a concrete result for the beneficiary of vaccine campaigns.(88. World Health Organization (WHO). Regional Office for the Eastern Mediterranean (EMRO). Health topics. Cholera. Geneva: WHO: EMRO; 2021 [citado 2021 Apr 28]. Available from: http://www.emro.who.int/health-topics/cholera/index.html
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As expected, the coronavirus disease 2019 (COVID-19) pandemic had a negative impact on the implementation of preventive measures, and the epidemiological control of numerous infectious diseases around the world.(99. Costa AC, Hasan MM, Xenophontos E, Mohanan P, Bassey EE, Hashim HT, et al. COVID-19 and Zika: an emerging dilemma for Brazil. J Med Virol. 2021;93(7):4124-6.,1010. Rocha IC, Hasan MM, Goyal S, Patel T, Jain S, Ghosh A, et al. COVID-19 and mucormycosis syndemic: double health threat to a collapsing healthcare system in India. Trop Med Int Health. 2021;26(9):1016-8.)Among African countries, the situation was no different. Poor surveillance systems got worse during the pandemic, which affected viral diseases, such as measles and yellow fever.(1111. Çavdaroğlu S, Hasan MM, Mohan A, Xenophontos E, Costa AC, Aborode AT, et al. The spread of Yellow fever amidst the COVID-19 pandemic in Africa and the ongoing efforts to mitigate it. J Med Virol. 2021;93(9):5223-5.,1212. Mohan A, Temitope RA, Çavdaroğlu S, Hasan MM, Costa AC, Ahmad S, et al. Measles returns to the Democratic Republic of Congo: a new predicament amid the COVID-19 crisis. J Med Virol. 2021;93(10):5691-3.)Based on empirical evidence, COVID-19 has severely impacted the preventive and control measures of cholera. However, the actual extent of the impact is not yet fully known, given lack of an efficient surveillance system.(44. World Health Organization (WHO). Regional office for Africa. Cholera. Geneva: WHO Africa; 2021[cited 2021 Apr 28]. Available from: https://www.afro.who.int/health-topics/cholera.
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) Data available from the first weeks of 2021 showed that West and Central Africa have recorded fewer cases of cholera. However, the case fatality rate at week 5, in 2021, is the highest in the last 3 years, and can be further explained by the underestimated impacts of the COVID-19 pandemic due to saturation of health facilities, reluctance to go to health facilities when presenting the first symptoms, and overload of surveillance services.(1313. ReliefWeb. Cholera Outbreaks in Central and West Africa: 2021 regional update- week1–5. Democratic Republic of the Congo: ReliefWeb; 2021 [cited 2021 Jun 20]. Available from: https://reliefweb.int/report/democratic-republic-congo/cholera-outbreaks-central-and-west-africa-2021-regional-update
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It is undeniable that the pandemic has created a fertile environment for future outbreaks. Both the healthcare settings and healthcare professionals are overburdened with the pandemic. This overload has significantly reduced the time devoted to non-COVID-19 patients. Shortly after the first cases were seen, over 6 million people were under the threat of losing sanitation, which is a major concern for a possible cholera outbreak.(1414. Wehinger Krafft R. Cholera in Yemen Post COVID-19: a case study on the Challenges Humanitarian organizations face in ending cholera [dissertation]. Uppsala (SWE): Uppsala University; 2021. p.38 [cited 2021 Apr 28]. Available from: http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-432710
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Coronavirus disease 2019 has also reduced health-seeking behavior, because of the increasing fear of being infected by the virus. This fear is attributed to lack of adequate resources, such as personal protective equipment, medicines, and proper sanitary conditions, as well as decreased immunization against cholera, and the major focus being the pandemic at hand.(1414. Wehinger Krafft R. Cholera in Yemen Post COVID-19: a case study on the Challenges Humanitarian organizations face in ending cholera [dissertation]. Uppsala (SWE): Uppsala University; 2021. p.38 [cited 2021 Apr 28]. Available from: http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-432710
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)Suspension of the fight against cholera, together with shortages in food and water, and displacements across the country have already caused an increase in cases in Ethiopia.(1515. Hassan OB, Nellums LB. Cholera during COVID-19: the forgotten threat for forcibly displaced populations. EClinicalMedicine. 2021;32:100753.)
