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Nigeria experiences its worst cholera outbreak in a decade.

It was the middle of the night when Aisha Mohammed noticed her two-year-old son, Umar, had started vomiting. Then he started “passing watery stool, like urine”. She recognised the symptoms from hearing people talk about a cholera outbreak on the radio, and from seeing local health promoters, who visited her neighbourhood, speak about it. “I don’t know how he got it,” she said.

Mohammed took Umar to the chemist, where they gave him an injection, then to the hospital, where he got more medication – but he seemed no better when he got home. Eventually, she was advised to bring him to a Médecins Sans Frontières (MSF) treatment facility in Maiduguri, northeast Nigeria.

It’s possible her son would have died if she hadn’t done so. When we spoke, some days later, the boy lay on a bed, intermittently reaching for her. “There’s improvement, his stool has changed now, it’s thick,” she said. She was getting ready to take him home.

In 2021, Nigeria experienced its worst cholera outbreak in a decade. As of mid-December, a total of 107,911 suspected cases, including 3,598 deaths, had been reported by the Nigeria Centre for Disease Control in 2021 – more than the 3,027 Covid-19 deaths confirmed since the beginning of the pandemic. Last July, the government was registering more than 7,500 new cholera cases per week.

Treatment for cholera – which involves rehydration and sometimes antibiotics – is relatively simple. A full recovery can take place within two to four days, but deaths occur when cholera victims cannot access treatment quickly. The disease gets particularly bad in the rainy season and in areas with poor sanitation.

Four Nigerian states – Bauchi, Jigawa, Kano and Zamfara – accounted for 54 per cent of all cases. Borno State, where Mohammed lives, reported more than 5,200 cases.

A cholera treatment centre in Maiduguri, northeast Nigeria. Photograph: Sally Hayden

A cholera treatment centre in Maiduguri, northeast Nigeria. Photograph: Sally Hayden

Exposure

Staff guided me around the MSF treatment centre in Maiduguri, the capital of Borno State, which is made up of tents and was set up last August. Patients brought in are assessed before being put on drips if needed. One tent is reserved for the critically ill. Medics explained that cholera can come on just four hours after exposure, and that, as well as diarrhoea, those infected can start vomiting water “like boiled porridge”.

Government-associated initiatives, such as airing educational jingles on the radio in both English and local languages, have aimed to educate Nigerians to spot the symptoms.

Challenges listed by the Nigeria Centre for Disease Control included difficulties accessing some communities due to security concerns; open defecation in certain affected neighbourhoods; a lack of adequate drinking water in some rural areas and city slums; inadequate health facility infrastructure; not enough vaccines to cover the affected areas; and a lack of trained personnel to help with case management.

“Cholera is not only in Nigeria, cholera is a disease that can happen everywhere across the world,” said Richard Mathela, an MSF medical co-ordinator. According to the World Health Organisation, there are between 1.3 and 4 million cases of cholera each year worldwide, and anywhere from 21,000 to 143,000 deaths.

While it is endemic in certain areas of Nigeria, other factors such as population movements or heavy rains can spread the disease, causing it to become an epidemic.

“[Last] year we also had a lot of population displacement because of crises, insecurities, people moving,” said Mathela. He said there were outbreaks across the country, including in camps for displaced people, boarding schools, villages and cities.

Vaccination campaign

For two years before the 2021 outbreak, he said there was no nationwide cholera vaccination campaign, which exacerbated the problem. “[In 2021], because of the huge cases of cholera some states did mass vaccinations, so [this] year we don’t expect to have cholera as an epidemic.”

While Nigeria’s official figures show Covid-19 killing fewer people than cholera, Mathela said death tolls in both cases were very likely being under-reported. “Less people were affected by cholera but there was high mortality; a huge number were affected by Covid-19 but the mortality rate was less.”

On top of that, he said, there were other diseases causing large numbers of deaths that were being overlooked because of international attention on the coronavirus pandemic: particularly malaria, which is also exacerbated by rain.

“Malaria is killing a lot as well. Some are underreported, dying in the communities, dying in the villages. It’s affecting pregnant women, under-fives. Malaria is always there and killing,” said Mathela.

In 2020, the World Health Organisation estimated there were 241 million cases of malaria worldwide and 627,000 deaths – 32 per cent of them, or roughly 200,000 – in Nigeria.

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