CHOLERA AS A PUBLIC HEALTH PROBLEM; INVESTIGATING THE ROLE OF THE HEALTH CARE SYSTEM IN PREVENTION OF CHOLERA PANDEMIC IN LAGOS STATE

CHAPTER ONE

INTRODUCTION

1.1 Background of the study

The term "public health sectors" refers to all organizations, whether public, private, and voluntary, that have a role in providing necessary public health services within a certain area. This notion guarantees that the contributions of all entities to the health and well-being of the community or state are acknowledged when evaluating the provision of public health services (Gareth, 2019). Public health focuses on the promotion and safeguarding of the well-being of entire populations. Public health interventions are implemented at several levels, including international, national, state, and local. Health departments in most towns provide services that involve the gathering and utilisation of epidemiological data to monitor and track diseases in the population. Health promotion and protection of population health are carried out globally by the World Health Organisation (WHO) and at the national level by public health agencies such as the Centres for Disease Control and Prevention, the Food and Drug Administration, the Environmental Protection Agency, and the Consumer Protection Agency (Ceasar, 2019).

The main objectives of public health are prevention and health promotion. Prevention refers to the proactive measures made to avert the happening of an event or to mitigate its consequences in the aftermath. The three levels of prevention are defined as follows: primary prevention, which focuses on reducing risk through measures like immunisation; secondary prevention, which involves early detection and treatment of diseases through screenings such as mammograms; and tertiary prevention, which aims to modify risk factors of diseases through treatments like cardiac rehabilitation (Idris, 2023). This study aims to examine the role of the healthcare system in preventing a cholera pandemic in Lagos state. 

Cholera is a gastrointestinal illness resulting from the invasion of the intestines by the bacteria Vibrio cholerae type 01 or 0139. It affects both children and adults, with variations in the kind and intensity of symptoms observed among people who are affected. Approximately 20% of individuals exhibited acute watery diarrhoea, while an additional 10-20% experienced severe watery diarrhoea accompanied by vomiting. If active case management is not implemented, the quick loss of a significant amount of fluids and salt might lead to severe dehydration (Kent, 2019). 

Vibrio cholerae is commonly spread by the fecal-oral route, which occurs when infected water and food are ingested. Some locations continue to face a continuous threat of cholera, with occasional outbreaks occurring worldwide, especially in regions where there are difficulties regarding water supply, sanitation, food safety, and hygiene (Kent, 2019). Nevertheless, in underdeveloped regions, cholera serves as a crucial measure of insufficient social progress and continues to be a significant issue in public health (Kent, 2019).

The 2010 cholera pandemic in Nigeria is considered to be one of the most severe cholera outbreaks in Nigeria in the past two decades. According to Ajayi et al (2014) and Julius (2018), an outbreak in Nigeria in October 2010 impacted more than 40,000 individuals, leading to at least 1,500 deaths and a case fatality rate (CFR) of at least 3.75%. The country's north-eastern area saw the greatest impact. According to the Nigerian Red Cross, more than 80% of the individuals impacted were women and children. The World Health Organisation (WHO) ascribed the abnormally elevated cholera prevalence to the confluence of seasonal elements, substandard hygiene conditions, and population migrations in the region, which are recurrently plagued by minor outbreaks (Urube, 2020). 

The Nigerian Institute of Medical Research Emergency Response Team (NIMRERT) from Yaba, Nigeria, visited the states of Bauchi, Borno, and Gombe in response to the outbreak. Their purpose was to assist the states in managing the outbreak by supplying relief goods. The team conducted an evaluation of public health strategies for the outbreak and offered research support for the laboratory evaluation, isolation, and typing of the circulating strains of V. cholerae in this location (Urube, 2020). It is important to emphasise that in a regulated cholera outbreak, the Case Fatality Rate (CFR) should not surpass 1% (Green, 2018). Hence, a CFR over 1%, as observed in the majority of African nations, indicates a deficiency in effectively managing cases, inadequate access to clean water and sanitation, and a lack of readiness and response to control the outbreak. 

The initial documented instances of cholera in Nigeria were documented in 1971 at a town situated close to the former capital city, Lagos. A widespread outbreak occurred, leading to 22,931 documented cases and 2,945 fatalities (WHO, 2013: Oguns, 2017). Oguns (2017) cited a 2011 estimate from the World Health Organisation (WHO) that stated there were around 59,478 recorded cases and 7,645 deaths in 1991. Lagos State is located in the southern region of Nigeria. Among the 36 states, this particular state boasts the second greatest population and the most compact land area. Lagos demonstrates significant urban disparities and marginalisation, characterised by a prevalent practice of open defecation and a lack of societal recognition for toilets (Akin, 2022). There is a widespread practice of disposing sewage without discrimination, and there is a lack of understanding about the danger posed by cholera. The Lagos State Government officially announced a cholera outbreak on 09 June 2024. According to the Emergency Operations Centre (EOC) report on June 12, 2024, there have been 324 suspected cases of cholera throughout the state. Out of these cases, 15 individuals have died and 40 have been discharged. Three alleged instances of cholera have been separately documented in the neighbouring states of Oyo and Ogun.

The current approach of addressing cholera epidemics in Lagos is predominantly reactive, characterized by an impromptu emergency response. While this technique may reduce the number of deaths caused by cholera, it is not effective in preventing the occurrence of cholera cases. This is because effectively controlling a cholera epidemic necessitates the immediate medical treatment of individuals affected by the disease. Hence, an effective monitoring system necessitates a well-coordinated implementation of preventative, preparedness, and response measures. It is crucial to prevent future incidents and manage outbreaks effectively (Kent, 2019). Therefore, the necessity for doing this investigation arises. 

1.2 Statement of the Problem

Cholera outbreaks are strongly linked to poverty and inadequate socioeconomic progress. Recent occurrences in developing nations have demonstrated that natural calamities, such as severe flooding and earthquakes, have resulted in the most severe instances in recent history (Park et al, 2021). These problems resemble the insufficient availability of drinkable and safe water and the unsatisfactory sanitary conditions observed in Lagos state. Hence, it is imperative for the Lagos administration to take the lead in implementing and sustaining measures to contain the epidemic. The government should take a leading role in ensuring the provision of safe water, implementing extensive health promotion efforts (especially in rural regions), and ensuring the availability of necessary medical equipment and supplies for public health professionals. 

The utilisation of personal protective equipment (PPE) and infection control measures has been recorded in the handling of cholera outbreaks in Lagos, Nigeria (Michael, 2022). A study indicates that implementing basic water supply and hand hygiene measures, such as point-of-use chlorination, using safe water containers, and practicing hand washing with soap, could effectively decrease the likelihood of transmission in both community settings and healthcare facilities. Nevertheless, even with the utilisation of personal protective equipment (PPE), instances of cholera infection among healthcare personnel participating in the treatment of cholera outbreaks remain common. This may be attributed to instances of breakthrough infection occurring when healthcare professionals were overwhelmed and failed to utilise personal protective equipment (PPE), or owing to the unavailability or failure to utilise PPE. In Hong Kong, there was a similar incident where the transmission of severe acute respiratory syndrome (SARS) occurred among hospital personnel despite the implementation of infection control measures during the SARS outbreak in 2003 (Drake et al., 2017).

Effective cholera epidemic control in Lagos state relies heavily on comprehensive emergency response training. However, a significant proportion of healthcare staff responsible for case management lack adequate or any training. This claim is substantiated by an Asian study that evaluated the level of readiness of primary health centres in the aftermath of the earthquake in Padang Pariaman, West Sumatra, Indonesia, in 2009 (Adeolu, 2024). In addition, they observed that the insufficient availability of necessary resources and inadequately qualified medical staff were contributing factors to an ineffective emergency response. The 2008 cholera outbreak in Kenya was attributed to a shortage of medical personnel and a lack of medical resources, which were identified as the primary causes of the high death rate during the outbreak (Chuks, 2023). In light of this context, this study aims to examine the role of the healthcare s in preventing a cholera pandemic in Lagos state. 

