The multi-sectorial emergency response to a cholera outbreak in Internally Displaced Persons camps in Borno State, Nigeria, 2017

Abstract

IntroductionIn August 2017, a cholera outbreak started in Muna Garage Internally Displaced Persons camp, Borno state, Nigeria and >5000 cases occurred in six local government areas. This qualitative study evaluated perspectives about the emergency response to this outbreak.MethodsWe conducted 39 key informant interviews and focus group discussions, and reviewed 21 documents with participants involved with surveillance, water, sanitation, hygiene, case management, oral cholera vaccine (OCV), communications, logistics and coordination. Qualitative data analysis used thematic techniques comprising key words in context, word repetition and key sector terms.ResultsAuthorities were alerted quickly, but outbreak declaration took 12 days due to a 10-day delay waiting for culture confirmation. Outbreak investigation revealed several potential transmission channels, but a leaking latrine around the index cases’ house was not repaired for more than 7 days. Chlorine was initially not accepted by the community due to rumours that it would sterilise women. Key messages were in Hausa, although Kanuri was the primary local language; later this was corrected. Planning would have benefited using exercise drills to identify weaknesses, and inventory sharing to avoid stock outs. The response by the Rural Water Supply and Sanitation Agency was perceived to be slow and an increased risk from a religious festival was not recognised. Case management was provided at treatment centres, but some partners were concerned that their work was not recognised asking, ‘Who gets the glory and the data?’ Nearly one million people received OCV and its distribution benefited from a robust infrastructure for polio vaccination. There was initial anxiety, rumour and reluctance about OCV, attributed by many to lack of formative research prior to vaccine implementation. Coordination was slow initially, but improved with activation of an emergency operations centre (EOC) that enabled implementation of incident management system to coordinate multisectoral activities and meetings held at 16:00 hours daily. The synergy between partners and government improved when each recognised the government’s leadership role.ConclusionDespite a timely alert of the outbreak, delayed laboratory confirmation slowed initial response. Initial responses to the outbreak were not well coordinated but improved with the EOC. Understanding behaviours and community norms through rapid formative research should improve the effectiveness of the emergency response to a cholera outbreak. OCV distribution was efficient and benefited from the polio vaccine infrastructure.

Early detection of cholera epidemics to support control in fragile states: estimation of delays and potential epidemic sizes

“…Seventy-six outbreaks from 34 countries met the inclusion criteria. Overall, 1970 documents were reviewed, and 138 documents were retained (1–4 documents per outbreak including 28 peer-reviewed articles and 110 gray literature sources as listed in Additional file 2 ) [ 34 – 171 ]. Where countries reported acute watery or severe diarrhea as a proxy for cholera (e.g., Ethiopia, Myanmar) [ 172 , 173 ] or where surveillance was poor due to conflict in remote areas (Myanmar, Northern Nigeria, and Syria as documented by Sparrow and colleagues) [ 19 ], few or no reports were located.…”

“…For example, in 2015, in Aleppo, Syria, an alert was issued through the EWARN via phone after RDT testing of a suspect, and an investigation initiated based on the positive result (2-day delay to investigation, ID 63). In 2017, in a displacement camp in Northern Nigeria, an alert of a suspect case was issued by MSF by phone through the EWARS on the same day of case presentation (2-day delay to investigation, ID 48), demonstrating the rapid recognition of a suspect case by health workers [ 171 ]. Comparisons of outbreaks within countries are instructive.…”

“…Longer delays to response were documented across the whole time period. Evaluations from Nigeria, Yemen, and other settings have shown that reasons for delays to detection include poor population access to health services due to disrupted health systems and/or insecurity, difficulty in discerning diarrhea and dehydration due to cholera from other causes without rapid diagnostics, reliance on laboratory confirmation before initiating response, and less effective local response [ 171 , 177 , 178 ]. Epidemic control more than 2 weeks post-onset carries a strong risk of epidemic propagation, particularly where the population is highly mobile.…”

“…Detailed case studies of cholera outbreaks provide practical observations on the mechanisms of surveillance, diagnosis, and response which can reduce delays. Early detection with high-quality epidemiological data has been augmented with the use of sentinel site surveillance at hospitals equipped with RDTs and trained and vigilant health workers in Kathmandu, Nepal [ 162 ]; community-based surveillance using existing community health worker or Red Cross volunteer networks to enable early warning of clusters in the community before patients appear at health facilities in Central African Republic and Haiti [ 71 , 152 , 182 , 183 ]; and other event-based surveillance mechanisms, including phone hotlines and mobile phone fleets, to enable immediate notification of suspect events in public, private, and NGO clinics and in the community, as seen in Northern Nigeria and Cameroon [ 171 , 184 , 185 ]. Response should not be delayed by poor laboratory capacity.…”

“…Response should not be delayed by poor laboratory capacity. A potentially stronger role for health workers in local facilities exists in their use of enriched, high-specificity RDTs [ 186 ] and aligned probable case definitions to validate clusters of suspected cholera cases that can trigger an immediate investigation and response [ 162 , 171 ]. This is directly applicable in remote districts and insecure areas where laboratory confirmation will be slow.…”