Occurrence of Cholera in Lukanga Fishing Camp, Kapiri-Mposhi District, Zambia
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OUTBREAK REPORT Occurrence of cholera in Lukanga fishing camp, Kapiri-mposhi district, Zambia R Murebwa-Chirambo1, R Mwanza2, C Mwinuna3, ML Mazaba1, I Mweene-Ndumba1, J Mufunda1 1. World Health Organization, Country office, Lusaka, Zambia 2. Ministry of Health, Provincial Health Office, Kabwe, Zambia 3. Ministry of Health, District Health Office, Kapiri Mposhi, Zambia Correspondence: Rufaro Murembwa-Chirambo ([email protected]) Citation style for this article: Murebwa-Chirambo R, Mwanza R, Mwinuna C, Mazaba ML, Mweene-Ndumba I, Mufunda J. Occurrence of cholera in Lukanga fishing camp, Kapiri-mposhi district, Zambia. Health Press Zambia Bull. 2017;1(1) [Inclusive page numbers] Most of the cholera outbreaks in Zambia have been There is need to employ interventions in the area of recorded from fishing camps and peri-urban areas of water and sanitation on the Lukanga swamps in order the Copperbelt, Luapula and Lusaka provinces. to address the annual cholera outbreaks. Cholera cases have been recorded every year in the Lukanga fishing camps in the last five years. This article Introduction documents a cholera outbreak reported at the Lukanga The first outbreak of cholera in Zambia was fishing camp in Kapiri Mposhi district in September, 2016. All cases that met the cholera case definition as reported in 1977/1978, then cases appeared prescribed in the Integrated Diseases Surveillance and again in 1982/1983. The first major outbreak Response guidelines were admitted and treated using occurred in 1990 and lasted until 1993. Since WHO standard protocols. A total of 27 patients all adult except 1, 26 of whom were male were seen at the cholera then, cholera cases were registered every treatment center. Two facility deaths were recorded year except in 1994 and 1995[1]. A suspected during the outbreak. All cases were linked to the fishing cholera outbreak was reported at the Lukanga camps, lack of clean drinking water and poor sanitary conditions among other factors. The incubation period swamps / fishing camp in Kapiri Mposhi was about 4 days. All patients responded well to district in September, 2016. treatment with doxycycline and intravenous fluids. There were 2 facility deaths recorded; Case Fatality Kapiri Mposhi district is situated about 180 Rate (CFR): 7.4%. All cases tested on RDT and the water samples were positive for cholera. The outbreak km from Lusaka and 50km from Kabwe on the Lukanga swamps is associated with choleravibrio. towns and lies along the Great-North road. It has 30 health facilities, managing a total population of 282,308. The Lukanga swamps Although most cholera infections are not are located 70km North West of Kabwe and detected, large cholera outbreaks, such as 130km from Kapiri Mposhi District. The those seen in Haiti [6] Viet Nam [7] and Lukanga swamps are shared among the four Zimbabwe [8] in recent years, can occur. districts of Central Province namely, Kabwe, Industrialized countries have seen Mumbwa, Ngabwe, Chisamba and practically no cholera cases for over a KapiriMposhi. The swamps are easily century because of their good water and accessible through Kabwe and fall within the sewage treatment infrastructure, though it Waya health centre catchment area of Kapiri remains the significant cause of illness and Mposhi district. Waya health centre has a death in many catchment population of 16,000 and 5000 African countries. The priority in living on the upper land and the Lukanga management of any watery diarrhoea is swamps respectively (CSO, 2010). replacing the lost fluid and electrolytes and providing an antimicrobial agent when Cholera is an acute secretory watery indicated. Although the disease may be diarrhoea caused by the Gram-negative asymptomatic or mild, severe cholera can bacterium Vibrio cholerae, with 01 and 0139 cause dehydration and death within hours of types being the principal ones associated with onset. Mortality is higher in pregnant women epidemics and they thrive wherever crowded and children [7]. housing conditions exist and water and sanitary conditions are suboptimal [2,3,4,5]. Mortality rates are lowest where intravenous It’s transmitted by the fecal oral route. The therapy is available [9]. In the twenty-first organism produces an enterotoxin, century, sub-Saharan Africa bears the brunt promoting secretion of fluids and electrolytes of global cholera, with a high mortality rate into the lumen of the small intestine. Cholera [10]. Improving global access to Water, epidemics have been increasing in intensity, Sanitation and Hygiene (WASH), as well as duration, and frequency, showing the need cholera treatment is a critical step to reducing for more effective approaches to prevention Africa's cholera burden [11]. The disease and control [6, 7]. burden in most outbreaks is underreported. Fear of travel-related and trade-related sanctions may contribute to underreporting and may jeopardize efficiency of control clinical history on every suspected case measures [12]. Limitations