Cholera is an acute diarrheal infection of the small intestine caused by the ingestion of food and water contaminated by bacterium vibrio cholera. An estimated 3–5 million cholera cases resulting to about 120 000 deaths yearly. Nigeria accounts for 38% of cases from Africa with 44,456 cases, with highest case fatality rate (CFR) of 5.1% in Sub-Sahara Africa (WHO, 2010). In Nigeria, 18 States in 2010 reported the outbreak of cholera with about 41,787 cases and1,716 deaths (case-fatality rate [CFR]: 4.1%). In 2010, men had a higher prevalence (5.1%) than in women (4.9%)

1. CHOLERA IN NIGERIA
By Olayinka Ariba
MB4002
Masters in Public Health
G20626133

2. OBJECTIVE
o To outline cholera in Nigeria
o To describe and interpret the needs of Nigerians using epidemiological,
quantitative and/or qualitative data.
o To describe the strategy implemented in Nigeria
o To describe how intervention will reduce the burden of cholera disease,
to provide evidence from the literature of the effectiveness of this
intervention.
o To review published literature to provide evidence on the effectiveness
of hand washing
o To outline what actions would need to be undertaken, and by whom, in
order to implement the intervention.

3. CHOLERA
is an acute diarrheal infection of the small intestine caused by the ingestion
of food and water contaminated by bacterium vibrio cholera.
 An estimated 3–5 million cholera cases resulting to about 120 000 deaths
yearly.
 Nigeria accounts for 38% of cases from Africa with 44,456 cases, with
highest case fatality rate (CFR) of 5.1% in Sub-Sahara Africa (WHO,
2010)
 In Nigeria, 18 States in 2010 reported the outbreak of cholera with about
41,787 cases and1,716 deaths (case-fatality rate [CFR]: 4.1%).
 In 2010, men had a higher prevalence (5.1%) than in women (4.9%)
 Highest cholera cases of 4,600 cases was reported in Bauchi and 5,704
in Katsina States.in the Northern Nigeria (Dalhat et al, 2014)

4. (WHO, 2010)

5. Epidemiologic week of first reported cases in the Local
Government areas during the three waves (Wave 1 (A): week 1 –
week 9; wave 2 (B): week 10 – week 24; wave 3 (C): week 25 –
week 42) (Dalhat et al., 2014)

6. DISTRIBUTION OF CHOLERA INCIDENCE BY
WEEKS IN NIGERIA
(Dalhat et al., 2014)

7. POPULATION AT RISK OF CHOLERA
 Everyone is at risk
 But the most vulnerable group are malnourished children, people
living with HIV and elderly people due to low level of immunity.
 40.9% of children below 5 years are mostly affected
 Refugees
 Internally displaced persons(IDPs)
(Sack et al, 2004)

8. AGE DISTRIBUTION OF CHOLERA AND AGE-
SPECIFIC CASE FATALITY RATES OF CHOLERA
CASES, NIGERIA 2010
.
(Dalhat et al., 2014)
Age
group
DocumentedC
ases
Attack
rate per
100,000
0-4
years
3940 3.9
5-
17years
5015 5.1
18-
44years
430 4.4
45-64
years
1282 9.5
65 and
above
297 14.5
Table 1 Table2

9. TRENDS IN CHOLERA CASES AND DEATH IN NIGERIA
Outbreak of cholera was
worsened by destroyed
sanitation and water
infrastructure .
Lower coverage of effective
drainage systems and latrines
resulting to overflowing of
latrines and contamination of
wells and surface water due to
flooding in the rainy season.
Year Cases Deaths CFR(%)
2010 41,787 1,716 4.1
2011 23,377 742 3.17
2012 597 18 3.02
2013 6.600 229 3.47

10. DATA ON MAJOR CHOLERA OUTBREAKS IN NIGERIA,
1991-1999
Year States Source No. Of
reported
cases
Case
Fatality
Rates
Age
grour
1991 Cross
river
--------- 588 13% ----
1992 Katsina Well
water
622 7.7% 11-30
years
1995/199
6
Kano Water
source
2,630 15% 0-5 years
1997 Jos flood 847 23% 20-29
years
1999 Kano --------- 2,347 2% 0-5 years
1996 Ibadan Satched
water
1,384 5.3% children
(Adagbada et al,, 2012)

11. POPULATIONS NEEDS
A study in Nigeria by Dalhat et al in identified the peples need as:
 Need for effective surveillance and response.
 Sufficient access to services
 Qualified health workers.
Another study in Nigeria by Adagbada et al in 2012 identified the
need of the people as:
o Need for adequate manpower, equipment and medications.
o Improvement on surveillance system, for early alert of cholera
outbreak.
o Mechanisms for quick intervention to prevent infection.
o Intervention measures to address poor sanitation and unsafe
water supplies in order to prevent new cholera cases.
o Establishment of communication channel and reporting.

