Nigeria is experiencing its worst cholera outbreak in recent times. What are we doing about it?
In the past year, Nigeria has recorded more than 100,000 suspected cases of cholera and we may be witnessing Nigeria’s most severe cholera outbreak in recent times. The worst of the outbreak is in northern Nigerian states of which four alone—Bauchi, Jigawa, Kaduna and Zamfara—accounted for about 53 per cent of cases as of January 2022.
The progression of the cholera outbreak has been a clear indicator of how the Nigerian healthcare system, as well as government bodies, have shown low preparedness in tackling health emergencies in Nigeria. This is particularly glaring in the country’s most vulnerable regions, especially in northern Nigeria. The trend in northern states illustrates a growing challenge in the health sector where already weak healthcare systems create even poorer outcomes in more vulnerable regions. The ongoing cholera epidemic is not only a health challenge; it is also a potential humanitarian crisis. But what is Nigeria doing about it?
Nigeria currently spends less than one per cent of its GDP on the health sector, compared to the World Health Organization’s recommended five per cent. However, communities in northern Nigeria are not only faced with the general challenges of health provision in the country, they also have to deal with the added disruption that insecurity causes to the distribution of already insufficient resources. Water, Sanitation and Hygiene or ‘WASH’ amenities are a necessity in preventing and mitigating disease outbreaks. The rise of insecurity, from militant forces like Boko Haram and bandits, has further limited the availability of such amenities, increasing the likelihood of disease outbreaks to occur. Presently, with on-going conflicts in the North East, only 58 per cent of health facilities are still functional making already susceptible communities, such as those already displaced due to insecurity, worse off in the event of an outbreak. The effects of insecurity on health provision are widespread, and the federal government’s efforts in the North East have fallen short of addressing these challenges. This is concerning in the case of cholera, a disease that thrives in regions with poor water supply, and where infected persons are not isolated appropriately.
In the past two decades, Nigeria has experienced three major cholera epidemics with most cases clustered in northern states. The national report on the cholera outbreak for 2021 recorded 3,604 deaths from the disease, indicating a mortality rate of 3.2 per cent, significantly higher than that recorded for previous outbreaks. The last outbreak of cholera was in 2018. There were 42,466 suspected cases and 830 deaths, showing a mortality rate of 1.95 per cent, almost half that of the latest outbreak.
WHAT THE GOVERNMENT HAS BEEN DOING
The Nigeria Centre for Disease Control (NCDC) is the national body tasked with the role of managing infectious disease outbreaks in Nigeria. The NCDC and the Federal Ministry of Health are at the forefront of managing the cholera outbreak; they also oversee the control of other infectious diseases like the ongoing Lassa Fever epidemic, and COVID-19.
In June 2021, the NCDC responded to the increase in cholera cases by creating a comprehensive cholera Emergency Control Centre. Cases had increased significantly, prompting the measure. Local health facilities were in charge of managing day-to-day cases of cholera. By liaising with affected communities, the NCDC worked on a more administrative level in controlling the outbreak.
The NCDC also supported sample testing from infected patients in laboratories across Nigeria. Additionally, the centre provided state-level laboratories to beef up areas with limited supply of these facilities. The centre rolled out training programmes and updated healthcare practitioners on the most appropriate methods in managing cholera cases. Finally, to prevent further spread of the disease, the centre provided WASH facilities, along with cholera vaccines.
These interventions led to significant improvements. According to the NCDC, as of February 2022, only 12 states reported suspected cholera cases in 2022, compared to 33 states in December 2021. Fatality rates were also down to 2.7 per cent as of February 2022, compared to 3.2 per cent in December 2021.
Despite these positive trends, the NCDC’s impact faced a glaring limitation: in Nigeria, state reporting of outbreaks is often lax and inconsistent. Insufficient or inaccurate data would have complicated the efforts put in place by the NCDC to control the disease outbreak; additionally, poor data makes it difficult to know the real extent of the NCDC’s impact.
Building capacity in reporting disease outbreaks has significant implications on disease control. In August 2021, for instance, as part of efforts to control the cholera outbreak in Bauchi State, the WHO trained healthcare personnel on reporting health-related data. Subsequently, largely as a result of improved detection and documentation, in Bauchi Local Government Area reported cholera cases rose from 2,000 to over 6,000. While improved data sourcing would have made it easier to understand the incidence of cholera in Bauchi, the heavy reliance on external funding is a major red flag. This is because it is possible that should the WHO stop funding the training programmes, there could be a deceptive fall in reported cholera cases in the future.
Another of the more recent efforts the NCDC has made towards controlling the cholera outbreak is to scale up advocacy to state governments to fund the acquisition of WASH facilities. The official responsibilities of state governments in Nigeria include providing healthcare through secondary health facilities such as general hospitals. State governments are also meant to support local governments in providing primary healthcare services.
Constitutionally, state governments can use the funds allocated to them towards healthcare without much input from the federal government. This autonomy allows states to focus on the health concerns unique to their regions, but it has the drawback of limited coordination of healthcare efforts with federal bodies such as the Ministry of Health and the NCDC. This lack of coordination is one reason why the NCDC has had to step in to compel state governments to invest more in WASH facilities.
One of the biggest hurdles in managing cholera outbreaks in most parts of the world is how to provide vaccines and ensure that such vaccines are administered to at-risk populations. Before the most recent cholera outbreak, securing cholera vaccines had been a challenge in Nigeria due to a global cholera vaccine shortage. Learning from earlier cholera outbreaks, Nigeria had begun working to request for vaccines as early as 2019 through the National Primary Healthcare Development Agency (NPHDA). As of 2019, the government had also developed a national plan to curtail the spread of cholera across Nigeria. However, due to constraints such as funding, logistics and limited availability of personnel, by 2022, the government had not fully implemented its plan.
The COVID-19 pandemic was a useful way for the government to learn and build capacity in managing epidemics. Although COVID-19 diverted a lot of attention from other diseases like cholera, as of July 2022 only about 13 per cent of Nigeria’s population had been vaccinated against COVID-19. This figure illustrates how weak disease management is not unique to cholera but a common threat in Nigeria.
Considering the severity of Nigeria’s 2021 cholera outbreak, the WHO worked with its partners to provide vaccines to Nigeria. The first roll out happened in August 2021, shortly after the outbreak was announced, and communities in Bauchi were the main recipients. At the time, Bauchi was the state most affected by the cholera outbreak.
More recently, in April 2022, the WHO announced it would provide an additional nine million cholera vaccines to Nigeria.
Additionally, to mitigate the threats of insurgency on intervention in the North, the government has broadened its counter-terrorism strategy to include peace keeping agencies. These agencies have been set up at local levels to battle the roots of insurgency and to prevent its occurrence. Just as in healthcare delivery, the local government is the foundation for other forms of intervention. Three northern states, Plateau, Adamawa and Kaduna, have been at the forefront of using peace-keeping agencies to manage community-level grievances in at-risk areas. These agencies help local governments set up committees, educate local residents and provide systems that foster early responses to possible violence. These agencies have also been commended by international organizations for helping to reduce insecurity, and could be used as a model in other at risk regions. In the case of cholera outbreaks (and disease outbreaks in general), however, peace-keeping agencies will need to prioritize local community health within their interventions.
One cause for concern at the community level is access to clean water and sanitation. WASH is an integral aspect of cholera control, yet studies revealed that as of 2018 60 million Nigerians lived without access to clean water. This figure was even higher northern communities around the Lake Chad Basin, as well as among those who had been displaced due to insurgency.
To improve clean water availability, in 2021, the federal government declared a state of emergency and launched the National Action Plan, whose aim was to revitalize Nigeria’s water supply by 2030. While significant strides have been made in this area—with, for instance, the construction of over 2,300 water points across Nigeria—a lot more still needs to be done.
Reports by UNICEF and Nigeria’s Federal Ministry of Water show that, as of 2019, a third of Nigeria’s population drank contaminated water. Additionally, as of November 2020, at the height of the COVID-19 pandemic in Nigeria, 167 million Nigerians did not have access to handwashing facilities.
The government needs to further its efforts in providing access to clean water. Nigeria also needs to place a high priority on regions in northern Nigeria, who are disproportionately affected. The government could intervene by supporting state and local government authorities with the needed funding and workforce to improve clean water access in at-risk populations. Doing this will empower the agencies closest to the communities with the power to make changes that are in line with their specific, local contexts.
LESSONS FROM CHOLERA
Despite the ongoing challenges, the latest reports from the NCDC show that there has been significant improvement regarding the cholera outbreak. While this is positive news, the NCDC continues to launch interventions not only to control the cholera outbreak, but to also ensure that communities, especially those in the North, are better prepared to prevent future cholera episodes.
Nonetheless, Nigeria remains cholera endemic; the factors that contributed to the outbreak persist, especially in the North. Newer issues are cropping up, too. These include the loss of health workers, who are seeking opportunities abroad to access better working conditions, compensation and career advancement. The low level of funding allocated to the health sector has created this reality and will need re-evaluating.
Tackling cholera, especially in northern states, will remain a challenge until the systemic causes are addressed. Especially as these causes relate to specific marginalized communities and the challenges they face. Such communities will need a unique approach to cholera control, and one that fits the needs of these communities, from local interventions up to federal government policy.
What Nigeria has learned while managing other diseases like polio is that efforts need to be constantly implemented even after outbreaks have been contained. Another lesson is that disease control is not a one-off event. It is when disease drivers are not routinely and proactively controlled that we watch preventable outbreaks turn into decade-long battles that cost lives⎈
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