Between November 11 and December 28, 2020, the municipalities of Golfe 1 and Golfe 6 in Lomé (Togo) reported 67 suspected cases of cholera, two of them fatal, with symptoms of diarrhea and vomiting; this represents a fatality ratio of 3%. Four health districts (Katanga, Adakpamé, Gbétsogbé in Golfe 1 and Kangnikopé in Golfe 6) of the affected municipalities reported at least one case.
On November 17, the laboratory of the National Institute of Hygiene in Lomé (Togo) confirmed the cases of cholera and reported it to the WHO. On November 19, the Togolese Ministry of Public Health, Hygiene and Universal Access to Health Care issued a press release declaring the appearance of a cholera outbreak, and on November 24 officially notified the WHO. Between November 11 and December 28, 2020, the National Institute of Hygiene of Lomé (Togo) confirmed, through cultures of 41 stool samples, 17 cases of Vibrio cholerae O1 Ogawa.
On November 16, the number of daily cases increased to six, including one death. Subsequently, after a decrease in the number of daily cases, the figures increased again to six cases reported on December 16, and another six on December 22. Cases whose symptoms appeared between November 11 and 15, 2020 were retrospectively detected in the context of active case searches in health center consultation records. Of the 67 cases, 19 (28%) were fishermen who frequently moved between Togo and neighboring countries (notably Benin, Ghana and Nigeria). The ratio between men and women is 1,48 (40 men and 27 women) and the average age is 24 years.
Public health response
Lomé is fully responding through various measures, including:
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- Implementation of the outbreak response plan
- Strengthening active surveillance: briefings for health workers and community health workers, active case detection
- Hygiene promotion at the community level
- Case management
- Improvement of infection prevention and control measures in health centers
- Distribution of water purifying products (chlorine tablets) among the population
- Installation of potable water tanks to distribute it to the population
- Disinfection of the homes of infected people
- Risk communication and community participation
- Coordination meetings
- Taking samples at water supply points, in order to carry out biochemical and bacteriological analyzes
The possibility of carrying out a vaccination campaign with the oral vaccine against cholera is being considered
Risk assessment by WHO
Cholera is an acute enteric infectious disease caused by ingesting water or food contaminated with the bacterium V. cholerae. Cholera can be serious and cause high rates of mortality and morbidity if it is not treated in time. Due to their short incubation period, outbreaks can spread rapidly depending on the frequency of exposure, the population exposed and the context involved.
Cholera outbreaks had previously been reported in Togo; the last of these was reported in 2016. The city of Lomé, currently affected by the outbreak, is one of the known cholera hotspots. In addition, Togo borders countries where the disease is endemic. A cholera outbreak in the Togolese capital Lomé, with an estimated population of around 2 million, has so far resulted in 000 suspected cholera cases, including two deaths (000% fatality ratio), of which 67 were confirmed by laboratory tests between November 3 and December 17, 11.
Most of the currently affected health districts (Katanga, Adakpamé, Gbétsogbé and Kangnikopé) are located in port areas where hygiene and sanitation conditions are poor. Strong response measures are needed to prevent the possible spread, given the fishing activities carried out in the affected localities, which attract residents from various districts of Lomé and other regions of Togo, and the proximity of Lomé to Benin and Ghana. In the Netherlands, one imported case of cholera and one secondary case were confirmed in travelers from Togo. The initial case was infected in Togo, and upon returning to the Netherlands, a cholera test on November 17 came back positive. The partner in the initial case developed cholera-like symptoms, including 'rice water' diarrhea and vomiting, and is believed to have been transmitted by secondary transmission from the initial case. Although there is no risk of further spread of the disease in the Netherlands, this event represents a case of international spread.
The Togolese health authorities took all necessary response measures, but the possibility of export of other cases to other countries cannot be discounted.
In the context of the current COVID-19 pandemic, there is a risk that access to health care will be altered, due to the burden on the health system and health workers as a result of COVID-19, and the decreased demand due to physical distancing requirements or community reluctance.
Another aspect to be taken into account during the current COVID-19 pandemic is the ability of local and national reference laboratories to perform cholera tests, due to the excessive demand for testing suspected COVID-19 samples. As of January 3, 2021, Togo had reported 3 COVID-683 cases, including 19 deaths.
WHO advice
Suspected cases of cholera are detected on the basis of clinical suspicions in patients with acute severe serous diarrhea in risk areas, areas where cholera is transmitted, or people who have traveled to areas where there is transmission. Detection can be facilitated by rapid diagnostic tests; confirmation is by culture or polymerase chain reaction. The most effective measures to combat cholera are: timely case management in specialized cholera treatment centers; expanding access to infrastructure for the supply of drinking water and sanitation; and improved hygiene and food safety practices in affected communities. Key public health messages should be disseminated to modify practices and behaviors, particularly in relation to hand washing, in order to slow the spread of the disease.
Based on the information available about the current outbreak, WHO advises against any restrictions on travel and international trade.