12. RISK FACTORS
 Poverty
 Age
 Gender
 Poor infrastructures
(slum)
 High population density
 low education,
 lack of previous exposure
 Low immunity
 Poor sanitary and
hygienic
 Exposure to
contaminated food and
water
 Periods of flood
(Ali et al, 2012;
Adagbada et al, 202;
WHO, 2014 )

13. HAND WASHING PROMOTION
 Hand washing with soap is a “do-it-yourself vaccine” that
prevents the spread of cholera infections.
 It is cost-effective, easy and effective.
(WHO, 2014)

14. ACTION: HAND WASHING INTERVENTION
 Advocacy: Promote campaign to create awareness
 IEC Materials (posters and flyers)
 Health Education on hand-washing
 Qualified health workers
Technique:
 Wet hands with safe water
 Lather with soap thoroughly, if no soap, scrub your
hands with sand or ash
 Cover all surfaces, including under nails
 Rinse hands well with safe water
 Dry hands using clean towel or air dry

15. STEERING GROUPS
This is the involvement/engagement of key stakeholders
which includes
 Federal Ministry of Health
 NGOs (UNICEF, WHO)
 Donor agencies
 Public health practitioners
 Community health workers
 Community gatekeepers
 Private organisation; pharmaceutical companies
 Mass media

16. EVIDENCE OF THE EFFECTIVENESS OF
HANDWASHING PROMOTION
 A study by Shahid, N.S., Greenough, W.B 3rd,, Samadi, A.R.,
Hug, M.I, Rahman, N., (1996) indicates that hand washing with
soap promotion can attain 26 to 62% decrease in the incidence
of cholera.
 A randomised control study done by...in Malawi, showed
incidence rate of cholera reduced from 69% to31% in under five
children.
 Hand-washing with soap can reduces the risk of cholera infection
by 42%-47% (Curtis and Cairncross, 2003).
 Hand-washing reduces cholera incidence by 89% (Wilson,
Chandler, Muslihatun & Jamiluddin, 1991).
 WHO reports that hand-washing with soap is one of the surest
ways to prevent cholera transmission.

17. ARTICLES ON THE EFFECTIVENESS OF HAND
WASHING INTERVENTION
Study Participant
s
Study type Results Strength Weakness
Hutin, Luby
& Paquet,
2009
102 cholera
cases
77
controlled
group
Case
control
study
Hand
washing
with soap
before
eating
reduces
outbreak of
cholera
from 26 to
62%
Groups
matched by
sex
Age
stratificatio
n
Use of
control
groups
Lack of
control:
response
initiative
Confounder
s:socio-
economic
status
Mahamud
et al., 2012
93 cases
and 93
controlled
group
Case
control
study
Provision of
soap and
being
educated
on hygiene
Groups
matched by
age and
area of
residence
Recall bias
of inquiry of
exposure
Unclear
transmissio
n route

18. ARTICLES OF THE RISK FACTORS OF CHOLERA
DISEASE
Study Participant
s
Study
Type
Findings Strength Weakness
Dubois,
Sinkala,
Kalluri,
Makasachi
koya &
Quick,
2006
71 cases
and 71
controls
Case
Control
Study
Hand
washing
interrupts
disease
transmissio
n in food
borne
outbreak
Groups
matched
by area
Controls
not tested
Huang, D.
and Zhou,
J. (2007).
75 cases &
73 controls
Randomise
d control
trial
Incidence of
cholera in
tervention
group was
lower than
in control
group
Process of
randomisa
tion
Similarity
in groups
Blindings
Recall bias
Generalisa
bility

19. Study Participa
nts
Study
Type
Findings Strengths & weakness
Danny V.
Colombar
a mail,
Karen D.
Cowgill,
Abu S. G.
Faruque,
2013
Hospitalis
ed under
five
children
Survey
study
Increasing age, lower
socioeconomic status,
and lack of breastfeeding
increased risk for cholera
among under five
large sample size
well-defined population,
systematic sampling, expert
laboratory diagnosis of V.
Cholerae
Misclassification bias
self-reported water and
sanitation measures
Dalhat,
M., Isa, A.,
Nguku, P.,
Nasir, S.,
Urban, K.,
&
Abdulaziz,
M. et al.
(2014).
populatio
n of
44,121,2
23 in the
10 states
Descriptiv
e study
Limited access to health
care;
Scarce health care
system ;
Poor sanitation ;
poor surveillance system
Large number of cases
Absence of data
Recall bias
Confounders
Temporality issues
ARTICLES OF THE RISK FACTORS OF CHOLERA
DISEASE