in surveillance were documented including age, sex, systems, inconsistencies in case definitions, residency and symptoms. variation in modalities, lack of standard Laboratory investigation: On admission, terminology, completeness and lack of Rapid Diagnostic Tests (RDT) using SD laboratory diagnostic capacities may also Bioline-Cholera Ag 01/01/39 for cholera contribute to under- as well as were conducted for all suspected cases. overreporting[13, 14]. Most of the cholera Water sampling was also performed. outbreaks in Zambia in the past have been Case management: WHO cholera treatment recorded from fishing camps and peri-urban protocols were implemented on all patients. areas of the Copperbelt, Luapula and Lusaka Infection control was a top priority using provinces. The article documents the disinfectants chlorine. All patients were epidemiological findings of the 2016 cholera treated with doxycycline, metronidazole and epidemic within the Lukanga swamps in intravenous fluids. Kapiri-Mposhi district. Data analysis: Data on the progress of in Methods patients and new admissions were sent 2 to 3 After having recorded several cases with times daily to the Ministry of Health, WHO diarrhoea and vomiting from the fishing and other partners. A line list was compiled camp, a suspicion of cholera was raised, daily to keep track of new admissions. A followed by establishment of a Cholera descriptive analysis of the outbreak and Treatment Centre (CTC), 100 meters away, review of literature was used to determine the from Waya health centre. extent and factors contributing to the epidemic. Case investigation: All suspected cases were admitted and managed and the Results Cholera Treatment Centre. A suspected A total of 27 cases were seen at the cholera case of cholera was defined as any person treatment centre from 13 different lagoons, admitted to the cholera treatment centre with majority coming from Namabala lagoon with acute watery diarrhoea, with or 5/27. There were two facility deaths without vomiting. The demographics and recorded; case ratality rate (CFR): 7.4%. All patients except one were male. Except for Three water samples from selected lagoons one 15 year old male, the rest were adults. were tested and were all positive for Vibrio The incubation period was about 4 days. cholerae. In addition, 14 RDTs were done on There were 5 additional cases reported from the water samples using Hydrogen Sulphide Kapiri Mposhi urban, 3 from Kabwe and 1 tests and they all showed heavy coliform from Chibombo districts, all linked to have contamination demonstrating the poor had visited the Lukanga swamps or received sanitary conditions. visitors from there. The index case was Environmental findings reported on 11th September, 2016 and the last case on the 21st October, 2016, as shown in Environmental surveillance revealed non- figure 1. availability of sanitation and clean drinking Laboratory results water infrastructure on the swamps being Laboratory investigations for stool culture factors that precipitated the outbreak. The with TCB media revealed growth of Vibrio persons affected, most of whom are Cholerae on all the 10 samples tested fishermen have no access to sanitary facilities confirming cholera. The sensitivity test and safe drinking water. They use the swamp results also revealed that the species waters for all need including drinking and organism was sensitive to doxycycline. The sanitation. 22 samples tested using RDT were also Discussion positive. All water samples collected were The outbreak that occurred in Kapiri Mposhi, positive for the cholera vibrio. in particular on the Lukanga swamps is 6 linked to infection with Vibrio 5 4 Cholerae as per laboratory 3 confirmation. Close to 30 2 No. ofNo. cases 1 persons on the swamps were 0 affected. Considering all those affected lived on the swamps which have no prescribed Date of onset sanitation or clean water Figure 1 Cholera incidence in Lukanga swamps, September, 2016 source, it can be assumed that the source of infection was the contaminated water from the swamps. There was evidence of water logistical obstacles to appropriate case contamination with Vibrio cholerae. Other management also contribute to a high case- persons outside the swamps from Kapiri- fatality rate in epidemic settings [17]. Of the Mposhi urban, Kabwe and Chibmbo districts estimated 3 to 5 million cases that occur which are in close proximity to the swamps globally every year, about 100 000 to who were exposed on visiting the swamp or 120 000 die [18]. in contact with persons from the swamps Analysis of reports from previous outbreaks were affected. indicate that cholera epidemics in Lukanga There were two facility deaths recorded swamps occur in the dry season, just before (CFR = 7.7%). WHO indicates CFRs up to the onset of the rains. The waters in the 20% in rural areas. It is also possible that the swamps are low and so the flow of water is denominator (cases investigated) is lower poor. The cholera outbreak showed two than the actual number of cases and so peaks, with an initial sharp rise at the increasing the CFR.