Funerals During the 1994 Cholera Epidemic in Guinea-Bissau, West Africa: the Need for Disinfection of Bodies of Persons Dying of Cholera
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Epidemiol. Infect. (1998), 120, 7–15. Printed in the United Kingdom # 1998 Cambridge University Press Funerals during the 1994 cholera epidemic in Guinea-Bissau, West Africa: The need for disinfection of bodies of persons dying of cholera " # $ G.GUNNLAUGSSON , J.EINARSDO; TTIR , F.J.ANGULO *, " " $ S.A.MENTAMBANAR , A.PASSA R.V.TAUXE "The Regional Health Board of Biombo, Ministry of Public Health, Bissau, Guinea-Bissau # The Department of Social Anthropology, Stockholm University, Stockholm, Sweden $ The Foodborne and Diarrheal Diseases Branch, Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA (Accepted 26 June 1997) SUMMARY The 1994 cholera epidemic in Guinea-Bissau resulted in 15878 reported cases and 306 deaths. Early in the epidemic, although the health ministry mandated that the bodies of persons dying of cholera be disinfected, outbreaks occurred in several villages following funerals in the region of Biombo. To determine the influence of disinfection and funeral activities on cholera transmission, we analysed surveillance data and conducted a case-control study following a funeral. The attack rate during the week following funerals was higher in villages where bodies were not disinfected (risk ratio ¯ 2±6, 95% confidence interval [CI] 1±9–3±8). Cholera was strongly associated with eating at a funeral with a non-disinfected corpse (odds ratio [OR] ¯ 14±5, 95% CI 0±9–786) and with touching (i.e., transporting, washing) the body (OR ¯ 36±2, 95% CI 2±6–1769). During cholera epidemics, in addition to other cholera prevention activities, health officials should inform community leaders about the risk of cholera transmission during funerals, meals should not be served at funerals, and bodies of persons dying of cholera should be disinfected. from stool samples collected from patients in Guinea- INTRODUCTION Bissau. During the 1994 epidemic, as in the 1987 The first cholera epidemic during this century in epidemic, the region of Biombo had the highest Guinea-Bissau occurred in 1987, almost 2 decades recorded cholera incidence outside of the capital. after the seventh pandemic reached West Africa [1]. In Previous investigations of cholera in Africa have late 1994, a second epidemic in Guinea-Bissau resulted demonstrated the importance of contaminated food in more than 15000 reported cases and 306 deaths and water in the transmission of cholera [1]. Further among the one million inhabitants [2]. The 1994 studies in West Africa have suggested that funerals epidemic began in the Bijago! s Islands and spread may also contribute to cholera transmission [3, 4], but rapidly to Bissau, the capital of Guinea-Bissau, and its rigorous investigations of funeral activities have not surroundings (Fig. 1). In mid-October the Guinea- been described. During the 1987 cholera epidemic in Bissau National Public Health Laboratory isolated Guinea-Bissau, a large outbreak (111 cases, 15 deaths) Vibrio cholerae O1, serotype Ogawa, biotype E1 Tor, occurred after a funeral in a village in Biombo belonging to the Papel ethnic group; most of the * Author for correspondence: Dr Frederick J. Angulo, Centers for persons with cholera apparently became infected Disease Control and Prevention, Mailstop A-38, 1600 Clifton Road, Atlanta, GA 30333. during the large community meal served at the funeral Downloaded from https://www.cambridge.org/core. IP address: 170.106.202.226, on 28 Sep 2021 at 00:22:35, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S0950268897008170 8 G. Gunnlaugsson and others Region of Cacheu Bijimita Senegal Mansoa River Guinea-Bissau Quinhamel Safim llonde Bissau Dorse Bissau Bijagós Islands Guinea San Martinho River Atlantic Ocean Prabis Ondame Health centre Atlantic Ocean Guinea-Bissau, West Africa Region of Biombo Fig. 1. Geographic location of the Republic of Guinea-Bissau and Biombo. [5]. At the beginning of the 1994 cholera epidemic, in the person who died, where the body is taken to an October, the Ministry of Public Health mandated that appropriate house for washing, often the home of the the bodies of all persons dying of cholera be deceased. The body is washed with soap and water at disinfected with 2% sodium