Cholera: Still a Major Public Health Issue in Sub-Saharan

Africa
Merlyn Dorsainvil

Journal of Health Care for the Poor and Underserved, Volume 32,
Number 4, November 2021, pp. 1734-1741 (Article)

Published by Johns Hopkins University Press

DOI: https://doi.org/10.1353/hpu.2021.0162

For additional information about this article

https://muse.jhu.edu/article/837316

[ Access provided at 16 Jan 2023 04:24 GMT from University of Montreal ]

COMMENTARY

Cholera: Still a Major Public Health Issue

in Sub-Saharan Africa
Merlyn Dorsainvil, DHSc, MPH, RN

Abstract: Cholera continues to be a public health issue in sub-Saharan Africa, specifically

the African Great Lakes region. Cases of cholera and deaths from cholera are increasing
yearly. Studies have identified lakes and war/conflict as the risk factors for cholera in the
African Great Lakes region. Other studies suggest that surveillance, handwashing, sanitation,
oral cholera vaccine, education, and access to care are effective preventive measures against
cholera in sub-Saharan Africa. But sub-Saharan Africa is not meeting the 2030 Sustain-
able Development Goal of ensuring availability and sustainable management of water and
sanitation for all. This commentary calls for research and implementation of interventions,
specifically tailored for the culturally, ethnically, and linguistically diverse populations in
sub-Saharan Africa, also taking into account the historical context of each population.
Keywords: cholera, sub-Saharan Africa, African Great Lakes Region, prevention

G lobally, diarrhea is the leading cause of malnutrition and the second leading cause
of death in children under five years old.1 It is estimated that 88% of diarrheal
deaths are due to a lack of access to sanitation facilities, together with inadequate avail-
ability of water for hygiene and unsafe drinking water.2
Cholera is an acute intestinal infection caused by ingestion of food or water con-
taminated with the bacterium Vibrio cholerae. It causes a copious, painless, watery
diarrhea that can quickly lead to severe dehydration and death without prompt treat-
ment.3 In 2017, 34 countries reported a total of 1, 227, 391 cases of cholera and 5,564
deaths. Yemen experienced an acute, country-wide epidemic of cholera that accounted
for 84% of the global reported cases and 41% of the cholera deaths. Excluding Yemen
from the total cases and deaths, the 2017 reporting still represents a 45% increase in
cases of cholera and 33% increase in deaths from the global totals in 2016. Africa has
the largest number of cases reported since 2011, with a sharp rise in the number of
people affected. Fourteen African countries reported a total of 179, 835 cases of chol-
era and 3,220 deaths.4 The African population, of all genders and ages, is suffering a
disproportionate burden of cholera in the world.

MERLYN DORSAINVIL is affiliated with the NYC College of Technology and City University of New
York. Please address all correspondence to Merlyn Dorsainvil, NYC College of Technology, Department
of Nursing, 285 Jay Street, Brooklyn, New York 11201; Email: mdorsainvil@citytech.cuny.edu.

© Meharry Medical College Journal of Health Care for the Poor and Underserved 32 (2021): 1734–1741.
 Dorsainvil 1735

