Since early part of May this year, there have been cases of reported cholera outbreaks in 12 counties in Kenya. During the same period and recently cases of cholera were also reported in Nairobi with the first 2 cases being reported in Mathare North. This has since continued to spread to other sub counties of Nairobi including Starehe, Karen and Kamukunji. Other parts of the country have also been affected including Dadaab Refufee camp in Garissa, Muranga, Vihiga and Mombasa.
Ever since December 2014, Kenya has been continuously experiencing large outbreaks of cholera with already more than 17.000 cases reported. At this point in time, still two counties – Garissa and Nairobi – have recorded active outbreaks, and as of this July a total of 1216 suspected cases and 14 deaths have been reported.
The ongoing cholera epidemic has led to an increase of hospitalization burden in Nairobi and its environs to already overstretched public health facilities. Nairobi is an economic hub for Kenya and large-scale transits of human population occur daily which could be a major driver of transmission of cholera to other parts of the country. Retrospective data from the county health information system show sustained infection with varied spikes since the year 2015. The county health systems are currently overwhelmed and unable to effectively detect, confirm, treat and report on the outbreak. The classical public awareness programmes such as barazas and roadshows have shown limited efficacy and only few clusters of the entire populations affected by the epidemic.
The causes of an outbreak like the last one in Kenya include the high population density that stimulates the spread of cholera bacteria, low access to safe water, and proper sanitation. Cholera is a diarrheal disease caused by the Vibrio cholerae bacteria. The infectious agent is acquired through consumption of contaminated water or food – the source of contamination is usually the faeces of an infected person. Severe cases are characterized by sudden onset of profuse, watery diarrhoea, nausea, and vomiting leading to rapid dehydration, which can result in death within hours if left untreated.
Cholera is a disease characterised by a sudden onset of acute watery diarrhoea that can lead to death by severe dehydration in its most severe form. Because of its extremely short incubation period – two hours to five days – outbreaks of cholera does often have an explosive pattern, making the number of cases rise quickly. However, about 75 percent of the people who are infected with the bacteria do not showcase any symptoms at all. But this does not mean they are out of danger: The pathogens stay in the faeces of the people infected for 7 to 14 days. Because of this, the bacteria often can shed back into society and will be able to infect other individuals. Cholera can affect both children and adults, and like other diarrhoeal diseases it can kill healthy people within hours. Especially malnourished children and people living with HIV are in greater risk of death if they become infected by the disease.
Surveillance on a local level
A multifaceted approach is the best way to prevent and control cholera and reduce its lethal causalities. The combination of surveillance, oral cholera vaccines, water, proper sanitation and hygiene is used to prevent people from getting infected. Through social mobilization people are informed about the disease and how they can protect themselves. And when infection of cholera is a fact, direct treatment can be provided in by the local medical staff.
In order to keep a good surveillance on Cholera, it is part of an integrated disease surveillance system that provides feedback at a local level – informing local communities about the disease and how to prevent infection – and information-sharing on a global level – making sure people are aware of the outbreaks and improving it prevention and treatment by international collaboration.
Surveillance starts on a local level, where medical professionals and employees of clinics suspect a Cholera infection when a patient showcases severe acute watery diarrhoea. From this person a stool sample will be taken and it will be tested for the V.cholerae bacteria. Local surveillance systems like this are crucial in the detection of a potential outbreak.
When counties find a cholera-infected area, the local capacity to detect infected patients is strengthened and on a national level preparedness to rapidly respond is fuelled.
Cholera and water
There is a strong connection between water and Cholera-disease: Over 1.8 billion people worldwide drink contaminated water because of contaminated faeces that it carries. And over 2.4 billion people do not have access to adequate sanitation facilities, increasing their risk to be contaminated by the cholera bacteria.
But it is also possible for water to intervene in the deathly process of cholera infection. To bring cholera under control, a long-term solution can be found in economic development and universal access to safe drinking water and sanitation of good quality. It will help prevent both epidemic and endemic cholera.
