Health facility preparedness for cholera outbreak response in four cholera-prone districts in Cameroon: a cross sectional study

Cholera remains a major public health problem in Cameroon with several episodes of outbreak registered since 1971 [1, 2]. According to the national surveillance data (unpublished sources), the most recent cholera outbreaks occurred in 2014, 2015 and 2018. Between 2000 and 2012, a total of 43474 cases of cholera were reported in Cameroon with 1748 deaths giving a case fatality rate of approximately 4.0% [3]. Based on literature, the most affected rural districts were in the Lake Chad basin in the Far North region while the most affected urban districts were in Douala, Littoral region [3‐6].

The risk of cholera outbreak in Cameroon remains high. This is due to the massive population exchange with, and persistent cholera outbreaks in the neighboring countries like Nigeria, Central Africa Republic, and Chad coupled with limited access to water, sanitation, and hygiene (WaSH) in the country [4, 7, 8]. According to the results of Multiple Indicators Cluster Survey 5(MICS5) conducted in 2014, 65.1% of the population did not have access to improved unshared latrines in Cameroon [9]. To the best of our search, no data exist in Cameroon on the situation of WaSH at Health facility.

An effective cholera control incorporates three major phases related to preparedness, response, and recovering (post-epidemic) phases [10]. Although each of these phases is equally very important, the level of preparedness is the backbone of cholera control since the success of cholera outbreak response depends largely on it. Based on existing evidence, the highest cholera case fatality in Cameroon is always registered at the beginning of each outbreak [3]. This is probably uncovering weaknesses of preparedness. Preparedness is a multi-sectoral, multi-disciplinary, and is implemented at all levels of the health system (community and health facilities) [10]. Also, preparatory interventions are principally focused on reinforcing surveillance, training, prepositioning of supplies for case management, and improving WaSH [10]. According to the Cameroon national cholera contingency plan, main strategies for cholera outbreak response include: surveillance, case management, training, communication for development, improving access to WaSH, vaccination, coordination, operational research, resource mobilization and monitoring. However, the monitoring and evaluation of these interventions are not done and information on the preparedness is usually lacking.

During cholera epidemics, patients are rushed to the health facilities for treatment. The surveillance system in place must be able to detect the outbreak on time and the health facility on its part must have sufficient resources to manage cases to quickly stop the spread of the disease and reduce the death rate. On the other hand, if the hygiene and sanitation conditions in the health facilities are not good, it can lead to the spreading of the disease to other patients and health staffs [11, 12]. As a consequence, this may increase the attack and death rates of the outbreak. A study in the Far North region of Cameroon revealed that a good number of deaths from cholera occurred in the healthcare facilities [13]. The objective of this study was to evaluate the level of preparedness of health facilities to cope with any sudden cholera outbreak in four cholera hotspot districts in Cameroon. It aims to call the attention of health authorities on important elements that may be consider to reduce the death rate of cholera during outbreaks.

A total of 134 health facilities were assessed among which 26 (19.4%) in the Far North region (Kousseri and Mada health districts) and 108 (80.6%) in Littoral region (Deido and Nylon health districts). Private health facilities predominated in Douala contrarily to the Far North where public health facilities predominated. In all, most of the facilities (89/134) were health centers and integrated health centers. Also, half of the total facilities are opened 24 h per day every day in the Far North whereas more than 4/5 of the facilities are opened 24 h per day every day in Douala.

This article describes the readiness of health facilities to respond to a sudden cholera outbreak in cholera-prone districts in Cameroon. The results reveal a number of weaknesses in the health facilities regarding cholera surveillance, case management, and access to WaSH. These weaknesses can greatly hinder the capacity of these health facilities to respond correctly and promptly to an outbreak of cholera.

For an effective cholera outbreak response, the surveillance system in place must first of all detect the outbreak on time [15‐17]. Though close to 75% of the health facilities had personnel trained on cholera surveillance in the last 12 months, most of them were working in urban health facilities in Douala. Interestingly, only 33% facilities had trained personnel in Kousseri Health district which is one of the most affected districts during recent epidemics [2, 19]. Also, some essential surveillance materials like case definition, reporting forms, investigation forms, and stool bottles were still lacking in the majority of the facilities. These results are in agreement with the results of previous studies which unveiled challenges and weaknesses of surveillance in Cameroon and Bangladesh [20‐22]. The consequences of this can be a delay in the detection and hence response. Any delay in the detection of a cholera outbreak can delay the outbreak response and complicate the outbreak due to the contamination of many water sources hence multiplication of sources of transmission, and prolonging the response duration [23‐25]. All health facilities in these districts must be supplied with basic materials and trained on surveillance to ensure that outbreaks are detected on time.

Case management is very important in ensuring the reduction of case fatality during cholera outbreaks. The results show that many health facilities lacked basic lifesaving supplies like the ORS and case management guide. Also less than 20% of these facilities had personnel trained on cholera case management in the last 12 months. This is a very serious situation especially in the Far North region where more than 70% of the health facilities did not have ORS since this region is always affected by most (if not all) cholera outbreaks and other enteric diseases in Cameroon [4, 6, 21]. The lack of ORS can lead to alarming death rate during an outbreak [26‐28]. According to the WHO, the correct use of ORS alone can maintain the case-fatality during an outbreak to less than 1% [23, 28]. This can be a possible explanation to the high deaths rate observed in these districts during previous cholera outbreaks [24]. However, most facilities (91%) had ringer lactate solution which is used in the management of moderate to severe cases of cholera and this can be critically useful in reducing the case fatality rate during outbreak. All health facilities in the four districts should be provided with essential supplies especially ORS and management guide to ensure proper management of cases in case of any outbreak so as to minimize case fatality.

Access to potable water is essential to ensure good hygiene and sanitation and to limit nosocomial infection. This is underlined in the United Nations’ Sustainable Development Goal 6(SDG6). Based on the results, access to water in these health facilities still required a lot of improvements. Though more than 95% of the health facilities were supplied with improved sources of drinking water, 7(5.1%) of the health facilities either relied on unimproved sources as their main sources of drinking water or did not have any source at all. Also, only 19.4% had improved secondary sources different from the main source. Urban and private health facilities were significantly more likely to have an improved water source. Besides, all health facilities reported frequent interruption of their water sources with some having and average duration of about 3 days/per week with no water. Low access to water at health facilities has be documented in other studies [12, 25]. During cholera outbreaks, all patients are polled to the health facilities and those facilities without improved sources of water can easily turn to ‘transmission milieus’ due to lack of water to ensure proper hygiene and sanitation [29, 30]. This can be very serious especially because patients are generally considered weak and vulnerable to infection [17]. This can increase the attack and death rates among in-patients, out-patients and even among health staffs to an extent. All health facilities should be provided with at least one source of water to ensure that the hygiene and sanitation conditions are up to standard so as to reduce the rate of infection and improve patient’s management and hence outcomes.

Access to water, sanitation and hygiene is a key component of the Sustainable Development Goal (SDG6) and this should be achieved both at community and health facilities levels so as to ensure an extended impact and sustainability. The results reveal a serious problem regarding hygiene and sanitation in these health facilities. In fact, more than 95% health facilities did not have the protocol for hand washing. Approximately 3% did not even have a toilet. To further worsen the situation, close to 56% did not have any budget allocated for hygiene of the facilities and 45% did not have soap for hand washing. Poor hygiene and sanitation in hospitals have been documents in a number of studies [31, 32]. Hand washing with soap is a very important component of body hygiene. Simple hand washing with soap has been proven to be effective in reducing infections [33‐36]. The protocol for hand washing and soap are very essential to ensure that staffs wash their hands correctly before medical interventions and can therefore contribute to reduce nosocomial infections. In the same line, the lack of toilet, septic tank, etc. coupled with no budget allocated for hygiene and sanitation can lead to compromised hygiene and waste management which turn to favor the transmission of diseases in the hospital milieu [37‐39].

This study did not collect data on all aspect of health facility preparedness like rate of supervision and community sensitization and the causes of the weaknesses observed were not investigated. Concerning supplies, we did not collect data on the quantity present which could be useful in estimating the capacities of health facilities that had these supplies in management the first cases of cholera during outbreak. Also, we did not collect data on the type of toilet, water quality, or investigate if facilities without a water source has source situated within 0.5KM from it. Furthermore, statistical test power was low due to low sample size. However, the results are largely informative and usable to identify priority interventions to improve cholera control in the study area.

The health facilities in these four districts have weaknesses in their capacity to cope with a cholera epidemic. These are grouped under the capacity in surveillance of cholera and case management and access to WaSH. In terms of surveillance, these facilities had few trained personnel and lacked basic surveillance materials and tools. This was most prominent in rural districts where cholera outbreak is most frequent. The ability of health facilities in case management need improvement in the training of personnel and prepositioning of supplies like ORS. To make things worse, poor access to WaSH was equally uncovered in many health facilities. Some facilities did not have any water source or relied on surface water like lake/river and others lacked toilets. Theses weaknesses can compromise the ability of the health facility to respond to cholera outbreak and can cause high case fatality of cholera during outbreaks. To improve on the readiness of these districts on cholera outbreak response, the following recommendations are made: