Cholera returns and kills five, so far

Photo: Médecins Sans Frontières (MSF)

Cholera is making a comeback

(IRIN) – Five people have died from cholera at two different locations in Zimbabwe, and 30 other people are undergoing treatment for the waterborne disease, raising the spectre of another epidemic.

The permanent secretary for health, Gerald Gwinji, told the state-run newspaper, The Herald, on 20 October that three people had died from cholera in Mashonaland West Province, in the northeast of the country, while two other deaths were recorded in Midlands Province, in central Zimbabwe.

Gwinji attributed the deaths in Gokwe North, Midlands, to “religious objectors who for a long time have been reluctant to seek medical attention. We are still trying to come up with ways of addressing this special group.”

A cholera outbreak that began in August 2008 and lasted for a year before it was officially declared at an end in July 2009 caused the deaths of more than 4,000 people and infected nearly 100,000 others.

The cause of this epidemic was dilapidated and broken sanitation and water infrastructure, much of which is still in the same state as a year ago, so the coming rainy season is likely to facilitate the spread of the disease.

“We have received confirmation of the cholera cases from the government and this poses a new challenge, in the sense that there is need to educate and sensitise some communities which are resisting prevention and medication for cholera,” said Tsitsi Singizi, a spokesperson for the UN Children’s Fund (UNICEF).

“Our education teams are already out in full force, and we hope that this time the effect of cholera will not be as it was last time,” she commented.

Samuel Sipepa Nkomo, the minister for water resources development and management, told IRIN that repairing the water and sanitation infrastructure in the capital, Harare, was the main priority, as this had been the epicentre of the previous cholera outbreak.

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Flood survivors face misery and hardship

Photo: Jason Gutierrrez/IRIN

Ryan Leyva, 25, ponders the future with his children at an evacuation centre in the Philippines

Evacuation centre volunteer Candy Regadillo calls on a long line of hungry and tired flood survivors to be patient as she hands out dwindling relief items, three days after flooding in Manila and surrounding areas left more than half a million displaced and nearly two million affected.

“Please behave. You, get back in the queue,” Regadillo shouts at a dishevelled-looking old man trying to get to the food and water first.

“We have to organize ourselves in this crisis,” she said.

Other volunteers link hands to keep the impatient crowd from moving, as several men begin shoving and cursing.

A pregnant, barefoot woman nearly faints, and is kept from falling by two elderly women, while overhead the distant sound of helicopters can be heard, indicating possible food drops.

Similar scenarios are being played out in hundreds of shelters around the capital for survivors of tropical storm Ketsana, which dumped the heaviest rainfall on the capital in four decades.

According to the National Disaster Coordinating Council (NDCC), as of 29 September at least 240 people were confirmed dead with more than half a million displaced by the storm, which pummelled the northern island of Luzon three days earlier [see map of Ketsana's path].

The floods destroyed much of the city’s health infrastructure, overwhelmed emergency response capabilities and forced the government of President Gloria Arroyo to appeal for international assistance on 28 September.

Massive needs

For hundreds of thousands of Filipinos displaced, survival is now a daily struggle in squalid, makeshift evacuation centres.

Food and water are inadequate, while keeping basic standards of sanitation remains problematic as receding flood waters leave piles of rubbish and debris everywhere.

For Ryan Leyva, 25, it means more suffering for his four children, who have been subsisting on biscuits and instant noodles for the past three days.

An accident left Ryan limping, forcing his wife Analiza to queue for hours just to receive a blue plastic bag containing meagre relief items.

But today, they were not so lucky. The supplies ran out even before she got halfway along the 200m queue.

“This has been a very difficult three days. While we are lucky to survive the flood, we have to suffer here,” Leyva told IRIN, indicating the packed basketball court in the impoverished San Andres village of Cainta, an eastern Manila suburb where many low-lying areas remain partly submerged in water and mud.

Survivors sleep on the cold cement floor, using cardboard boxes as matting, while grimy children run around in various states of undress.

Pets, including dogs and potbellied pigs, are tied to posts, sleeping in the same area.

Sanitation remains a huge problem as water supplies have yet to be restored and up to 3,000 share a single bathroom.

Sanitation issues

Photo: Jason Gutierrez/IRIN

Flood survivors queue for relief in Cainta District, east of Manila, three days after the storm

“The flood came swiftly early Saturday. It submerged my house, which is on the banks of a river,” Leyva recalled.

“We were already poor and whatever little we had was taken away. Asking for rations is worse than begging on the streets. We have to suffer this indignity until after the waters finally dry up and we can reclaim our house.”

Meanwhile, many children remain traumatized and cry whenever the rains start up again.

