Epidemic cholera among refugees in Malawi, Africa: treatment and transmission

Abstract

Between 23 August and 15 December 1990 an epidemic of cholera affected Mozambican refugees in Malawi causing 1931 cases (attack rate = 2.4%); 86% of patients had arrived in Malawi < 3 months before illness onset. There were 68 deaths (case-fatality rate = 3.5%); most deaths (63%) occurred within 24 h of hospital admission which may have indicated delayed presentation to health facilities and inadequate early rehydration. Mortality was higher in children < 4 years old and febrile deaths may have been associated with prolonged i.v. use. Significant risk factors for illness (P < 0.05) in two case-control studies included drinking river water (odds ratio [OR] = 3.0); placing hands into stored household drinking water (OR = 6.0); and among those without adequate firewood to reheat food, eating leftover cooked peas (OR = 8.0). Toxigenic V. cholerae O1, serotype Inaba, was isolated from patients and stored household water. The rapidity with which newly arrived refugees became infected precluded effective use of a cholera vaccine to prevent cases unless vaccination had occurred immediately upon camp arrival. Improved access to treatment and care of paediatric patients, and increased use of oral rehydration therapy, could decrease mortality. Preventing future cholera outbreaks in Africa will depend on interrupting both waterborne and foodborne transmission of this pathogen.

Transmission of epidemic Vibrio cholerae O1 in rural western Kenya associated with drinking water from Lake Victoria: an environmental reservoir for cholera?

“…The fact that 67% of such patients in our study who provided specimens had stools yielding V. cholerae O1 validates the use of this definition. The antimicrobial susceptibility patterns we observed were similar to those seen in recent East African cholera epidemics 3 (CDC, 1998 unpublished data).…”

“…1 In addition, 6,216 deaths were reported, representing a case fatality rate of 5.7% and accounting for 93% of all reported cholera deaths worldwide. 1 Cholera is essentially a disease of poor sanitation, and epidemics in Africa have been linked to consumption of food and water from unsafe sources, e.g., drinking or bathing in lakes, 2 drinking river water, 3 eating at large funeral feasts, 4 and eating cold leftover foods. 3 Western Kenya has had several discrete waves of cholera during the seventh pandemic, in 1971-1972, 1980-1984, 1992-1993, and most recently, beginning in 1997.…”

Long-term Impact of Integration of Household Water Treatment and Hygiene Promotion with Antenatal Services on Maternal Water Treatment and Hygiene Practices in Malawi

“…Household water storage in wide-mouthed, uncovered, containers, into which cups or other utensils are dipped to obtain water, has been repeatedly implicated in diarrheal disease transmission. [14][15][16][17] Results of this evaluation also showed that the ability to demonstrate proper handwashing behavior was sustained over three years among program participants and their relatives/ friends. These findings were consistent with at least two other studies that showed sustained handwashing knowledge after a relatively brief intervention.…”

Child health in complex emergencies

“…Outbreaks of cholera have been reported frequently in complex emergencies. 13,14 Few published studies have evaluated preventative or treatment measures for reducing child morbidity and mortality due to diarrhoeal diseases in complex emergencies, although the importance of clean water, appropriate sanitation, and rehydration is established. After a programme to distribute soap in a Malawi refugee camp for Mozambican refugees, households with soap reported 27% fewer episodes of diarrhoea than those without.…”