Cholera in Internally Displaced Persons Camps in Borno State—Nigeria, 2017: A qualitative study of the multi-sectorial emergency response to stop the spread of the outbreak

Abstract Introduction/Background In August 2017, a cholera outbreak started in Muna Garage IDPs camp, Borno State-Nigeria, and >5000 cases occurred in six local government areas. This qualitative study evaluated perspectives about the emergency response to this outbreak. Methods/Findings We conducted 39 key informant interviews and focused group discussions, and reviewed 21 documents with participants involved with surveillance, water-sanitation-hygiene, case management, oral cholera vaccine, communications, logistics, and coordination. Qualitative data analysis used thematic techniques comprising key-words-in-context, word-repetition, and key-sector-terms. Authorities were alerted quickly, but outbreak declaration took 12 days due to a 10 day delay waiting for culture confirmation. Outbreak investigation revealed several potential transmission channels, but a leaking latrine around the index cases’ house was not repaired for >7 days. Use of chlorine disinfectant was initially not accepted by the community due to rumors that it would sterilize women. This could have been avoided with improved community consultation. Initially, key messages were communicated in Hausa, although ‘Kanuri’ was the primary language; later this was corrected. Planning would have benefited using exercise drills to identify weaknesses, and inventory sharing to avoid stock outs. The response by the Rural Water Supply and Sanitation Agency was perceived to be slow and an increased risk from Eid El Jabir festival with increased movement and food sharing was not recognized. Case management was provided at treatment centers, but some partners were concerned that their work was recognized asking, “who gets the glory and the data?” OCV was provided to nearly one million people and it distribution benefited from a robust polio vaccine structure; however, logistical problems related to payment of staff needed resolution. Initial coordination was thought to be slow, but improved by activating an Emergency Operations Centre. The Borno Ministry of Health used an Incident Management System to coordinate multi-sectoral response activities. These were informed by daily reviews of epi curves and geo-coordinate maps. The synergy between partners and government improved when each recognized the government’s leadership role. Conclusions/Significance Despite a timely alert of the outbreak, the delayed declaration led to a slowed initial response, but this improved during the course of the outbreak. OCV distribution was efficient and benefited from the OPV infrastructure. Improvements in laboratory capacity are urgently needed. Author Summary In August 2017, a cholera outbreak started in the Muna Garage Internally Displaced Persons (IPDs) camp in Borno State, Nigeria. By October, it appeared in six local government areas with a total of 5,340 cases reported including 61 deaths. We evaluated the perspectives of the emergency response by the government of Nigeria and implementing partners to stop the outbreak. We conducted 39 interviews and group discussions and also studied 21 documents related to the outbreak response. We found that epidemiologic surveillance timely alerted the health authorities about the outbreak, but the outbreak was declared 12 days later, awaiting for culture confirmation. This led to delays in the initial response. We also observed that conditions in the IDPs camps like overflowing latrines, overcrowding, and open defecation were highly favorable to cholera transmission. Improved IDP camp conditions are needed to prevent cholera and other water born infections and strengthened laboratory capacity is needed to enable a more rapid response.