Cholera receiving red carpet treatment in Ghana

BY EDMUND SMITH-ASANTE

Two boys fetching water from a contaminated source for household use at Dixcove in the Western Region

He looked at me and smiled. But what he was about to tell me was no laughing matter.

“I will never forget the day I got cholera. It was in 2012 during the elections, when after doing some monitoring I felt very hungry. I saw some ‘waakye’ (rice cooked with beans) at the roadside, bought some and ate my fill,” a colleague narrated to me.

“Thereafter I visited a very popular chop bar at Kwashieman, and ordered a bowl of fufu – In fact the fufu was very nice and I enjoyed every bit of it. Later in the night I had to visit the toilet several times where I passed watery stools, felt very sick and got dehydrated within few hours,” he continued.

According to the colleague, Kwame Fred (not real name), he had to report sick at a health facility the next day when he realised his condition was getting worse. “It was there that I got diagnosed as having cholera and the nurse who attended to me asked, ‘Why? Do you want to kill yourself?’”

Kwame Fred was fortunate his condition did not result in any fatality but was treated and discharged.

Many others – 100 in all, according to available statistics, lost their lives to the icy hands of death as a result of cholera in Ghana in 2012 – just last year.

All those unfortunate people, as well as fortunate ones like Kwame Fred who are still alive today although they also got the cholera disease, ate someone’s faeces, which is the main mode of transmission.

Impending Disaster

Experts say insanitary conditions which are very prevalent in Ghana, are the best courtesies to be extended for cholera to continue to fester like a viral wound. And as things stand now, Ghanaians have laid the red carpet for cholera to walk on, ever so majestically!

They maintain that even though Ghana has not recorded cholera deaths as yet, this year 2013, conditions are still very ripe for disaster to strike at any time. This is all the more because some cases have been reported already in different parts of the country.

At a recent launch of a special community-based campaign on cholera at Nima in Accra to educate people living in high risk areas including Maamobi and Agbogbloshie on how to prevent the disease, Dr. Alfred Sugri Tia, Deputy Health Minister, said although no cholera case has been confirmed this year, the possibility of an outbreak is high, as the risk factors still exist.

Mr John Yaw Donkor, Ashanti Regional Environmental Health Officer also stated Thursday, September 5, 2013 at a media cholera sensitisation workshop in Kumasi that although there have not been any reported cases of death in Ghana this year, there might be unreported cases or isolated cases. He thus cautioned all Ghanaians to be wary, as the conditions for an epidemic still exist.

Mr Maurice Quaye

A United Nations Children’s Fund (UNICEF) consultant, Maurice Ocquaye, who spoke at the same workshop on September 5, 2013, said; “In my rounds, what I see makes me very sad as a Ghanaian. I think that it is only by the grace of God that we have not recorded any deaths yet for this year. The practices have not changed – they are still the same.”

Warning that Ghana is sitting on a time bomb, he stated; “We don’t have potable water, open wells are there, we share them with our animals and we drink from those sources, we don’t treat our water, we don’t wash our hands after using the toilet. All the practices that will actually give us the opportunity to prevent the infection; we are not really doing them.”

History of Cholera in Ghana

The prevalence of cholera in Ghana dates back to September 1, 1970 when a Togolese in transit at the Kotoka International Airport from Conakry, Guinea, collapsed and was found to have cholera.

However, it was not until much later that the disease took root in Ghana, and this happened when the corpse of a fisherman, who had apparently died from cholera, was smuggled into Ghana for burial by boat.

History has it that when some Ghanaians went for fishing in the waters of Togo, Liberia and Guinea, one of the fishermen died and his corpse was smuggled into his home town, and the usual burial rites performed.

This was the beginning of Ghana’s cholera woes and the disease began to spread along the shores of Ghana and swept through many coastal villages in epidemic proportions. It kept on spreading and by July 1971, the Ashanti region began to report cases, indicating that cholera was spreading across the country.

During those periods, reported outbreaks were investigated, treatment camps set up, people vaccinated against cholera, and the population also educated on measures to prevent the spread of the disease.

However, all these attempts to prevent cholera from taking root in Ghana failed and since then, cholera has existed in both epidemic and endemic forms in Ghana.

According to health officials, cholera is caused by a bacterium known as vibrio cholera, and reached West Africa and Ghana during the seventh pandemic (seventh world outbreak).

From 1999 to 2005, Ghana officially reported a total of 26,924 cases and 620 deaths to the World Health Organisation (WHO).

The cholera disease

Cholera, an acute intestinal bacterial disease characterised by a sudden onset of profuse painless watery diarrhoea or rice-water like diarrhoea, is often accompanied by vomiting, which can rapidly lead to severe dehydration and heart seizure and death if left untreated.

Experts say it can be found in virtually any coastal water body, especially in the tropics and sub tropics, can survive and grow in different kinds of freshwater as well as water of moderate or high salinity. 

The highest concentrations of vibrio cholerae are known to occur when the water temperature is between 20^oC and 30ºC and they can also survive in variety of food stuff and water up to five days in ambient temperatures and up to 10 days at 5 – 10 degrees. 

