Baluku*1 M, 2Agwu E 3Kasule A, 4Moazzam ML
1, 3, 4 Department of Public Health, School of Allied Health Sciences, Kampala International University, Western Campus Box 71, Uganda. 2Department of Microbiology Kampala International University, Western Campus Box 71, Uganda.
Correspondence: Baluku Moses: [email protected]: Tel: +256-772-884084
Citation: Baluku M, Agwu E Kasule A, Moazzam ML. The transmission dynamics of the cholera epidemic in Kasese district, Uganda. Spec Pathog Rev J. 2015; 1(1): 030-039
Background: Cholera is still a big public health problem in the Kasese District of Uganda, which deserves effective intervention for a free and safe society.
Objectives: to survey the transmission dynamics of cholera epidemics in endemic Kasese District of Uganda.
Materials and methods: A descriptive cross-sectional study was carried out among 240 adult participants (quantitative data) with a history of cholera and 7 key informants (qualitative data). Analysis was done by SPSS using chi-square at the bivariate level and linear regression at the multivariate level. Statistical significance was assessed using p (< 0.05).
Results. The dynamics of the cholera epidemic were defined by environmental factors, effectiveness of existing interventions such as Cholera epidemic Task Force; Cholera Treatment Centers; Health education campaign; and Village Community meetings about cholera. This is backed by poor uptake of cholera intervention programs and others.
There are still gaps in the uptake of cholera control interventions in Kasese District manifested by the laxity of the District’s Cholera epidemic Task Force; inadequate disinfection and cholera treatment kits in the Cholera epidemic Treatment Centers; low PHC funds and low listenership to media campaigns for health education about cholera; finally, rare and poorly attended village community meetings on cholera which influenced the spread and development of cholera outbreaks in Kasese District.
Conclusion and recommendations Cholera epidemic in Kasese District was mainly induced by the consumption of cholera contaminated food and water. The interventions existing in the district are ineffective and inefficient due probably to gaps in the uptake of existing cholera cholera epidemic control interventions. District Health Offices should therefore strengthen health education and promotion about cholera; through a case-control study that will give more focus on the importance of the factors contributing to cholera in Kasese District.
The choleraepidemic continues to be a major public health problem in many developing countries and it has remained one of the causes of morbidity and mortality in many regions of the world. The epidemic has been reported in many areas of the world and these include India, South and Central America, outbreaks associated with limited safe water supply, poor hand hygiene practices, poor health systems, poor sanitation and social-cultural behaviors of community members, low latrine coverage and poor practices of disposal of human feces (2-3).
Cholera epidemics are reported in the world (4-5) and Africa is referred to as a homeland for frequent cholera outbreaks. Cholera is endemic in sub-Saharan Africa where poor sanitation and lack of clean water facilitate the spread of the disease (6). Cholera outbreaks feared because of their ability to cause sudden and intense diarrhea, vomiting, dehydration causing a victim to go from seemingly healthy condition to death in twenty-four hours (7).
The cholera epidemic has become an inherent part of the biophysical environment in Africa (8). The crude fatality rate for cholera in South African countries was reported to be 5.4% in August 2008 (8). Africa is under the threat of cholera and needs a complete paradigm shift if this persistent occurrence is to be stopped and the shift is only feasible provided the leadership in the continent shows the good political will to help transform African countries through improved health (9).
In 2009, at least 125,018 cholera patients incidence/were reported to World Health Organization by African countries and two years later, at least 178,677 cholera patients cases) were also reported including 4033 deaths from across the world (10). According to WHO (11), 62% cases and 56.7% deaths out of 125,018 cholera patients, occurred in Africa. Cases of cholera increased in all regions of Africa in 2009 (14, 12).
By July 2009, the counts of cases of cholera epidemic showed 9,859 people who had been infected and a total of 4,288 died from cholera (12). By 2010, the cholera epidemics were recorded in all the ten provinces of Zimbabwe with a higher number of cholera patients recorded in the Districts of Harare, Beitbridge, and Mudzi (13).
Forty cholera patients were reported to have been admitted across the four Health sub Districts of Kasese district of whom four cholera patients died (14). In May 2013, cholera spread was reported in the Nyakiyumbu sub-county of Bukonzo County and Kyabarungira sub-county of Busongora County. The first 13 cholera patients were reported in Kayanzi fishing village with 3 deaths while 1 death of the disease was reported in Nyakiyumbu sub-county.
By 9th May 2013, the disease had spread to a total of eight sub-counties notably Hima, Lake Katwe, Kisinga, Kyarumba, Munkunyu, and Karambi and the number of cholera patients had reached up to 40 and 4 deaths. In May 2013, there was yet another devastating cholera outbreak in Kasese District which is said to have taken more than three weeks to be contained and the factors which contributed to its spread were not clear (15).
It is important, to mention that cholera was reported to be attributed to the uneven distribution of health facilities in the district and low staffing levels as at when? (16). The district had low latrine coverage in 2013 as reported mainly in the Sub Counties of Kitswamab (59%), Kyabarungira (75%), Kyarumba (77%), Hima 44% Kilembe, Nyakiyumbu 43%, Kilembe, (54%), and Nyakiyumbu (36%). Some households with latrines are said to be in poor hygienic conditions because they are not properly used by children whose feces are not properly disposed of (17).
The district authorities constructed some public toilets during the cholera outbreaks in some markets, schools, and all fishing villages, but most of them are not clean and are not properly supervised (18). Among the Bakonzo people especially the Balegha clan, a pregnant woman nearing delivery is not allowed to use a latrine for fear of induced abortion (19) instead are allowed to practice open defecation in which women defecate in shopping bags and throw the excreta into the road, market square or football field; thus increasing vulnerability for cholera outbreaks.
There are limited hand hygiene practices among the people especially after visiting the toilet and consumption of fruits like mangos, passion fruits, and jack fruits (18). It is further reported that interfamilial relationships at the household level are related to cholera because children share food and dip their hands in the same feeding pot and can wash their hands dipping them in the same container in which case the Vibrio cholera can be carried from the hands to the food and the mouth (20).
The cholera epidemic is due to uneven distribution of health facilities in the district and low staffing levels because most of the health centers are in the low lands than in the uplands while the staffing level in the health sector is as low as 40% and the percentage of district annual budget allocation to health is as little as 13% (18).