Cholera
Vibrio cholerae is a gram-negative rod bacterium that causes a spectrum of infection
ranging from asymptomatic colonization to rapidly fatal secretory diarrhea called
cholera gravis. V. cholerae is classified into many serogroups based on the O antigen
of its lipopolysaccharide but only O1 and O139 serogroups cause epidemic cholera.
The O1 serogroup is subclassified into two biotypes, classical and El Tor. In the 1960s,
the O1 El Tor biotype emerged as a major cause of cholera. In 1992, the O139 biotype
was first recognized in South Asia as a cause of epidemic cholera. Due to variations in
the predominating serogroup, biotype, and serotype in circulation, the epidemiology
of cholera is in constant flux.3,5,6
Cholera is an acute infection with no chronic symptoms. Dehydration and electrolyte
imbalances are the main complications of cholera but massive diarrhea, up to one liter
an hour, can lead to hypotensive shock and death within hours. Death rates in untreated
patients with severe cholera exceed 70%. Complications from severe hypotension can
cause strokes and renal impairment. Vomiting, a common feature, can lead to aspira-
tion pneumonia.3,6
There are descriptions of a disease thought to be cholera written in Sanskrit as far
back as the 5th century BC. In 1817, cholera spread beyond the Indian subcontinent
and six worldwide pandemics occurred between 1817 and 1923.6 In historical treatises
on cholera, sea-borne transportation of cholera supports the current theory of dis-
semination. Initial cases typically occurred along coastal areas, and outbreaks were
commonly attributed to ships arriving from cholera-epidemic areas.7 In 1849, during
the second pandemic, Dr. John Snow, a physician in London, determined that cholera
was a communicable disease spread through mixing drinking water and sewage. Then in
1884, Robert Koch isolated Vibrio cholerae in pure culture. The El Tor biotype was first
isolated in 1905 in El Tor, Egypt and caused the seventh cholera pandemic in 1961 in
Indonesia.3,6,8 Since 2007, the three most severe cholera epidemics were caused by a new
atypical El Tor strain. This strain is associated with more severe outcomes of disease.9
Epidemiological triad. Cholera occurs in both endemic and epidemic patterns.
Endemicity of cholera carries the potential of epidemic flare-ups and pandemicity
is always a threat, particularly in developing countries having poor sanitation, lack
of hygiene, and crowded living conditions.3,8,9 Cholera epidemics arise in long cycles
superimposed on existing endemic disease. This happens because of declining levels
of population-level immunity from a previous outbreak overlaid on cycles of climate
variability.6,9 Thus, environmental and host factors influence susceptibility to the agent,
Vibrio cholerae.
Agent. V. cholerae are present in human stool. In environmental water, it converts
to conditionally viable environmental cells within 24 hours. But upon reintroduction
into people, the bacteria are infectious again. After ingestion of V. cholerae, most of
the bacteria are killed by gastric acid. Those not killed, colonize the small intestine
and excrete cholera toxin, the main virulence factor. When V. cholerae O1 leaves a
person, the organisms have a phenotype referred to as hyperinfectivity. That translates
to an infectious dose that is 10 to 100 times lower than for non-human shed organ-
1736 Cholera in the African Great Lakes Region

isms. Hyperinfectivity of recently shed organisms persists in water for five to 24 hours.
Therefore, some key components of cholera transmission include the concentration of
V. cholerae O1 or O139 in the stool and the rapidity of spread from person to person.6
Host. Cholera affects all age groups; however some host factors may contribute to
susceptibility. Concurrent infection with enteropathogenic bacteria or parasites decreases
V. cholerae-specific immunity. It was also found that blood group O is associated with
an increased risk of severe cholera and increased severity of cholera was observed in
those infected with both O1 and O139 serogroups.5,6
Environment. The environment plays a major role in the epidemiology of cholera.
It is believed that high levels of phytoplankton, a microscopic organism that inhabits
most oceans and bodies of fresh water, leads to high numbers of cholera-containing
copepods. It was found that the upwelling of cold, nutrient-rich, deep ocean waters,
high sea surface temperature, and river discharges were the drivers for phytoplankton
abundance.10 Therefore, it is comprehensible that cholera rates increase during flood
periods and natural disasters.
Cholera rates and health risks. In 2016, almost 90% of the total cases of cholera
worldwide were from two areas: Hispaniola and Africa. Fifty-four percent of cases were
reported from Africa. In 2016, 2,420 deaths were reported, an 85% increase from 2015.11
The number of cases of cholera and deaths continued to increase in 2017.4 The burden
of cholera remains high globally, especially in sub-Sahara Africa which accounts for
the majority of the global burden.12 More specifically, much of this burden is in the
African Great Lakes region (AGLR) of sub-Saharan Africa.
Cholera first emerged in the AGLR in 1977 to 1978. Since then, it has become of the
most active foci of cholera. From 1998 to 2008, the AGLR reported 20% of all cholera
cases worldwide despite a wide underestimation in the numbers due to lack of access
to health care facilities for many individuals. The spread of cholera to this region is
thought to be facilitated by global climactic and local environmental factors. It was
found that cholera cases in the AGLR greatly increases during years of El Niño warm
events and decreases or stabilizes between these warm events.13
Populations most severely affected by cholera differ between endemic and epidemic
settings. The most severe cases of cholera in endemic settings are concentrated among
young children and previously unexposed persons. However, in an epidemic, severe
disease occurs in adults as frequently as in children and is associated with high case
fatality rates.6,13
Globally, cholera continues to be underreported due to inadequate national reporting
systems. Not only does cholera have a severe toll on public health, it causes serious social
and economic disruption. In addition, the epidemiology of cholera is proving to be more
complicated than just water temperatures and bacterial resurgence. There is a crucial
need for better monitoring and reporting in order to improve control measures.3,9,13

