CHOLERA PREVENTION AND CONTROL IN KENYA Gretchen A. Cowman A dissertation submitted to the faculty of the University of North Carolina at Chapel Hill in partial fulfillment of the requirements for the degree of Doctor of Public Health in the Department of Health Policy and Management in the Gillings School of Global Public Health. Chapel Hill 2015 Approved by: Harsha Thirumurthy Suzanne Babich Jamie Bartram Michael Emch Sandra B. Greene © 2015 Gretchen A. Cowman ALL RIGHTS RESERVED ii ABSTRACT Gretchen A. Cowman: Cholera Prevention and Control in Kenya (Under the direction of Harsha Thirumurthy) Kenya experienced widespread cholera outbreaks in 1997-1999 and 2007-2010. The reemergence of cholera in Kenya in the first months of 2015 suggests that cholera remains a public health threat. This study employed a mixed methods approach to investigate the successes and challenges of cholera prevention and control in Kenya through analysis of cholera surveillance data and key informant interviews. The goal of this study was to produce information that will be useful to the Government of Kenya in establishing or strengthening policies and programs that effectively prevent and control cholera. Key findings from analysis of cholera surveillance data indicate: (1) cholera has been recurrent in various geographic regions with differing climatic conditions, (2) cholera has affected some of the least densely populated rural areas as well as Kenya’s largest cities, and (3) cholera occurrence appears to be associated with open defecation, access to improved sanitation, access to improved water sources, poverty, and level of education. Interventions, policies, and strategies that are perceived to be effective in cholera prevention and control include: (1) Community Led Total Sanitation, which aims to eliminate open defecation, (2) provision of clean water, and (3) the Integrated Disease Surveillance and Response strategy, which is Kenya’s platform for implementation of the International Health Regulations. Key challenges include: (1) lack of access to improved water and sanitation for a iii large proportion of the population, (2) limited laboratory capacity to diagnose cholera, and (3) poor availability of intravenous fluids and oral rehydration solution. The findings of this study suggest that there is need to intensify efforts to expand access to improved sanitation and safe drinking water, to strengthen laboratory capacity and disease surveillance, to improve availability of basic medical supplies for rehydration, and to expand poverty reduction programs. Community Led Total Sanitation and the Integrated Disease Surveillance and Response strategy have created programs that should continue to be supported, strengthened and expanded. Devolution of government services from national to county level presents both opportunities and challenges for cholera prevention and control. Both levels of government have key roles to play, and effective collaboration is necessary for success. iv To my mother, Norma Cowman, and my brother, Paul Cowman In memory of my father, Richard Cowman Thank you for believing in me v ACKNOWLEDGEMENTS I am grateful to those who provided guidance and support during my doctoral studies. From the Ministry of Health I am thankful to my co-investigator, Dr. Shikanga O-tipo, for his valuable contributions to this study. I am thankful to Dr. Ian Njeru and Dr. William Maina for their leadership support of this study and to David Mwangi and Annastacia Muange for compiling and sharing cholera surveillance data. From CDC Kenya I am thankful for the guidance and support I received from Dr. Kevin De Cock, Dr. Joel Montgomery, Suzanne Theroux, Dr. Kipruto Chesang, Daniel Wako, Peter Young, and Thomas Achia. From CDC Atlanta I am thankful to Dr. Eric Mintz for his guidance and suggestions as the idea for this study was being formed. I am grateful to all of the individuals who were interviewed in this study for taking time out of their busy schedules to share their insights on cholera in Kenya. From the University of North Carolina I am thankful to the DrPH faculty, my committee members, and my colleagues in the C8 cohort. I would not have been successful without the support that I received. vi TABLE OF CONTENTS LIST OF TABLES…………………………………………………………..…………………….x LIST OF FIGURES ....................................................................................................................... xi LIST OF ABBREVIATIONS ....................................................................................................... xii CHAPTER 1: INTRODUCTION .................................................................................................. 1 Statement of the issue ................................................................................................................ 1 Background ................................................................................................................................ 3 Environmental reservoirs and climatic factors ...................................................................... 3 Risk factors and control measures ......................................................................................... 4 Cholera and the International Health Regulations ................................................................. 5 Cholera occurrence: Global and regional trends ................................................................... 6 Kenya ..................................................................................................................................... 6 National policies and strategies relevant to cholera prevention and control ......................... 9 The research question and significance ................................................................................... 13 CHAPTER 2: LITERATURE REVIEW ..................................................................................... 15 Cholera in Kenya from a global and continental perspective .................................................. 16 Climate and ecology ................................................................................................................ 17 Causative organism .................................................................................................................. 21 Outbreak investigations ........................................................................................................... 22 Influence of social and cultural factors .................................................................................... 27 Interventions ............................................................................................................................ 30 vii Review of surveillance data ..................................................................................................... 31 Discussion ................................................................................................................................ 34 CHAPTER 3: METHODS ........................................................................................................... 39 Theoretical framework ............................................................................................................. 39 Quantitative investigations ....................................................................................................... 41 Variables and data sources ................................................................................................... 42 Data management and analysis ............................................................................................ 47 Key informant interviews ........................................................................................................ 49 Study population .................................................................................................................. 50 Data collection procedures ................................................................................................... 51 Data management and analysis ............................................................................................ 52 Ethical considerations .......................................................................................................... 54 CHAPTER 4: RESULTS ............................................................................................................. 56 Quantitative investigations ....................................................................................................... 56 Key findings ......................................................................................................................... 57 Descriptive statistics ............................................................................................................ 58 Geographic patterns of cholera occurrence .......................................................................... 59 Relationship between cholera occurrence and development and demographic indicators .. 64 Key informant interviews ........................................................................................................ 71 Descriptive analysis ............................................................................................................. 71 Key findings ......................................................................................................................... 72 Other considerations ...........................................................................................................