Disease outbreak news
4 January 2021
From 11 November to 28 December, 2020 a total of 67 suspected cholera cases presenting with diarrhea and vomiting, including two deaths a case fatality ratio (CFR: 3%) were reported from the municipalities “Golfe 1” and “Golfe 6” in Lomé, Togo. A total of four health areas (Katanga, Adakpamé, Gbétsogbé in Golfe 1, and Kangnikopé in Golfe 6) in the affected municipalities reported at least one case.
On 17 November, cholera was confirmed by culture in the laboratory of the National Institute of Hygiene (INH) in Lomé, Togo and WHO was informed. On 19 November, the Minister of Health, Public Hygiene and Universal Access to Care of Togo issued a press release declaring a cholera outbreak and on 24 November WHO was officially notified. From 11 November to 28 December 2020, a total of 17 out of 41 stool samples tested positive for Vibrio cholerae O1 serotype Ogawa by culture in the National Institute of Hygiene (INH) in Lomé, Togo.
The daily number of cases peaked on 16 November with six cases, including one death. Then, after a decrease in the number of daily cases, they once again peaked with 6 cases reported on both 16 and 22of December. The cases with symptom onset between 11 to 15 November 2020 were found retrospectively by active case searches in health facilities from consultation registers. Of the 67 cases, 19 (28%) were fishermen who move frequently between Togo and neighboring countries (especially Ghana, Benin, and Nigeria). The male / female ratio is 1.48 (40 males and 27 females) with an average age of 24 years.
Public health response
Full response is ongoing in Lomé, including but not limited to:
- Implementation of the outbreak response plan is in progress
- Strengthening of active surveillance: briefing of health workers and community health workers, active case finding
- Hygiene promotion in the community
- Case management
- Strengthening of infection prevention and control in health facilities
- Distribution of water treatment products (chlorine tabs) to the population
- Installation of drinking water tanks for distribution to the population
- Disinfection of the homes of the cases
- Risk communication and community engagement
- Coordination meetings
- Sample taking at water points for biochemical and bacteriological analysis
The possibility of an oral cholera vaccination (OCV) campaign is under discussion.
WHO risk assessment
Cholera is an acute enteric infectious disease caused by ingesting water or food contaminated with V. cholerae bacteria. Cholera is a potentially serious disease, causing high rates of morbidity and mortality in the absence of timely treatment. Due to the short incubation period of cholera, outbreaks can develop rapidly depending on the frequency of exposure, the population exposed, and the context involved.
Cholera outbreaks have previously occurred in Togo with the last outbreak reported in 2016. The city of Lomé, currently affected by the outbreak, is one of the known hotspots for cholera. In addition, Togo borders countries where this disease is endemic. A cholera outbreak in the Togolese capital, Lomé, with a population estimated at around of 2 000 000, has so far amounted to 67 suspected cholera cases including two deaths (CFR 3%) of which 17 have been confirmed by culture between 11 November to 28 December 2020.
The currently affected health zones (Katanga, Adakpamé, Gbétsogbé and Kangnikopé) are mostly located in port areas with poor hygiene and sanitation conditions. Strong response activities are necessary to prevent the possible spread, given the fishing activities carried out in the affected localities that attract inhabitants from several districts of Lomé and other regions of Togo as well as Lomé’s proximity to Ghana and Benin. One imported confirmed cholera case and one secondary case were reported in the Netherlands in travelers from Togo. The index case was infected in Togo and upon return to the Netherlands tested positive for cholera on 17 November. The partner of the index case developed cholera-like symptoms including ‘rice water’ diarrhea and vomiting and is considered to have acquired the disease through secondary transmission via the index. Even though there is no risk for further spread of the disease in the Netherlands this event represents an international spread.
Togolese health authorities have been implementing all necessary response measures, nevertheless, the possibility of exportation of additional cases to other countries cannot be excluded.
With the current COVID-19 pandemic, there is a risk of disruption to health care access due to both COVID-19 related burden on the health system and health care workers and a decreased demand because of physical distancing requirements or community reluctance.
Another aspect to take into consideration during the current COVID-19 pandemic, is the capacity of the local and national reference laboratories to handle cholera testing due to the over demand in processing COVID-19 samples. As of 3 January 2021, Togo reported 3 683 of COVID 19 cases with 68 deaths.
Suspected cholera cases are detected based on clinical suspicion in patients who present with severe acute watery diarrhea in at risk areas, areas with ongoing cholera transmission or in persons who have travelled to areas with ongoing transmission. Detection can be facilitated using cholera rapid diagnostic tests (RDTs); confirmation is made by culture or PCR. Proper and timely case management in dedicated cholera treatment centers (CTCs), improving access to potable water and sanitation infrastructure, and improved hygiene and food safety practices in affected communities, are the most effective means of controlling cholera. Key public health communication messages should be provided to modify behavioral practices, including hand washing, to contain the spread of the disease.
WHO advises against any restriction to travel to and trade with the international community based on the information available on the current outbreak.
For more information on cholera please see: