Cholera Outbreak: Alarm! Cooperation! Success!

Cholera recently erupted at one of the refugee camps in which Action Against Hunger works.

Nearly everyone knows that cholera can kill. It's a bacterial infection of the small intestine that causes massive, watery diarrhea, usually accompanied by vomiting. Untreated, the disease kills by dehydrating its victims. The Vibrio cholerae bacterium is contracted through contaminated food and water, and large outbreaks are usually the result of contaminated water supplies.

Symptoms of cholera can appear within a day of infection. Surprisingly, most people who ingest the bacterium don't become ill, though their intestines can host the bacteria for as long as two weeks. More than 90% of patients who get sick have mild or moderate symptoms. The disease, however, wallops the rest, usually young children. And if communities lack treatment and sanitation facilities or are uninformed about the correct medical response, an attack of cholera can be devastating. Death rates have been known to hit 50%.

The Cholera Outbreak

This past October in Uganda, doctors at a camp for internally displaced personsdiagnosed eight cases of cholera in a single day and dozens more over the next two days. They immediately sounded an alert. The camp is in Pabbo, 45 minutes from the town of Gulu (during the dry season, that is-during the rainy season, the drive can take more than an hour). Pabbo is the largest of 16 camps in Northern Uganda, where Action Against Hunger serves nearly 60,000 beneficiaries who live in tightly clustered mud huts sharing water and sanitation facilities.

One medical center at Pabbo is overseen by Doctors Without Borders, another by local authorities. ACF maintains a Supplementary Feeding Center at the camp, and we're also in charge of the water and sanitation facilities. The physicians who recognized the cholera infections were from Doctors Without Borders.

A Coordinated Humanitarian Response

Response to the alert was immediate. Doctors Without Borders set up an isolated ward for Pabbo's cholera patients. Everything carried in and out of the ward was disinfected with chlorine (a mild 5% solution of bleach is effective). Patients' clothes were burned, and patients themselves were scrubbed with disinfectant and medicated with a solution containing rehydration salts that replace water and electrolytes lost through diarrhea. Cholera can also be treated with antibiotics, most often tetracycline, but medicine is seldom necessary if rehydration begins soon enough.

At the same time, Doctors Without Borders and ACF met with local authorities in Gulu to assemble a crisis management team. ACF's assignment was to clean up Pabbo's water supplies and educate the camp's residents. Our water/sanitation team at Pabbo is financed by a grant from the European Community Humanitarian Office (ECHO), but the terms of the grant don't cover an emergency response to a cholera outbreak. So ACF asked ECHO for permission to cooperate. In fact, however, we assumed that ECHO would want ACF to take action immediately, so our team began work before permission arrived. Our assumption was correct. "There's a huge amount of respect both ways," explains Desk Officer Roger Persichino at ACF-USA headquarters in New York.

Everyone needs a bare minimum of 20 to 30 liters of water a day for drinking and sanitation. Because cholera patients lose so much fluid and also need water for rigorous disinfecting, they require at least 50 to 60 liters a day. ACF's water and sanitation team began supplying chlorinated water (less appetizing than Evian but no worse than swallowing water in a swimming pool), and the team chlorinated everything food-related. Camp residents who brought jerricans to fill at water pumps, for example, had their containers scrubbed and their water supplies treated with chlorine pills.

We also began instructing camp residents. We explained the nature and source of cholera; symptoms to watch for; and how to stay healthy. We taught them sanitary regimens: boil water; cook food thoroughly; eat it while it's hot; keep cooked food separate from raw food; avoid eating raw fruits and vegetables unless they're peeled or cooked; and wash your hands carefully after using latrines and before any contact with food and water.

Field-level Coordination for Effective Assistance

ACF's teamwork with Doctors Without Borders has many precedents. Both organizations have collaborated in other countries including Afghanistan, Burundi and D.R. Congo. In fact, relief organizations commonly cooperate. After Hurricane Mitch devastated Nicaragua, for example, ACF worked with the Adventist Development and Relief Agency, CARE, Plan International and Save the Children to feed displaced victims and rehabilitate their communities.

Moreover, if Doctors Without Borders and ACF hadn't already been on site, bringing relief could have required as long as three months to gear up. But because the two were already present and cooperating, says Persichino: "We never went to crisis stage. The response was very swift and very effective." By the end of November, fewer than a dozen patients with cholera remained under treatment in the camp. The outbreak never reached epidemic proportions (defined as affecting at least 1% of the population), and no camp resident died from the disease.

The cholera outbreak in Pabbo was a textbook illustration of the most effective way to handle health emergencies in the field.