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Epidemic Cholera in Guinea-Bissau: the Challenge of Preventing Deaths in Rural West Africa Geir Gunnlaugsson, Phd;*+ Frederick J

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Epidemic Cholera in Guinea-Bissau: the Challenge of Preventing Deaths in Rural West Africa Geir Gunnlaugsson, Phd;*+ Frederick J Original Report Epidemic Cholera in Guinea-Bissau: The Challenge of Preventing Deaths in Rural West Africa Geir Gunnlaugsson, PhD;*+ Frederick J. Angulo, PhD;* J6nina Einarsdbttir, BA;s Albert0 Passa,RN;* and Robert V: Tauxe, MPH+ ABSTRACT be prevented by strengthening the infrastructure of health ser- vices in the rural areas and by enhanced public education Objectives: An epidemiologic investigation was conducted to regarding the need for persons with cholera to promptly seek identify factors associated with cholera mortality in a rural medical care. African setting and interventions likely to prevent deaths in future epidemics. Key Words: Africa, developing country: epidemiologj4 Methods: The authors reviewed surveillance data from rural mortality, surveillance, Vibrio cholerae 01 Biombo, Guinea-Bissau, interviewed family members of per- sons who died of cholera, and conducted a case-control study Int J Infect Dis 1999; 4%13. in the catchment area of a health center with a high case:fatal- ity ratio (CFR). In its severe form, cholera results in profuse watery diar- rhea, which, if untreated, leads to rapid dehydration, aci- Results: Forty-three deaths occurred among the 1169 persons dosis, circulatory collapse, and death. Prompt fluid who reported to health centers with cholera during the epi- therapy with adequate volumes of electrolyte solution to demic (CFR = 3.7%). Delayed rehydration and over-hydration correct dehydration, acidosis, and hypokalemia is the key- probably contributed to IO of these deaths. An additional 19 stone of cholera therapy l If fluid replacement is delayed, cholera deaths occurred outside health centers. In the case- the case:fatality ratio (CFR) among persons with cholera control study, persons with cholera who died were 5.4 times may exceed 50%.2 With appropriate oral and intravenous (95% Cl = 1 .O-53.4) more likely to be in poor health or intoxi- rehydration3 the CFR among persons with cholera may cated at illness onset than persons with cholera who survived. Fatal cases were 6.0 times (95% Cl = 1 .I-60.8) more likely to be reduced to less than l%.* Case:fatality ratio, therefore, not attend the health center than survivors. often is used as a measure of the quality of care provided to cholera patients.5-7 Accurate interpretation of differ- Conc/usions: The low overall CFR in Biombo, compared to ences in CFRs requires an evaluation of the methods used CFRs reported during other epidemics in sub-Saharan Africa, for ascertaining cholera cases and deaths. Such investi- suggests that medical care provided at rudimentary rural health gations have not been reported from Africa, where sur- centers prevented numerous deaths. Additional deaths may veillance for cases of infectious diseases often is incomplete, particularly in rural areas. In addition, although most cholera deaths in recent years have occurred in subSaharan Africa,sj9 factors associated with mortality have not been reported except during epi- *Regional Health Board of Biombo, Ministry of Public Health, Bissau, demics associated with famine or refugee camps.l’-l2 Guinea-Bissau; *Department of Women’s and Children’s Health, Section The 1994 cholera epidemic in Guinea-Bissau, the first for International Maternal and Child Health, University Hospital, Upp- in that country since 1987, was caused by Vibrio cholerae sala, Sweden; +The Foodborne and Diarrhea1 Diseases Branch, Division 01, serotype Ogawa, biotype El ‘I’or, and resulted in 15,878 of Bacterial and Mycotic Diseases, National Center for Infectious reported cases and 292 deaths among the one million Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA; and “The Department of Social Anthropology, Stockholm University inhabitants of that nation8 During the epidemic, the Stockholm, Sweden. region of Biombo had the highest recorded cholera inci- dence outside of the capital city of Bissau, partly as a Supported in part by DanChurchAid, Copenhagen, Denmark. result of high risk funeral practices.” Marked differences Address correspondence to Dr. Geir Gunnlaugsson, Department of in CFRs were reported among patients attending the var- Women’s and Children’s Health, Section for International Maternal and ious rural health centers in Biombo. Therefore, an epi- Child Health, University Hospital, S-751 85 Uppsala, Sweden. E-mail: [email protected]. demiologic investigation was conducted to identify Mortality in Epidemic Cholera in Guinea-Bissau/ Gunnlaugsson et al 9 factors associated with cholera mortality in Biombo and access to that facility is limited by transportation and eco- to determine what interventions might best prevent nomic constraints. None of the rural health centers in future deaths. Biombo has electricity; only three have adequate access to water. Medicines and medical supplies are limited and often in short supply. Most centers have two beds and are PATIENTS AND METHODS normally staffed by two to four nurses. In October 