It is because of this importance of the water and the impact access to water can have, that Amref Flying Doctors participated in the WASH alliance (Water, Sanitation, Hygiene alliance). Since January 2016 this alliance started a co-operation with local ngo’s, governments, and the private sector to secure (better) access to sustainable and affordable water and sanitation services. Together with more than a hundred partners it strives to improve one’s hygienic living conditions. Having a more hygienic environment, and having access to clean water would not only mean a better protection from any infection, it also improves an individual’s health, dignity and economic living standard. Increased improved access to and use of safe water and sanitation services and improved hygiene practices.
Children and sanitation
School-age children are an important means of transmitting information on sanitation and hygiene to their communities. Behaviour concerning sanitation, hygiene, and other practices involving water can be easily taught in school. Teaching children in the class how to prevent infection by washing your hands after visiting the toilet for example, provides an entire generation with the info how an easy act like that can help them and their family stay healthy. Giving children the knowledge and skills on sanitation and hygiene, and they can become the new behaviour change agents in their families and communities. Building toilets and hand washing stations around school will not only benefit the children and teachers, but will also enhance and empower the communities around those schools.
A nice example of where this program has unfolded is in Kenya. Here, the WASH-alliance has been implemented, and is there a water pump installed next to a school. “Ever since the water pump started working, more kids come to school because they do not need to go and get water at the lake a few kilometres down the road”, is what school principle Josephine tells us. Because of the working water pump and the two water tanks – which collect the rain from the school’s rooftop – the people have now a sustainable supply of clean water. It also provides a water source for the village’s animals, thereby contributing to the quality of the food and economy of the village. From the water pump there are two pipelines going to the school’s playing grounds making sure the kids have a secured access to the clean water collected there.
“Before the water pump was repaired, we had to ask our school children to bring their own supply of water to their class”, continues Josephine. “Students were forced to walk great distances with heavy jerry cans to meet our request. Also, we did not always know where the children got the water from, and we were not sure whether it was clean or not. Thanks to our own water pump we can now be sure our students receive clean water.”
A lesson in WASH
“For a short while now I get a lesson in WASH. We learn why it is important to wash our hands before and after dinner, and after we have been to the toilet. We wash our hands at a leaky tin, which is a jerry can tied to a tree in which we have pierces a hole at the bottom for a little stream of water mixed with soap to run. The water running down from our hands falls on the ground where the tree can collect it and drink it. In this way we do not waste a single drop!”
It is the story of Namunyak, a Kenyan girl telling us about her school and the water supply she receives there. At her school they also have separate toilets for girls, boys, and teachers. That way contamination is limited, and in addition to this, girls get their privacy when they might have their period. Principal Josephine explains: “It is not good when boys and girls share a toilet. When girls have their period but they cannot find a suitable toilet, they might not come at all to school. Because we have a separate toilet with a closed off shower for girls, they can clean themselves and learn about personal hygiene, without feeling uncomfortable while menstruating. That way they can stay in school.”
Hygiene promotion and social mobilization
As the example above shows, hygiene and clean water does not only stop infections by providing hygiene to people, it also has an effect on children, education, and contributes thereby to the future of an entire population. Adaption of hygiene practices such as hand-washing with soap, safe preparation of food and safe disposal of faeces should be integrated on a grand scale to provide health improvement for all. Teaching, informing and instructing people of all ages about the qualities of good, clean water, and how it can protect and provides a person’s health is of the most importance. It will improve the overall quality of life and might prevent another Cholera-outbreak like the one in Kenya.
How to protect yourself and your family from infectious diseases:
1. Wash your hands with running water and soap before eating, after visiting the toilet, and before cooking.
2. Thoroughly wash fruits and vegetables before eating or cooking
3. Whenever possible eat your food while it’s still hot.
4. Avoid eating food from unhygienic premises.
5. Only drink water that has been treated. As a safety precaution, boil drinking water fetched from the tap or treat it using appropriate chemicals.
6. Faeces and vomit from every person including children must be safely disposed in a toilet. Faeces pose the greatest transmission risk for cholera.
7. Flies and dust can carry cholera germs to food. Keep food covered at all times.
8. Disinfect any materials or clothes contaminated with faeces or vomit using appropriate chemicals.
*Patricia Vermeulen is CEO of Amref Flying Doctors in the Netherlands.