The African Great Lakes Region

The African Great Lakes are some of the largest freshwater systems in the world. They
are part if a series of 15 lakes that twist down the two arms of the Great Rift Valley.
 Dorsainvil 1737

Eight of the 15 lakes are considered great lakes due to their size and depth. Lake Vic-
toria, located between Uganda to the west and Tanzania and Kenya to the east, is the
second-largest freshwater lake in the world. Lake Tanganyika, located on the border
between Democratic Republic of Congo (DRC) and Tanzania, is the second in terms
of depth. The African Great Lakes region comprises Burundi, Rwanda, DRC, Uganda,
Kenya, and Tanzania.14
The region’s rich soil draws many people. Millions of people live within 50 miles of
Lake Victoria making it one of the most heavily populated areas in Africa. The shores
of Lake Tanganyika are also densely populated.14
Despite the abundance of resources, the AGLR is not without strife. There have been
volcanic eruptions in DRC. In addition, the AGLR has been the site of more than a
decade of unrest. The region hosts more than a million refugees and ten million internally
displaced people. There was a mass exodus of more than two million Rwandans in the
wake of the 1994 genocide. That set in motion further cycles of conflict in the region,
including a devastating war in the DRC that killed more than three million people.15

Cholera in the African Great Lakes Region

The history of cholera reveals a remarkably strong association with the sea. The great
pandemics followed coastlines of the world.8,16 As previously discussed, the AGLR has
been one of the most active foci of cholera since it first emerged there in 1977 to 1978.13
Most studies of cholera were done in coastal areas and the main risk factors identified
include heavy rainfall, increase in plankton, and increase in sea surface temperatures.10
Few studies have been carried out to assess risk factors in inland areas, particularly
the risk factors of the AGLR. The literature was reviewed to assess the impact of lakes,
war/conflict, and natural disasters on rates of cholera in the AGLR.
Lakes. All the studies of cholera in the AGLR found that lakes were a risk factor for
cholera. Two epidemiological studies in DRC found that the number of cases of cholera
were significantly higher in lakeside areas.16,17 A case-control study by Birmingham and
colleagues18 in Burundi found that bathing in and drinking water from the lake was
significantly associated with cholera illness. The odds of cholera illness increased with
time spent in the lake, indicating a dose-response relation. Another case-control study in
Kenya by Shapiro and colleagues19 found that the patients from whom V. cholerae were
isolated were more likely to live in a village bordering Lake Victoria. Drinking water
from Lake Victoria or a stream was an independent risk factor for cholera. Additional
independent risk factors were sharing meals with someone with watery diarrhea and
attending funeral feasts.
War/Conflict. The literature was conflicted regarding the impact of war and conflict
on rates of cholera. One study found that displacement from war in DRC caused no
significant exacerbation of cholera cases.17 Another found that an exacerbation was
noted when civilians fled trying to escape civil war in the DRC.16 In addition, a study
in Kenya found that following civil unrest from a disputed presidential election in 2008,
there was a cholera outbreak with significantly higher mortality. There was a 200%
increase in fatal cholera cases. The case fatality ratio increased from 5.5% to 11.4%.20
1738 Cholera in the African Great Lakes Region

Natural disasters. Only one study assessed the impact of volcanic eruptions in DRC.
It found that the volcanic eruption was not followed by an exacerbation of cholera
incidence.17