1994, when cholera was detected in The rural region of Biombo (1994 population 61,522), Guinea-Bissau, the international community rapidly pro-, with 73 inhabitants per square kilometer, is the most vided the Ministry of Public Health with supplies (includ- densely populated of the nine regions outside the capi- ing oral rehydration solution, lactated Ringer’s solution, tal of Bissau in the West African country of Guinea-Bis- intravenous infusion sets, antibiotics, and bleach); limited sau (Figure 1). The 136 villages in Biombo have a median supplies were distributed to the rural health centers in population of 316 inhabitants (range, S-3557). The vil- Biombo. Early in the epidemic, to reduce cholera trans- lages are arranged in compounds, in which extended fam- mission, the Ministry of Public Health mandated that the ily members live in thatched-roof huts. Few villages have bodies of all persons dying of cholera be disinfected with latrines or electricity. Walking is the principal means of bleach by health center personnel before burial. This pol- transportation. The population is predominately Papel icy was enforced by local police during the epidemic. (73%) or Balanta (19%) ethnic groups that adhere to tra- Following the standard World Health Organization ditional African religions. case definition,‘* a cholera case was defined as the acute Routine health services in Biombo are provided by occurrence of watery diarrhea in a Biombo resident 2 nurses assigned to one of seven state-operated rural years of age or older who presented to a health center health centers; each health center is responsible for most in Biombo during the period of the cholera epidemic. medical services within a defmed catchment area of 5 to Health center nurses registered cholera cases and 31 villages. Although 40% of the population of Biombo prospectively completed surveillance case report forms, lives within 3 kilometers of a health center, 40% of Biom- which contained information on demographics and clin- bo residents live more than 5 km from a center and some ical outcome. For this study, a cholera death was defined residents live 20 km from a center. Individuals also may as the death of a person with cholera-like illness (whether seek medical care at the general hospital in Bissau, but or not he or she had attended a health center). Although Figure 1. Location of the Republic of Guinea-Bissau and Biombo region. 10 International Journal of Infectious Diseases / Volume 4, Number 1 not considered cholera cases for surveillance purposes, tion was paid to reasons for not seeking care, and the health center nurses also completed case report forms for time sequence and chain of events from illness onset to cholera deaths that occurred outside of their health cen- presentation at the health center or death. Recall of par- ter but within their health center catchment area. Stool ticipants was facilitated by the severity of cholera symp- specimens were collected from selected patients with toms and the many associated deaths. cholera-like illness and submitted in alkaline peptone Univariate analysis of the data was performed with water to the National Public Health Laboratory in Bissau Epi Info (IJSD Inc., Stone Mountain, GA, USA). Statistical for culture and antimicrobial sensitivity testing. Anti- comparisons were done with the Mantel-Haenzel chi- microbial sensitivities to chloramphenicol, trimethoprim- squared test with Taylor series 95% or exact confidence sulfisoxazole, tetracycline, doxycycline, erythromycin, intervals (CI) calculated for the risk ratio (for surveillance furazolidone, ciprofloxacin, nalidixic acid, ampicillin, sul- data) and exact 95% confidence intervals (CI) were cal- fisoxazole, streptomycin, and kanamycin was determined culated for matched odds ratios (mOR) (for the case-con- at the Centers for Disease Control and Prevention (CDC) trol study). Multivariate analysis was performed using in Atlanta, USA, by disk diffusion.15~16 conditional logistic regression (PHREG/SAS). Cholera deaths were identified by reviewing health center case report forms. An attempt was made to ascer- RESULTS tain unrecorded cholera deaths during frequent inter- views with health center staff and visits to the villages. During the epidemic, between October 1994 and January Only deaths among persons who presented to a health 1995, 1 I69 cases of cholera were reported in Biombo center were used to determine CFRs. Estimated village (20.4 cases per 1000 population) (Table 1). The cholera populations extrapolated from the 1991 census, were incidence was higher among females (24.9 cases per used to determine the health center-specific attack rates, lOOO), and persons 45 years of age or older (38.4 per and age- and sex-specific death rates. Extensive inter- 1000). The incidence also was higher among persons liv- views, using a pretested, standardized questionnaire, were ing less than 3 km from a health center (28.0 per 1000). conducted with health center nurses and family mem- Among the health center catchment areas, the lowest bers of all persons who died of cholera in the region dur- incidence was in Ondame (12.2 per 1000) the highest ing the epidemic. Following such interviews, researchers was in Dorse (24.7 per 1000).
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