Although cholera has been eliminated in many developed countries, it is still a major public health problem (21) (Repeated). Over sixteen countries in Africa including Uganda are the homeland of rampant cholera outbreaks (22). Four outbreaks of cholera resulting in 144 admissions and 4 deaths occurred in Kasese district in the year 2012 across the health centers (18, 14).
At the time of this study in May 2013, a total of 40 cholera patients had been admitted to various health units and 4 of them had died of cholera. In two years, eight sub-counties out of twenty-five were reported to have had three outbreaks of cholera. A Cholera Task Force is reported to have been established in the district but its efficiency in the control of cholera spread had not been significant (19).
The objective of this study was to establish the environmental factors associated with cholera outbreaks in Kasese District, validate the specific existing interventions the District Health Office has in place to respond to cholera outbreaks within the district, and assess the up-take of the cholera control interventions existing in the district.
MATERIALS AND METHODS
This study was a descriptive cross-sectional study that used both quantitative and qualitative data to highlight community-related concerns about cholera outbreaks. Participants for quantitative interviews were adults with a history of cholera in their households while the participants for qualitative interviews were adults who knew cholera in the study area.
Kasese district has a total population of 671,000 by the year 2006, with a sex distribution of 348,400 females and 322,600 males (23). About 52% of the total population is females while 48% are males. The largest age group in the district ranges from 15-49 years making up 43% of the total population. The population growth rate is 3.6%. Kasese is a multi-ethnic district. The main languages and ethnic groups that dominate the population are the Bakonzo, Banyabindi, and Basongora. The population density is 185 persons per square kilometer.
Most of the people predominantly practice subsistence farming and their livelihood is based on it. They grow crops and rear animals for their employment and survival. Other activities include fishing among the fishing communities in the fishing villages of Kayanzi, Hamukungu, and Kahendero. Settlement is more concentrated in rural areas than urban areas. Most of the crop growing activity is done in the low lands where cotton, beans, and maize are grown among others (24). The population is made up of clans.
The target respondents were aged 18 years and above from households with a history of cholera in Kasese District. The District consists of two counties namely; Bukonzo and Busongora counties. The entire district is made up of 25 sub-counties; of these, eight sub-counties were the target population studied as a representative figure of the entire district. These were; Kyabarungira, Hima Town Council, Lake Katwe, Kisinga, Kyarumba, Munkunyu, Nyakiyumbu and Karambi.
The District has a health system managed by the District Medical Officer who is also a member of the District Cholera Task Force. With a total of 94 health facilities in the district, three are hospitals, 9 Health Center 1Vs, 30 Health Center IIIs and 55 are Health Center IIs. The district health facilities are not equally distributed. Busongora county has more health facilities (62% coverage) while Bukonzo has few health facilities with 38% coverage.
At the time of the study, the Health Office is said to have established a District Cholera Task Force whose primary responsibility was to oversee the control of cholera outbreaks in Kasese District. The task force was a team of seven members namely: the district medical officer, the health inspector in charge of water and sanitation, the medical superintendents of Rwesande Health Center, Kilembe, Kagando, and Bwera hospitals respectively (19).
Kasese District has many water bodies including lakes, rivers, among others. The rivers are more concentrated in the uplands of the Rwenzori ranges but widely spaced in low lands as they pour their water into the lakes of George and Edward mainly. In the wet season, most of the rivers flood and override surrounding valleys and cause weak latrines to collapse, mainly around the lake shores and fishing villages of Kayanzi, Hamukungu, Kahendero, and Katwe. The contents of collapsed latrines sometimes end up in rivers and lakes.
The sample size was calculated according to Fisher’s formula (20) which states that: n=Z2 P (1-p)/ d2, Where; n=required sample size; Z= standard value=1.96). P=prevalence of cholera in Kasese District = 31%, (21). Absolute precision was 5%. Using the above formula, the sample size was obtained to be 264.
The multistage purposive sampling technique was used to select the participants for the quantitative interviews as follows: At the District level, two counties were deliberately selected namely Bukonzo county and Busongora county because the District has only two counties. In Bukonzo County, five sub-counties were selected and also 3 sub Counties from Busongora County because cholera outbreaks were mainly observed in those sub-counties. This meant that 8 out of 25 Sub Counties were deliberately selected because cholera outbreaks were mainly observed in those Sub counties.
This stage was followed by the selection of parishes. One parish was selected from each of the 8 sub-counties with the help of the respective sub-county chiefs because those parishes frequently have cholera outbreaks. This stage was also followed by the selection of villages. In each parish, 3 villages were selected using simple random sampling in which village names were written on pieces of paper mixed in a box and an independent person randomly picked any three.
Finally, 10 households were selected using simple random sampling from each of the 3 villages with the help of the Village Health Team Members purposively because they knew households with a history of cholera for the past three years. All adult persons of 18 years and above had a chance to be interviewed. Where there was no patient with cholera, a family member was interviewed. This meant that 240 subjects participated in the quantitative interviews.
Selection of Key informant participants for the qualitative interview
The seven Key Informants were purposively selected to participate in the qualitative interviews because they were members of the District cholera Task Force who knew cholera in Kasese District. These were: The District chairperson, District Health Officer, District Health Inspector in charge of water and sanitation, Medical Superintendents of Rwesande Health, Kilembe Health, Kagando Health, and Bwera Health sub-districts.
Data collection instruments
Quantitative data were collected using a piloted structured questionnaire which consisted of both open-ended and closed-ended questions. Data was collected by six research assistants recruited for the purpose. They were trained and calibrated for validity and reliability by the principal investigator. Village Health Teams (VHT) were engaged during the administration of the questionnaires since they assisted in finding out homes of respondents with a history of cholera patients from their registers.
Type of data collected included: social-demographic characteristics of the respondents, environmental and social-cultural factors associated with cholera outbreaks, the specific interventions the District Health Office had put in place to control cholera outbreaks, and the uptake of the cholera control interventions.
Qualitative data were collected from the key informants by the researcher using the Key informant interview guide. They were seven interviewees in total. These were engaged for interviews because they had the technical knowledge about cholera in the district. Interviews were conducted on a one-to-one basis by the principal investigator. Each participant took 40-60 minutes. The interview proceedings were tape-recorded.