“Our most pressing problem is sanitation. The hardest thing to teach these people is cleanliness,” said Vesta Macatangay, principal of the 25-room Kabisig Elementary School in Cainta, housing more than 2,000 displaced, adding that rubbish, including used nappies and old food, were left rotting by the evacuees on the school grounds when they first began arriving on Saturday.

“At first we were not paying any mind, but have since instituted strict rules to clean up or they will be asked to leave.”

Already three toilets were backed up and overflowing, and heads of families were being asked to take turns to clean them up.

“These people need to take charge if they are to stay here for an extended period,” she said, adding that the school may have to remain closed in the next few weeks until the displaced can return to their ruined homes and try to rebuild.

“We need medicines. Many children have coughs, colds and some are feverish,” she said, pointing to a young mother bathing her infant in brownish water that she had fetched from a nearby stagnant pool.

“We don’t know how long we can keep this school as a temporary shelter,” she said.

Humanitarian crisis “at new low”

Isack Abdinor Satar, 80, remembers a green and lush Baidoa, in south-western Somalia, with waterfalls in areas that are now the town’s suburbs.

Over the years, population pressure, drought and changing weather patterns have caused most of these waterfalls and springs to dry up, totally changing the town’s vegetation cover and ushering in perennial water shortages.

“In my youth, water was really available any time, anywhere in town,” Satar said. “Water flowed in different directions from various sources but all these have now dried up. I think drought has seriously affected all water sources in Bay region.”

Baidoa – seat of Somalia’s Transitional Federal Government – is facing a severe water shortage after most of its water points and wells dried up. These include the Garbadda water source, in the centre of town.

“Each day, hundreds of families brought their animals [to Garbadda] for watering,” Hussein Sheikh Aden, a local resident, said. “Since last year, I have seen a very different situation. Due to lack of sufficient rainfall and increasingly high temperatures, the water point has dried up.”

Farmers and pastoralists had long relied on Garbadda for their water supply, but now they have to search long and hard for small amounts of water. “We tried to dig a well; we dug really deep but we failed to find water,” Aden said.

Halima Ibrahim Abdi, another resident, told IRIN: “I was born in Baidoa; I am now 60 years old. Baidoa used to be blessed with many water sources; we had water running under most bridges but, since last year, all this has changed.”

Photo: Mohamed Adawe Aden/IRIN

A dried-up water source in Isha, Baidoa

A local journalist, who requested anonymity, told IRIN on 10 August that a 200-litre barrel of water cost 100,000 Somali shillings (US$3.50), a steep amount for many residents.

Grain production has also declined significantly, raising the price of cereals. Moreover, job opportunities had declined, the journalist added, as fewer traders and farmers were taking on casual labourers.

Desperate IDPs

In Geneva, a spokeswoman for the UN Office for the Coordination of Humanitarian Affairs said the humanitarian crisis in Somalia had reached a new low.

“There are 3.2 million people in need of urgent assistance,” Elizabeth Byrs told UN radio. “Since May 2009, 200,000 people have fled insecurity in Mogadishu and there are a total of 3.9 million displaced – meaning one out of seven people is displaced in Somalia.”

In the port city of Kismayo, IDPs said lack of food, health facilities and sanitation were the most pressing issues for about 30,000 people in various camps around the city.

Mohamed Muse Ali, chairman of the IDPs in Kismayo, said no aid agency was operating in any of the camps.

IDP camps between Mogadishu and Afgoye have recorded an increase in the number of new arrivals fleeing violence between government troops and Islamist insurgents in the city, according to camp leaders.

Photo: Mohamed Adawe Aden/IRIN

A donkey cart near the Isha well in Baidoa. Carts like this have to wait until nighttime to ferry water as none is available during the day

In central Somalia and the semi-autonomous region of Puntland, drought had displaced many pastoralist families who had also lost livestock. Many such families were facing hunger and disease outbreaks because of unsafe water.

For Somalis who have fled to neighbouring Kenya, congestion is the main problem in the three refugee camps in Dadaab.

Halima Aadan, a refugee in one of the camps, said congestion had contributed to a water shortage and high food prices, as well as difficulties accessing services such as health and sanitation.

“Refugees need more help because more are arriving daily; the new arrivals do not have shelter and have to live with relatives and other families; they should be allocated land on which to live,” Aadan said.

An anatomy of cholera

Cholera is a waterborne disease that has surfaced in almost all parts of the world, and the mere mention of its name is often enough to induce panic in communities. IRIN answers frequently asked questions about the disease that has killed nearly 3,000 people in its latest large-scale outbreak in Zimbabwe since August 2008.

What is Cholera?

Vibrio cholerae is a rod-shaped bacterium. It has two major biotypes: classic and El Tor. El Tor is the biotype responsible for most of the cholera outbreaks reported from 1961 to the present.

Photo: Tim McKulka/UNMIS

Cholera at home in water

Cholera is a diarrhoeal disease caused by infection of the intestine. In most cases, infection causes only mild diarrhoea or no symptoms at all. In 5 percent to 10 percent of cases, however, patients develop severe watery diarrhoea and vomiting from 6 hours to 5 days after exposure to the bacterium.

The initial symptoms of the disease are queasiness, nausea and abdominal gurgling, followed by acute diarrhoea. The loss of large amounts of fluids can rapidly lead to severe dehydration. In the absence of adequate treatment, death can occur within hours. Those who are malnourished or already have intestinal parasites can be at especially high risk of death.

How did cholera get its name?

The disease’s name was coined from the Greek word, Khole, meaning “flow of bile”. Cholera’s watery diarrhoea is often referred to as “rice-water” stool, as it contains flecks, which are mucus and epithelial cells. The diarrhoea causes victims to lose huge amounts of potassium ions, which can also lead to cardiac complications and circulatory failure.

Where did Cholera originate?

The first known cholera outbreak was recorded in the Indian sub-continent in 1817. Since then at least seven distinct cholera pandemics have been recorded, the first six from the Ganges Delta, viewed as the “ancestral home” of the disease.

How did cholera travel to other parts of the world?

It is thought that cholera was inadvertently transported from India to the shores of the colonial power, Britain, in the bilge water of English ships. The contaminated water was dumped on arrival at home ports, and the disease moved rapidly to Europe and then to Russia. Emigrants to the New World were thought to have taken the disease to the Americas.

In 1832 a cholera epidemic swept through New York, killing 3,515 of the city’s then population of 250,000.

In 1991 a Chinese registered freighter discharged bilge water into a Peruvian harbour, sparking a cholera pandemic that affected 322,562 people after a nearly 100-year hiatus of the disease in South America.

By 1994 there were more than 1 million cases recorded in South America.
In the aftermath of the Rwandan genocide in July 1994, cholera struck Goma’s refugee camps in the neighbouring Democratic Republic of Congo. There were about 70,000 cases and 12,000 deaths.

How is cholera spread?

A Ukrainian parliamentarian remarked during a 1994 outbreak of the disease in his country that “the spread of cholera and other infectious diseases is the calling card of an economy in trouble.”

The spread of cholera and other infectious diseases is the calling card of an economy in trouble

Cholera infects humans through the consumption of infected water or contaminated food. The consumption of raw or poorly cooked seafood, raw fruit and vegetables, and other foods contaminated during preparation or storage can lead to infection. Bacteria present in the faeces of those infected are the main source of contamination. The bacterium can also survive in brackish rivers and coastal waters. The disease spreads rapidly where sewage and drinking water supplies are inadequately treated.

When was the disease identified?

British doctor and epidemiology pioneer John Snow, and Robert Koch from Germany, the 1905 Nobel Prize recipient for Physiology or Medicine, are credited with unlocking the mysteries of cholera.

In 1831 England experienced its first cholera outbreak, where the disease was attributed to “miasma [pollutants] in the atmosphere”. Another outbreak occurred in 1854 and on 31 August the London district of Soho suffered what Snow was later to call “the most terrible outbreak of cholera which ever occurred in the kingdom.”

Within three days 127 people living close to Soho’s  Broad Street succumbed to the disease; by 10 September 500 had died and nearly three-quarters of the residents had fled their homes.

Snow suspected cholera was a waterborne disease and zeroed in on the Broad Street pump which served the area. He convinced the authorities to close the pump down and immediately deaths in the area were rapidly reduced.

Can cholera be prevented?

Yes. People living in high-risk areas can  protect themselves with good hygiene and safe food preparation, such as washing their hands before preparing food and eating, by thoroughly cooking food and eating it while it is hot, by boiling or treating drinking water, and using sanitary facilities.

The simple rule is: boil it, cook it, peel it, or forget it.

What treatments are available?

The most important  treatment is rehydration, which consists of prompt replacement of the water and salts lost through severe diarrhoea and vomiting. Early rehydration can save the lives of nearly all cholera patients. Most can be rehydrated quickly and easily by drinking large quantities of a solution of oral rehydration salts. Patients who become severely dehydrated may need to receive fluid intravenously.

Packets of oral rehydration salts are available from most city pharmacies and health care facilities. If you have diarrhoea – especially severe diarrhoea – and are in an area where there is cholera, seek treatment immediately from a physician or other trained health care provider. Begin drinking water and other non-sweetened fluids, such as soup, on the way to getting medical treatment. – IRIN

Sources: World health Organisation, MedicalEcology.org, University of California, Los Angeles Department of Epidemiology, International Public Health and Human Rights in the Developing World (A Case Study in Peru), Tropical infectious diseases, principals, pathogens and practice.