20. Study Particip
ants
Study
Type
Findings Strengths & weakness
Rosewell, A.,
Addy, B.,
Komnapi, L.,
Makanda, F.,
Ropa, B., &
Posanai, E.
et al. (2012).
54
suspec
ted
cholera
cases
and
122
control
s.
Case
control
study
piped water distribution
system and sanitation
will likely reduce
transmission
by enabling enhanced
hygiene and limiting the
contamination of water
sources.
Groups matched by
age,sex, education and
employment
Use of a control group
Small sample size
Acosta, C.,
Galindo, C.,
Kimario, J.,
Senkoro, K.,
Urassa, H., &
Casals, C. et
al. (2001).
180
cases
and
360
matche
d
control
s
Case
control
study
bathing in the river,
eating dried fish, and
living>10 minutes
walking distance from
the closest water
source.
Groups matched by
age
Use of control group
Small sample size
Temporality issues
ARTICLES OF THE RISK FACTORS OF CHOLERA
DISEASE

21. EVIDENCE FOR LITERATURE SEARCH
SOURCE SEARCH TERMS HITS LIMITERS REVI
EWE
D
Medline Cholera*, cholera in
Nigeria,
Vibro cholerea
5 Nigeria, Full text,
Abstract, Peer reviewed,
Public health,
Academic Journal,
3
Cinhal cholera OR vibro
cholerae AND risk
factors in Nigeria OR V.
cholerae AND Nigeria
29 English language, full
text, scholarly journals
date (2000-2014)
2
PubMed Cholera , cholera in
Nigeria, Vibro cholerea
57 Nigeria, Full text,
Abstract, Peer reviewed,
Ten years, advanced
search
3
Search resulted in 4 studies chosen to be included in this presentation after most suitable
abstract where reviewed .

22. CONCLUSION
 Nigeria accounts for 38% of cholera cases from Africa
with 44,456 cases With highest case fatality rate (CFR) of
5.1% in Sub-Sahara Africa
 Everyone is at risk, but the most vulnerable group are
malnourished children, people living with HIV and elderly
people due to low level of immunity.
 Typical at-risk areas with cholera infection are
communities with poor infrastructures, poor sanitation and
hygiene and exposure to contaminated water and food.
 Evidence shows that Handwashing with soap is an
effective intervention that prevents the spread of cholera
infections

24. REFERENCES
Acosta, C., Galindo, C., Kimario, J., Senkoro, K., Urassa, H., & Casals, C. et
al. (2001). Cholera Outbreak in Southern Tanzania: Risk Factors and
Patterns of Transmission. Emerg. Infect. Dis., 7(7), 583-587.
doi:10.3201/eid0707.017741
Ali, M.; Emch, M.; Donnay, J.P; Yunus, M. & Sack R.B. (2002a). Identifying
environmental risk factors of endemic cholera: a raster GIS approach.
Health & Place 8 (3): 201-210
Ajoke Olutola Adagbada, Solayide Abosede Adesida, Francisca Obiageri
Nwaokorie,Mary-Theresa Niemogha, Akitoye Olusegun Coker,(2012)
Cholera Epidemiology in Nigeria: an overview.
The Pan African Medical Journal;12:59
Andrawa, M., Anguzu, P., Anguaku, A., Nalwadda, C., Namusisi, O., &
Tweheyo, R. (2010). Risk factors for repeated cholera outbreak in Arua
municipal council, north-western Uganda. International Journal Of
Infectious Diseases, 14, e65. doi:10.1016/j.ijid.2010.02.1633
Adagbada, A. O., Adesida, S. A., Nwaokorie, F. O., Niemogha, M.-T., & Coker,
A. O. (2012). Cholera Epidemiology in Nigeria: an overview. The Pan
African Medical Journal, 12, 59.