Before the COVID-19 pandemic, 47 African countries adopted the Regional Framework for the implementation of the global strategy of cholera prevention and control. The countries in line with the framework have committed themselves to limit the spread of cholera by taking evidence-based actions, improving treatment strategies, tightening border surveillance, as well as promoting use of OCV with increasing investments in water supplies.(1616. World Health Organization (WHO). Regional office for Africa. African Health Ministers commit to ending cholera outbreaks by 2030. Geneva: WHO Africa; 2018 [cited 2021 Apr 28]. Available from: https://www.afro.who.int/news/african-health-ministers-commit-ending-cholera-outbreaks-2030
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) However, the pandemic had a negative impact on several strategies that would be adopted, such as decline in the provision of water, sanitation and hygiene (WASH) services, vaccine supplies, vaccine campaigns, and humanitarian aid, which were harmed due to measures of isolation and social distance, to prevent contagion against the coronavirus.(1717. Health Europa. COVID-19, infection control, and cholera. United Kingdom: Health Europa; 2021 [updated 2021 Apr 16; cited 2021 June 20]. Available from: https://www.healtheuropa.eu/covid-19-infection-control-andcholera/107561/
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To mitigate the situation and avoid future outbreaks, a scientific approach and surveillance programs for cholera, to understand the epidemiology and detect risky areas, are essential to manage prevention and spread of the diseases. The Centers for Disease Control and Prevention (CDC), have a public database of cholera cases. However, the true number of cases is underestimated, which makes it difficult to take measures appropriate to the actual epidemiological situation.(33. Centers for Disease Control and Prevention (CDC). Cholera - vibrio cholerae infection. Africa by Country. Atlanta (GA): CDC; 2021 [cited 2021 Apr 28]. Available from: https://www.cdc.gov/cholera/africa/locations.html
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)Therefore, it is necessary to improve laboratory and epidemiological surveillance systems. Moreover, the provision of WASH services and commodities is essential to prevent infection during the outbreak of infectious diseases, including cholera. In addition, to improve cholera control, it is necessary to improve health systems capacity to diagnose the disease, since inconsistencies in case definitions and lack of laboratory diagnostic also contribute to underreporting.
Even during the COVID-19 pandemic, it is necessary to reinforce the need to improve the multifactorial approach, as a key to prevent and control cholera outbreaks in Africa. It is undeniable that only with effective and continuous surveillance, vaccination, water, sanitation, and hygiene programs, associated with social mobilization and treatment, will African countries be able to provide a rapid and effective response to cholera outbreaks.
In conclusion, cholera is responsible for major outbreaks in Africa. Hygiene is crucial for both cholera and coronavirus transmission. Adhering to cholera prevention commitments alongside an efficient surveillance system, to track cholera outbreaks and to detect public health needs towards combating cholera in Africa, is the essential need in the current pandemic.
REFERENCES
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1World Health Organization (WHO). Cholera. Geneva: WHO; 2021 [ updated 2021 Feb 5; cited 2021 Aug 8]. Available from: https://www.who.int/news-room/fact-sheets/detail/cholera
» https://www.who.int/news-room/fact-sheets/detail/cholera -
2Mengel MA, Delrieu I, Heyerdahl L, Gessner BD. Cholera outbreaks in Africa. Curr Top Microbiol Immunol. 2014;379:117-44.