1.3 Objectives of the study 

The primary objective of this study is to critically investigate the role of the health care system in prevention of cholera pandemic in Lagos state. Specific objectives of this study are to:

To ascertain the prevalence level of cholera in Lagos state

To identify the role of the health care system in the prevention of cholera in Lagos state.

To identify the challenges faced by health care system in cholera prevention.

To proffer strategies to address the challenges faced by health care system in preventing cholera.

1.4 Research Questions

The following research questions which are in line with the objectives of this study will be answered in this study:

What is the level of prevalence of cholera in Lagos state?

What is the role of the health care system in the prevention of cholera in Lagos state?

What are the challenges faced by the health care system in cholera prevention?

What strategies should be adopted to address the challenges faced by health care system in cholera prevention?

1.5 Research Hypothesis

Ho: The healthcare system do not play a significant role in preventing of cholera in Lagos state.

Ha: The healthcare system plays a significant role in preventing of cholera in Lagos state.

1.6 Significance of the study

The investigation of the health care system's role in preventing cholera pandemic in Lagos State is of utmost significance. This initiative tackles a crucial health problem that significantly impacts the overall health and welfare of the community, especially in marginalized populations. The project intends to support policy development, improve healthcare practices, boost community awareness, and eventually reduce the incidence of cholera by offering useful insights into the efficiency of the healthcare system in avoiding cholera. Additionally, it will function as a reference point for students and scholars.

This project will have a positive impact on communities by increasing awareness about cholera prevention, hence encouraging healthier behaviors and practices. Additionally, it will emphasize the significance of health education and its function in averting cholera, resulting in enhanced community involvement and participation.

Moreover, the study will provide valuable information to policy makers, offering them insights that might enhance regulatory frameworks and improve the execution of health programs. The study will have great importance for health practitioners as it will uncover deficiencies and obstacles in the current healthcare system's strategy for preventing cholera and facilitate specific enhancements.

Additionally, this study will function as a valuable resource for students and academics seeking to pursue further studies and future research.

1.7 Scope of the study

Broadly, this study focuses to critically investigate the role of the health care system in prevention of cholera pandemic in Nigeria. Specifically, this study focuses on ascertaining ascertain the prevalence level of cholera in Nigeria and identifying the role of the health care system in the prevention of cholera in Nigeria.

 Further, this study will focus on identifying the challenges faced by health care system in cholera prevention and it also seeks to develop strategies to address the challenges faced by health care system in cholera prevention.

This study will be carried out in Ikeja, Lagos state.

1.7 Limitations of the study

As is typical in all human endeavours, the researchers faced minor limitations during the study. One significant drawback of the study is the researcher's financial constraint, as they are a full-time student with no source of money to support themselves.

Another constraint was the scarcity of comprehensive literature on the topic, since there is a limited amount of data accessible on cholera as a public health problem; investigating the role of the health care system in prevention of cholera pandemic in Lagos state. As a result, a substantial investment of time and effort was required to find the suitable resources, books, or material, and to collect data. Furthermore, this study is limited by its diminutive sample size and restricted geographical range, as it solely concentrates on Lagos state. Hence, the findings of this study cannot be extrapolated, thereby allowing for more investigation.

1.9 Definition of terms

Cholera: Cholera is an infectious disease that causes severe watery diarrhea, which can lead to dehydration and even death if untreated. It is caused by eating food or drinking water contaminated with a bacterium called Vibrio cholerae.

Diarrhoea: This is a condition in which feces are discharged from the bowels frequently and in a liquid form. a range of symptoms including diarrhea and vomiting.

Communicable disease: Communicable diseases are illnesses caused by viruses or bacteria that people spread to one another through contact with contaminated surfaces, bodily fluids, blood products, insect bites, or through the air. There are many examples of communicable diseases.