25. Contzen, N., & Mosler, H. (2013). Impact of different promotional channels on handwashing
behaviour in an emergency context: Haiti post-earthquake public health promotions
and cholera response. Journal Of Public Health, 21(6), 559-573. doi:10.1007/s10389-
013-0577-4
Colombara DV, Cowgill KD, Faruque ASG (2013) Risk Factors for Severe Cholera among
Children under Five in Rural and Urban Bangladesh, 2000–2008: A Hospital-Based
Surveillance Study. PLoS ONE 8(1): e54395. doi:10.1371/journal.pone.0054395
Curtis , V & Cairncross, S, (2003) Effect of washing hands with soap on diarrhoea risk in the
community: a systematic review. Lancet Infect Dis 3: 275–281.
Dalhat, M., Isa, A., Nguku, P., Nasir, S., Urban, K., & Abdulaziz, M. et al. (2014). Descriptive
characterization of the 2010 cholera outbreak in Nigeria. BMC Public Health, 14(1),
1167. doi:10.1186/1471-2458-14-1167
DUBOIS, A., SINKALA, M., KALLURI, P., MAKASA-CHIKOYA, M., & QUICK, R. (2006).
Epidemic cholera in urban Zambia: hand soap and dried fish as protective factors.
Epidemiol. Infect., 134(06), 1226. doi:10.1017/s0950268806006273
Huang, D. and Zhou, J. (2007). Effect of intensive handwashing in the prevention of diarrhoeal
illness among patients with AIDS: a randomized controlled study. Journal of Medical
Microbiology, 56(5), pp.659-663.
Hutin Y., Luby S., Paquet C.(2003) A large cholera outbreak in Kano City, Nigeria: The
importance of hand washing with soap and the danger of street-vended water. J. Water
Health.;1:45–52.

26. Igomu T.(2011) Cholera epidemic: Far from being over. : Nigerian Latest News
Papers News Online. Retrieved 21 November 2014, from
http://www.nigerianbestforum.com/blog/cholera-epidemic-far-from-being-over/
Kelly, L. (2001). The global dimension of cholera. Glob. Chang. Hum. Health 2(1):6-
17
Mahamud, A., Ahmed, J., Nyoka, R., Auko, E., Kahi, V., & Ndirangu, J. et al. (2012).
Epidemic cholera in Kakuma Refugee Camp, Kenya, 2009: the importance of
sanitation and soap. J Infect Dev Ctries, 6(03). doi:10.3855/jidc.1966
Rosewell, A., Addy, B., Komnapi, L., Makanda, F., Ropa, B., & Posanai, E. et al.
(2012). Cholera risk factors, Papua New Guinea, 2010. BMC Infect Dis, 12(1),
287. doi:10.1186/1471-2334-12-287
Sack DA, Sack RB, Balakrish G, Siddique AK. (2004) Cholera. Lancet;363:223—33
Shahid N, Greenough W, Samadi A, Huq M, Rahaman N. (1996)Hand washing with
soap reduces diarrhoea and spread of bacterial pathogens in a Bangladesh
village. J Diarrhoeal Dis Res 1996; 14:85–89
United Nations Office for the Coordination of Humanitarian Affairs (2010) Haiti:
cholera situation report #24. Available: http://reliefweb.int/node/377376.
Accessed 4 May 2011

27. UNICEF (2014) Nigeria Cholera Situation Report Retried
from:http://reliefweb.int/report/nigeria/unicef-nigeria-cholera-situation-report-10-
february-2014
Wilson, J., Chandler, G., Muslihatun, & Jamiluddin,. (1991). Hand-washing reduces
diarrhoea episodes: a study in Lombok, Indonesia. Transactions Of The Royal
Society Of Tropical Medicine And Hygiene, 85(6), 819-821. doi:10.1016/0035-
9203(91)90468-e
World Health Organization, (2010) Global Task Force on Cholera Control. In Weekly
Epidemiological Record: Cholera Articles. WHO.
World Health Organisation Statistics,(2009) Retrieved
from:http://www.who.int/whosis/whostat/2009/en/ elected infectious diseases.
World Health Organisation,. (2014). WHO | Cholera. Retrieved 11 December 2014, from
http://www.who.int/mediacentre/factsheets/fs107/en/
World Health Organization Global Task Force on Cholera Control (2011) Prevention.
Prevention and control of cholera outbreaks: WHO policy and recommendations.
Available: http://www.who.int/cholera/technical/pre​vention/control/en/index2.html.
World Health Organization,. (2014). WHO | SAVE LIVES: Clean Your Hands - WHO's
global annual campaign. Retrieved 11 December 2014, from
http://www.who.int/gpsc/5may/en/