Data collection tools were designed by the principal investigator so that the items were set effectively in the right procedure suitable to the specific objectives of the study. Research assistants were trained to equip them with the skills of correct data collection while using the questionnaires. The questionnaire was pre-tested in five households and was selected randomly in one of the villages in the study area to check the effectiveness of the question items in the tool.
Appropriate adjustments were made to better ensure the validity and reliability of the tool. The chief investigator closely supervised the data collection process. A triangulation (What is triangulation?) of data was made which helped to provide evidence and support of correct information gathered from the quantitative interviews and qualitative interviews.
After collecting data for quantitative interviews, it was sorted and checked for completeness. It was then entered into the computer excel spreadsheet. The edited data was entered in SPSS version 16 for analysis. The analysis was done to generate main study outcomes and detect associations between the independent variable and other variables using the Chi-square test, to detect associations or effects between them.
The dependent variable was a history of cholera in the household while the independent variables were factors contributing to a cholera outbreak. The relationship between a dependent variable and the independent variables was computed using standard methods (α=0.05). The results were then summarized. Finally, a multivariate analysis of the significant factors was done by using linear regression analysis in which modeling was performed to eliminate confounding variables. The results were summarized (in figures, tables, or chats?).
Qualitative data were transcribed from the tape-recorded interviews. They were coded into meaningful themes and sub-themes for interpretation. Qualitative data (Data from the key informants) was presented in descriptive narratives and subsequently analyzed accordingly.
The principle of informed consent was adopted and emphasized. This process involved informing the participants that the study was about a cholera outbreak which enabled them to understand the purpose of the study. During the process, the participants were made to understand that they were competent to participate in the study.
The discussion was held by each of the participants that helped to arrive at a decision that was not subject to coercion, with no undue influence of inducement and no intimidation. Confidentiality for safeguarding the privacy of respondents was emphasized during the interviews by ensuring that no names of people were taken but only their study number. It was also ensured that whatever information given by the respondent was confidential and was not released to anyone.
Confidentiality also involved securing the interview place at an agreed location in the villages for the participants. In so doing, the participants were able to gain trust and communicate well during the interviews. The respondents were informed that there were no risks in the study since the information collected will be used only for the study. No other motives were involved.
The respondents were informed that no immediate benefits were to be given to them as a result of their participation. They were not to be paid or rewarded in monetary terms. The participants had the right to participate or refuse in the study without losing their rights and integrity. Permission to collect data from the community was obtained from the community leaders (LC I and LC II).
The people who participated in the research freely gave the information to the researcher about cholera outbreaks in their community because they were at liberty to do so. A letter of introduction to the field by the District Medical officer enabled the local council chairpersons (LC I and II) to allow the researcher to enter the respective communities studied
Owing to the sensitivity of health-related information, informants were not very free to provide detailed cholera information because they belonged to a District Cholera Task Force whose image they wanted to protect. It is important to mention that it was not easy for the Key informants to fit the interviewing program into their busy schedules. We, therefore, had to re-schedule some of their interviews to fit their convenience. There were cases of suspected exaggerations by some people during the field survey. Some found it hard to answer the questions because cholera had led to the loss of lives of their relatives.
Female respondents (53.7%) were more than their male (47.8%) counterparts. Respondents aged 18-35 years (59.5%) purposively described as early adulthood were more than those aged 36-53 years (29.9%) tagged late adulthood while the elderly respondents were those aged 54 years and above with a prevalence of (12.1%) respectively. Married respondents were (64.1%) prevalent compared to unmarried single respondents (18.6%). Peasant participants had the highest relative prevalence (51.6%), followed by those who had formal employment (20.8) while the least were those with unclassified occupations recorded as others (17.7%).
Most (31.6%) of the respondents had a primary level of education followed by (25.1%) who never went to school and (22.9%) who had a secondary level of education and finally (22.9%) who had a tertiary level of education. Most (79.5%) of the respondents were Christians followed by (16.5%) Muslims and finally, the least were others (8.3%). The majority of the respondents were of household size range from 1-5 people (58.7%) followed by 6-10 people (36.8%) and finally, the least was 10 people and above (5.6%).
Factors associated with cholera outbreaks
The environmental and social-cultural factors associated with cholera outbreaks were analyzed at a bivariate level using chi-square. The dependent variable was a history of cholera in the household and the independent variables were factors contributing to cholera spread. The result of the analysis is shown in the table below:
Domestic water source of respondents was from lakes and rivers and it played a significant role in the development of cholera (P= 0.004 CI 0.0050-0.043). Cooking food at funerals of cholera victims was also found to be a significant factor in the spread of cholera in the study area with mourners more at risk of the disease when they ate food prepared in the funerals. P= 0.03 (CI -0.081-0.009).
Social Demographic Characteristics of the respondents
Table 1 Demographic information of respondents n=240
Above 54 years
Above 10 people
Water shortage was found to be a significant factor in the development of cholera in the study area with periods of water scarcity when clean safe water was not available at the taps, springs, and boreholes. P= 0.02 (CI -0.103- -0.076). Food vending also came out significant in the contribution to a cholera outbreak in the study area with buyers of foods, juice, and fruits in markets that were sold, bought, and consumed under minimum hygiene put consumers more at risk of cholera disease.
P= 0.000 (CI 0.101 -0.354). Finally, other factors did not come up to be significant and these were: sex of the respondents, age of the respondents, marital status, occupation of respondents, level of education, the religion of respondents, size of the household, water purification methods, availability of latrine, condition of a latrine, availability of handwashing facility at a latrine, the season of cholera, condition of vended food, washing dead bodies before burial, sitting diarrheal patients inflowing rivers, and depositing solid waste.
Multivariate analysis of the significant factors was done by using linear regression to eliminate confounding variables. The statistical relationship between the dependent variable (history of cholera in the household) and the independent variable (factors leading to cholera outbreak) was analyzed with SPSS version 16. The results of the analysis are shown.
Table 2: Bivariate analysis of the factors associated with a cholera outbreak in Kasese
|Independent factor||Chi-square statistics||p-value||CI|
|Sex of respondents||0.554||0.554||0.187-3.789|
|Age of respondents||0.035||0.512||1.435-96.535|
|Occupation of respondents||1.796||0.712||-0.065-0.019|
|Level of education||0.502||0.502||0.142-40.315|
|Religion of respondents||2.369||0.130||0.757-7.604|
|Size of household||1.987||0.610||0.012-0.789|
|Water source (lakes/rivers)||5.419||0.004||0.050-0.043|
|Water purification method||2.440||0.221||0.754-7.334|
|Water shortage period||0.852||0.002||-0.103- -0.076|
|Availability of a latrine||1.295||0.510||-0.202- -0.025|
|Condition of a latrine||0.440||0.601||-0.202- -0.025|
|handwashing facility at latrine present||0.184||0.221||-0.040-0.095|
|Season of a cholera outbreak||0.598||0.150||-0.065-0.031|
|Consumption of vended food||1.337||0.000||-101- 0.354|
|Condition of consumed vended food||0.120||0.111||-0.200-0.043|
|Eating food at funerals||0.715||0.003||-0.081—0.009|
|Washing dead bodies before burial||1.117||0.121||-101-.0453|
|Conduct of diarrheal patients inflowing rivers||0.855||0.122||-0.081- -0.009|
|Deposit of solid waste||0.852||0.326||-0.074-0.095|
Dependent variable: History of cholera in the household, R Square= 0.714,
The statistical relationship between the dependent variable (history of cholera in the household) and the factors which lead to the spread of cholera outbreak (Independent variable) was analyzed as shown in the table above. The findings revealed that the statistically significant factors were as follows:
Consumption of vended food: p= 0.000 (CI 0.101-0.354)
This factor came out significant in the quantitative interviews as one of the environmental factors that put people in the study area more at risk of the disease and contributed to the cholera outbreaks. In all the qualitative interviews with the key informants, they repeatedly assured the researcher that ‘our people eat many things in the markets during the rural market days. They drink locally made banana juice called “isande” and juice made from passion fruits even when cholera is seriously making people sick.
You even find them eating mangoes in the market during a cholera outbreak. They do not wash them at all. Today, two female cholera patients are now admitted in Kagando hospital that is said to have been admitted in the cholera ward shortly after drinking “isande” juice in Kisinga market. Three informants said ‘….women have a habit of eating anyhow because they eat this and that be it in public places or even in their homes..’. Two others said ‘…. The cooked food our people sell in these markets is not covered and the fruits are not washed….’.
Water shortage: p = 0.02 (CI -0.103- -0.076).
This factor also came out significant in the quantitative interviews as one of the contributing factors of cholera outbreak in the District with people who did not get access to reliable clean water more at risk of the disease. In all the general interviews with the key informants, it was acknowledged that ‘…. In the dry seasons, most of the taps, wells, and springs dry up. As an alternative, the people collect water from rivers and lakes.…’
Six informants added that ‘…. the fishermen defecate in lakes as they fish because they have nowhere to go and our people still use the same water raw in their homes…’ One other said ‘… In some places of the district, people use stagnant water in the roads after it has rained and used the water raw for domestic purposes that make them get cholera….’.
Safe water source: p= 0.04 (CI=0.050-0.43).
The safe water source was negatively associated with cholera outbreak when rivers merged out significantly as the main source of water for domestic purposes in the study area during the quantitative interviews. Asked during the qualitative interviews, informants generally acknowledged that ‘…..The main source of water here in the district is open water usually rivers. They are contaminated by the cholera patients who wash their linen after discharge from hospitals as they travel back to their homes……..’
Consuming food in funerals: p= 0.03 (CI= -0.081- -0.009)
Consumption of food at funerals of cholera victims was also found significant in the spread of cholera in the study area with mourners more at risk of the disease when they ate food prepared in the funerals of cholera patients. The p values of this significant factor were 0.03 and the confidence intervals were -0.081- -0.009. The key informants generally acknowledged that people ate food that had been cooked at the funerals.
In their interviews, they frequently said that ‘…. People here still believe that it looks funny for mourners to go back hungry after the burial feast. They cook food at funerals despite the cause of death. In cholera outbreaks, the close relatives of the deceased still prepare food at night when they know that none of the health workers are around.…’. Four others said ‘… a cholera patient died last week in Nyakiyumbu Sub County and the people who slept there at night were given food to eat but the next day, one of them was admitted in cholera ward in Bwera hospital and two others in Kayanzi Health.…’
Specific interventions in Kasese District responding to a cholera outbreak
During the quantitative interviews, participants were asked the interventions taking place in their locality that prevent cholera outbreaks. They were summarized in the table below:
This is one of the cholera interventions which came out significant (39.8%) in the study. It was a District Cholera Task Force that was also networking with the community health workers referred to as the Village Health Teams (VHTs). Asked during the qualitative interviews why the approach of the establishment of a cholera task force was undertaken in the district, the informants generally acknowledged that
‘…the purpose is the coordination of cholera control activities in Kasese district to reduce the number of cases and deaths caused by cholera through improved surveillance to obtain better data for risk assessment, improved preparedness to provide a rapid response to outbreaks and limit their spread, improved case management to reduce deaths among patients, accelerated research on the burden of cholera and how best to manage the growing cholera problem, partnerships with the community, media and NGOs, and health education focused on behavioral change…’
Cholera Treatment centers
The establishment of cholera treatment centers in strategic locations of the district was found to be a significant cholera control intervention in Kasese District. It had 25.4% in the quantitative interviews. Asked during the qualitative interviews why the approach of establishing Cholera Treatment Centers in the district was undertaken, Key Informants repeatedly said that
‘….CTCs are vital for isolating and managing severely sick cholera patients, provide efficient treatment and stabilization of cholera patients, help to contain the spread of the disease….’ Two other informants mentioned that ‘…One major feature of CTCs is that the access points are controlled so that whoever enters and leaves is sprayed with chlorine to disinfect them properly and prevent further spread of infection…..’. Two others said ‘…..the closer a CTC is to you the better the chances of your survival if you do become infected with cholera….’
Health education campaigns
Health education campaign was also found significant in the study. This gave it 9.5%. Asked informants how the health messages were disseminated, informants said were media campaigns on local radios and display of Information Education Communication materials. Asked why the approach of health education campaigns was undertaken, all Key Informants acknowledged that
‘…..health education is the key to public awareness and cooperation that an outbreak of cholera can be more quickly controlled when people understand how to help limit its spread….’. Asked what constituted the health education messages, most of the informants acknowledged three elements; ‘….cook your food, boil your water, wash your hands….’ Asked who did the Health education, they said ‘….experienced health educators, community and service organizations are playing a useful role in disseminating health messages in the epidemic control…..’.
Village community meetings
As indicated by 9.1%, cholera control and preventive interventions through village community meeting sessions came out significant as one of the major activities that the District Health Office involved in to prevent cholera in Kasese District. Asked why the meetings were held four informants said ‘…we demand village community health workers have meeting sessions down there about the health situations so that our people can get to learn about cholera and other diarrheal diseases….’
Finally, other interventions which were implemented in the district but did not come up significant as cholera control measures in the district were but not limited to the following: Distribution of water treatment tablets to the residents; usage of IEC materials; celebrating national sanitation days; cholera warning systems and training of community health workers on cholera case management.
Assessment of the uptake of cholera control interventions in Kasese District
The function of cholera Task Force initiatives in the control of cholera
From the quantitative interviews, 54.9% of the participants strongly disagreed with the statement that the district is effectively making use of a District Cholera Task Force in coordinating activities that prevent cholera spread in Kasese District. Asked during the qualitative interviews the nature of the cholera Taskforce initiatives in the prevention and control of cholera spread, all key informants indicated that ‘….there is a lot of laxity among the community health volunteers.
They start talking about cholera issues when cholera patients have either been admitted or died….’. One other key informant said ‘….by the way am reliably informed that cholera task force members are not known in some villages here. Some people have come to my office saying they have never seen them or heard of them….’ Five others said ….The village community health workers in the villages are not trained as first responders to any suspected cholera cases in the community…..’. One other said ‘….in fact some people in the community do not respect village health workers claiming that they are people they normally play with who are not qualified health workers and do not talk new things…..’.
The function of Cholera Treatment Centers’ initiatives in the control of cholera
From the quantitative interviews, 53.2% of the participants strongly disagreed with the statement that the district is efficiently making use of isolation and management of cholera patients in the cholera wards at Health facilities. Asked during the qualitative interviews the quality of Cholera Treatment Centers, key informants generally acknowledged that ‘ ….we identified the fishing villages as better places to establish cholera treatment centers on top of the Health Sub Districts we have here though they at times run short of medical supplies for managing cholera patients…’.
All informants further said ‘…there are inadequate treatment modules of the cholera kit for managing admitted patients including those referred by VHTs at the Cholera Treatment Centers…’ Four informants asserted that ‘….the problem with the Cholera Treatment Centers we have in the District usually experience inadequate infection control activities especially spraying and the tents make the cholera wards uncomfortable since the heat during the day raises room temperature in the wards….. Two others asserted that ‘….I remember two cholera patients who died in Bwera cholera treatment center when the Uganda Red Cross ran short of fluids….’.
Effectiveness of Health Education Campaign initiatives in the control of cholera
From the quantitative interviews, 64.0% of the participants strongly disagreed with the statement that the district is competently taking up the dissemination of health messages to prevent cholera in Kasese District. Also, participants of the qualitative interviews were asked the nature of health education campaigns in the prevention of cholera; they generally acknowledged that ‘… ineffective health education is one of our major weaknesses because we are often hampered by limited PHC funds…’
Two key informants commented ‘….Even our people here do not mind reading the Information Education communication messages that we put on public notice boards that facilitate hygiene promotion during cholera outbreaks. Three others said that ‘……..with the media health talks on Messiah and Guide local radios by the District Health Officer, some of our people here do not usually listen to the health talks instead they tune to other stations to listen to music……..’.
All informants acknowledged that ‘… gone are the days when we have taught these people that it is not good to get fruits and just eat without washing but our people are not minding. We keep on telling them that no cooking of food in funerals including those who die of cholera but they do not listen to that…’…. Another exclaimed ‘……even these people who call themselves educated are still drinking raw water from rivers and lakes without purifying it and we are seeing them getting cholera……’
Other three informants commented that ‘…… you see this cholera awareness and environmental talks on messiah local FM station, most of our people do not like them. They change stations saying we are getting bored of what these health people tell us about cholera issues. Don’t they have other things to talk about….’.
Effectiveness of Village Community Meeting initiatives in the control of cholera
From the quantitative interviews, 52.8% of the participants strongly disagreed with the statement that the district is effectively making use of village community meetings to prevent cholera in Kasese District. Also during the quantitative interviews, Key Informants were asked the nature of village community meetings. The majority of them did acknowledge that ‘…. We do not usually conduct village meetings about cholera since the Village Health Teams are not facilitated.
They were promised bicycles, T-shirts, bags to facilitate them mobilize village meetings but the Health offices’ promise has not been fulfilled….’. One other said ‘…I am not sure if the community health workers have programs of their meetings.. .’. Three other informants assured the researcher that ‘….Kasese District local Government has never considered the Request of VHTs to pay them salaries a reason why they rarely hold village meetings on cholera and other sanitation issues…’.
Two other informants said ‘…it is not easy to mobilize people for health meetings especially the fishing communities who claim are busy in the lake. Even when there is an opportunity to gather them, they will ask for sitting allowances and lunch which VHTs don’t have and this is why cholera is always coming and going….’ All informants said ‘….we don’t normally follow up the volunteers and we may not easily tell if meeting resolutions are put in practice by the people…’
Social- Demographic characteristics of the respondents
The results of this study indicated that females were significantly more affected than males by cholera. The fact that key informants acknowledged two female cholera patients admitted to Kagando hospital shortly after eating unwashed mangoes and drinking locally made banana juice in one of the rural markets, this finding indicated that females mainly attended rural markets and ate food sold in such public places under minimum hand hygiene.
Previous studies about cholera demonstrated that cholera is hypothesized as a disease of deficient personal hygiene mainly hand hygiene practices. Poor hand hygiene practices in Guinea Bissau and Togo when people ate raw poorly washed vegetables and fruits poorly washed hands may have accounted for 67.7% of cholera admissions across some hospitals in the said countries. Poor hand hygiene practices were also responsible for 327 deaths majority of whom being females and 17400 cholera admissions in the countries of Zimbabwe and Sierra Leon (21-24).