According to scientists, the bacterium can be destroyed by radiation and heat above 70 degrees centigrade, while it is also sensitive to acidity and drying.

It can take anywhere from a few hours to five days for symptoms to appear after infection but typically appear in two to three days.

Symptoms of cholera

There are several ways the cholera bacterium manifests in its host.

These include watery diarrhoea that often contains flecks of whitish material that are about the size of pieces of rice. The diarrhoea is termed "rice-water stool” and smells like fish.

Health experts say the volume of diarrhoea can be enormous and that high levels of diarrhoeal fluid such as 250 c³ per kg or about 10 to 18 liters over 24 hours for a 70 kg adult can occur.

Other symptoms and signs that may occur are vomiting, rapid heart rate, loss of skin elasticity (washer woman hands sign), dry mucous membranes and low blood pressure.

The rest are thirst, muscle cramps, restlessness or irritability (especially in children) and mortality (death) rate can be as high as 50% to 60%.

Very elderly or young people are more susceptible to severe cholera and it is known that about 5% to 10% of previously healthy people are affected, while the number is higher if a population is compromised by poor nutrition.

Such people can develop severe dehydration, leading to acute renal (kidney) failure, severe electrolyte (chemicals in the bloodstream that regulate important functions of the body) imbalances (especially potassium and sodium), and coma. If untreated, this severe dehydration can rapidly lead to shock and death.

Health professionals say severe dehydration can often occur four to eight hours after the first liquid stool, ending with death in about 18 hours to a few days in under-treated or untreated people.

In epidemic outbreaks in underdeveloped countries where little or no treatment is available, the mortality rate can be as high as 50% to 60%.

Everyone is at risk

But in actual fact, no one is safe from the marauding cholera if a section of the Ghanaian public decide not to observe the basic tenets of personal hygiene and dispose of waste anyhow. With cholera, what goes round comes around.

Vectors of distribution such as flies are ever present to generously spread the disease, while floods are still an annual ritual in Ghana to ensure contaminated water enters homes and offices.

Open defecation is still rife in Ghana with over 5.7 million (23%) of the populace engaging in the abominable act, according to the 2011 Multi Indicator Cluster Survey (MICS) report.

Rubbish is strewn and packed in open drains and waste water rather poured on streets and roads – What an irony!

Experts say contaminated food and/or water is the main mode of transmission and that food can be contaminated through soiled hands during preparation or eating or even the “democracy approach”, which John Donkor, Ashanti Regional Environmental Health Officer explains as people picking and dropping food or meat in the process of buying from the food vendor.

Another way to easily invite cholera is consuming vegetables grown with contaminated water or washing vegetables with untreated (sewerage) water and preparation of beverages with contaminated water.

Corpses of cholera patients are highly infectious through their excreta and are known to be very lethal. Money exchanging hands after an infected person uses the toilet, as well as buying and drinking sachet water, ice cream, yoghurt or the like (common practices in Ghana) from an infected person or vendor, can also be very catastrophic.

Moreover, physical contact and food preparation and consumption during funerals can also lead to ingestion of contaminated food and beverages, especially when simple hand-washing with soap is not adhered to after shaking several hands.

Interestingly, it is believed cholera treatment centres (CTC) can also become main sources of contamination if hygiene and isolation measures are insufficient.

Types of cholera infection

Minor forms of cholera constitute the majority and health professionals say 70% to 85% of the cases of infection are asymptomatic or result in simple diarrhoea.

Cholera stool

In moderate forms there are frequent watery stools but fluid loss and dehydration are moderate, while in severe forms there is intense diarrhoea and vomiting, with significant fluid loss of about 500 ml to 1000 ml per hour and more than 10 to 20 litres a day.              

Severe dehydration is known to appear quickly, often in less than 12 hours and if left untreated, can result in up to 50 % mortality. However, with proper timely re-hydration it is believed mortality can reduce to less than 1 %.

How to prevent cholera

Health experts say cholera can be prevented by several methods including having adequate water-treatment plants, food-preparation facilities that usually practice sanitary protocols, and ensuring most people have access to toilets and hand-washing facilities.

Individuals can also prevent or reduce their chance of getting cholera by thorough hand washing, avoiding areas and people with cholera, drinking treated water or similar safe fluids and eating cleaned (thoroughly washed) and well-cooked food.

In addition, there are two vaccines available that can help prevent cholera with effectiveness ranging from 50% to 90%, although injected vaccines have not proved to be very effective. Unfortunately, both offer protection for only about two years and are given in two doses, about one to six weeks apart.

The vaccines also have limited availability, while their recommended use is for people going to known areas of outbreaks with the likely possibility the person may be exposed to cholera. Some researchers however suggest this limited oral vaccine availability should be changed, and cite data that oral vaccine may help limit outbreaks, even after they have begun.

During outbreaks too health authorities always suggest a ban on social gatherings including funerals, seen as one most effective way to prevent up-scaling of the disease, as well as dealing with all the risk factors.

This article was first published in the Daily Graphic on September 19, 2013