hypochlorite bleach by night; the bowels are not evacuated. Deceased women health personnel and buried within 24 h after death. are washed by their close female relatives; deceased Early in the epidemic, however, several cholera men are washed by their wives, daughters, and close outbreaks in Biombo again seemed to follow funerals. male relatives (children are not involved in the We launched an investigation to determine the washing of the body). After being washed, the body is influence of various funeral activities and disinfection wrapped with funeral shrouds and a meal is usually on the transmission of cholera in Biombo. served to participants. Every morning until the corpse is buried, women enter the funeral house and ‘offer rice’ for the deceased by eating small amounts of cooked rice and sprinkling rice on the floor. During METHODS the day, the body is taken out of the funeral house by Biombo (pop. 61522), with an estimated 73 in- male relatives and wrapped with additional shrouds, habitants per square kilometre, is the most densely before being returned to the funeral house in the populated of the nine regions outside of the capital evening. The body is usually buried 3–5 days after Bissau. The median population of the 136 villages in death. A large community meal is served for which Biombo is 316 inhabitants (range 8–3557) (Table 1). animals are slaughtered if, through divination, the The villages are arranged in compounds, in which ‘spirits’ are thought to be favourable. In certain extended family members live in several thatch-roof situations, including emergencies such as a cholera huts. Water is collected from shallow wells or springs. epidemic, the religious leaders may postpone the large Few villages have latrines or electricity. Soap is rarely community meal. used for handwashing. The diet consists largely of rice The Balanta have funeral activities similar to those and fish, usually served in a common bowl and eaten of the Papel except there is less manipulation of the from the hand. The population is predominately body, there are fewer shrouds, and the body is usually Papel (73%) or Balanta (19%) ethnic groups; both buried within 24 h after death. The Balanta also tend groups adhere mainly to African religions. to have larger community meals during funerals than the Papel. Funerals Surveillance The Papel usually have prolonged funerals, which include large social gatherings. After the death of an For surveillance purposes, a case of cholera was adult, the body is transported to the native village of defined as acute, watery diarrhoea in a Biombo Downloaded from https://www.cambridge.org/core. IP address: 170.106.202.226, on 28 Sep 2021 at 00:22:35, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S0950268897008170 https://doi.org/10.1017/S0950268897008170 Downloaded from https://www.cambridge.org/core Table 1. Cholera attack rates and average time to burial, by disinfection and funeral history, for 136 villages in Biombo, Guinea-Bissau, October 1994–January 1995 Village cholera Number of villages Number of Cholera attack Number of Average adult attack 95% (median village Population cholera cases rate (%) cholera time to rate (%) % 1 week Relative confidence population) & 2 years & 2 years & 2 years funerals burial (h) after funeral risk interval . IPaddress: Villages with cholera 5 (616) 2700 129 4±8 6 43 2±62±61±9–3±8 funeral – bodies not disinfected 170.106.202.226 Villages with cholera 26 (520) 18902 575 3±056111±0 (Referent) — funeral – bodies disinfected Villages without cholera 69 (342) 28920 484 1±7————— , on funeral Villages without cholera 36 (170) 6836 — — — — — — — 28 Sep2021 at00:22:35 case All villages 136 (316) 57358 1188 2±162———— compounds in theNovember village, to 4 confirmed December there 1994, weapproximately were visited 520 each no were of the lated from the 1991 census, was 914 persons, of whom community meal. death), butbody the was funeral48 washed did h after her (approximately not death. 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(i.e., same compound, Estimated touching, and, village presence transporting) for of persons the cholera amongbefore family onset members of living diarrhoea. in Exposuresand included information travel, on potentialforms, which exposures contained in information on the demographics cases week andJanuary, 1995.