October 19, 2021

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Are pandemic precautions responsible for lowering cholera?

LUSAKA, ZAMBIA – When COVID-19 was detected in Zambia last year, Jennifer Phiri said she was preparing for a “double tragedy”.

His neighborhood, a cluster of iron-roofed houses that rely primarily on untreated well water, was already a hot spot for another disease. “I freaked out,” says Phiri, a single mother of three. “But thank God, the cholera has spared us.”

Zambia has recorded over 200,000 cases of COVID-19, the disease caused by the coronavirus, and over 3,500 deaths. But as of June 2019, there have been no confirmed cases of cholera, a bacterial disease endemic in parts of Africa and Asia.

Lloyd Mulenga, director of infectious diseases at the Ministry of Health, attributes this in large part to “increased hygiene” after a broad public health campaign to prevent the spread of the coronavirus. It is also the result, he says, of a cholera vaccination campaign that began in 2018 that immunized an estimated 2 million Zambians.

In Kanyama, the densely populated Lusaka town where Phiri lives, megaphones cars regularly play reminders to dress up, socially get away and wash your hands. Coronavirus posters are pasted on trees. And hand washing sinks have been installed in public spaces, including schools and clinics.

“We’ve rarely seen people carry hand sanitizers, but that’s normal now,” Phiri says, agreeing that COVID-19 messaging could keep cholera at bay. “We have hardly heard anything about cholera, but fortunately we have not had any outbreaks.”

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Prudence Phiri, GPJ Zambia

Jennifer Phiri draws treated water from a faucet she and her neighbors installed after her youngest son nearly died of cholera in 2018.

Hand washing with soap can limit the spread of cholera, a severe diarrheal infection contracted by consuming food or water contaminated with the stool of an infected person.

It is unclear whether there is a direct connection between measures to curb COVID-19 and cholera rates, but some recent studies have explored the impact of the measures on other infectious diseases. Last year, for example, researchers found that flu season in the Northern Hemisphere was interrupted by six weeks, suggesting blockages and social distancing helped.

According to the World Health Organization, cholera infects up to about 4 million people every year. Some people experience mild or no symptoms, but severe cases can cause vomiting, thirst, and leg cramps along with the typical watery diarrhea.

However, cholera remains easily treatable – most people recover with oral rehydration or, in the worst cases, with intravenous fluids and antibiotics. But the infection can kill within hours if left untreated.

“We have rarely seen people bring hand sanitizers, but now it’s normal.” resident in Lusaka

Sitting in the red doorway of her one-room house, Phiri remembers the day she nearly lost her youngest daughter to illness.

“He threw up all night,” says the fruit and vegetable seller. “I took her to the clinic after noticing that she couldn’t even stand on her own due to dehydration.”

It was November 2018, six months after the worst cholera outbreak in Zambia in about a decade. The 12-year-old from Phiri survived after a week in hospital, but nearly 6,000 Zambians fell ill and 114 died, mostly in Kanyama, between October 2017 and June 2018.

The situation improved the following year, with zero cholera deaths in Lusaka, according to Mazyanga Mazaba, an information officer at the Zambia National Public Health Institute.

But the congested town of Kanyama is still poised for the disease. Most residents rely on shared pit latrines, underground toilets that are not connected to a sewer system. Many are near shallow wells where people draw untreated water, which is often contaminated with fecal material.

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Experts say overemphasizing the role of hygiene in fighting cholera may disprove the bigger problem of inadequate sanitation. Basic drinking water services were only available to about two-thirds of the Zambian population in 2018, according to the United Nations Children’s Fund, known as UNICEF, while 10% of people practiced outdoor defecation .

“The vaccinations and constant hand washing are excellent,” says Pamela Chisanga, national director of WaterAid Zambia, a non-governmental organization. “But we have to use this window of emptiness to put in place permanent measures that will not see a resurgence of the disease. That is, sanitation, access to clean water and clean toilets ”.

After her family’s experience, Phiri and five neighbors pooled their savings to install an outdoor tap that draws treated water.

They also share a modernized latrine emptied by the local sewer company, as part of a new effort run by WaterAid Zambia and the Lusaka Sanitation Program in partnership with the government.

A major challenge to preventing cholera, health workers say, is its stigma as a “dirty disease” affecting the poor. This perception may have contributed to a delay in the search for health care and the high number of deaths during the latest Lusaka outbreak, according to a 2018 study in The Journal of Infectious Diseases, a medical journal published by Oxford University Press.

“When your neighbors here know you have cholera, you become an outcast,” Phiri says. “The time my daughter was inside [the] hospital, I tried to hide it. But then I thought I had to tell my neighbors the truth to protect them too ”.

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Prudence Phiri, GPJ Zambia

Former pit latrines in Kanyama are often found near wells that people rely on for drinking water, which can be contaminated with cholera-causing bacteria.

Mulenga, the director of infectious diseases, points out that the government has always taken cholera seriously.

“We may not have received real-time updates like we do with COVID, but that doesn’t mean [cholera] it’s an inferior disease, “he says, adding that he hopes Zambians will become as proactive about the disease as the pandemic. The government is also working closely with the private sector, Mulenga says, to provide more sanitation and safe drinking water.

Other African countries have not seen the same break in cholera infections. A June editorial in the International Journal of Public Health reported recent outbreaks of the disease in nations including Burundi, Nigeria and Uganda. The authors said cholera surveillance and health promotion may have decreased due to the focus on COVID-19. A February Lancet report also highlighted the increased risk of cholera in conflict-affected regions such as Ethiopia at a time when health systems are overwhelmed by the pandemic.

Back in Kanyama, Phiri is grateful for the cholera respite and hopes it will last. The fact that COVID-19 has devastated all sectors of society in almost every part of the world has motivated Zambians in a way that cholera has never done, he says.

“The coronavirus shook everyone,” Phiri says. “I’ve never seen people in my community wash their hands like they do now.”


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