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3Centers for Disease Control and Prevention (CDC). Cholera - vibrio cholerae infection. Africa by Country. Atlanta (GA): CDC; 2021 [cited 2021 Apr 28]. Available from: https://www.cdc.gov/cholera/africa/locations.html
» https://www.cdc.gov/cholera/africa/locations.html -
4World Health Organization (WHO). Regional office for Africa. Cholera. Geneva: WHO Africa; 2021[cited 2021 Apr 28]. Available from: https://www.afro.who.int/health-topics/cholera
» https://www.afro.who.int/health-topics/cholera -
5Tarh JE. An overview of cholera epidemiology: a focus on Africa; with a keen ınterest on Nigeria. Int J Trop Dis Heal. 2019;40(3):1-17.
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6Ajayi A, Smith SI. Recurrent cholera epidemics in Africa: which way forward? A literature review. Infection. 2019;47(3):341-9. Erratum in: Infection. 2019 Mar 11. Review.
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7Hsueh BY, Waters CM. Combating cholera. F1000Res. 2019;8:F1000 Faculty Rev-589. Review.
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8World Health Organization (WHO). Regional Office for the Eastern Mediterranean (EMRO). Health topics. Cholera. Geneva: WHO: EMRO; 2021 [citado 2021 Apr 28]. Available from: http://www.emro.who.int/health-topics/cholera/index.html
» http://www.emro.who.int/health-topics/cholera/index.html -
9Costa AC, Hasan MM, Xenophontos E, Mohanan P, Bassey EE, Hashim HT, et al. COVID-19 and Zika: an emerging dilemma for Brazil. J Med Virol. 2021;93(7):4124-6.
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10Rocha IC, Hasan MM, Goyal S, Patel T, Jain S, Ghosh A, et al. COVID-19 and mucormycosis syndemic: double health threat to a collapsing healthcare system in India. Trop Med Int Health. 2021;26(9):1016-8.
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11Çavdaroğlu S, Hasan MM, Mohan A, Xenophontos E, Costa AC, Aborode AT, et al. The spread of Yellow fever amidst the COVID-19 pandemic in Africa and the ongoing efforts to mitigate it. J Med Virol. 2021;93(9):5223-5.
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12Mohan A, Temitope RA, Çavdaroğlu S, Hasan MM, Costa AC, Ahmad S, et al. Measles returns to the Democratic Republic of Congo: a new predicament amid the COVID-19 crisis. J Med Virol. 2021;93(10):5691-3.
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13ReliefWeb. Cholera Outbreaks in Central and West Africa: 2021 regional update- week1–5. Democratic Republic of the Congo: ReliefWeb; 2021 [cited 2021 Jun 20]. Available from: https://reliefweb.int/report/democratic-republic-congo/cholera-outbreaks-central-and-west-africa-2021-regional-update
» https://reliefweb.int/report/democratic-republic-congo/cholera-outbreaks-central-and-west-africa-2021-regional-update -
14Wehinger Krafft R. Cholera in Yemen Post COVID-19: a case study on the Challenges Humanitarian organizations face in ending cholera [dissertation]. Uppsala (SWE): Uppsala University; 2021. p.38 [cited 2021 Apr 28]. Available from: http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-432710
» http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-432710 -
15Hassan OB, Nellums LB. Cholera during COVID-19: the forgotten threat for forcibly displaced populations. EClinicalMedicine. 2021;32:100753.
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16World Health Organization (WHO). Regional office for Africa. African Health Ministers commit to ending cholera outbreaks by 2030. Geneva: WHO Africa; 2018 [cited 2021 Apr 28]. Available from: https://www.afro.who.int/news/african-health-ministers-commit-ending-cholera-outbreaks-2030
» https://www.afro.who.int/news/african-health-ministers-commit-ending-cholera-outbreaks-2030 -
17Health Europa. COVID-19, infection control, and cholera. United Kingdom: Health Europa; 2021 [updated 2021 Apr 16; cited 2021 June 20]. Available from: https://www.healtheuropa.eu/covid-19-infection-control-andcholera/107561/
» https://www.healtheuropa.eu/covid-19-infection-control-andcholera/107561/
Publication Dates
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Publication in this collection
02 May 2022 -
Date of issue
2022
History
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Received
24 July 2021 -
Accepted
25 Aug 2021