Environmental factors contributing to a cholera outbreak
Food vending captured in the quantitative interviews is similar to the sale and consumption of banana juice and mangoes in rural markets mentioned by most of the informants in the qualitative interviews. The fact that the two women ate the mangoes and drank banana juice in one rural market and shortly were admitted in Kagando Hospital Cholera Ward suggested that the food they ate may have been contaminated. As such, houseflies which is a known vector for cholera transmission may have contaminated the drinks they took.
Given that food, especially the locally-made banana juice and mangoes were sold and eaten in rural markets, one may therefore assume that the food was consumed under minimum hand hygiene that had a significant influence and encouraged the spread of cholera in the study area. Previous studies about cholera have concluded that elevated risks have been documented in individuals who had consumed beverages and food from street vendors, commercial distribution of food in restaurants and to food aid distributors, consumption of first foods take-away in which cholera bacterium survives for a long time (23, 25, 12).
Water shortage periods
The finding of water shortage which appeared significant in the quantitative interviews relates to what the informants emphasized that clean water from the taps and wells became irregular in the dry months that forced people to collect water for domestic use from lakes and rivers. The fact that informants repeatedly said that lake water was contaminated with feaces of the fishermen during their fishing activities and used it raw in home settings, meant that cholera germs in human feaces of the fishermen might have exposed the people in the study area to the risk and development of cholera.
Given that alternative, the lake water was contaminated by the feaces of the fishermen and used raw by the fishermen and in-home settings by the people in the fishing villages, one can therefore conclusively assume that feaces of fishermen increased the risk and development of cholera among the fishermen themselves since they used the same water to drink and prepare food, hence, influencing the epidemiological characteristics of cholera spread among the fishing communities in the lake regions and the entire study area.
Previous studies about cholera have demonstrated that water shortage was responsible for cholera outbreaks in Korea and the Philippines. The alternative source of water for domestic use was rivers and lakes which had been contaminated with people who were infected and washed their clothes upon discharging them from the hospitals. These water sources were contaminated by other cholera sufferers when their untreated diarrheal discharge was allowed to get into the waterways or drinking water supplies. Drinking any of the infected water and eating any foods washed in that water (26).
Safe water source
The fact that safe water sources were negatively associated with cholera as was captured in the quantitative interviews, this finding is similar to what most of the informants said who acknowledged that rivers were the main source of water for domestic purposes. The fact that one informant emphasized that rivers were one of the contaminated open water sources in the area, is similar to what the majority of the key informants said that rivers were contaminated by cholera patients who washed their linen upon discharge from hospitals on their way home.
This finding implied that river water was not safe to be used raw in home settings because the dirty clothes of the discharged cholera patients contaminated the rivers with cholera bacterium and exposed cholera to the people in the study area who consumed it raw.
Given that the main water source for domestic purposes were rivers that were used to wash clothes of some people who had had cholera and discharged as they traveled back to their homes, one can therefore conclusively assume that the infected linen increased the risk and development of cholera among people who had used river water while raw.
The relationships of these findings with previous studies on cholera have concluded that cholera outbreaks are endemic in areas where water bodies were contaminated by human feaces. The source of cholera is usually other people with cholera disease when their untreated discharge is allowed to get into water bodies. When people drink such water, they contract cholera.
Demonstrated evidence has indicated that the 1974-1975 Zimbabwe cholera outbreak was linked to polluted water especially lakes, rivers, and wells that were contaminated with human feaces. About 90% of all cholera outbreaks in the whole world are attributed to the consumption of open water that has been contaminated with human feaces. (6, 25).
Consuming food at funerals
The finding of eating food in funerals that significantly appeared in the quantitative interviews sharply agreed with what the informants emphasized who said the food was often prepared and eaten in burial feasts. This finding implied that it was a pattern of behavior of mourners whose cultural belief demanded that they eat food so that they do not return to their homes hungry.
The fact that informants generally referred to one cholera death at Bwera hospital and two cholera deaths at Kayanzi Health center with a history of having eaten food at a burial of a cholera victim in one sub-county meant that probably the food handlers had previously handled the body of the cholera victim to the effect that their hands became contaminated with the cholera bacterium. As the mourners consumed the contaminated food, they became exposed to the risk and development of cholera.
Given that three mourners at a burial feast of a victim of cholera had consumed food that had been prepared in the burial of the said cholera patient, it may be very important for one to conclusively assume that such behavioral pattern of eating food in funerals influenced the spread of cholera in the study area. Previous studies on cholera have concluded that the 1982 cholera outbreak in Bangladesh affected all people who had lost their family members with cholera disease. They were members of the same household living together. Shortly before burial, they ate food from the same eating pot.
The households which were in the neighborhood closely linked to each other also got cholera infections. The shone people of Zimbabwe washed the dead body of a cholera victim in Mutwiri River before burial and all people who washed the body contracted cholera. (25, 6). Specific interventions in Kasese District responding to cholera outbreaks
The Cholera control interventions
The participants were asked the interventions already in place that were addressing cholera and specifically why the interventions were put in place in the prevention of cholera in their localities. The following discussion explains the interpretation of the findings concerning the interventions.
Cholera Task Force
A cholera Task Force came out as one of the important interventions the Health Office put in place to stop the spread of cholera outbreak. The finding that there was a Task Force consisted of some members of the District Health Team and VHTs at lower Village Levels implies that the District Health Team and VHTs were involved in the coordination of all cholera control activities in the district to reduce the cholera morbidity and mortality.
From these findings, it may suffice to conclude that the Taskforce undertook the role of addressing the spread of cholera through a network of improved surveillance to obtain better data for the risk assessment and early detection of the outbreak, improved preparedness to provide a rapid response to outbreaks and limit their spread, improved case management to reduce deaths among cases, research on the burden of cholera and how best to manage the growing problem, partnerships with politicians, service organizations, the media, and the community, and health education focused on behavioral change.
Previous studies on cholera control have concluded that effective control of cholera demands multisectoral collaborations; it cannot be achieved in isolation. Recognizing this, WHO brought together a consortium of partners and established the Global Task Force on cholera control. The Task Force is a coalition of non-governmental organizations, United Nations Agencies, and scientific institutions; its purpose is the coordination of cholera control activities.
A multisector approach to the control of cholera is essential and the factors that contribute to limiting the spread of the disease include access to safe water and proper sanitation, improved food safety, and health education. Dealing with cholera in an open and transparent well-coordinated manner has contributed to demystifying the disease. A well-organized and adequate response by a Health Team in an affected country can limit cholera spread and lower the death rate to less than 1%. (23, 27).
Establishment of cholera Treatment Centers
The establishment of Cholera Treatment Centers (CTCs) captured in the quantitative interviews is similar to what informants mentioned by acknowledging that CTCs were established at all the Hospitals and Kayanzi Health Center by Uganda Red Cross Society. Asked during the qualitative interviews why the approach of establishing CTCs was undertaken, most of the informants mentioned that the purpose was that they played a vital role in isolating and treating cholera patients.
This finding is related to the fact that informants said CTCs were specialized isolation wards for patients designed by the Uganda Red Cross Society and the Health Office to prevent the spread of the disease. The finding might justify the statement which some informants made saying the closer a CTC is to you the better the chances of your survival if you do become infected with cholera.
Given the initiative of establishing Cholera Treatment Centers in strategic locations in the District, one might conclude that CTCs were meant to provide efficient treatment and stabilization of cholera patients to prevent the spread of cholera disease.
Former studies about the control of cholera outbreaks have concluded that Cholera Treatment Centers help to contain cholera if it is well equipped and maintained. A prominent feature of a CTC is that access points are controlled that anyone who enters walks through a basin of chlorinated water to disinfect the feet and to wash hands (33).
Patients displaying severe symptoms are hospitalized in the acute area of the CTC where they should receive treatment involving the use of an IV to administer a saline solution for dehydration. As they recover, they progress to the use of Oral Rehydration Salts that are mixed with water. Contaminated waste is incinerated and or buried in the pit to control the spread of cholera.
Latrines are provided to ensure that any human waste is contained helping to prevent the spread of cholera. A clean water supply is essential as treatment involves rehydrating patients for the fluids they have lost through diarrhea and vomiting. The water supply is chlorinated to ensure that bacterium levels are safe for human consumption.
Health Education Campaigns
This intervention also emerged in the quantitative interviews as one of the major cholera interventions the District Health Office was involved in the control of cholera. The fact that health education took the form of mainly media campaigns and dissemination of Information Education Communication Materials might relate to what informants acknowledged that health education is the key to public awareness on cholera as a disease that can be more quickly controlled and treated with simple measures when people understand how to help limit its spread.
This finding is related to what informants mentioned when they acknowledged that health education was conducted by experienced health educators in the district and the package of the health message which was passed to the public on cholera through local radios of Messiah and Guide, constituted; ‘ cook your food’, ‘ boil your water, and ‘ wash your hands.
Previous studies on the control and prevention of cholera outbreaks have concluded that it is important to mobilize the community to adhere to safe hygienic practices as the key to behavior change and the techniques to use for community mobilization include; social media and peer connections. It is also important to understand the perceptions of the public about the risk for cholera and the potential for its prevention and control. In the community, health workers remain a key component in the prevention initiatives.
A person contracts cholera by ingesting something usually water or food that has been contaminated with fecal matter infected with cholera germs. Cholera can be reliably prevented and controlled only by stopping their contamination cycle and the key elements of interrupting the cycle include dissemination of health messages on safe drinking water, improving sanitation conditions, and ensuring proper hygiene (34)
Village community meetings
The initiation of village community meetings came out significant in the quantitative interviews as one of the activities that helped to control cholera outbreaks. Asked during the qualitative interviews that convened the Village community meetings on cholera, most of the informants acknowledged that they were conducted by the Community Health Workers (volunteers). The fact that the organizers of those meetings were mainly health volunteers, meant that the community health workers were able and willing to offer themselves help by choice and without being forced.
Former studies about cholera have considered that understanding what motivates people to make healthy choices in the context of cholera prevention and control by health volunteers is important often because health gain is not only the motivation factor to offer ones’ self for service but also convenience for practicing a specific behavior, fear of the imminent death of people in your area or fear of cholera disease, might be the driving forces behind voluntarism in cholera outbreaks (36, 15).
The uptake of cholera Task Force initiatives in the control of cholera epidemic
The fact that majority of the participants of the quantitative interviews strongly disagreed with the statement that the district is effectively making use of a District Cholera Task Force in coordinating activities that prevented cholera in Kasese District, most of the informants also supported by acknowledging that laxity was a common characteristic of most of the VHTs and the message taught was not complete. This finding might be a reason why it was acknowledged that the VHTs waited to hear any cholera patient and then taking an action thereafter.
The fact that community members viewed VHTs as qualified community health workers may be similar to what was mentioned in that some VHTs had not been trained as first responders to any suspected cholera cases in the community. Even though most VHTs had laxity to conduct health promotion about cholera and were not trained as first responders to any suspected cholera cases in the villages, one might conclusively assert that VHTs were not pro-active, case management initiatives were not improved, preparedness to provide rapid response was not improved, surveillance was not improved which led to the slow uptake of the intervention and the intervention did not work well which greatly influenced the development of cholera spread in the study area.
Further still, one can conclude that the coordination of cholera control activities was not well done and was ineffectively put to use by the District Health Office that could have contributed to their slow uptake which greatly influenced the spread of cholera in the District.
Former studies about cholera outbreaks have concluded that the laxity of the Zimbabwe Government resulted in the late declaration of the December 2008 cholera outbreak led to the further spread of cholera. All the health institutions and members of the community were unprepared since they thought cholera only affects people in Harare. Although procedures were in place even in the form of legislation to invoke necessary sections of the act to contain the disease, these were not followed and the outbreak intensified.
Cholera committees in the villages of ward 28 were not trained on cholera and did not help much to prevent cholera. Inadequate health staffing increases cholera spread when the only available trained personnel is transferred to areas where cholera is endemic living in endemic areas catching cholera. (37-38).