Prevention of Cholera in the African Great Lakes Region

Surveillance. A study evaluating the implementation of the Integrated Disease Surveil-
lance and Response (IDSR) strategy was carried out in Uganda. The IDSR strategy was
recommended by the World Health Organization to create a coordinated approach to
the collection, analysis, interpretation, use, and dissemination of surveillance data for
guiding decision making on public health actions. Uganda successfully implemented this
strategy and it found that from 2001 to 2007, the strategy was associated with improved
surveillance and response efforts that resulted in a decrease in the case fatality rate of
cholera, a target priority disease, from 7% to 2%.21
Hand washing and sanitation. Two case-control studies in Kenya found that proper
sanitation and hand washing were effective, inexpensive measures to prevent cholera.
It was found that there was a significant reduction in the risk of cholera in individuals
who reported having soap in the home and washing their hands with soap.20,22 Having
a latrine in the home and access to a clean latrine was also associated with a lower
risk of cholera. Sharing a communal latrine and using a dirty water storage container
increased the risk of illness.22
Oral cholera vaccine. An observational cohort study was done in recipients of the
oral cholera vaccine and non-recipients in Zanzibar. It was found that the vaccine
gave 79% direct protection against cholera in participants who received two doses of
cholera vaccine. Herd protection was shown by a decrease in the risk for cholera of
non-vaccinated residents within a household’s neighborhood as the vaccine coverage
in that neighborhood increased. This suggests that the oral cholera vaccine is highly
effective in a sub-Saharan African setting.23
Education and access to care. A case-control study in Kenya after civil unrest
found that some protective measures against dying from cholera including having
been educated about cholera before becoming ill, being treated in a government health
facility, having been educated about cholera by a health worker, and being admitted
to a hospital overnight.20

Cholera Prevention
The World Health Organization (WHO) policy and recommendations for prevention
and control of cholera outbreaks consists of providing clean water, proper sanitation,
and education on basic hygiene and food safety. They also recommend strengthening
cholera surveillance and early warning.24 Although research has shown that the use
of cholera vaccine gave 78% to 79% protection against cholera 23,25 it has never been
recommended by the WHO except in complex emergencies. Complex emergencies are
situations of disrupted livelihoods and threats to life produced by warfare, civil distur-
bance and large-scale movements of people, in which any emergency response must
be conducted in a difficult political and security environment. In these situations, the
 Dorsainvil 1739

WHO states that the oral vaccine should always be used as an additional public health
tool and should not replace the usually recommended control measures.24 On June 1,
2019 the WHO and the DRC Ministry of Health vaccinated over 800,000 people in
regions near Lake Kivu in DRC with the oral cholera vaccine. Since January 2019, the
country has had over 10,000 cases of cholera and over 240 deaths.26
Despite the effectiveness of the oral cholera vaccine, successful cholera control
programs have consisted of improving sanitation, improving access to safe drinking
water, education on hygiene, increasing surveillance of cholera, and mobilizing local,
regional, and national health authorities. These measures have been shown to be effec-
tive in Haiti, Dominican Republic, South India, and Kenya.20,22,27,28
In 2015, all United Nations Member States set 17 Sustainable Development Goals
(SDG). Goal six is to ensure availability and sustainable management of water and
sanitation for all. The 2018 report shows that a majority of the world’s population still
lacks safe sanitation, and three in 10 lack safe drinking water.29 In sub-Saharan Africa,
only 24% of the population has access to safely managed drinking water services and
34% to basic drinking water services. Furthermore, only 28% had access to basic sani-
tation services and 15% to basic handwashing facilities.29
The literature on preventing cholera in sub-Saharan Africa consistently shows strong
evidence that primary preventative measures are highly effective, even during times
of civil unrest. However, sub-Saharan Africa continues to suffer an increasing burden
of cholera and progress towards the SDG is limited. What should now be considered
are effective means of implementation. Are these measures successfully executed at the
community, regional, national, or international level? Do the countries in sub-Saharan
Africa, specifically the AGLR, plagued by other public health issues, political issues, and
poverty, have the capacity to sustain prevention programs? These are just some of several
questions that the global health community should consider as resources are allocated.

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