The uptake of Cholera Treatment Centers’ initiatives in the control of cholera
The fact that majority of the participants of the quantitative interviews strongly disagreed with the statement that the district is efficiently making use of isolation and management of cholera patients in cholera wards in Health facilities in the prevention of cholera in Kasese District, two informants generally said that tents heated up during the day that made the cholera patients uncomfortable.
This finding meant that cholera patients might have requested early discharge before they are completely cured and missed health education messages concerning cholera disease. Once this happens, the family members of the patients who had been discharged early can be at risk of acquiring the cholera disease. The fact that the majority of the informants said CTCs experienced inadequate infection control activities especially spraying meant that the attendants and health workers might have been exposed to the risk of cholera infection.
Further still, the majority of the informants said the CTCs experienced inadequate treatment modules of the cholera kit to manage cholera admissions which might have increased the death rate of cholera patients admitted in the CTCs. This finding might also be a reason why informants said two cholera patients died at Bwera Hospital Cholera Treatment center when Uganda Red Cross Society ran short of intravenous fluids and could have led to the spread of cholera since infection controls of disinfecting were inadequate.
More still, since the Uganda Red Cross Society was requested to put in its support at a time when the cholera problem was already intensified meant that the District Health Office could not contain cholera spread without external support and this might have led to the persistent occurrence of cholera outbreak in the study area. The finding further indicated that the district does not have an effective notification system between the community health workers and the District Health Office that might have exposed people in the community to the risk and development of cholera disease.
It might therefore be important to conclude that given admission of cholera patients in built-up CTCs that experienced inadequate infection control activities especially spraying and inadequate treatment modules of the cholera kit to manage admissions, meant that CTC initiatives were not well done and inefficiently put to use by the District Health Office which might have contributed to the slow uptake in the isolation, treatment of cholera patients in the Cholera Treatment Centers that influenced the spread of cholera in Kasese District.
Former studies about the cholera outbreak and assessing the outbreak response and improving preparedness (38) have concluded that although all hospitals were declared Cholera Treatment Centers in Kivu province in the Democratic Republic of Congo, this intervention was not successful in a curative sense since treatment of cholera patients was not applied appropriately when they did not administer ORS in time and rarely cleaned the cholera wards that did not contribute to the prevention of cholera disease.
The uptake of Health Education Campaign initiatives in the control of cholera
The fact that most of the participants of the quantitative interviews strongly disagreed with the statement that the district is competently taking up the dissemination of health messages to prevent cholera spread in Kasese District, also most of the informants supported this finding who acknowledged that it was one of their major weaknesses.
Although some health education campaigns were done, the finding that they were weak in this intervention appears similar to the fact that most people did not mind since they rarely read health messages pinned on public notice boards, changed radio stations in favor of music when the District Health Educator presented the health message about cholera was a clear indication that the people ignorantly interacted with the vehicles that transmitted cholera.
Since informants also said the District received little Primary Health Care funds might imply that media campaigns were not effective and I.E.C materials were not adequate due to financial constraints in the District Health Office. Even though informants said some educated people still did not mind preserving their drinking water and ate anyhow under minimum hygiene meant that such patterns of behavior exposed the people to the risk of cholera.
Given that there were inadequate PHC funds in the District Health Office and limited listenership to media campaigns, made public awareness in the dissemination of health messages incompetently taken up and difficult to be performed by the District Health Office that might have been responsible for the slow uptake of the Health education campaigns in the prevention of cholera in Kasese District.
Previous studies about cholera have indicated that most governments of low developing countries delay declaring cholera outbreaks in their countries because their health workers are always willing to mobilize and plan cholera control initiatives but they find it difficult as their countries have inadequate financial resources (24).
The uptake of Village Community Meeting initiatives in the control of cholera
The fact that most of the participants of the quantitative interviews strongly disagreed with the statement that the district is effectively making use of village community meetings to prevent cholera in Kasese District, this finding is also supported by the majority of the informants who said village community meetings were rarely conducted in the villages.
The fact that the community health workers who were to hold those health meetings were not given salary, T-shirts, bicycles made them lose morale in the initiation of routine village community meetings about cholera control. The fact that it was not easy to mobilize fishing communities meant that the health messages about cholera were incomplete among the fishermen and their uptake for health meetings was very slow. This finding of the fishermen in the fishing villages may relate to the fact that people demanded lunch and meeting allowances which were not available.
The finding might also indicate that the people preferred lunch allowance to disseminate cholera control messages. Since the activities of the community health workers were not usually followed up by their supervisors and the attendance of the meetings was low meant that very few people in the study put into practice the health messages and resolutions that were passed in the meetings.
Given that the village community meetings about cholera were rarely organized, scarcely attended by the people, and the community health workers poorly motivated, one can conclude that the District Health Office did not effectively put to use the village community meetings and contributed to their slow uptake in the district which might have influenced the spread of cholera in Kasese District.
Other studies previously conducted by UNICEF, (37), about water, sanitation, and hygiene concluded that there were no village gatherings in ward 28 of Chipinge district in Zimbabwe about cholera awareness messages. They were held only when CARE staff took along with the food and handouts. Some villagers could build latrines in their own homes but be reluctant to do so because they were waiting for free cement from CARE staff. As a result, most of the deaths due to cholera occurred in Chipinge district at a time when CARE stopped serving the community members with food during village gatherings.
Concussions and Recommendations
From the findings and discussion, the following conclusions can be made;
- Environmental factors were significantly associated with cholera spread and outbreaks in Kasese district notably; eating contaminated food in funerals, consumption of contaminated banana juice and mangos sold in rural markets; domestic usage of raw river water contaminated by the linen of cholera patients discharged from CTCs; and domestic usage of raw lake water contaminated by feces of fishermen during periods of safe water shortages.
- The interventions including Cholera Task Force; Cholera Treatment Centers; Health education campaign on cholera; and Village Community meetings about cholera are in place that responds to cholera outbreaks were validated but are ineffective and inefficient.
3 There are still gaps in the uptake of cholera control interventions in Kasese District manifested by the laxity of a District Cholera Task Force toward response, surveillance, and case management; inadequate disinfection and cholera treatment kit in the Cholera Treatment Centers; low PHC funds and low listenership to media campaigns for health education about cholera; finally, rare and poorly attended village community meetings on cholera that influenced the spread and development of cholera outbreaks in Kasese District.
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